Mental health professionals tend to have a negative view of patients with BPD, and to speak about them in pejorative terms. Professionals often regard these patients as manipulative, selfish people. This negative view of patients with BPD is destructive to their treatment. As soon as the therapist views the patient negatively, the therapist feeds into one of the 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 patients with BPD is tumultuous and intense. Often the therapist’s own schemas are triggered. Later in this chapter we discuss how therapists can work with their own schemas when treating patients with BPD.
In our view, the most constructive way to view patients with BPD is as vulnerable children. They may look like adults, but psychologically they are abandoned children searching for their parents. They 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 patients with BPD 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 themselves; when they are alone, they feel panicked.
When therapists become confused in their treatment of patients with BPD, we sometimes find that mentally superimposing the image of a small child over the patient can help the therapist understand the patient better and figure out what to do. This strategy seems to counteract negative reactions to the patient’s behavior, reminding the therapist that—whether the patient is angry, detached, or punitive—underneath she is an abandoned child.
Patients with BPD almost always need more than the therapist can provide. This does not mean that the therapist should attempt to give these patients everything they need. On the contrary, therapists have rights, too. Therapists have the right to maintain a private life, to be treated respectfully, and to set limits when patients infringe on these rights. This does not mean that therapists have to get angry when patients infringe on their rights, however. Patients with BPD do not infringe on therapists’ rights 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. The patient with BPD has the rights and needs of a very young child. The patient needs a parent. Because 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 what the therapist can give. No one is to blame for this. It is not that the borderline patient wants too much and that the schema 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. Conflict is inherent in the fact that the patient with BPD will always have greater needs than the therapist can meet. The patient will predictably become frustrated with the therapist. Patients with BPD are thus apt to view professional boundaries as cold, uncaring, unfair, selfish, or even cruel.
At some point in therapy, many patients with BPD have the fantasy that they will live with the therapist—perhaps the therapist will adopt them, marry them, or move in with them. This is not usually primarily a sexual fantasy. Rather, what the patient wants is a parent who is always available. Patients with BPD 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, patients often flip modes and become 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 and without becoming victims of burnout.
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 the reason that effective treatment of the patient with BPD at a deep level cannot be brief. To treat this disorder fully requires relatively long-term treatment (at least 2 years and often longer). Many patients with BPD stay in treatment indefinitely. Even though they improve dramatically, as long as circumstances permit, they continue to attend therapy. Most patients can only terminate once they have established a stable, healthy relationship with a partner. Even when 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 patients with BPD. As we have noted, no matter how much the therapist gives, it still falls short of what the patient requires. If the patient becomes demanding or hostile, there is a risk that the therapist might retaliate or withdraw and thus contribute to a vicious cycle with the potential to destroy therapy. As noted, 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 patient must be characterized by mutual respect and genuineness. The therapist must truly care about the 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 a therapist. Patients with BPD are frequently very intuitive and immediately detect any falseness on the part of the therapist.
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 and Impulsive Child and help patients in this mode to 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 session, 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; if the patient is in the Detached Protector mode, the therapist uses the strategies designed specifically for the Detached Protector. (We discuss the strategies for each mode 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 serves as the “good parent.” The patient gradually identifies with and internalizes the therapist’s reparenting as her own Healthy Adult mode.
In order to give readers an overview of schema therapy for the patient with BPD, 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 in which we introduce them to the patient. In the next section, we present a more detailed description of the steps involved in treatment.
Mirroring early child development, the treatment has three main stages: (1) the Bonding and Emotional Regulation stage, (2) the Schema Mode Change stage, and (3) the Autonomy stage.
The Therapist Bonds with the Patient, Bypasses the Detached Protector, 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 (Winnicott, 1965). The therapist begins by 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 and to bond with 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 problematic modes.
In order to bond with the Abandoned Child, the therapist must first bypass the Detached Protector. This can be a difficult process, because, usually, the Detached Protector does not trust anybody. In a pilot treatment outcome study in the Netherlands that compared schema therapy with psychoanalytic therapy for outpatients with BPD, it was our observation that most schema therapists found that the first year of treatment was typically devoted to overcoming the Detached Protector mode so that they could reparent the Abandoned Child.
The Therapist Encourages Expression of Needs and Emotions in Sessions. A silent, reflective therapeutic stance is generally not suitable for patients with BPD. 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 might ask, “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 makes special efforts to encourage her to express 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 that 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 does in the previous 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 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 patient probably never got from a parent. In this way, the schema therapist tries to break the cycle of subjugation and detachment in which the patient is caught.
When the therapist encourages the patient to express emotions and needs, these emotions and needs generally arise from the Abandoned Child mode. Keeping the patient in the Abandoned Child mode and nurturing the patient is stabilizing to the patient’s life. 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 and Impulsive Child mode to express them. She will not have to flip into the Detached Protector mode to shut off her feelings. And 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 thus reparents her, gradually the patient’s dysfunctional modes drop away.
The Therapist Teaches the Patient Coping Techniques to Manage Moods and Soothe Abandonment Distress. The therapist teaches the patient coping techniques to contain and regulate affect as early as possible in therapy. The more severe the patient’s symptoms are (especially suicidal and parasuicidal behaviors), the sooner the therapist introduces these techniques. Many of the skills elucidated by Linehan (1993) as part of dialectical behavior therapy (DBT)—such as mindfulness meditation and distress tolerance—can be helpful in reducing these destructive behaviors.
However, we have found that the majority of patients with BPD cannot accept and benefit from cognitive-behavioral techniques until they trust both the therapist and the stability of the reparenting bond. If the therapist introduces these techniques too early, they tend not to be effective. Early in treatment, the patient’s primary focus is on the therapist-patient bond—on making sure the bond is still there—and she lacks the free attention to focus on most cognitive-behavioral techniques. Although some patients with BPD are able to use the techniques early in treatment, many more 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.
There is another danger in introducing cognitive techniques too early: The patient might misuse the techniques to strengthen the Detached Protector mode. Many cognitive techniques can become good strategies for detaching from emotion. In teaching the techniques to the patient, the therapist risks bolstering the Detached Protector mode. Because the overriding goal of therapy is to elicit and treat all the modes in the sessions, if the therapist teaches the patient techniques that suppress the other modes—the Abandoned Child, the Angry and Impulsive Child, and the Punitive Parent—then the therapist ultimately undermines this goal.
When we decide that the patient seems amenable to cognitive techniques, we usually begin with techniques designed to enhance the patient’s self-control of moods and self-soothing. These might include safe-place imagery, self-hypnosis, relaxation, self-monitoring of automatic thoughts, flash cards, and transitional objects—whatever appeals most to the patient. The therapist also educates the patient about schemas and begins to challenge the patient’s schemas using the cognitive techniques we described in Chapter 3. The patient reads Reinventing Your Life (Young & Klosko, 1993) as part of this educational process. Through these coping techniques, the therapist seeks to reduce schema-driven overreactions and to build the patient’s self-esteem.
The Therapist and the Patient Negotiate Limits Regarding Therapist Availability, Based on Severity of Symptomatology and the Therapist’s Personal Rights. Limit-setting is an important part of the early stage of treatment. Limit-setting is based foremost on 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 on 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 and therefore resent later.
For example, if the patient wants to leave the therapist a short message on the answering machine each evening and if the therapist feels this will not lead to resenting the patient over time, then the therapist might agree. But if the therapist believes that, eventually, these daily messages will cause resentment toward the patient, then the therapist should not agree. Because sources of resentment are personal matters, specific limits 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 on adjunctive resources. The therapist also helps the patient put the emotional regulation skills discussed previously into practice when crises arise.
The therapist is the primary resource for the borderline patient in crisis. Most crises occur because the patient is feeling worthless, bad, unloved, abused, 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 and respects her, in contrast to 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 on adjunctive resources in the community to help manage the patient, such as 12-Step groups, groups for incest survivors, and suicide hotline numbers.
The Therapist Initiates Experiential Work Related to the Patient’s Childhood. As therapy progresses and the patient stabilizes, the therapist begins imagery work based on the nontraumatic aspects of the patient’s early childhood experiences. (Later, the therapist uncovers and focuses on 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 one another.
The therapist models the Healthy Adult mode by reparenting the patient. The Healthy Adult acts to soothe and protect the Abandoned Child, to set limits on the Angry Child, to replace the Detached Protector, and to expunge the Punitive Parent. The patient gradually internalizes this Healthy Adult mode. This is the essence of schema therapy. In the pilot outcome study we mentioned earlier, after the bonding stage, schema therapists devoted much of the second year of treatment to combating the Punitive Parent mode, which is resistant to change. Once the Punitive Parent mode has been substantially weakened, usually change progresses rapidly.
The Therapist Advises the Patient about Appropriate Partner Choices and Helps Generalize Changes in Session to Relationships Outside of Therapy. As they move into the third stage, the therapist and patient focus intensively on the patient’s intimate relationships outside of therapy. When a patient enters treatment in the midst of a destructive relationship, the therapist offers advice early on about ways of changing or leaving the relationship. However, we have observed repeatedly that, until the reparenting bond is secure, the patient is usually unable to follow the advice. The patient typically cannot let go of the destructive relationship and tolerate the feelings of abandonment.
Once the patient bonds with the therapist and the therapist becomes a stable base—and as the mode work brings about a greater sense of self-esteem and mood regulation—the patient can often let go of the destructive relationship and begin forming healthy relationships. The therapist helps the patient make better partner choices and behave more constructively in relationships. The patient learns to express affect in appropriate, modulated ways and to ask appropriately for what she needs.
The Therapist Helps the Patient Discover Her Natural Inclinations and Follow Them in Everyday Situations and Major Life Decisions. As the patient stabilizes and spends less time in the Detached Protector, Angry and Impulsive Child, and Punitive Parent modes, she gradually becomes more able to focus on self-realization. The therapist helps the patient identify life goals and the sources of fulfillment in life. The patient learns to discover and follow her natural inclinations in areas such as career choice, appearance, subculture, and leisure activities.
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. The therapist allows the patient to initiate and set the pace for termination. The therapist permits as much independence as the patient can handle but is there as a secure base when the patient needs refueling.
We now present a more detailed description of our treatment of the patient with BPD, emphasizing strategies for working with each of the modes.
As we have noted, the therapist’s first and primary goal is to facilitate the reparenting bond. The therapist and patient discuss the patient’s current concerns and presenting problems, and the therapist seeks to provide safety, stability, empathy, and acceptance. The therapist asks the patient to describe her previous therapy experiences and what attributes she desires in a therapist. The therapist listens attentively to the patient and tries to create an open, receptive atmosphere.
Therapists can strengthen the reparenting bond in a number of ways. One is through tone of voice. Rather than speaking coldly and clinically, the therapist speaks in a warm and sympathetic manner. Therapists can strengthen the bond by truly giving of themselves emotionally. Rather than acting the role of the detached professional, the therapist is a real person who responds spontaneously, shares emotional responses, and self-discloses (when it would be helpful to the patient). Therapists can strengthen the bond by making direct statements to the patient conveying that the therapist wants to hear everything the patient has to say, understands what she is feeling, and supports her. Essentially, it is by caring about the patient that the therapist facilitates the reparenting bond.
Throughout, the therapist encourages the patient to speak freely about her needs and feelings regarding the therapist. The therapist is direct, honest, and genuine and encourages the patient to be the same.
The therapist spells out the goals of therapy in a personal way, making such statements as: “I want to give you a safe place in therapy”; “I want to be there for you so you’re not so alone”; “I want to help you become more aware of your own needs and feelings”; “I want to help you establish a stronger sense of identity”; “I want to help you become less self-punitive”; “I want to help you handle your emotions more constructively”; and “I want to help you improve your relationships outside therapy.”
The therapist tailors the presentation of goals to the individual patient, weaving in what the patient has said so far in the therapy. The therapist explains how therapy will address the patient’s presenting problems, and elicits her goals for therapy. If the patient states a goal that is countertherapeutic (such as remaining in a destructive relationship), the therapist does not agree to it but postpones focusing on the discrepancy until the reparenting bond is stronger. Eventually, the therapist discusses the goal with the patient and, through guided discovery, helps the patient recognize why the goal is self-defeating.
The therapist asks about the patient’s life, emphasizing the patient’s early childhood experiences in the family and with peers. Proceeding informally, the therapist takes a history. The therapist assesses whether the four predisposing factors identified earlier in this chapter were present in the patient’s early childhood environment, especially within the family: (1) abuse and lack of safety; (2) abandonment and emotional deprivation; (3) subjugation of needs and feelings; and (4) punitiveness or rejection. The therapist and patient begin to identify themes and triggers.
Patients who are willing to do so gradually complete the following assessment instruments for homework:
Multimodal Life History Inventory
Young Parenting Inventory
Young Schema Questionnaire (if the BPD diagnosis is unclear)
These assessment instruments were discussed in greater detail in Chapter 2.
Although completed inventories are extremely useful, the therapist’s first priority is to establish the reparenting relationship. If patients with BPD resist filling out the forms, the therapist does not press the issue; and, if the patient is very fragile, we suggest that the therapist forgo the forms altogether. Completing the forms can be distressing to many patients, because doing so can trigger painful memories and emotions. Other patients with BPD find filling out questionnaires too mechanical. Many of these patients will fill out the forms later, without needing to be pushed, as they become better able to deal with their emotions and modes.
We have found that, of all the forms, the one that is usually most helpful with patients with BPD is the Young Parenting Inventory. In this questionnaire, the patient rates her mother and father on a variety of dimensions. The patient fills out the inventory for homework and brings it to the next session. The therapist uses the inventory as a starting point for a discussion about childhood origins of schemas and modes. The therapist does not “score” the inventory, but points out items with high scores and asks the patient to talk more about them. Discussing the items helps patients begin to explore their childhoods and to understand the origins of their problems. It also helps patients begin to see their parents more objectively and realistically.
The Young Schema Questionnaire is useful primarily for diagnostic purposes. Because most patients with BPD have almost every schema and because filling out the questionnaire can be upsetting to them, we administer it only when the BPD diagnosis is unclear. If the diagnosis is clear, the questionnaire does not yield much additional information.
The therapist discusses the forms with the patient in a personal way. How the therapist presents the forms in large measure determines how the patient will respond to them. If the therapist presents them in a mechanical way, most likely the patient will not accept them. If the therapist uses the forms as a way to connect emotionally to the patient, then most likely the patient will respond positively to them.
The therapist explains the schema modes to the patient. If the therapist presents the modes in a personal way, most patients with BPD relate to them quickly and well. Here is how Dr. Young explained them to Kate (in an abbreviated form, because of time constraints imposed by the nature of the consultation):
THERAPIST: Let me tell you a little bit about the way that we view the type of problems that you have, and tell me if it fits. Let me write it down for you, and you can try to follow along. The idea is that people with the type of problems you have, have different sides of themselves, and the different sides sort of click in at different times.
One side I call the Abandoned Child. The Abandoned Child is the part that feels lost, lonely, that no one cares, alone. Can you relate to that side?
KATE: Yes. (Cries.) All the time.
THERAPIST: Is that what you feel most of the time?
KATE: Yes.
THERAPIST: The next side is called the Punitive Parent. And that’s the side that’s down on yourself, attacking yourself, wanting to punish yourself, like “I’m bad, I’m no good.” Do you relate to that side at all?
KATE: (Nods yes and cries.)
THERAPIST: When does that side come up? Can you think of what happens when you feel that side? What does it feel like?
KATE: Just that I’m bad, I’m just evil, that I’m dirty. That’s what I feel.
THERAPIST: What do you usually do when you feel that side, the Punitive Parent side? Do you do something to distract yourself?
KATE: Yes. That’s usually what I do. I try to fill my life up a lot.
THERAPIST: The third part we call the Detached Protector. The Detached Protector is the side that tries to keep you from feeling these other things. So what it does is, it tries to block feelings out, escape, drink, think about other things….
KATE: (Interrupts.) Or become somebody else?
THERAPIST: Yes, or become somebody else.
THERAPIST: Then the last side, we call the Angry Child, which is the part that feels she was mistreated—people weren’t nice to her….
It is worth noting that, in practice, we speak of a mode as if it were a person. This has been therapeutically effective, because it helps patients distance from and observe each mode. However, we do not actually view a mode conceptually as a separate personality.
Notice the ease with which Kate relates to the four modes. However, some patients with BPD reject the idea of modes. When this happens, the therapist does not insist. Rather, the therapist drops the labels and uses some other expressions, such as “the sad side of you,” “the angry side of you,” “the self-critical side of you,” and “the numb side of you.” It is important that the therapist label these different parts of the self in some way, but it does not have to be with our labels.
The therapist asks the patient to read chapters in Reinventing Your Life that relate to the modes (and to the particular patient). Although the book does not mention modes directly, it describes the experience of the schemas—how it feels to be abused, abandoned, deprived, subjugated—and the three coping styles of surrender, escape, and counterattack. The therapist asks the patient to read relevant chapters. It is important that the therapist assign one chapter at a time and pace the chapters, because when patients with BPD read Reinventing Your Life, they tend to see themselves everywhere and become overwhelmed.
To reiterate, the therapist’s general approach to treatment is to track the patient’s modes from moment to moment and utilize the strategies appropriate for the current mode. The therapist acts as the good parent. The goal is to build the patient’s Healthy Adult mode, modeled on the therapist, to care for the Abandoned Child, reassure and replace the Detached Protector, overthrow and banish the Punitive Parent, and teach the Angry Child appropriate ways to express emotions and needs.
The Abandoned Child is the patient’s wounded inner child. It is the child part of the patient who was—in our hypothesized, prototypical family of origin—abused, abandoned, emotionally deprived, subjugated, and harshly punished. Within the limits of the therapy relationship, the therapist attempts to furnish the opposite: a relationship that is safe, secure, nurturing, encouraging of genuine self-expression, and forgiving.
The Therapist—Patient Relationship. The therapeutic relationship is central to the treatment of the Abandoned Child mode. Through limited reparenting, the therapist seeks to provide a partial antidote to the patient’s toxic childhood. The therapist works to create a “holding environment” (Winnicott, 1965) in which the patient can develop from a young child into a healthy adult. The therapist becomes a stable base upon which the patient gradually builds a sense of identity and self-acceptance. By empathizing with the abandoned-child part of the patient, the therapist tries to guide the patient into the Abandoned Child mode and keep her there, and then to nurture the patient as a parent nurtures a child.
The therapist reparents the patient within the appropriate boundaries of the therapeutic relationship. This is what we mean by “limited reparenting.” There is the danger that the therapist will go too far and become enmeshed with the patient or try to become like an actual parent. The therapist stays within the appropriate limits of the therapeutic relationship. For example, the therapist does not meet with the patient outside of the office, use the patient as a confidante or caretaker, touch the patient, engage in dual relationship with the patient, or foster excessive dependence. However, we go further in reparenting than therapists from many other therapeutic modalities do.
Within these boundaries, the therapist tries to satisfy many of the patient’s unmet childhood needs for safety, caring, autonomy, self-expression, and appropriate limits. When the patient is in the Abandoned Child mode, she is very vulnerable. The therapist tells the patient: “I’m here for you,” “I care about you,” “I won’t abandon you,” “I won’t abuse or exploit you,” “I won’t reject you.” These messages affirm the therapist’s role as a stable, nurturing base.
The therapist uses direct praise to help build the patient’s confidence. When patients are in the Abandoned Child mode, the therapist attempts to give as much direct, sincere praise as possible. Patients with BPD usually do not recognize their own assets. They need the therapist to tell them what their assets are—for example, that they are generous, loving, intelligent, sensitive, creative, empathic, passionate, or loyal. If the therapist waits for the patient to identify her assets on her own, it will probably never happen. When therapists tell patients what they admire about them, the patients almost always deny that they are worthy of admiration. The patient switches from the Abandoned Child to the Punitive Parent mode, and the Punitive Parent negates the praise. However, even though the Punitive Parent negates the praise, the Abandoned Child still hears it. Months later, the patient might bring up what the therapist has said, even though she discounted it at the time.
Through the use of reciprocity and self-disclosure, the therapist uses the therapy relationship to model for the patient how to respect the rights of others, express emotions appropriately, give and receive affection, assert needs, and be authentic. It is important for therapists to be willing to share their personal reactions with patients. We do not mean to imply that therapists should share intimate details of their personal lives. Any type of self-disclosure is helpful—it does not have to go very deep. It could be about a trivial matter, such as an interaction with a stranger on the street or an experience with a salesperson in a store. Therapists acknowledge their vulnerable side to patients. In doing so, they model how to be vulnerable, accept their feelings, and share their feelings with another human being.
Experiential Work. In imagery, the therapist nurtures, empathizes with, and protects the Abandoned Child. Gradually, patients internalize these therapist behaviors as their own Healthy Adult mode, which then replaces the therapist in the imagery.
In imagery, the therapist helps the patient work through upsetting events from childhood. The therapist enters the images and reparents the child. Later in therapy, when the therapeutic bond is secure and the patient is strong enough not to decompensate, the therapist guides the patient through traumatic images of abuse or neglect. Once again, the therapist enters the images to take care of the child. The therapist does whatever a good parent would have done: removes the child from the scene, confronts the perpetrator, stands between the perpetrator and the child, or empowers the child to handle the situation. Gradually, the patient takes over the role of the Healthy Adult, enters the image as an adult, and reparents the child.
Experiential work can also help the patient manage upsetting situations in her current life. The patient can work through her trepidations about a given situation: She can close her eyes and generate an image of the situation or act out the situation in role-plays with the therapist. Sometimes the patient plays whichever mode is active while the therapist plays the Healthy Adult. In other situations, the patient expresses, in turn, the conflicting feelings and desires she has in each mode; then, through mode dialogues, she negotiates a healthy response to the situation.
Cognitive Work. The therapist educates the patient about normal human needs. The therapist begins by teaching the patient about the developmental needs of children. Many patients with BPD have never learned what normal needs are, because their parents taught them that even normal needs were “bad.” These patients do not know that it is normal for children to need safety, love, autonomy, praise, and acceptance. The early chapters of Reinventing Your Life are helpful in this stage of treatment, because they validate the normal developmental needs of children.
Cognitive techniques can help patients with BPD feel connected to the therapist in upsetting situations. For example, one patient with BPD who suffered from panic attacks told her therapist that reading flash cards in phobic situations was helpful because the cards made her feel connected to the therapist. To make it even more personal, the patient can talk to the therapist in the upsetting situation, either in her mind or with pen and paper.
Behavioral Work. The therapist helps the patient learn assertiveness techniques. The patient practices these techniques both during sessions, in imagery or role-play exercises, and between sessions, in homework assignments. The goal is for the patient to learn to manage affect in productive ways and to develop intimate relationships with appropriate significant others in which she is able to be vulnerable without overwhelming the other person.
We discuss cognitive-behavioral coping skills for patients with BPD further in the section on helping the Angry Child and the Abandoned Child to cope.
Dangers in Working with the Abandoned Child Mode. The first danger is that the patient might become overwhelmed. She might leave the session in the Abandoned Child mode and become depressed or upset. Patients with BPD cover a broad spectrum of functionality, and what one patient can handle, another cannot. It is best for the therapist to observe the patient closely and come to know what she can manage. The therapist is careful not to overwhelm patients when they have opened themselves up, as opening up can be so difficult for many patients with BPD to do. The therapist starts with simple strategies and gradually moves to those that are more emotionally charged.
A second danger is that the therapist might inadvertently act in a way that causes the patient to shut off the Abandoned Child mode. For example, if the therapist responds to the patient when she is in this mode by trying to solve a problem, the patient might flip into the Detached Protector mode. The patient might interpret the therapist’s behavior to mean that the therapist wants her to be objective and rational rather than subjective and emotional. Similarly, if the therapist treats the patient too much like an adult and ignores the patient’s childlike side, the patient might switch into the Detached Protector because the child feels unwanted. All their lives, most patients with BPD have been given the message that their Vulnerable Child mode is not welcome in interpersonal interactions.
A third danger is that the therapist might become irritated with the patient’s “childish” behavior and poor problem-solving when she is in the Abandoned Child mode. Any display of anger or irritation on the therapist’s part will immediately shut off the Abandoned Child. The patient will flip into the Punitive Parent mode, to punish herself for making the therapist angry. The therapist can use the technique of superimposing the image of a young child over the patient to maintain empathy. This will help the therapist to regard the patient as in a more developmentally appropriate stage and thus to have more reasonable expectations.
The Detached Protector mode serves to cut off the patient’s emotions and needs in order to protect the patient from pain and to keep the patient from harm by appeasing and mollifying others. This mode is an empty shell of the patient, which acts to please automatically and mechanically. The Detached Protector does this because, in this mode, the patient feels that it is not safe to be truly vulnerable with the therapist (or with other people). The Detached Protector exists to protect the Abandoned Child.
The Therapist—Patient Relationship. The therapist reassures the Detached Protector that it is safe to let the patient be vulnerable with the therapist. The therapist consistently protects the patient so that the Detached Protector does not have to do it. This can be accomplished in several ways. The therapist helps the patient contain overwhelming affect by soothing the patient so that it is safe for the Detached Protector to let the patient experience her feelings. The therapist allows the patient to express all her feelings (within appropriate limits), including feelings of anger at the therapist, without punishing the patient. When necessary, the therapist increases the frequency of contact with the patient so that the patient feels nurtured. By reparenting the patient, the therapist ensures that the patient feels safe.
Bypassing the Detached Protector. There are several steps to bypassing the Detached Protector. The therapist begins by labeling the Detached Protector mode, helping the patient to recognize the mode and to identify the cues that trigger it. Next, the therapist analyzes the development of the mode in the patient’s childhood and highlights its adaptive value. The therapist helps the patient observe events preceding activation of the mode in her outside life and the consequences of detaching. Together, the therapist and patient review the advantages and disadvantages of detaching in the present as an adult. It is important for the therapist to be forceful in insisting that the patient agree to fight the Detached Protector and experience other modes in therapy because no real progress can occur as long as the patient remains in the Detached Protector mode. As the Healthy Adult, the therapist challenges and negotiates with the Detached Protector. When all these steps have been navigated successfully and the therapist has bypassed the Detached Protector, then the patient is ready to do imagery work.
Here is an example with Kate. Dr. Young begins by pointing out to the patient that she is in the Detached Protector mode and, reminding her of why the mode is there, asks her to generate an image of her Abandoned Child mode.
THERAPIST: Close your eyes. (Pause.) Remember I talked about the Abandoned Child? You know, Little Kate, the little girl who wants to be loved. Picture yourself as a little girl. (Pause.) Can you picture yourself? Can you get an image of Little Kate?
KATE: Yes, I have a photograph of me, and that’s what I’m looking at.
THERAPIST: And what do you look like in the photo? Can you see what Little Kate feels?
KATE: In that picture I was happy, and I was four.
THERAPIST: So that’s a happy image of little Kate. Can you get an image of Little Kate where she’s not so happy? Picture her where she’s sad or alone. Maybe she’s in the house and nobody’s paying attention to her, maybe her father’s off in his own world. Can you get any image like that?
KATE: Yeah, a little bit. I guess. I don’t know.
THERAPIST: Is it that you really know, but you’re afraid to say it, or is it that you don’t want to look at it?
KATE: I guess I don’t want to look at it. But I forget things, too. It’s just hard for me.
THERAPIST: This is what I call the Detached Protector mode. That’s the side of you that’s trying to protect you from these feelings, and it’s jumping in right now and saying, “Kate, don’t let yourself think about these things or look at these things, because it’s going to hurt you too much.” Is it possible that’s what’s happening?
KATE: (Cries and nods yes.)
The therapist asks the patient to call up an image of the Detached Protector and begins a dialogue with the mode. The Detached Protector becomes a character in the image. In conducting the dialogue, the therapist’s goal is to convince the Detached Protector to step aside and allow the therapist to interact with the Vulnerable Child and other child modes. The therapist approaches the Detached Protector with an attitude of empathic confrontation.
THERAPIST: Could you say something to this detached side of yourself, to say that you need to let yourself look at some of these things?
KATE: It’s just hard. It’s just really hard. It’s just painful. And the more I try to think, the more I forget. The more I try to concentrate, the more I can’t.
THERAPIST: Again, it’s the struggle between this little child part and the detached part. Can you get a picture of the part of you that’s afraid to let you do this? Can you picture a side of you that’s sort of saying, “Kate, don’t feel these things”?
KATE: Yes.
THERAPIST: Can you talk to her and ask her, “Why don’t you want to let me look at these things? Why do you confuse me like this?” What does she say?
KATE: I think she’s just trying to take care of herself.
THERAPIST: Let me talk to her. “Kate, what are you afraid is going to happen if you let these feelings out and you remember these things?”
KATE: Then I’m just gonna be so angry and mad, just so angry that I won’t know what to do.
THERAPIST: Are you afraid that the feelings are going to go out of control or that the anger will hurt somebody?
KATE: Yes.
THERAPIST: Would it be too scary to get an image of Angry Kate and see what she looks like?
At this point the therapist and Kate are finally able to break through the Detached Protector to the Angry Child already activated beneath.
Experiential Work. Once the therapist has bypassed the Detached Protector, the imagery work can begin. From this point on in the treatment, the therapist can usually utilize imagery work to bypass the Detached Protector. We find that the best single strategy for getting a patient with BPD out of the Detached Protector mode is imagery work, particularly imagery work utilizing modes. When we ask patients with BPD to close their eyes and picture their Vulnerable Child, quite often they can immediately access the feelings underlying their affectively blank persona.
We describe the imagery work in more detail in discussing the treatment of the other modes.
Cognitive Work. Education about the Detached Protector mode is useful. The therapist highlights the advantages of experiencing emotions and connecting to other people. To live in the Detached Protector mode is to live as one who is emotionally dead. True emotional fulfillment is available only to those who are willing to feel and to want.
Beyond educating the patient in this way, there is something inherently paradoxical about doing cognitive work with the Detached Protector. By emphasizing rationality and objectivity, the process of doing cognitive work itself reinforces the mode. For this reason, we do not recommend focusing on cognitive work with the Detached Protector (other than educational work). Once the patient recognizes intellectually that there are important advantages to supplanting the Detached Protector with better forms of coping, the therapist moves on to the experiential work.
Biological Work. If the patient is overwhelmed by intense affect whenever she switches out of the Detached Protector mode, then the therapist can consider referring the patient to a psychopharmacologist for a medication evaluation. Medication sometimes helps the patient better tolerate coming out of the Detached Protector mode into the other modes. Medications such as mood stabilizers or antidepressants can place a container around the patient’s emotions so that she does not become so overwhelmed. As we have noted, it is only in the other modes that real progress can be made in treatment. If the patient cannot stay in the other modes in therapy and remains frozen in the Detached Protector mode, then little progress is possible.
Behavioral Work. Distancing from people is an important aspect of this mode. The Detached Protector is extremely reluctant to open up to people emotionally. In behavioral work, the patient attempts to open up—gradually and incrementally—despite this reluctance. The patient practices shifting out of the Detached Protector mode and into the Abandoned Child and Healthy Adult modes with appropriate significant others.
The patient can practice imagery or role-plays with the therapist in sessions and then carry out homework assignments. For example, a patient might have the goal of sharing more of her feelings about a certain topic with one of her close friends. She might practice expressing her feelings to this friend in role-plays with the therapist and then actually do so with this friend in the week following as a homework assignment.
In addition, the patient can join a self-help group (Alcoholics Anonymous, Adult Children of Alcoholics, etc.). The patient can then practice moving out of the Detached Protector and into the Abandoned Child and Healthy Adult modes in the context of a supportive group.
It is important for the therapist to be consistently confrontational in fighting the Detached Protector. In Chapter 8 we presented a transcript of a session conducted by Dr. Young that demonstrates this process in greater detail.
Dangers in Treating the Detached Protector Mode. The first danger is that the therapist might mistake the Detached Protector for the Healthy Adult. The therapist believes the patient is doing well, but the patient has merely shut down and is behaving in a compliant manner, like a “good child” who is passive and obedient. The key distinguishing factor is whether the patient is experiencing any emotions. The therapist can say, “What are you feeling right now?” The patient who is in the Detached Protector mode will answer, “I’m not feeling anything,” or “I feel numb.” The therapist can say, “What would you like to do right now?” and the patient will answer, “I don’t know,” because when the patient is in the Detached Protector mode, she does not have a sense of her own wishes. The therapist can say, “What are you feeling toward me right now?” and the patient in the Detached Protector mode will respond, “Nothing.” The patient can experience emotion in the other modes, but not in the Detached Protector mode.
A second danger is that the therapist might become drawn by the Detached Protector into problem-solving without addressing the underlying mode. Many therapists fall into the trap of trying to solve the problems of their patients with BPD, especially in the early stages of treatment. Often the patient does not want solutions—she wants caring and protection. She wants the therapist to empathize with the mode underlying the Detached Protector, with the hidden Abandoned Child and Angry Child modes.
A third danger is that the patient might become angry and the therapist fail to recognize it. The Detached Protector cuts off the patient’s anger at the therapist. If the therapist does not break through the Detached Protector and help the patient express her anger, then the patient’s anger will build up, and eventually the patient will act out or leave. For example, the patient might go home and cut herself, drive recklessly, engage in substance abuse, have an impulsive, unsafe sexual encounter, or abruptly terminate therapy.
The Punitive Parent is the patient’s identification with and internalization of the parent (and others) who devalued and rejected the patient in childhood. This mode punishes the patient for being “bad”—which can mean almost anything, but especially expressing genuine feelings or having emotional needs. The goal of treatment is to defeat and cast out the Punitive Parent. Unlike the other modes, the Punitive Parent serves no useful purpose. The therapist battles the Punitive Parent, and the patient gradually identifies with and internalizes the therapist as her own Healthy Adult mode and then battles the Punitive Parent herself.
The Therapist—Patient Relationship. By modeling the opposite of punitiveness—an attitude of acceptance and forgiveness towards the patient—the therapist proves the Punitive Parent false. Rather than criticizing and blaming the patient, the therapist acknowledges the patient when she expresses her genuine feelings and needs and forgives the patient when she does something “wrong.” The patient is a good person who is allowed to make mistakes.
By making the self-punitive part of the patient into a mode, the therapist helps the patient undo the identification and internalization process that created that mode in early childhood. The self-punitive part becomes ego-dystonic and external. The therapist then allies with the patient against the Punitive Parent.
In joining with the patient to fight the Punitive Parent, the therapist assumes a stance of empathic confrontation. The therapist empathizes with how difficult it is for the patient, even while pushing the patient to fight the punitive voice. Staying focused on providing empathy helps prevent the therapist from inadvertently identifying with the Punitive Parent and coming across as critical or harsh.
Experiential Work. The therapist helps the patient fight the Punitive Parent mode in imagery. The therapist begins by helping the patient identify which parent (or other person) the mode actually represents. From then on, instead of calling the mode the Punitive Parent, the therapist calls the mode by name (i.e., “your Punitive Father”). Sometimes the mode represents both parents, but more often the mode is the internalized voice of one parent. Labeling the mode in this way helps the patient externalize the voice of the Punitive Parent: It is the parent’s voice, and not the patient’s own voice. The patient becomes more able to distance from the punitive voice of the mode and more able to fight back.
Here is an example from Dr. Young’s interview with Kate. In this segment, Kate flips from the Angry Child to the Punitive Parent mode: The Punitive Parent attempts to punish the Angry Child for getting angry. Kate identifies the Punitive Parent as her father.
THERAPIST: Now I want you to try to be Angry Kate. Talk back to your father, and tell him, “I’m sick of my brother getting all the attention. I deserve some, too.”
KATE: (to father in image) I’m just tired of him taking everything out on me, and beating me, and having you yell at me.
THERAPIST: (coaching Kate) “It’s not fair.”
KATE: (Repeats.) It’s not fair.
THERAPIST: (still coaching) “And that’s why I want to destroy my room. Because I’m so angry at you for doing this.”
KATE: I just want you all to die.
THERAPIST: OK, that’s good that you said that, Kate. Now, are you feeling bad about yourself for saying it, or does it feel like a relief?
KATE: No. (Cries.) It’s wrong.
THERAPIST: Can you be the part of you that feels that’s wrong right now? Is that your father now, telling you that?
KATE: (Nods yes.)
THERAPIST: Can you be your father now, telling you that’s wrong?
KATE: (as father) “It’s wrong for you to think those things and to feel those things, and to be angry, and to want me dead, to want us dead. We take care of you.”
The therapist then enters the image to fight the Punitive Parent.
THERAPIST: Can you bring me into the image and let me talk to your father for a second, to protect you a little bit from him? Can we do that? Can you picture me there in the image with your father and you?
KATE: (Nods yes.)
THERAPIST: Now I’m going to speak up for you to the Punitive Father: “Look, it’s not wrong for Kate to be angry with you. You don’t give her the normal amount of attention and caring that a father gives, and your wife is no better. She doesn’t give her the attention, either. No wonder she’s angry. No wonder she hates all of you. What do you do to make her care about you? What do you do to make your daughter love you and feel close to you? All you do is get angry with her and blame her for things. Even when her brother beats her, you still blame her. Do you expect her to love you for that and be happy? Is that fair?” What are you feeling as I say these things for you?
KATE: I feel guilty.
THERAPIST: Do you feel like hurting yourself, like you deserve to get punished?
KATE: Like, after you leave, I’m going to get beat up.
THERAPIST: Who’s going to beat you up?
Kate has lost track momentarily of the line between imagery and reality: The imagery has taken on the quality of a flashback for her. Her statement that, after the therapist leaves, she is going to get beat up by her brother blends the present and the past. She has shifted into the Abandoned Child mode. The therapist acts to protect her and to remind her that this is only an image.
THERAPIST: But he’s not in your life now, right?
KATE: (Nods yes.)
THERAPIST: So this is only in the image now that you are seeing that? Is that what happens in the image? It feels like he’s going to beat you up for saying it?
KATE: (Nods yes.) For sticking up for myself.
THERAPIST: Can you in the image now imagine giving yourself some kind of wall or something to protect yourself from him in the image? What could you give yourself?
This segment with Kate demonstrates the rapidity with which patients with BPD flip modes. Kate flips from the Angry Child to the Punitive Parent (to punish the Angry Child) to the Abandoned Child (who is afraid her brother will retaliate for her anger). For patients with BPD, this kind of rapid flipping of modes does not occur only in imagery. This is how most of these patients live their lives—with the same rapid flipping of modes.
The previous segment illustrates the strategy of locating the punitive voice in the character of the parent in the image. Whenever the patient switches into the Punitive Parent mode, the therapist identifies the mode with the parent who modeled it. The therapist says, “Be your father saying that to you.” It is no longer the patient’s voice, it is the parent’s voice. Now the therapist can join with the patient in fighting the parent.
As in the preceding segment, most patients with BPD need the therapist to step in and fight the Punitive Parent. Early in the treatment, most patients are too intimidated and afraid of the Punitive Parent to fight back in imagery. Later, as patients internalize the voice of the therapist and develop a stronger Healthy Adult mode, they become more able to fight the Punitive Parent on their own. Earlier in the treatment, the patient is essentially an observer of the battle between the Punitive Parent and the therapist. The therapist uses whatever means necessary to win this battle without overwhelming the patient. Once again, the goal is to expunge the Punitive Parent as completely as possible, not to integrate it with the other modes.
Therapists do not conduct imagery dialogues in which patients picture themselves as the punitive one; rather, patients always picture one of their parents. If they picture themselves instead of the parent, the therapist’s attacks against the punitive voice would seem to be attacks against the patient, and the patient would not be able to distinguish between attacks on the parent and attacks on the patient. Identifying the punitive voice with the parent solves the problem of how to fight the Punitive Parent without seeming to fight the patient. Once the voice is labeled as belonging to the parent, it is no longer a debate between the therapist and the patient; it is now a debate between the therapist and the parent. In this debate, the therapist verbalizes what the Angry Child has been feeling all along. The therapist finally says what the patient feels underneath but has been unable to express because the Punitive Parent is so tyrannical.
The therapist models setting limits with the Punitive Parent rather than debating the mode or becoming defensive. The patient learns not to defend herself against the Punitive Parent but to fight the parent. The patient does not have to defend herself to prove her rights and worthiness. Rather, the patient tells the Punitive Parent, “I won’t let you talk to me like that.” The patient learns to set consequences when the Punitive Parent violates the patient’s limits.
The therapist can use other experiential techniques. For example, the therapist can use the Gestalt “two-chair” method. The therapist asks the patient to conduct dialogues between the Healthy Adult and the Punitive Parent modes, switching chairs as she switches modes. Ideally, the therapist serves as coach, but not as either mode. This locates the conflict within the patient where it belongs, not between the therapist and the patient. In addition, patients can write letters to the people who have been punitive toward them in the past, stating their feelings and asserting their needs. The patient can write these letters as homework assignments, then read them aloud to the therapist in subsequent sessions.
Cognitive Work. The therapist educates the patient about normal human needs and feelings. It is not “bad” to have them. Due to their emotional deprivation and subjugation, most patients with BPD believe that they are wrong to express their needs and feelings and deserve punishment when they do. In addition, the therapist teaches the patient that punishment is not an effective strategy for self-improvement. The therapist does not support the idea of punishment as a value. When the patients make mistakes in their lives, the therapist teaches them to replace self-punishment with a more constructive response involving forgiveness, understanding, and growth. The goal is for the patients to look honestly at what they did wrong, experience appropriate remorse, make restitution to anyone who might have been negatively affected, explore more productive ways of behaving in the future, and, most important, forgive themselves. In this way, the patients can take responsibility for their mistakes without punishing themselves.
The therapist works to reattribute the parent’s condemnation of the patient to the parent’s own problems. Here is an example from Dr. Young’s interview with Kate. Kate is describing how much her mother disliked her for being “unhappy” and “bitchy.”
THERAPIST: Do you still think your mother was right?
KATE: Yes. But there was a reason why I was acting that way, maybe it just wasn’t something that came from me. I’m starting to realize that now; this has been a long time coming, these feelings. Instead of just internalizing it, maybe it just wasn’t me.
THERAPIST: But you’ve always felt, until recently, that the reason your family treated you this way was because there was something wrong with you. You have basically believed what they said.
KATE: I still believe it.
THERAPIST: But you’re trying not to.
KATE: Yes.
THERAPIST: But it’s a struggle.
KATE: Yes.
It can often take a year or more to conquer the Punitive Parent, as Kate is trying to do, and it is a crucial step in the treatment of patients with BPD. Over time, somehow the therapist must convince patients that their parents’ mistreatment of them occurred not because they were bad children but because their parents had problems of their own or because the family system was dysfunctional. Patients with BPD cannot overcome their feelings of worthlessness until they can make this reattribution. They were good children and did not deserve mistreatment; in fact, no child deserves the mistreatment they experienced.
Together, the therapist and patient go through a process of understanding why the parent mistreated the patient. Perhaps the parent mistreated all the children (in which case the parent had a psychological problem); or the parent was jealous of the patient (in which case the parent had low self-esteem and felt threatened by the patient); or the parent was not able to understand the patient (in which case the patient was different from the parent, but not “bad”). Once patients understand the parent’s reasons for mistreating them, they are more able to break the emotional tie between their parent’s treatment of them and their self-esteem. They learn that, even though their parent mistreated them, they were worthy of love and respect.
The patient struggling to make this reattribution faces a dilemma. In blaming and getting angry at the parent, the patient risks losing the parent, either psychologically or in reality. This dilemma highlights once again the importance of the reparenting relationship. As the therapist becomes the (limited) substitute parent, the patient is no longer so dependent on the real parent and is more willing to blame and get angry at the parent. By becoming a stable, nurturing base, the therapist gives the patient the stability to let go of or stand up to a dysfunctional parent.
In general, it is much better for patients with BPD not to live with or have frequent contact with their families of origin, especially in the early stages of treatment. The family is very likely to continue reinforcing the very schemas and modes the therapist is fighting to overcome. If a patient is living with her family of origin and the family is still treating her in harmful ways, the therapist makes it a priority to help her find a way to move out.
Another way in which therapists can fight the Punitive Parent is by elaborating the patient’s positive qualities. The therapist and patient can keep an ongoing list, periodically adding to it or reviewing it. Patients can gather data about their positive qualities for homework assignments (for example, by asking close friends) and set up experiments to counteract their negativity (for example, by sharing more genuine needs or feelings with select significant others and observing what happens). The therapist and patient can summarize this work on flash cards.
Repetition is a vital aspect of the cognitive work. Patients need to hear the arguments against the Punitive Parent over and over again. The Punitive Parent mode has developed over a long time through countless repetitions. Each time patients fight the Punitive Parent mode with self-love, they weaken the Punitive Parent mode a little bit more. Repetition slowly wears down the Punitive Parent.
Finally, it is important that the therapist and patient acknowledge the parent’s good qualities. Often the parent gave the patient some love or acknowledgment, held all the more precious by the patient because it was so rare. However, the therapist insists that the parent’s positive attributes do not justify or excuse the parent’s harmful behavior.
Behavioral Work. Patients with BPD expect other people to treat them the same way their parents treated them. (This is part of the Punitiveness schema.) Their implicit hypothesis is that almost everyone is, or will become, the Punitive Parent. The therapist sets up experiments to test this hypothesis. The purpose is to demonstrate to the patient that expressing needs and emotions appropriately will usually not lead to rejection or retaliation by healthy people. For example, a patient might have the assignment of asking her partner or close friend to listen to her when she is distressed about work. The therapist and patient role-play the interaction until the patient feels comfortable enough to attempt it, and then the patient carries it out as a homework assignment. If the therapist and patient have chosen the significant other wisely, then the patient will be rewarded for her efforts with a positive response.
Dangers in Treating the Punitive Parent Mode. One danger in helping patients fight the Punitive Parent mode is that the Punitive Parent might fight back by punishing the patient. After the session, the patient might flip into the Punitive Parent mode and punish herself with parasuicidal behaviors, such as cutting or starving herself. It is important for the therapist to keep monitoring the patient for this possibility and to take steps to prevent its occurrence. The therapist instructs the patient not to punish herself and provides alternative activities for the patient when she experiences urges to do so. These activities include reading flash cards or mindfulness meditation.
Another danger is that the therapist might underestimate how frightened the patient is of the Punitive Parent and fail to provide enough protection during the experiential exercises. Often the punitive parent was also an abusive parent. The patient usually needs a great deal of protection to oppose the Punitive Parent. The therapist provides this protection by confronting the Punitive Parent and setting limits on the Punitive Parent’s treatment of the patient in the imagery.
Similarly, the therapist might not take an active enough role in fighting the Punitive Parent. The therapist might be too passive or too calmly rational and not aggressive enough. The therapist has to fight the Punitive Parent aggressively. The therapist has to say, “You’re wrong,” to the Punitive Parent; the therapist has to say, “I don’t want to hear you criticize her anymore. I don’t want to hear your mean voice. I’m not going to let you punish her anymore.” Dealing with the Punitive Parent is like dealing with a person who has neither good will nor empathy. One does not reason with such a person; one does not make appeals to empathy. These approaches do not work with the Punitive Parent mode. The method that works most often is standing up to the Punitive Parent mode and fighting back.
Another danger in doing the experiential work is that the therapist might never teach the patient how to face the Punitive Parent on her own. The therapist steps in and fights the Punitive Parent only as a transitional measure. Eventually the patient must learn to fight the Punitive Parent alone. The therapist gradually withdraws from the imagery sessions, allowing the patient to assume an increasing level of responsibility for fighting the Punitive Parent.
A final danger is that the patient might feel disloyal for criticizing the Punitive Parent. The therapist assures the patient that, later, she can choose to forgive the parent, but for now it is important to look at the truth.
The Angry Child mode expresses rage about the mistreatment and unmet emotional needs that originally formed her schemas—the abuse, abandonment, deprivation, subjugation, rejection, and punishment. Although the rage is usually justified in regard to childhood, in adult life this mode of expression is self-defeating. The patient’s anger overwhelms and alienates other people and thus makes it even more unlikely that the patient’s emotional needs will finally be met. The therapist reparents the Angry Child by setting limits on angry behavior, while at the same time validating the patient’s underlying needs and teaching her more effective ways of expressing anger and getting her emotional needs met.
The Therapist—Patient Relationship. What is the therapist’s strategy when the patient with BPD flips into the Angry Child mode and becomes angry at the therapist? Anger at the therapist is common with these patients and, for many therapists, is the most frustrating aspect of treatment. The therapist often feels exhausted trying to meet the patient’s needs. Thus, when the patient turns against the therapist and says, “You don’t care about me. I hate you,” the therapist naturally feels angry and unappreciated. Patients with BPD can sometimes be abusive. They can be manipulative and try to coerce the therapist into giving them what they want. They engage in many behaviors that anger the therapist and tempt the therapist to retaliate. Patients do these things not to hurt the therapist but out of desperation. When therapists feel anger toward patients with BPD, their first priority is to attend to their own schemas. What schemas, if any, are being triggered in the therapist by the patient’s behavior? How can the therapist respond to these schemas so as to maintain a therapeutic stance toward the patient? We discuss the issue of the therapist’s own schemas later in the chapter.
The next step is to set limits if the patient’s anger is abusive. There is a line patients can cross from simply venting anger, which is healthy, to being abusive toward the therapist. Patients cross this line when they call the therapist demeaning names, attack the therapist personally, swear at the therapist, yell loudly enough to disturb others, try to physically dominate the therapist, or threaten the therapist or the therapist’s possessions.
The therapist does not tolerate any of these behaviors and responds with a statement such as, “No, I can’t let you do that. You have to stop yelling at me. It’s OK for you to be angry, but it’s not OK for you to scream at me.” If the patient still does not stop behaving abusively, then the therapist imposes a consequence: “I would like you to go out into the waiting room for a few minutes until you can calm down. When you’re calm, then you can come back in and resume telling me about your anger, but without screaming at me.” The therapist gives the patient two messages: The first is that the therapist wants to hear the patient’s anger; the second is that the patient has to express the anger within appropriate limits. We further discuss limit-setting later in the chapter.
In fact, most patients with BPD do not behave abusively toward the therapist, although their anger can be very intense. When the patient is in the Angry Child mode and not behaving abusively, then the therapist responds by following these four steps in order: (1) ventilate; (2) empathize; (3) reality-test; and (4) rehearse. We describe these steps one by one.
1. Ventilate. First, the therapist allows the patient to express the anger fully. This helps the patient feel calm enough to settle down and be receptive to the second step. The therapist says, “Tell me more about that. Explain why you’re angry at me.” The therapist allows the patient broad latitude in venting anger, even if the intensity seems unwarranted or exaggerated. If the therapist shows empathy at this stage, it usually neutralizes the anger. Because this is not the initial goal, it is important for the therapist to use a flat or neutral tone, not a nurturing one, and simply repeat: “And what else are you angry at me about?”
2. Empathize. Second, the therapist empathizes with the patient’s underlying schemas. Underneath the patient’s anger is usually a sense of abandonment, deprivation, or abuse. The Angry Child is a response to the unmet needs of the Vulnerable Child.
The therapist says something like, “I know that you’re angry at me right now, but I think that underneath what you’re feeling is hurt. You’re feeling that I don’t care about you. Underneath, you’re feeling abandoned by me.” The therapist tries to label what is happening in schema terms for the patient.
The goal of empathizing is to shift the patient from the Angry Child into the Abandoned Child mode. Then the therapist can reparent the Abandoned Child and remedy the source of the anger.
3. Reality-test. Third, the therapist helps the patient engage in reality-testing related to the source of the anger and its intensity. Was the patient’s anger really justified, or was it based on a misunderstanding? Are there alternative explanations? Is the anger in proportion to the situation? After they have vented and they feel that the therapist understands, most patients are willing to test reality in this way.
The therapist is neither defensive nor punitive and acknowledges any realistic components of the patient’s accusation. There is a fine line between reality-testing and becoming defensive. If there is any truth in what the patient is saying, the therapist admits it and apologizes. The therapist says, “You’re right,” and “I’m sorry.”
Then, the therapist confronts the distorted, exaggerated aspects of the patient’s anger, usually through personal self-disclosure: “On the other hand, when you say I don’t care about you at all, that’s where I feel you’re going too far.” The therapist shares what it is like to hear the patient say this: “When you say I don’t care at all, it makes me feel that all the ways I’ve tried to show I care mean nothing to you.” The therapist also shares what it feels like to experience the patient’s anger when it is expressed inappropriately: “When you yell like that, I can’t listen to what you’re saying. All I can hear is that you’re yelling at me and I want you to stop.”
4. Rehearsal of appropriate assertiveness. If the patient’s anger has diminished considerably after the first three steps, therapist and patient move to the final step, which is practicing appropriate assertion. The therapist asks the patient, “If you could do it over again, how would you express your anger to me? How could you express what you need and feel in a way so that I, or other people, can listen and not become defensive?” If necessary, the therapist models the behavior, and then the patient practices it. The therapist helps the patient learn how to express anger in more appropriate, assertive ways.
Experiential Work. In the experiential work, patients vent anger fully toward the significant others in their childhood, adolescence, or adult life who mistreated them. The therapist encourages them to vent in any way they like, even to imagine attacking the people who hurt them. (The exception, of course, is the previously violent patient: Therapists should not encourage patients who have a history of violent behavior to imagine violent fantasies.)
However, most patients with BPD do not have a history of violent behavior; most have a history of victimization. Rather than harming others, they have been harmed. It helps these patients to express their anger in imagery—to imagine fighting back against the people in their early lives who victimized them. By doing so, they feel empowered rather than helpless. Venting anger helps them release strangulated affect and place the current situation in perspective. Patients can do role-plays with the therapist in which they practice venting anger, and they can write angry letters addressed to people in their lives who have harmed them (although they usually do not send the letters). Patients can also use physical outlets to release their anger while doing experiential work, such as pounding a pillow or soft piece of furniture.
Patients practice healthier ways to express anger in their current lives. They utilize imagery or role-plays with the therapist to work out constructive ways to behave in problematic situations. Doing mode work, they conduct negotiations between the Angry Child and Healthy Adult and other modes to find compromises. Usually the compromise is that the patient can express anger or assert her needs, but she must do it in an appropriate manner. For example, the patient cannot yell at her boyfriend, but she can quietly tell him why she is upset.
Cognitive Work. As we pointed out, education about normal human emotions is an important part of the treatment of patients wih BPD. It is especially important to teach patients about the value of anger. Patients with BPD tend to think of anger as all “bad.” The therapist reassures them that all anger is not bad: feeling angry and expressing it appropriately is normal and healthy. It is not that their anger is inherently bad; rather, their way of expressing anger is problematic. What they need to learn to do is to express their anger more constructively and effectively. Rather than flipping from passivity to aggression, they need to find a middle ground utilizing assertiveness skills.
The therapist teaches patients reality-testing techniques so that they can formulate more realistic expectations of other people. Patients come to recognize their “black and white thinking” and to stop themselves from impulsively overreacting to emotional slights. Patients can use flash cards to help themselves maintain self-control. When patients feel angry, they take a time-out and read the flash card before responding behaviorally Rather than lashing out or withdrawing, they think through how they want to express their anger.
For example, one patient named Dominique, who frequently paged her boyfriend, Alan, became furious whenever he failed to call her back immediately. With the therapist’s help, she composed the following flash card:
Right now I’m angry because I just paged Alan and he isn’t calling me back right away. I’m upset because I need him and he’s not there for me. If he could do this to me, I believe that he doesn’t care about me anymore. I feel scared that he’s going to break up with me. I want to keep paging him over and over again until he answers me. I want to tell him off.
However, I know that this is my Abandonment schema getting triggered. It’s my Abandonment schema that’s making me think Alan’s going to leave me. The evidence that the schema is wrong is that I’ve thought Alan was going to leave me a million times before and I’ve always been wrong. Instead of paging him over and over or telling him off, I’m going to give him the benefit of the doubt and trust that he’s got a good reason for not calling me back right away and that he’s going to call me back when he can. When he finally reaches me, I am going to answer him in a calm and loving way.
Asking the patient to generate alternative explanations for the behavior of others can also be helpful. For example, the patient just described might generate a list of alternative explanations for her boyfriend not calling her back immediately, including such items as: “He’s busy at work,” “He’s in a situation in which there’s no privacy to call me,” and “He’s waiting for a good time to call.”
Behavioral Work. The patient practices anger management and assertiveness techniques, both in imagery and role-plays during sessions and in homework practices between sessions.
We discuss these and other cognitive-behavioral techniques further, in the next section, “Helping the Abandoned Child and the Angry Child Cope.”
Dangers in Treating the Angry Child. When patients are in the Angry Child mode, there is a particularly high risk that the therapist will behave countertherapeutically One danger, already mentioned, is that the therapist might become too defensive and deny the realistic components of the patient’s complaint. Therapists need to work on their own schemas so that they are prepared to respond therapeutically when their schemas are triggered by the Angry Child.
A more serious danger is that the therapist might counterattack. If the therapist retaliates by attacking the patient, this will trigger the patient’s Punitive Parent mode, and the patient will join with the therapist in the attack.
Another danger is that the therapist might withdraw psychologically. When patients with BPD are in the Angry Child mode, therapists often shut down emotionally, retreating into their own “detached protector” modes. Psychological withdrawal on the part of the therapist is problematic because it gives the patient the message that the therapist cannot contain the patient’s anger. In addition, withdrawal is likely to trigger the patient’s Abandonment schema, as the therapist is emotionally disconnecting from the patient.
At the other extreme, the therapist may allow the patient to go too far in expressing anger, to the point at which the patient actually becomes abusive. Such behavior on the part of the therapist reinforces the patient’s Angry Child in unhealthy ways. The therapist gives the patient permission to carry her anger to abusive extremes and fails to set appropriate limits. If the patient leaves the session feeling that her anger was totally justified, then the therapist has probably not done enough reality-testing or limit-setting.
Another risk is that the patient might flip into the Punitive Parent mode after the session to punish herself for getting angry at the therapist. It is important for the patient to hear that she is not “bad” for having gotten angry, that the therapist does not want her to punish herself afterward, and that the therapist wants to help her. The therapist says: “You’re not bad for getting angry at me, so I don’t want you to punish yourself after the session. If your Punitive Parent starts to punish you, you need to stop him [or her]; and, if you can’t, you need to call me so that I can stop him [or her]. I don’t want you hurt in any way because of what happened in our session today.”
A final danger is that the patient might discontinue therapy because she is angry at the therapist. However, we have found that, in most cases, if the therapist allows the patient to vent fully within appropriate limits and expresses empathy, the patient does not leave therapy. The patient feels validated and accepted, and therefore stays.
We describe various cognitive-behavioral techniques for helping patients cope when they are in the Angry Child or the Abandoned Child modes or under assault by the Punitive Parent. Although these techniques can be introduced at any point during the treatment at which the patient is receptive to trying them out, we usually try to teach them to patients early on, during the first stage.
Mindfulness meditation is a particular type of meditation that helps patients calm themselves and regulate their emotions (Linehan, 1993). Rather than shutting down or becoming overwhelmed by emotions, the patient observes the emotions but does not act on them. The patient focuses on the present moment, attending to the sensory aspects of current experience. Patients are instructed to stay focused on mindfulness meditation until they are calm and can think through the situation rationally. This way, when they act, it will be in a thoughtful, rather than impulsive, way.
For example, the patient might practice using mindfulness meditation as a coping technique for self-soothing. When faced with an upsetting situation, she uses meditation as a tool to calm down enough to think through the situation. She focuses on the present moment, observes her emotions without acting on them, and watches her thoughts. Feeling upset is the cue that alerts the patient to do the meditation exercise.
The therapist encourages the patient to nurture her Abandoned Child by engaging in pleasurable activities. These vary from patient to patient, depending on what that person finds pleasurable. Some examples might include taking a bubble bath, buying oneself a small gift, getting a massage, or cuddling with a lover. These activities counter the patient’s feelings of deprivation and worthlessness. The therapist can assign them to patients as homework assignments.
Flash Cards. Flash cards are the single most helpful coping strategy for many of our patients with BPD. Patients carry these cards around with them and read them whenever they feel upset and one of their modes has been activated. The therapist composes the flash cards with the patient’s help. The cards can be in the therapist’s handwriting, or the patient can write them. Therapists usually compose different cards for different trigger situations—such as when the patient gets angry, a friend disappoints her, her boss is angry with her, or her partner needs some space apart from her. In addition, we have one or more cards for each of the four modes.
In order to help therapists compose flash cards, we provide a template (see Figure 3.1). What follows is a sample flash card, written using the template as a guide, for a patient to read when her therapist is away on vacation. The therapist personalizes the flash card for the individual patient.
Right now I feel scared and angry because my therapist is away on vacation. I feel like cutting or burning myself. However, I know that these feelings are my Abandoned Child mode, which I developed from having parents who were alcoholic and left me alone for long stretches of time. When I’m in this Abandoned Child mode, I usually exaggerate the degree to which people will never return and don’t really care about me.
Even though I believe that my therapist will not come back, will not want to see me again, or will die, the reality is that he will come back, will be safe, and will want to see me again. The evidence in my life supporting this healthy view includes the fact that every time he has gone away before, he has always come back, has always been fine, and has always still cared about me.
Therefore, even though I feel like hurting myself, instead I will do something good for myself. I will call the backup therapist; spend time with people who love me; or do something enjoyable (take a walk, call a friend, listen to music, play a game). In addition, I will listen to my relaxation tape in my therapist’s voice (or other transitional object) to help soothe me.
In addition to writing the flash card, the therapist can dictate it onto a tape that the patient can play at home. It can be helpful for the patient to hear the therapist’s voice. However, it is important also to put the flash card into the more portable written form. That way, patients can carry the flash card around with them and take it out to read whenever they have the need. Many patients report to us that, when they have flash cards with them, they feel as though they have a piece of their therapist with them.
The Schema Diary. The Schema Diary (see sample in Figure 3.2) is a more advanced technique because, unlike the flash card, it requires patients to generate their own coping response when they are upset. The cue for filling out the Schema Diary is that the patient feels upset and is unsure how to handle it. In some ways, it is similar to the Daily Record of Dysfunctional Thoughts in cognitive therapy (Young et al., 2001, p. 279). Filling out the form helps the patient think through a problem and generate a healthy response. The form provides a medium for the Healthy Adult mode. The patient generally relies more on the Schema Diary later in the therapy process.
It is important to provide patients with BPD with assertiveness training throughout the therapy so that they learn more acceptable ways to express their emotions and meet their needs. As we have noted, they especially need to improve their skills in expressing anger, because most tend to swing from extreme passivity to extreme aggression. Patients learn anger management in conjunction with assertiveness training: Anger management teaches patients self-control over their angry outbursts; assertiveness training teaches them appropriate ways to express anger. The therapist and patient role-play various situations in the patient’s life that call on assertiveness skills. Usually, the patient plays herself and the therapist plays the other characters in the situation, although any configuration can be helpful. Once the patient develops a healthy response, the therapist and patient rehearse it until the patient feels confident enough to carry it out in real life.
Before turning the patient’s attention to behavioral techniques in the session, the therapist gives the patient the opportunity to vent all her emotions about the upsetting situation and linked situations from childhood. Patients with BPD need to vent before they can apply behavioral strategies, or they will not have the ability to focus on appropriate assertiveness.
Therapists use the following basic guidelines when setting limits.
1. Limits are based on the patient’s safety and the therapist’s personal rights. When making decisions about limits, the two questions schema therapists ask themselves are: “Will the patient be safe?” and “Will I resent what I am agreeing to do?” (The therapist also inquires about the safety of others, although this is less often an issue with patients with BPD.)
The patient’s safety is the first consideration. The therapist has to do whatever is necessary to make sure the patient is safe, whether the therapist will resent it or not. If the patient is actually in danger (and if the therapist has already tried other strategies), the therapist must set some limit that provides safety. Even if the patient is calling in the middle of the night or during the therapist’s vacation, the therapist must take steps to save the patient (i.e., notify the police, then stay on the phone with the patient until they arrive).
However, if the patient is safe but asking the therapist to do something the therapist will resent doing, the therapist should not agree to do it. The therapist should express the refusal in a personal way, as we explain later.
2. Therapists should not start doing anything they cannot continue doing for the patient unless they expressly state that they will only continue doing it for a specified time period. For example, the therapist should not, as a matter of course, read long e-mails from the patient each day for the first 3 weeks of treatment and then abruptly announce that reading e-mails is now against the therapist’s policy and will have to stop.
However, if the patient is going through a crisis, the therapist might agree to check in with the patient each day until the crisis passes, explaining to the patient that this will continue for a limited period of time. For example, the therapist might say: “For the next week, I want to check in with you every evening for a few minutes while you’re going through this crisis.”
It is important that therapists determine their limits ahead of time and then adhere to them. In the heat of the moment, the therapist does better to have limits already in mind than to try to figure them out on the spot.
3. The therapist sets limits in a personal way. Rather than using impersonal explanations of limits (i.e., “It is the policy of our center to forbid suicidal behavior”), the therapist communicates in a personal manner (i.e., “For the sake of my peace of mind, I have to know that you’re safe”). The therapist uses self-disclosure of intentions and feelings whenever possible and avoids sounding punitive or rigid. The more the therapist gives personal reasons for limits, the more patients will accept them and try to abide by them. This policy is in line with our general stance of limited reparenting.
4. The therapist introduces a rule the first time the patient violates it. Unless the patient is extremely low functioning or hospitalized, therapists do not recite their limits ahead of time to patients, nor do they set up an explicit contract (except in unusual cases). Such a list or contract sounds too rigid and clinical in the context of limited reparenting. Rather, the therapist states and explains a limit the first time the patient oversteps it and does not impose any consequences until the next time the patient oversteps the limit. We explain this process in more detail later.
The therapist explains the rationale for imposing the limit and empathizes with the patient’s difficulty in keeping to the limit. The therapist uses personal self-disclosure to emphasize the importance of the limit, sharing feelings of concern or frustration. The therapist attempts to understand the cause of the limit violation and the relevant modes.
5. The therapist sets natural consequences for violating limits. Whenever possible, therapists set consequences for limit violations that follow naturally from what the patient did. For example, if the patient called the therapist more often than agreed on, then the therapist sets a period of time during which the patient cannot call. If the patient expresses anger inappropriately (for example, by shouting at the therapist) and will not desist, then the therapist leaves the office for a period of time or subtracts the time from a future session. If the patient is persistently self-destructive (for example, by abusing drugs), then the therapist insists that she take steps to ensure her safety, such as increasing her level of care.
Just knowing that the therapist is upset with the patient is usually a powerful deterrent. When the therapist says, “What you are doing upsets me,” or “I feel angry about what you’re doing,” many times this will be enough. When it is not, the therapist imposes other repercussions. For example, if the patient keeps paging the therapist saying she is suicidal, the therapist says, “If you keep calling me too much, we’ll have to agree on another procedure for you to follow if you become suicidal, such as going to an emergency room.”
When treating patients with BPD, we tend to enforce limits more strictly as therapy progresses. We are less strict at the beginning of therapy, before the patient has formed a strong attachment to the therapist. Generally, the stronger the attachment to the therapist, the greater the patient’s motivation to adhere to the limits the therapist has set.
The second time the limit is broken, the therapist expresses firm disapproval, follows through on the promised consequence, and explains the outcome the next time the limit is violated. This latter consequence should be more serious than the one following the patient’s first violation of the limit. If the violated limit is a serious one, it may be necessary to escalate the consequences quickly. The therapist must do what is necessary to keep the patient safe, including hospitalizing the patient. Once the therapist has ensured the patient’s safety, the therapist again explores the causes of the limits violation in terms of schemas and modes.
The third time the limit is broken, the therapist imposes even more serious consequences for the next violation, such as a temporary break in therapy for a defined length of time or temporary transfer to another therapist. The therapist might warn of permanent termination if the limit is violated a fourth time, with referral to another therapist.
There are four areas in which therapists frequently need to set limits for patients with BPD. In this section, we explain how the general guidelines listed here can be applied to each area.
Limiting Outside Contact. The first area is limiting outside therapist-patient contact. We believe that therapists who work with patients with BPD must, at times, be prepared to give patients extra time outside sessions. But how much? How do our guidelines clarify this issue?
Our first guideline states that, once therapists have ensured the patient’s safety, they should not agree to do anything for the patient that they will resent doing later. In other words, therapists should do what they feel comfortable doing: They should give patients as much outside contact as they can give without becoming angry. Patients can generally benefit from as much contact as therapists can give them—they are genuinely needy of a high degree of reparenting. The question therapists should ask themselves is, “How much am I willing to give to this patient without becoming resentful?” In order to answer this question, therapists must know themselves well. Limits concerning outside contact are a personal matter and vary from therapist to therapist. For example, some therapists allow patients to leave messages on their answering machines whenever they are upset. As long as patients do not abuse the privilege by frequently leaving extremely long messages, these therapists are comfortable. Other therapists would not be comfortable with this arrangement, and therefore should not agree to it.
Therapists should not initiate or permit any form of outside contact that they are not going to be able to continue giving indefinitely except for a circumscribed, explicit period of time. For example, the therapist should not begin speaking to the patient every night on the phone and then suddenly tell the patient that talking on the phone every night is too much and has to stop. If the therapist feels the need to check in with the patient frequently, then the therapist can institute this procedure for a preset period of time, such as a day or a week.
Therapists should tell patients about their limits when patients first overstep them, and they should do so in a personal way. For example, a patient may initiate more phone contact than the therapist feels comfortable giving. The therapist speaks in terms of personal feelings rather than professional rules, saying something such as:
“If you want one extra 10-minute phone contact a week besides our sessions, I’m comfortable with that. That’s fine with me, and I’ll be glad to speak with you. But now you’ve been calling two or three times a week, and I’m not comfortable with that. I feel like it’s too much for me, given my other commitments, and I don’t want to start resenting you.”
If possible, the therapist should set the limit in person, rather than on the phone, at the next session.
The therapist imposes natural consequences when patients violate limits. The therapist does so with empathic confrontation. As an example, consider the following scenario: a patient with BPD pages her therapist three times in one week for nonemergency situations (e.g., her boyfriend is late for a date). The therapist has asked the patient to use the pager only in cases of emergency. Before setting a consequence, the therapist empathizes with the feelings the patient must have had during the week to have used the pager so often. The therapist says, “You’ve been paging me a lot in the past week, and I know it’s because you feel like you’re in crisis, and there are a lot of upsetting things happening to you.”
Next, the therapist explains in a personal way what is wrong with the patient’s behavior:
“Even though I care about you, it was too stressful for me this past week to get paged so often. It was making me annoyed with you, and I don’t want to feel that way. If you keep paging me too often [here the therapist specifies the acceptable amount], I’m going to stop answering your pages, and we’re going to have to set up another way for you to handle emergencies, such as going to the emergency room. I don’t want this to happen. I want to be the one who’s there for you in an emergency. Can you understand how I’m feeling?”
Patients with BPD are usually empathic and can understand the therapist’s point of view when it is presented in a personal manner. The therapist helps the patient find a replacement for the problematic behavior: “Are there any other arrangements we could make to help you when you’re in crisis, such as leaving me a message on my answering machine or calling a crisis hot line?”
In addition to setting a limit and modeling appropriate assertion, the therapist is conveying to the patient a lesson about the nature of anger. This helps the patient understand her own pattern—that her own unexpressed anger builds until she flips into the Angry Child mode—and how to overcome the pattern by addressing sources of annoyance assertively, before they have a chance to build to anger.
Contacting the Therapist When Suicidal or Parasuicidal. The therapist asks patients to agree that they will not make a suicide attempt without contacting the therapist first. This agreement is a condition of therapy. The therapist brings up the condition the first time patients say that they are suicidal or have been suicidal in the past. Patients must agree to the rule if they want to continue therapy. Patients with BPD can express the wish to commit suicide as much as they need to do in therapy sessions, but they cannot act on this wish: Patients must speak to the therapist directly before they act, so that the therapist has an opportunity stop them.
We have found that requiring patients with BPD to agree that they will not commit suicide does not work, because they experience suicide attempts as beyond their control and often cannot bear to give up the coping mechanism of preserving suicide as a backup. Thus many patients with BPD refuse to agree not to commit suicide. Rather than exclude them from treatment, we modified the requirement, asking these patients to agree to call and reach the therapist before making an attempt. Patients with BPD tend to see this requirement as caring and agree to it readily.
The therapist provides the patient with a home phone number or personal pager number for emergency access. We believe that therapists who treat patients with BPD should be willing to offer this kind of access as a vital component of the limited-reparenting relationship. A “surrogate,” such as a colleague or doctor-on-call, is not an adequate replacement, except when the therapist is unreachable; in that case, the therapist provides someone else for the patient to access instead. The therapist explains that home or pager access is for life-or-death emergencies only and sets limits if the rule is violated.
Following Specific Rules When Suicidal or Parasuicidal. In order to continue in therapy, patients must agree not only to contact the therapist before attempting suicide but also to follow the hierarchy of rules that the therapist sets down for dealing with suicidal crises. We discuss what these rules are in the section, “Handling Suicidal Crises.” The point we want to make here is that the therapist sets the following limit: Whenever the patient is suicidal, the patient must agree to follow a specific sequence of steps. It is up to the therapist, not the patient, to determine what these steps are. The therapist is the ultimate authority about what steps the patient must take in order to be safe.
The therapist brings up the limit the first time the patient expresses suicidal ideation. If the patient refuses to adhere to the limit, even after being warned, the therapist sees the patient through the current suicidal crisis and then terminates with the patient. The therapist warns the patient in advance that this is what will happen if the patient refuses to adhere to the limit and gives the patient a chance to reconsider and follow the limit. The therapist says: “I respect your rights, and you have to respect mine. I can’t live my life with you as my patient knowing that, when you become suicidal, you won’t follow the rules I think you must follow in order to be safe. It’s just too anxiety-provoking for me, and I can’t work that way.”
Limiting Impulsive Self-Destructive Behaviors. Patients with BPD can become so inundated with unbearable affect that impulsive, self-destructive behaviors such as cutting themselves or abusing drugs seem the only viable forms of release. Teaching patients coping skills, such as those we described previously, can help these patients learn to tolerate distress, but sometimes they become too overwhelmed to benefit from their coping skills. Until the reparenting bond is firmly established, the therapist will probably not be able to get the patient to completely stop all self-destructive behaviors. The therapist attempts to set firm limits but realizes that, at the beginning of therapy, it will be necessary to tolerate some of these behaviors because the patient is not stable enough to stop doing them completely. The therapist expects, though, that within approximately 6 months of therapy, the patient will no longer be exhibiting these behaviors with significant frequency.
Once patients with BPD connect to the therapist as a stable, nurturing base, and once they are able to express anger toward the therapist and others directly during sessions, then the impulsive self-destructive behaviors tend to reduce significantly in all but the most extreme environmental circumstances, such as the loss of a long-term relationship.
This behavior can derive from any of the four schema modes, although the Angry and Impulsive Child mode may be the most common. Many of these behaviors occur because the patient is angry at someone and cannot express it directly. The patient’s anger builds, eventually coming out in the form of impulsive self-destructive behaviors. Other impulsive behaviors come from the Abandoned Child, Punitive Parent, or Detached Protector modes. As we have noted, when patients with BPD cut themselves, they may be in the Abandoned Child mode and attempting to use physical pain as a distraction from emotional pain; or they may be in the Punitive Parent mode and punishing themselves; or they may be in the Detached Protector mode and trying to break through the numbness to feel that they exist. The therapist sets limits in accordance with which mode is generating the self-destructive behavior.
The therapist does not tolerate any destructive behaviors toward others. If the patient is a threat to other people, then the therapist sets the following limit: If the patient does anything that is in any way abusive or destructive to other people, such as hitting, stalking, or sexual abuse, then the therapist will have to notify the endangered person and/or call the police, depending on the severity of the behavior. The therapist says something such as, “If I know that you’re about to harm someone, I must step in to stop you. I will not let you abuse or hurt other people.”
Limiting Absences and Breaks. The therapist does not allow patients with BPD to miss sessions habitually. Missed sessions are primarily an expression of the Detached Protector mode. For example, if a patient flips into a mode that distresses her during a session—such as the Abandoned Child or the Angry Child—she might miss the next session in order to avoid a recurrence. Alternatively, if a patient is angry at her therapist and afraid of flipping into the Angry Child mode, she might miss a session. Therapy cannot proceed this way, because the therapist needs to work with patients when they are actively in these modes in order to make progress. Patients must agree to come to therapy sessions regularly and only to miss sessions in extreme situations (e.g., illness, the funeral of someone close to them, a snowstorm shutting down the city).
If patients persist in missing sessions, the therapist imposes a consequence for missing any more sessions. For example, the therapist might say: “If you miss another session, I’m going to discontinue contact with you outside of our sessions for a week,” “If you miss again, we’re going to have to take a break from therapy for a week,” or, “If you miss a session, the entire next session will be focused only on why you missed it.”
The therapist imposes the limit in a way that sounds caring rather than punitive. The therapist says, “I’m not doing this to punish you or because I think you’re ‘bad.’ I’m doing it because the only way I can help you is if you come to our sessions, even when you’re upset. If you don’t come to our sessions, I can’t help you. So I have to impose a limit on you to get you to come even when you really don’t want to be here.”
Their noncompliance of patients with BPD is usually not part of the Abandoned Child mode. The exception is contacting the therapist too frequently because the patient feels separation anxiety. The Abandoned Child is dependent on the therapist and relies on the therapist for guidance and therefore is likely to be compliant. The noncompliance usually comes from one of the other modes—the Detached Protector, the Punitive Parent, or the Angry and Impulsive Child. In order to overcome the patient’s non-compliance, the therapist works with these modes until the patient abides by the limits.
For example, the therapist might ask the patient to conduct a dialogue between the noncompliant mode (such as the Detached Protector) and the Healthy Adult. The therapist might ask the Angry Child to vent anger at the therapist about the limit, then empathize and reality-test. The therapist might ask the patient to enact each mode in turn, expressing feelings about the limit.
Ultimately, the therapist’s ability to set limits rests on the strength of the reparenting bond. This bond is the therapist’s leverage in persuading patients to follow the rules. The patient usually agrees to follow rules out of respect for the therapist’s feelings, even if she cannot always comprehend the reason for the rules.
Therapists follow a hierarchy of steps whenever a borderline patient is suicidal or parasuicidal.
This is the first step and very important; usually therapist contact is the most effective antidote to the patient’s suicidality If the therapist checks in with the patient a few minutes each day until the crisis has passed, it is often sufficient. The suicidal crisis passes, and the therapist does not have to go any higher on the hierarchy.
The therapist assesses which mode is generating the patient’s suicidality and uses the strategies appropriate to that mode. If it is the Abandoned Child mode, the therapist nurtures and protects the patient. If it is the Angry Child, the therapist allows the patient to vent, empathizes, then reality tests. If it is the Punitive Parent, the therapist defends the patient and fights the punitive voice. When the Punitive Parent is generating the urge, then the therapist sets limits on parasuicidal behavior as well, as the patient might resort to parasuicidal behavior in order to numb herself.
When a patient is in a suicidal crisis, the therapist assesses suicidality each time he or she talks to the patient. The therapist says, “What is the actual risk that you are going to hurt yourself between now and the next time we talk?” The therapist can ask the patient to rate the risk on a scale of “high,” “medium,” and “low.” If the level of suicidality is high, then the therapist goes to the next step on the hierarchy, which is obtaining permission to contact significant others.
The therapist says,
“We only have a few options right now, because you are so acutely suicidal. Either you have to go to a hospital, or we have to find someone who can stay with you, a friend or family member who will watch over you and keep you company until the crisis has passed. Is there anybody you can stay with temporarily or who can stay with you? If you do not want to go into the hospital, then you’re going to have to let me talk to somebody close to you, because I don’t feel secure that you can go from now until our next contact without hurting yourself.”
(Note: The family of origin should be used only as a last resort if the family environment was what largely formed the patient’s schemas.)
Concurrently, the therapist arranges a consultation with a cotherapist. This person shares the burden of the patient’s suicidality, so that the therapist does not have to carry it alone, and helps ensure that the therapist handles the suicidality optimally. The therapist shares the patient with the cotherapist, who serves as a backup to the principal therapist. If the patient cannot reach the principal therapist, or if the patient and therapist are having a conflict that they cannot resolve themselves, then the cotherapist can intercede. Therapists who treat patients with BPD can work together and support one another by serving as cotherapists for each other.
If the therapist is not a psychiatrist, the therapist arranges a consultation with a psychiatrist. The psychiatrist can handle issues of medication and hospitalization. Many patients with BPD respond well to psychotropic medication. Medication can significantly reduce their terror and pain and allow them to function at higher levels.
The therapist considers adjunctive treatments that might provide the patient with additional support. Some examples include: day hospitals, group therapy, telephone crisis lines, incest survivor support groups, and 12-Step groups.
Both the intensity and frequency of suicidal crises determine whether patients require hospitalization. If a patient is extremely suicidal, or suicidal too much of the time, then the patient requires hospitalization. The therapist says, “If you’re chronically in a life-or-death situation, then you should be in the hospital where you’ll be safe.”
If the patient refuses to go into the hospital and suicide seems imminent, then the therapist hospitalizes the patient involuntarily. The therapist does whatever is necessary to keep the patient alive, including calling the police to take her against her will. The therapist says, “If you refuse to go into the hospital voluntarily, then I will have no choice but to hospitalize you involuntarily. I want you to know that, if I have to do that, I will no longer be your therapist when you come out.” The therapist imposes a consequence for the patient’s refusal to cooperate and gives her a chance to relent: “If you go to the hospital voluntarily, I’ll remain your therapist, and I’ll resume treatment with you when you come out of the hospital. If you will not go voluntarily, I will have to arrange for an involuntary admission. I cannot be your therapist if you will not accept my limits.”
Working through traumatic childhood memories is the last and most difficult stage of the experiential work. With the therapist acting as guide, the patient recalls and relives traumatic memories of abuse or abandonment in imagery (or other traumatic memories).
The therapist does not begin traumatic imagery work until certain conditions are met. The first is that the patient is stable and functioning at a high enough level to withstand the process without becoming overwhelmed or suicidal. The therapist and patient can decide together whether the patient is ready. Second, the therapist does not begin traumatic imagery work until the therapist and patient have discussed the patient’s trauma at length in earlier sessions. In other words, the therapist and patient work through the trauma on a cognitive level before attempting the experiential work. Third, we believe that therapists should obtain advanced training in working with trauma before applying imagery techniques to traumatic material.
The defining characteristics of trauma are fear, helplessness, and horror (DSM-IV; American Psychiatric Association, 1994). The emotions connected with traumatic memories are not ordinary emotions, but extreme ones. They overwhelm the ordinary human capacity to endure emotion. Trauma that is human-made, occurs early in life, and is repeated over an extended period of time is especially devastating, characteristics that are unfortunately often true of childhood abuse and neglect.
The therapist helps the patient contain the emotions associated with the trauma within the context of the therapeutic relationship, so that the patient does not have to experience them alone. Ultimately it is the security of the therapist-patient bond that enables the patient to bear the emotions and live through the trauma again. The therapist-patient bond counteracts the meaning the patient has typically attributed to the original trauma: that she is worthless, helpless, and alone. In contrast, the therapy bond allows the patient to feel valued, sheltered, and connected to other human beings, despite the traumatic experience.
Because memories of abuse can evoke painful emotions, it is important to give patients a convincing rationale for reliving them. Without the context of a good rationale, reliving the abuse in imagery can be retraumatizing rather than healing. It can hurt rather than help the patient.
The therapist presents the rationale in the form of “empathic reality-testing.” The therapist empathizes with the patient’s pain in remembering the abuse, expresses understanding of her wish to avoid it, but confronts the reality of the situation. The more the patient avoids remembering the abuse, the more the abuse will dominate the patient’s life; whereas the more the patient processes the abuse, the less power the abuse will have over her life. As long as the patient continues to dissociate the memories, the memories will continue to overwhelm the patient’s life in the form of symptoms and self-destructive behaviors; whereas if the patient can recall and integrate the memories, the patient will eventually become free of symptoms.
The therapist explains the purpose of reliving the abuse. The patient will first experience the emotions and memories of the trauma without blocking them; and then, with the therapist’s help, she will fight back against the abuser. This will help the patient feel empowered in the future, both against the abuser and against any other individual who attempts to abuse her. It will also weaken the trauma’s hold on her life as she explores what happened and gives it a new meaning in her life. If the patient can create something “good” out of the abuse, then she can feel victorious over it.
The therapist reassures the patient of the therapist’s steady presence during the imagery. The therapist says, “I’ll be here with you. I’ll help you bear the painful feelings.” The goal is to get to the point at which the memories of abuse are no longer so devastating to the patient.
Once the patient has understood and accepted the rationale, the therapist is ready to begin the imagery. In order to increase the patient’s sense of control, the therapist begins by explaining what is going to happen. The therapist says,
“I’m going to ask you to close your eyes and picture an image of the abuse (or abandonment) you told me about earlier. When the image comes, I want you to tell me what’s happening in as much detail as you can. Talk in the present tense, as though it’s happening right now. If you become frightened and want to run away from the image, I’ll help you to stay with it, but, if you want to stop at any time, raise your hand, and we’ll stop. Afterward, I’ll help you to make the transition back from the imagery to the present moment, so that we can talk about what happened in the image. We can talk about it for as long as you like.”
The therapist asks if the patient has any questions.
In working with traumatic memories, the therapist conducts very short imagery exercises and often allows a couple of weeks to pass before resuming the procedure. During this time, the therapist and patient discuss the imagery thoroughly. The process is one of gradual exposure, not flooding. Patients are often reluctant to engage fully in traumatic imagery, especially the most harrowing parts. The therapist helps the patient by approaching the feared images gradually.
The first time the patient describes the image, the therapist says very little, speaking only when the patient becomes stuck in order to encourage the patient to go on. Otherwise, the therapist remains quiet and listens. Over successive imagery sessions, the therapist gradually becomes more active. When patients start to block images, the therapist helps them persist. When patients relive memories, the therapist helps them experience the memories vividly. The aim is increasing the patient’s emotional involvement with the imagery. The therapist slows the action down by asking questions and encourages the patient to put more of the story into words. What is the patient seeing, hearing, touching, tasting, smelling? What are the patient’s bodily sensations? What is the patient thinking? What are all the patient’s feelings? Can the patient express all her feelings aloud?
When dealing with traumatic memories, often the patient is able to generate only disconnected images of what happened. She is able to get only “flashes” of images or is unable to see the whole image. Most survivors of child abuse have certain moments they cannot bear to remember. As they approach these moments in the imagery, the narrative breaks down. They may see only a series of frozen images. Often when they remember these moments, they are flooded with emotion. They may shake in fear, experience waves of nausea, raise their hands to ward off the images, or turn their heads away. The therapist helps patients assemble these fragments into a coherent narrative that integrates most of the traumatic images. The goal is that, by the end, as little of the memory will remain dissociated as possible. The therapist must be especially careful not to “suggest” elements of the memory and thus create a “false memory.” (This issue was discussed more fully in Chapter 4, “Experiential Strategies.”)
The therapist encourages patients to do or say things in the image that they could not in their childhood, such as fighting back against the abuser. The therapist enters the image in order to help the patient. In our opinion, fighting back against the abuser in imagery is central to the treatment of childhood abuse. Until the patient can fight back against the abuser—and thus against her own Punitive Parent mode—she will not be able to heal from the abuse. We allow patients to fight back in any way they choose, including aggressive behaviors, with one important exception. We do not help patients elaborate fantasy images of committing violence if they have a history of violent behavior.
After ending an imagery exercise, the therapist leads the patient through some kind of relaxation procedure. This could be any of the self-soothing skills the patient has learned thus far in treatment, such as mindfulness meditation, progressive muscle relaxation, safe-place imagery, or positive suggestions. The therapist continues the relaxation procedure until the patient is calm. Once the patient is calm, the therapist takes a few moments to ground the patient in the present moment. The therapist draws the patient’s attention to the immediate surroundings; for example, the therapist asks the patient to look at something in the office, gives the patient a drink of water, or talks quietly with the patient about mundane matters.
Once the patient is calm, the therapist thoroughly discusses the imagery session with the patient. The therapist encourages the patient to fully express all of her reactions to reliving the abuse and praises the patient for having the strength to endure it. The therapist is careful to leave enough time for the patient to recover (at least 20 minutes). The therapist does not let the patient leave the session extremely upset about the imagery work. If necessary, the therapist allows the patient to remain in the waiting room after the session or asks the patient to call later in the day or evening to check in.
As treatment progresses, the therapist fosters generalization from the therapy relationship to appropriate significant others outside of therapy. The therapist helps the patient select stable partners and friends and then encourages the patient to develop genuine intimacy with them.
When the patient resists engaging in this process, the therapist responds with empathic confrontation: The therapist expresses understanding of how difficult it is for the patient to risk intimacy but acknowledges that only through such measured risks will the patient experience meaningful intimate relationships with others. When the patient avoids intimacy, the therapist conducts mode work with the avoidant part of the patient; the therapist makes the “resistant” part a character in the patient’s imagery and then carries on dialogues with that mode. The therapist also empathically confronts self-defeating social behaviors, such as clinging, withdrawal, and excessive anger.
In addition, once the patient has stabilized, the therapist helps her individuate by discovering her “natural inclinations.” She learns to act on the basis of her genuine needs and emotions rather than in order to please others. In Dr. Young’s interview with Kate, she poignantly expressed the importance of this part of treatment:
KATE: I can say I have a strong conviction or I feel really strongly about something, but, in the next minute, it’s just gone. It’s weird, but a couple of months ago I figured out what my favorite color was, and I was so excited (laughs). Because I had a favorite color. And it was something that I actually pointed to.
THERAPIST: And you knew it was you.
KATE: Yes. (Cries.) I was 27 years old and that was it. This is the color that I really like, not because somebody says it’s the color I should like, or somebody that I want to be like likes it, it’s just—to me—it’s very pleasing. So I was real proud of myself (laughs).
THERAPIST: That’s wonderful. So you were able to find the part of yourself that’s real, as opposed to the part that’s trying to be what everyone else wants you to be.
THERAPIST: And that’s something you haven’t been able to do for much of your life.
KATE: And it’s funny, but, whenever I see that color, I just want to hang on to it, because it’s something that I know that I like and it’s important to me. Because there are so few things that I know that I like and that I want.
The final step is for the therapist to encourage gradual independence from therapy by slowly reducing the frequency of sessions. As we have noted, we have found that, in most cases, successfully treated patients with BPD never completely terminate. Even if long periods pass between contacts, most of these patients eventually call the therapist again. The patient views the therapist as a substitute parent and continues to maintain contact.
Because their modes are continually shifting, patients with BPD do not have a stable internal image of the therapist. Instead, their image of the therapist shifts along with their modes. In the Abandoned Child mode, the therapist is an idealized nurturer who might suddenly disappear or who might engulf the patient. In the Angry Child mode, the therapist is a devalued depriver. In the Punitive Parent mode, the therapist is a hostile critic. In the Detached Protector mode, the therapist is a distant, remote figure. The patient’s perceptions of the therapist are thus perpetually changing. These shifts can be highly disconcerting for the therapist. Therapists who are the object of these shifting appraisals are prone to a variety of intense countertransference reactions, including guilt feelings, rescue fantasies, angry desires to retaliate, boundary transgressions, and profound feelings of helplessness.
We briefly list some of the dangers that therapists most often face when treating patients with BPD. The dangers are tied to the therapist’s own particular schemas and coping styles.
Therapists who have Subjugation schemas and who use surrender or avoidance as coping styles face the danger of becoming too passive with their patients. They may avoid confrontation and fail to set appropriate limits. The consequences can be negative for both the therapist and the patient: The therapist becomes increasingly angry over time, and the patient feels increasingly anxious about the lack of limits and may engage in impulsive or self-destructive behavior.
Therapists who have Subjugation schemas must make conscious and determined efforts to confront patients whenever it is indicated—through empathic confrontation—and to set and enforce appropriate limits.
A danger for therapists with Self-Sacrifice schemas (and almost all therapists have this schema, in our experience) is that they permit too much outside contact with patients and then become resentful. Underlying most therapists’ Self-Sacrifice is an underlying sense of Emotional Deprivation—many therapists give to patients what they wish they had been given themselves as children. The therapist gives too much, resentment builds, and eventually the therapist withdraws or punishes the patient.
The best way for therapists with this schema to manage the situation is to know their own limits ahead of time and to adhere to them faithfully.
Therapists with any of these schemas risk feeling inadequate when the patient with BPD fails to progress, relapses, or criticizes the therapist. It is important for therapists with these schemas to remember that the course of treatment with a patient with BPD is characterized by discouraging periods, relapses, and conflicts, even under the best of circumstances with the best of therapists. Having a cotherapist and good supervision can help therapists maintain a clear vision of what is realistic to achieve in what time period.
This pitfall is extremely dangerous and can destroy the therapy relationship. If the therapist tends to be a schema overcompensator—that is, tends to counterattack—then the therapist may become angry and blame or punish the patient. Therapists who tend to be schema overcompensators are at high risk for damaging patients with BPD rather than helping them and should be closely supervised when they treat these patients.
Therapists who are schema avoiders may inadvertently discourage the patient’s expression of intense needs and emotions. When the patient expresses strong affect, these therapists feel uncomfortable and withdraw or otherwise express dismay. Patients with BPD often detect these reactions and misinterpret them as rejections or criticisms. Therapists sometimes encourage termination prematurely to avoid the intense affect of these patients.
In order to be an effective therapist for patients with BPD, schema avoiders must learn to tolerate their own and their patients’ emotions.
Therapists who have the Emotional Inhibition schema often come across to patients with BPD as aloof, rigid, or impersonal. This is a serious danger. Therapists who are extremely emotionally inhibited may cause harm to patients with BPD and probably should not work with them. The patient with BPD needs to be nurtured and reparented. An outwardly cold therapist is probably not going to be able to give the patient the nurturing she needs in a manner that she can recognize and accept.
If the therapist chooses to try to heal the schema, there is the possibility of overcoming the emotional inhibition through therapy.