1	Schema Therapy for Borderline Personality Disorder
2	Conceptual Model And Overview
3	Schema Modes in the Borderline “Schema Flipping” The Abandoned Child The Angry & Impulsive Child The Punitive Parent The Detached Protector The Healthy Adult
4	Detached Protector Mode: Overview Function: Cuts off needs & feelings; detaches from people Signs & Symptoms: Depersonalization, emptiness, boredom, substance abuse, binging, self-mutilation, psychosomatic complaints
5	Abandoned Child Mode: Overview Helpless to get needs met or find protection Signs & Symptoms: Depressed, hopeless, needy, frightened, victimized, worthless, unloved, lost, frantic efforts to avoid abandonment, idealized view of nurturers
6	Punitive Parent Mode: Overview Function : Punishes the child for expressing needs and feelings, or for making mistakes Signs & Symptoms: Self-hatred, self-criticism, self-denial, self-mutilation, anger at self for neediness
7	Angry & Impulsive Child: Overview Function: Acts impulsively to get needs met or vents feelings in inappropriate ways Signs & Symptoms: Intensely angry, impulsive, demanding, devaluing, “manipulative,” controlling, abusive, suicidal threats, promiscuity
8	Hypothesized Origins Family Environment UNSAFE : Physically, sexually, verbally abusive; threat of explosive anger or violence DEPRIVING: Absent or inconsistent parental nurturing and empathy HARSHLY PUNITIVE: Critical, rejecting SUBJUGATING: Suppresses individual needs & feelings of child Biological High emotional intensity & lability
9	Concept of Limited Reparenting
10	Borderline Treatment: Overall Objectives Help patient to incorporate the Healthy Adult mode, modeled after the therapist, to: Empathize with and protect the Abandoned Child Help the Abandoned Child to give and receive love Fight against, and expunge, the Punitive Parent Re-channel the Angry & Impulsive Child to express emotions & needs appropriately; reaffirm child’s basic rights Reassure, and gradually replace, the Detached Protector
11	Philosophy of Treatment View as vulnerable child Genuinely needy, not greedy Therapist has rights too Don’t blame when frustrated Parallels child development Mutual respect & genuineness
12	Three Stages of Treatment Bonding and Emotional Regulation Schema Mode Change Autonomy
13	Schema Therapy for Borderline Personality Disorder: Treatment Protocol
14	Stage I: Bonding & Emotional Regulation Bonding with the Patient Bypassing the Detached Protector Healing the Abandoned Child Teaching Affect Regulation & Coping Skills
15	Bonding and Socialization to Therapy Empathize with current problems Convey warmth and nurturance Ask about previous therapy experiences and desirable attributes in a therapist Ask about personal reactions to you as a person Outline therapy goals Discuss life history, including childhood (YPI) Explain schema modes
16	Bypassing the Detached Protector (1) Label the Detached Protector mode. Help patient to feel Detached Protector and recognize cues Explain development of mode in childhood and empathize with its adaptive value Review pros and cons of detaching in the present, as an adult Practice dialogues (two-chair technique) between Detached Protector and Healthy Adult
17	Bypassing the Detached Protector (2) Ask patient to close eyes and picture Little [Judy] as a child. "What does she look like? How does she feel right now?“ Continue with other experiential work described below, depending on which modes emerge in image. Bring therapist into image as Healthy Adult to demonstrate adaptive responses to each mode
18	Healing the Abandoned Child Through Limited Reparenting Validation of needs and feelings Nurturing, stable base Confidence-building through praise Reciprocity & self-disclosure
19	Affect Regulation & Coping Skills Affect Regulation & Distress Tolerance Skills Mindfulness Meditation Schema Diary Flashcards Assertiveness Training Pleasurable Activities
20	Stage II: Schema Mode Change Combating the Punitive Parent Rechanneling the Angry & Impulsive Child Setting Limits Handling Crises
21	Combating the Punitive Parent Educate about universal needs & feelings Reattribute childhood rejection to parents’ issues Reattribute adult failings to schemas, not self Highlight successes and positive qualities Fight the Punitive Parent through imagery and dialogues
22	Re-Channeling the Angry & Impulsive Child Through the Therapy Relationship Set limits when abusive or destructive Ventilate fully Empathize with underlying schemas Reality-test : realistic vs. exaggerated Share personal reactions to anger Practice appropriate assertion
23	Setting Limits (1) Limit outside contact (Abandoned Child) Limit impulsive, destructive behavior (Angry & Impulsive Child) Limit absences and breaks (Detached Protector) Contact therapist when suicidal and follow therapist’s instructions during crises (Any of the 4 modes)
24	Setting Limits (2) Base on patient safety and therapist’s personal rights (Will patients be safe? Will therapist resent it?) Communicate in personal manner, not punitively or rigidly If limits are violated, follow specific steps in applying consequences (see outline) Terminate treatment as a last resort
25	Handling Suicidal Crises Establish limit that patient must follow therapist’s instructions during suicidal crises, or therapy will be terminated after crisis Increase frequency of contact with patient Determine which mode patient is in; initiate strategies appropriate for the mode Assess suicidality at each contact Consider other steps, such as consultation, medication, group treatment, and contacting significant others Arrange voluntary hospitalization, if necessary
26	Therapist Pitfalls Doesn’t enforce limits; avoids confrontation; passive (Subjugation) Offers patient too much outside time (Self-Sacrifice) Feels inadequate (Unrelenting Standards, Failure) Becomes angry, resentful (Overcompensation) Encourages termination prematurely (Avoidance) Discourages intense needs & emotions (Avoidance) Aloof, rigid, impersonal (Emotional Inhibition)
27	Autonomy Stage Developing healthy relationships Individuation: Following natural inclinations Gradual “Termination” Contact after termination