Schema Therapy for Borderline Personality Disorder. Hannie van Genderen
Jeffrey Young for what they taught our team in their workshops. Jeffrey Young in particular deserves my thanks, as he developed a model that not only matched with my own early thinking about borderline personality disorder, but also developed a comprehensive treatment, which is the subject of this book. My therapist and research colleagues, among whom are my former PhD candidates Laura Dreessen, Anoek Weertman, Simkje Sieswerda, Joos Bloo, Thea van Asselt, Marjon Nadort, Lotte Bamelis and Jill Lobbestael, I also want to thank for the help they provided with developing the treatments and the research into borderline personality disorder. Moreover, I would like to thank the research assistants and interns who have conducted many studies, and especially the patients who have taken part in the treatment and the research, without whom we could not have gained insight into these complex problems and their treatment.
Ultimately, this book could not have come about without the opportunities offered by the Maastricht Community Mental Health Centre to the academic project of the Research Institute of Experimental Psychopathology of the Maastricht University, as well as the grants from the Dutch National Fund for Mental Health and the Fund for Developmental Medicine by the College for Care Insurances. Their grants enabled the training of the therapists for the multi‐center trial into treatments of borderline personality disorder and the conducting of this study, which empirically tested the effectiveness and cost‐effectiveness of the treatment outlined in this book.
Thanks are due to Kyra Sendt and Jolijn Drost for their help with translating the original Dutch book into the first English edition.
Arnoud Arntz
Introduction
Until recently, patients with borderline personality disorder (BPD) were known as particularly difficult patients. They were viewed as patients who either could not be helped by therapy or, in the best‐case scenario, showed low success rates to treatment. Meanwhile, their demands on both medical and mental health care are great and their dropout rates from treatment programs are high.
In this book we describe a treatment for patients with BPD, which, in most cases, leads to recovery from this disorder or substantial clinical improvement. Schema therapy (ST) not only leads to a reduction in BPD symptoms, but also to lasting changes in the patient's personality.
In Chapter 1, BPD is defined and described, followed by a discussion of the development of this disorder.
Chapter 2 gives an explanation of ST for BPD, developed by Jeffrey Young. The treatment is based on the schema mode model. The different schema modes for patients with BPD are described in this chapter.
In Chapter 3 we explain the aims and different phases of the therapy.
Chapters 4–8 discuss different treatment methods and techniques. Chapter 4 involves seeing the therapeutic relationship as an instrument of change. Also the essential concept of “limited reparenting,” a central point of ST, is discussed at length.
Chapter 5 describes experiential techniques that use experiencing to bring about change. These techniques are: imagery rescripting; role playing; the two‐or‐more‐chair technique; and experiencing and expressing feelings.
The cognitive techniques used in this book are described and explained in Chapter 6. As there is a great deal of literature about these techniques, they are only briefly defined. This is also the case for the behavioral techniques described in Chapter 7.
Chapter 8 deals with a number of specific therapeutic methods and techniques. While these are not relevant for all BPD patients, they can be important and useful for specific patients and applications.
Chapter 9 explains which techniques are the most appropriate to each schema mode. The art of addressing different modes in a single session is also discussed in this chapter.
The latest developments in the field of ST are explained in Chapter 10. In particular, Group‐ST, and ST with couples where one of the two partners has BPD, are discussed. We also briefly discuss the application of ST in day treatment and inpatient settings, the use of nonverbal therapies as adjunct to ST, and the application of ST for children and youths, and older people.
Chapter 11 deals with the final phase of therapy during which the patient no longer has BPD, but perhaps retains some of the personality characteristics and/or coping strategies, which could stand in the way of further positive changes.
Chapter 12 contains the summary and conclusion.
Considering that a large percentage of BPD patients are female, the authors refer to the patient in the feminine form. Although many therapists are female, for the sake of clarity the authors refer to the therapist using the masculine form.
1 Borderline Personality Disorder
What Is Borderline Personality Disorder?
Patients with borderline personality disorder (BPD) have problems with almost every aspect of their lives. They have problems with constantly changing moods, their relationships with others, unclear identities, and impulsive behaviors. Outbursts of rage and crises are commonplace. Despite the fact that many BPD patients are intelligent and creative, they seldom succeed in developing their talents. Often their education is incomplete, and they remain unemployed. If they work, it is often at a level far below their capabilities. They are at a great risk of self‐harm by means of self‐injury and/or substance abuse. The suicide risk is high and approximately 10% die as a result of a suicide attempt (Paris, 1993).
In this book, the DSM‐5 diagnostic criteria for BPD are used for the diagnosis of BPD and not the psychoanalytical definition of the borderline personality organization (Kernberg, 1976, 1996; Kernberg, Selzer, Koenigsberg, Carr, & Applebaum, 1989). The borderline personality organization includes a number of personality disorders and axis‐I disorders and is therefore far too extensive for the specific treatment for BPD that will be described here. According to the DSM‐5, patients must satisfy at least five of the nine criteria, as listed in Table 1.1, to obtain a diagnosis of BPD. The essential general feature of the DSM‐5 definition of BPD is instability and its influence on the areas of interpersonal relationships, self‐image, feelings, and impulsiveness.
Table 1.1 DSM‐5 diagnostic criteria for borderline personality disorder
Source: After: American Psychiatric Association (APA, 2013) DSM‐5.
| A pervasive pattern of instability of interpersonal relationships, self‐image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: |
|
Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self‐mutilating behavior covered in criterion 5.)A pattern of unstable and intense interpersonal relationships |