SCHEMA THERAPY FOR

BORDERLINE PERSONALITY
DISORDER

Clark Sim
Clinical Psychologist

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 OUTLINE

 Borderline Personality Disorder (BPD)

 Beliefs about Self
 Why Schema Therapy?
 Schema Therapy components and process
 Questions / Comments / Sharing

Acknowledgement and praise for role of BPD supporter

Message to you:
Listen and engage intently, although I don’t really care whether you listen or not
I am excited and happy, although annoyed and certainly rather be elsewhere
You are the only audience that really seems to understand, although you just don’t
seem to get it
I love you and hate you

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 BPD – DIAGNOSTIC CRITERIA / SYMPTOMS

1.Frantic efforts to avoid real or imagined abandonment

2. A pattern of unstable and intense interpersonal relationships
3. Identity disturbance: marked & persistent unstable self-image or sense of self
4. Impulsivity in at least two areas potentially self-damaging
5. Recurrent suicidal behaviour, gestures, threats, or self-harm
6. Affective instability due to a marked reactivity of mood
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger
9. Transient, stress-related paranoid ideation or severe dissociative symptoms

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 TREATMENT COMPARISONS
 DBT and other forms of CBT (e.g., anxiety/mood management)
- safety, distress tolerance
- mindfulness, emotional regulation, affective stability
- interpersonal skills

Less direct targeting of…

 Identity disturbance (maladaptive sense of self)
- direct link with personality, ‘Who I am’; long-term, pervasive
- ‘what is left after the chaos is reduced or better managed?’
- prone to drop-out & relapse; on-going, periodic crises;
-‘chameleon effect’

DBT considered best speciliased treatment modality; essentially standard cognitive-

behavioral techniques for emotion regulation and reality-testing with concepts of
distress tolerance, acceptance, and mindful awareness largely derived from
contemplative meditative practice.

Dialectical behavior therapy (DBT). ...

Schema-focused therapy. ...
Mentalization-based therapy (MBT). ...
Systems training for emotional predictability and problem-solving (STEPPS). ...
Transference-focused psychotherapy (TFP). ...
Good psychiatric management.

maladaptive sense of self: more prone to threat reactions due to lack of sense of
control and consistency across contexts

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WHY SCHEMA THERAPY FOR PD?
Often need to adapt general CBT approach as…
 Cognitions and behaviours are more rigid with PD clients
 Many PD clients will not follow traditional CBT techniques
(especially ‘homework’)
 High ‘drop-out’ rates
 Intimate interpersonal problems are more central to problems of
PD clients
 Need more directed at broader conceptions of self
 Gap between cognitive & emotional change is much greater
with individuals with PD
“I intellectually get it but I don’t feel it”

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 SCHEMA THERAPY

Developed by Jeffrey Young for use in treatment of personality disorders and

other chronic disorders, such as when patients fail to respond or relapse after
having been through other therapies (e.g., traditional CBT).

 An integrative psychotherapy combining theory and techniques from CBT,

psychoanalytic object relations theory, attachment theory, and Gestalt
therapy.

Object relations theory in psychoanalytic psychology is the process of developing a

psyche in relation to others in the childhood environment. It designates theories or
aspects of theories that are concerned with the exploration of relationships between
real and external people as well as internal images and the relations found in them.[1] It
maintains that the infant's relationship with the mother primarily determines the
formation of his personality in adult life.[2] Particularly, the need for attachment is the
bedrock of the development of the self or the psychic organization that creates the
sense of identity.[2]
Modern Attachment Theory is based in three principles which include bonding as an
intrinsic human need; regulation of emotion and fear to enhance vitality; and
promoting adaptiveness and growth
Gestalt therapy is an existential/experiential form of psychotherapy which emphasizes
personal responsibility, and focuses upon the individual's experience in the present
moment, the therapist–client relationship, the environmental and social contexts of a
person's life, and the self-regulating adjustments people make as a result of their
overall situation

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SCHEMA THERAPY
 Greater emphasis on the therapeutic relationship

 More emphasis on affect (imagery, role-playing)

 More discussion of childhood origins and developmental processes.

 More active confrontation of cognitions

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 EARLY MALADAPTIVE SCHEMA
 Disconnection/Rejection includes 5 schemas:
 Abandonment/Instability
 Mistrust/Expect Abuse
 Emotional Deprivation
 Defectiveness/Shame
 Social Isolation/Alienation
 Impaired Autonomy and/or Performance includes 4 schemas:
 Dependence/Incompetence
 Vulnerability to Harm or Illness
 Enmeshment/Undeveloped Self
 Failure

A broad, pervasive theme; Regarding oneself and one's relationships with others; AKA
Lifetraps
Developed during childhood and elaborated throughout one's lifetime and
Dysfunctional to a significant degree

Result from an interplay of temperament with everyday noxious experiences as a child

with parents, siblings, or peers
Capable of generating high levels of disruptive affect, extremely self-defeating
consequences; and/or significant harm to others
Capable of interfering significantly with meeting core needs for autonomy, connection,
self expression, etc.

Disconnection/Rejection: most commonly associated with BPD

Use example

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EARLY MALADAPTIVE SCHEMA
 Impaired Limits includes 2 schemas:
 Entitlement/Grandiosity
 Insufficient Self-Control and/or Self-Discipline
 Other-Directedness includes 3 schemas:
 Subjugation
 Self-Sacrifice
 Approval-Seeking/Recognition-Seeking
 Overvigilance/Inhibition includes 4 schemas:
 Negativity/Pessimism
 Emotional Inhibition
 Unrelenting Standards/Hypercriticalness
 Punitiveness

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 COPING STYLES
A person's behavioral responses to schemas.
1) Avoidance (flight)
2) Surrender (freeze)
3)Overcompensation (fight or counterattack)

E.g., defectiveness
E.g., abandonment

Defectiveness schema: A person using an avoidance coping style might avoid situations
that make them feel defective, or might try to numb the feeling with addictions or
distractions. A person using a surrender coping style might tolerate unfair criticism
without defending themself. A person using the counterattack/overcompensation
coping style might put extra effort into being superhuman/perfectionistic
Abandonment example: having imagined a threat of abandonment in a relationship and
feeling sad and panicky, a person using an avoidance coping style might then behave in
ways to limit the closeness in the relationship to try to protect themself from being
abandoned. The resulting loneliness or even actual loss of the relationship could easily
reinforce the person's Abandonment schema

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 SCHEMA MODES

Mind states that cluster schemas and coping styles into a

temporary "way of being" that a person can shift into
occasionally or more frequently

e.g., Vulnerable Child: likely be a state of mind encompassing

schemas of Abandonment, Defectiveness, Mistrust/Abuse; and
a coping style of surrendering (to the schemas).

For example, a Vulnerable Child mode[4] might be a state of mind encompassing

schemas of Abandonment, Defectiveness, Mistrust/Abuse and a coping style of
surrendering (to the schemas).

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 COMMON MODES IN BPD

 The Vulnerable/Abandoned Child

 The Angry Child
Psychologist <strong>Clark Sim </strong>spoke at our
 The Punitive Parent
February meeting, about what <strong>Schema
 Therapy</strong>
The Detached Protector is,
 The Healthy Adult (Healthy Self)

The four categories are: Child modes, Dysfunctional Coping modes, Dysfunctional
Parent modes, and the Healthy Adult mode. The four Child modes are: Vulnerable Child,
Angry Child, Impulsive/Undisciplined Child, and Happy Child. The three Dysfunctional
Coping modes are: Compliant Surrenderer, Detached Protector, and Overcompensator.
The two Dysfunctional Parent modes are: Punitive Parent and Demanding Parent.

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 THE ABANDONED CHILD

mode in which a client may feel defective in some way, thrown aside, unloved,
obviously alone, or may be in a "me against the world" mindset. The patient may feel as
though peers, friends, family, and even the entire world have abandoned them.
Behaviors may include falling into major depression, pessimism, feeling unwanted,
feeling unworthy of love, and perceiving personality traits as irredeemable flaws.
Rarely, a patient's self-perceived flaws may be intentionally withheld on the inside;
when this occurs, instead of showing one's true self, the patient may appear to others
as "egotistical", "attention-seeking", selfish, distant, and may exhibit behaviors unlike
their true nature. The patient might create a narcissistic alter-ego/persona in order to
escape or hide the insecurity from others. Due to fear of rejection, of feeling
disconnected from their true self and poor self-image, these patients, who truly desire
companionship/affection, may instead end up pushing others away.

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 THE ANGRY CHILD

Angry Child is fueled mainly by feelings of victimization or bitterness, leading towards

negativity, pessimism, jealousy, and rage. While experiencing this schema mode, a
patient may have urges to yell, scream, throw/break things, or possibly even injure
themself or harm others. The Angry Child schema mode is enraged, anxious, frustrated,
self-doubting, and feels unsupported.

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 THE PUNITIVE PARENT

Beliefs that they should be harshly punished, perhaps due to feeling "defective", or
making a simple mistake; may feel that they should be punished for even existing.
Sadness, anger, impatience, and judgment are directed ‘to self from self’. The Punitive
Parent has great difficulty in forgiving themself even under average circumstances in
which anyone could fall short of their standards. The Punitive Parent does not wish to
allow for human error or imperfection, thus punishment is what this mode seeks.

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 THE DETACHED PROTECTOR

Detached Protector is based in escape. Patients in Detached Protector schema mode

withdraw, dissociate, alienate, or hide in some way. This may be triggered by numerous
stress factors or feelings of being overwhelmed. When a patient with insufficient skills
is in a situation involving excessive demands, it can trigger a Detached Protector
response mode. Stated simply, patients become numb in order to protect themselves
from the harm or stress of what they fear is to come, or to protect themselves from
fear of the unknown in general.

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 THE HEALTHY ADULT

Healthy Adult is the mode that schema therapy aims to help a patient achieve as the
long-lasting state of well-being. The Healthy Adult is comfortable making decisions, is a
problem-solver, thinks before acting, is appropriately ambitious, sets limits and
boundaries, nurtures self and others, forms healthy relationships, takes on all
responsibility, sees things through, and enjoys/partakes in enjoyable adult activities and
interests with boundaries enforced, takes care of their physical health, and values
themself. In this schema mode the patient focuses on the present day with hope and
strives toward the best tomorrow possible. The Healthy Adult forgives the past, no
longer sees themself as a victim (but as a survivor), and expresses emotions in ways
which are healthy and cause no harm.

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 TREATMENT GOALS
 Encourage assumption that (maladaptive) schemas are
either incorrect or greatly exaggerated
 Emotional processing of ‘schema developing’ early
experiences
 Reduce dysfunctional modes (showing ultimate
unhelpfulness)
 Define and support the healthy adult side to develop so
that the dysfunctional coping modes are less necessary

Tendency for long(er)-term and intensive; varies according to prior treatment, relative
severity of symptoms, etc

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 TREATMENT PROCESSES
1. Cognitive strategies expand on standard CBT such as listing pros and cons
of a schema, testing the validity of a schema, or conducting a dialogue
between the "schema side" and the "healthy side".
2. Experiential and emotion focused: expand on standard Gestalt therapy;
use psychodrama, empathetic confrontation, and imagery rescripting
techniques.
3. Behavioral: pattern-breaking strategies such as role playing an interaction
and then assigning as homework; event scheduling, exposure.

 Use of therapeutic relationship central: "limited re-parenting".

 Also Flash cards and schema diary or logbook

Gestalt Psychodrama:
Role plays & exercises designed to illicit emotional responses to work on congruence &
integration
Empathetic confrontation
Empty Chair to promote awareness & integration
Address unfinished business to gain insight, awareness and address past issues
Bring attention to non-verbals and their meaning
Explore how past influences relations within / outside therapy context

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 RESEARCH – SCHEMA FOR BPD

 Arnoud Arntz, Netherlands, 2004: In-patient BPD approx. 50% ‘full

recovery’and 70% achieving "clinically significant and relevant
improvement“, relatively low drop-out high intensity, long duration 3 + 1
year) 70% achieving "clinically significant and relevant improvement".
 Arntz, Netherlands 2006: Out-patient lower intensity/duration, similar
effectiveness and similarly low dropout rates.
 Farrell, Shaw and Webber, USA, 2014: 30 session schema therapy group in
addition to DBT; dropout DBT + Schema = 0%, BPD only = 25%; no longer met
BPD diagnostic criteria DBT + Schema = 94%, DBT only = 16%.

Outcome studies on schema therapy[edit]

Schema therapy vs transference focused psychotherapy outcomes[edit]
Dutch investigators, including Josephine Giesen-Bloo and Arnoud Arntz, compared
schema therapy with transference focused psychotherapy (TFP) in the treatment of
borderline personality disorder. 86 patients were recruited from four mental health
institutes in the Netherlands. Patients in the study received two sessions per week of
SFT or TFP for three years. After three years, full recovery was achieved in 45% of the
patients in the SFT condition, and in 24% of those receiving TFP. One year later, the
percentage fully recovered increased to 52% in the SFT condition and 29% in the TFP
condition, with 70% of the patients in the SFT group achieving "clinically significant and
relevant improvement". Moreover, the dropout rate was only 27% for SFT, compared
with 50% for TFP.
Patients began to feel and function significantly better after the first year, with
improvement occurring more rapidly in the SFT group. There was continuing
improvement in subsequent years. Thus investigators concluded that both treatments
had positive effects, with schema therapy clearly more successful.[19]
Less intensive outpatient, individual schema therapy[edit]
Dutch investigators, including Marjon Nadort and Arnoud Arntz, assessed the
effectiveness of schema therapy in the treatment of borderline personality disorder

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when utilized in regular mental health care settings. A total of 62 patients were treated
in eight mental health centers located in the Netherlands. The treatment was less
intensive along a number of dimensions including a shift from twice weekly to once
weekly sessions during the second year. Despite this, there was no lessening of
effectiveness with recovery rates that were at least as high and similarly low dropout
rates.[20]
Pilot study of group schema therapy for borderline personality disorder[edit]
Investigators Joan Farrell, Ida Shaw and Michael Webber at the Indiana University
School of Medicine Center for BPD Treatment & Research tested the effectiveness of
adding an eight-month, 30-session schema therapy group to treatment-as-usual (TAU)
for borderline personality disorder (BPD) with 32 patients. The dropout rate was 0% for
those patients who received group schema therapy in addition to TAU and 25% for
those who received TAU alone. At the end of treatment, 94% of the patients who
received group schema therapy in addition to TAU compared to 16% of the patients
receiving TAU alone no longer met BPD diagnostic criteria. The schema therapy group
treatment led to significant reductions in symptoms and global improvement in
functioning. The large positive treatment effects found in the group schema therapy
study suggest that the group modality may augment or catalyze the active ingredients of
the treatment for BPD patients.[21] As of 2014, a collaborative randomized controlled
trial is under way at 14 sites in six countries to further explore this interaction between
groups and schema therapy.[22]

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CONCLUSION

Questions / Comments/ Sharing ?

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