Professionals often view patients with borderline personality as manipulative, selfish people. This negative view is destructive to treatment. As soon as the therapist views the patient negatively, the therapist is feeding into one of the patient’s unhealthy “modes” (see How to treat Borderline Personality Disorder (Part 1).
Often the therapist becomes the punitive parent, angry with the patient, critical and rejecting. This approach is damaging to the patient (Young, Klosko, Weishaar, 2003).
It is important to remember that borderline patients will always need more than the therapist can provide; that is because they are desperate. Working with these types of patients is tumultuous and intense.
Often, the therapist’s own schemas are triggered (Young, Klosko, Weishaar, 2003). Therapists working with this population should take proactive measures of self-care and consultation in order to remain effective and emotionally healthy themselves.
The Power of Desperation
In almost all cases, borderline patients always need more than anyone in their lives can provide. Have I mentioned they are desperate? Never underestimate the power of this desperation.
Healing from borderline issues is hard work, but it is possible.
Conflict is inherent in treatment because the patient’s needs are greater than the provider can meet.
Remember, the goal is to re-parent this individual by providing new, inner working models of healthy relating and attachment–something that will not come easily or quickly.
Patients with borderline issues are always looking for a parent. Because of this constant neediness, it is important for the healer to understand that he needs to maintain healthy boundaries. The therapist has rights too – rights to a private life, to be treated respectfully, to have time for himself and others, etc. The therapist cannot, nor should, give the patient everything he wants or needs.
The patient’s progress in treatment, in some respects parallels child development. Psychologically, the patient “grows up” in therapy. Treatment takes years.
Here are the steps to take, practically, to heal the borderline patient’s maladaptive schemas:
1. Empathize with and protect the abandoned child.
2. Help the abandoned child give and receive love.
3. Fight against, and expunge, the inner punitive parent.
4. Set limits on the behavior of the angry and impulsive child and help the patient while in this mode to express emotions and needs appropriately.
5. Reassure, and gradually replace, the detached protector with the healthy adult.
Here’s how (Young, Klosko, Weishaar, 2003):
- Stage 1: Bond with the patient. Bypass the detached protector and become a stable, nurturing base. Work at forming a secure emotional attachment with the patient. This approach is the beginning step of re-parenting the patient’s abandoned child, but providing safety and emotional holding. Try to connect with the patient in the abandoned child mode. Ask questions about his feelings and problems. Help him learn how to bond. Learn to endure the unpleasant modes (angry and detached modes).
- Stage 2: Schema mode change. The therapist models how to be a healthy adult by re-parenting the patient. The healthy adult acts to soothe and protect the abandoned child and to set limits on the angry child; the healthy adult must also replace the detached protector mode. The therapist helps the patient learn how to parent himself. Slowly the patient internalizes the modeling of the therapist. After much time (perhaps a year), the therapist can start weakening the borderline’s internal punitive parent.
- Stage 3: Autonomy. The therapist advises the patient about appropriate partner choices and helps generalize changes within their relationship (therapist and patient) to other relationships. The focus at this stage is on teaching the borderline patient how to let go of destructive relationships and how to develop healthy intimate relationships. In addition, the therapist teaches the patient proper emotional expression. It is also important for the therapist to teach the patient how to self-soothe and not look to others in destructive ways in order to find fulfillment.
The therapist needs to educate the patient about the limits of what any relationship will be capable of providing.
Research has been conducted on the effectiveness of schema therapy for the treatment of BPD, which shows that the treatment is a very effective intervention for people struggling with the disorder. In fact, schema therapy was found to be more than twice as effective of various psychodynamic approaches, including transference focused psychotherapy. (Giesen-Bloo, et al, 2006).
According to the outcome research, schema therapy leads to complete recovery in approximately 50% of patients, and significant improvement in two-thirds. It was found that the effectiveness of the therapy strongly correlates to length of therapy and intensity of process (two sessions every week for three years)
It’s encouraging news for those with the disorder and also for their loved ones (Giesen-Bloo, et al, 2006).
American Psychiatric Association (2014). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: DSM-V. Arlington, VA: American Psychiatric Association.
Giesen-Bloo, J., van Dyck, R. Spinhoven P.; van Tilburg, W. Dirksen, C.; Thea van Asselt, T., Kremers, I., Nadort,& Arntz, A. (2006). Outpatient Psychotherapy for Borderline Personality Disorder: a randomized trial of Schema focused therapy versus Transference focused therapy. Archives of General Psychiatry (63)6. pp. 649-658.
Young, J.E.; Klosko, J.S.; Weishaar, M.E. (2003). Schema Therapy: New York, NY. Guilford Press.
Therapy session photo available from Shutterstock