her insecurity she avoids social activities which makes her feel lonely and depressed. If she cannot avoid social contact, she behaves tougher than she is with the result that she gets exhausted.
Nora grew up in a family with two brothers and one sister. Her father was a dominant, aggressive man who drank too much out of insecurity. Without alcohol he was only verbally aggressive, but when he got drunk, he also became physically aggressive. Mother is a gentle, kind but also anxious and submissive woman. For fear of her husband she kept her mouth shut and didn't protect the children. After father's outbursts she always tried to hush up the abuse. Her statement was “Ah you know him” and “you better stay quiet because saying something will only make things worse.”
If it all became too much for mother, she would sometimes go to her family for a few days. That was very frightening for Nora because she never knew if and when mother would return. Mother could not handle the family and often called on Nora to help her.
Nora has always felt lonely and different in relation to peers. Her family was considered to be different and people were afraid of her father. She did well at school because she has an above‐average intelligence, but due to her problems at home she just managed to complete lower level education.
Diagnostically there is a recurrent depressive disorder in partial remission, a generalized social anxiety disorder, and a borderline personality disorder with dependent and avoidant features.
The initial phase of the therapy involves approximately five sessions during which a case conceptualization is made. The therapist uses three pathways to gather the information that is needed to make a comprehensive overview of the actual problems, the (origin of) the schemas and modes and the connection between these parts. That means that he tries to gather information via cognitive, behavioral, and experiential channels.
The different ways to gather information are:
Cognitive:A diagnostic interview (information from former therapies)The downward arrow techniqueQuestionnaires
Behavioral:Information from therapeutic relationshipBehavioral patterns reported by patient (and by referral and/or family members, if seen)
Experiential:Imagery and two chair technique historical role play
Diagnostic interview
In the first place a complete diagnostic interview takes place. During this interview, all information relevant to the patient's problems and complaints is described in detail by the patient. A comprehensive anamnestic interview is conducted, and the therapist begins to search for the relationship with parents/caregivers and possible events that are relevant to the formation of dysfunctional schemas. Information from former therapies can also be very relevant (see ST step by step 1.01). This is a more cognitive pathway.
In the diagnostic interview, the therapist also looks into contraindications before continuing with treatment (see Chapter 2, “(Contra‐) Indications”) as well as measuring the patient's level of functioning and BPD symptoms. If the therapist works in a mental health center, contraindications have usually already been checked, but as there is often a waiting list, therapists are recommended to check them again for possible changes.
Downward arrow technique
A cognitive technique that helps to gather more information about the schemas of the patient is the downward arrow technique which is extensively described in the literature on Cognitive Therapy. Therefore, this technique is only briefly summarized here.
When a patient formulates thoughts about themes that seem very important to explain the problems, the therapist can ask questions about the meaning of this thought. So, he doesn't start to explore or evaluate the evidence for this thought, but he asks, “what does this mean to you?” If the answer is not clear he repeats this question a few times. Most of the time the patient is not able to identify the underlying schema instantly, so the therapist can ask some more questions to reveal this. At first, he explains to the patient that he empathizes with her negative thoughts and feelings, but he also explains that he has some more questions to understand the problem of the patient even better. He could use the following questions:
if this is really true so what?
What's so bad about …?
What's the worst part about …?
What does that mean about you (others)?
The therapist can stop with this downward arrow technique when he discovers an important core belief on schema level and/or the patient shows a negative shift in affect.
Questionnaires
To assess the patient's schemas and modes, the Young Schema Questionnaire (YSQ; Young, 1999), the Schema Mode Inventory (SMI; Lobbestael, van Vreeswijk & Arntz, 2008) and other questionnaires are completed by the patient along the first few sessions. The results are discussed with the patient. The Young Parenting Inventory can be helpful in clarifying factors that have influenced the development of the modes. The Borderline Personality Disorder Severity Index (BPDSI) is a structured interview that assesses the seriousness and frequency of BPD symptoms and expressions that meet DSM‐IV criteria and have been experienced within the previous three‐month period (Arntz et al., 2003; Giesen‐Bloo et al., 2006; Giesen‐Bloo, Wachters, Schouten, & Arntz, 2010).
With the help of the BPD checklist the patient can indicate to what extent her BPD symptoms have been a burden to her in the past month (Bloo, Arntz, & Schouten, 2017). The Personality Disorder Beliefs Questionnaire (PDBQ) includes a subscale with statements specifically relating to BPD (Arntz, Dreessen, Schouten, & Weertman, 2004). From the Personality Beliefs Questionnaire (PBQ) a series of items specific to BPD have been derived (Butler, Brown, Beck, & Grisham, 2002).
When the patient has a high score in the YSQ or SMI, you can be sure that this is an important problem. But be aware of the fact that questionnaires can give incomplete or biased information. Because of the personality problems, patients might be unwilling to reveal specific information, might present a too good picture of themselves to be true, or might over‐report problems. Patients might not be aware of specific modes or schemas, they might misinterpret items, or respond in a way they think is desirable. Patients with strong overcompensating modes usually don't report an abandoned/abused child mode (or any vulnerable child mode), which is actually predicted by schema mode theory, as overcompensating modes have the function to make the patient believe that he or she is the opposite (Bamelis, Renner, Heidkamp, & Arntz, 2011). Fortunately, questionnaires are not the only way to gather information about the schemas and modes of the patient. Thus, the therapist is recommended to use all kinds of information in the collaborative formulation of the mode model, including the patient's request for help, her description of current and past problems, current and past relationships, study/work history, her developmental history, file information, including from past treatments, and the patient's behavior during the sessions. A schema or a mode might also appear during experiential techniques such as imagery, or when there is a “decompensation,” when the situational triggers are so strong that they cannot be avoided or overcompensated anymore. If an exceptionally large number of modes (or schemas) is reported by the patient, the therapist should try, in collaboration with the patient, to pick the most important ones, so that the mode model remains surveyable. Another possibility is to combine two modes that have a similar function into one mode. The “abandoned/abused child
