negative
It is strongly recommended to not postpone experiential techniques to later phases of therapy. The idea that it is contraindicated to use for instance empty chair techniques or imagery rescripting of aversive childhood memories early in treatment has been proven wrong. By using such techniques, the detached protector mode is bypassed, the abandoned/abused child mode is supported and healed, and the punitive parent mode weakened. Thus, the current treatment model states that almost every session of this central phase should contain experiential work, and that one should start within a few minutes with this, to prevent that one avoids emotional work and runs out of time. Talking and understanding can be done at the end of the session.
Be sure to reserve around 5–10 min at the end of each session to draw conclusions on schema and mode change and to strengthen the healthy adult.
Final phase of therapy
In the final phase of therapy, the emphasis is shifted from processing the past to changing behavioral patterns. The experiential techniques change in nature because the patient now increasingly takes on the role of the healthy adult. The exercises will be more focused on future situations. In the final phase it will also be possible to use more cognitive techniques that the patient can use outside of sessions. In the following chapters, each technique will be discussed in more detail with the shift of emphasis from child mode to healthy mode
Changing behavioral patterns
Young, Klosko, and Weishaar (2003) referred to this phase of promoting more autonomy and changing behavior, as crucial (see Chapter 11, “Behavioral Pattern‐Breaking”). Even when the patient is no longer ruled by constantly changing modes and the healthy adult has been developed, enacting upon these new behaviors is not always easy. The patient starts to apply what she learned in therapy outside the safe environment of the therapy and is able to do more complicated homework assignments. In most cases this phase starts in the second year of treatment with less frequent sessions and a more coaching attitude of the therapist to acquire new, healthier behavior.
Ending therapy
According to Young, ending therapy is considered when the patient no longer meets the criteria for a diagnosis of BPD and has built up a relatively stable social network and has found a meaningful way of filling her days. So originally, ST for BPD was open‐ended: treatment finished when patient and therapist agreed it to be complete. However, recent experiences demonstrate that a time‐limited ST for BPD is in general as successful as open‐ended ST (see Chapter 11, “Ending Therapy”). When there is no progress at all after at least one year of ST, it is also recommended to seriously consider stopping treatment, as research indicates that there is little chance that improvement will be accomplished later.
Frequently Asked Questions About Treatment
1 Should I use a mode model, or can I also use a schema model? Given that most borderline patients sore high on almost all schemas we advise to use a mode model. You can add the information about the schemas by explaining which schema is present in each mode (see Figure 3.2).
2 How much time do you spend creating a case conceptualization? Creating a case conceptualization usually takes around five sessions. In exceptional cases, especially if the patient is very distrustful, it can take more time. If there is a strong angry protector who rejects working with a mode model, it can also take more time to make a case conceptualization.It may be necessary to gain the patient's trust first. Or it may be helpful to explain to the patient that her behavior is a survival strategy that hinders working on the problems. A role play with role reversal can sometimes be very enlightening.You must realize that the case conceptualization is always a working model. If new relevant information emerges during therapy, the case conceptualization can be adjusted.
3 What can I do when the patient is still in panic or desperate at the end of the session? You can offer the patient some support outside the session like calling her later that day or letting her sit in the waiting room. An interesting observation is that most patients automatically go into their detached protector when they leave the room of the therapist at the end of a session in order to stop the bad feelings.
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