Schema Therapy for Borderline Personality Disorder (BPD): An Alternative to DBT
What is Borderline Personality Disorder (BPD)?
Borderline personality disorder (BPD) is a complex mental health disorder marked by a persistent, pervasive pattern of instability in the following domains:
Interpersonal relationships: a pattern of intense or unstable interpersonal (predominately romantic) relationships marked by alternations between idealisation and devaluation. Underlying these relationships is a strong fear of and consequent frantic efforts to avoid abandonment, with the experience of imagined or perceived abandonment resulting in extreme emotional dysregulation, dissociation/paranoid ideation, a loss of self, and suicidal thoughts and behaviour. Frantic efforts to avoid abandonment can range from obsessive texting to parasuicidal behaviour.
Emotional Dysregulation: persistent affective instability due to a marked reactivity in mood, particularly in relation to interpersonal stressors, alongside difficulty controlling anger. Patients typically present with a general dysphoric mood as well as mood swings of anger, irritability, anxiety, and sadness that typically last for a few hours and no more than a few days.
Sense of Self: an unstable sense of identity, which is highly influenced by interpersonal relationships and moods. Chronic feelings of emptiness are also commonly reported.
Impulsivity: marked impulsivity in areas that are potentially self-damaging (e.g., binge eating, alcohol/drug abuse).
What is Schema Therapy?
Schema Therapy is an integrative therapy that addresses schemas, which are cognitive and emotional patterns that arise from unmet emotional needs in childhood, and one's consequent coping behaviour. In schema therapy, schemas and coping behaviours are identified and targeted using myriad cognitive, experiential (such as imagery work), and behavioural strategies; these techniques hinge upon the therapist meeting the client's emotional needs in the confines of the therapeutic relationship (limited reparenting). Whilst schema therapy was traditionally designed to target schemas and coping behaviours, the therapy can also take a mode-focused approach (modes are states of being when schemas are triggered). The mode approach is a common adaption for treating personality disorders.
Why Consider Schema Therapy for BPD Clients Instead of Dialectical Behaviour Therapy (DBT)?
Patients presenting with BPD in private practice settings often hold the preconceived notion, as well as their referrers at times, that there is only one effective therapy for BPD: dialectical behaviour therapy (DBT). However, this is not true. In fact, two other therapies, schema therapy and psychodynamic therapy, have level-1 evidence for the treatment of the disorder.
Given the cost of entering a comprehensive DBT program and the fact that the evidence surrounding DBT for BPD is based predominately on comprehensive DBT rather than DBT-informed therapy, schema therapy is a great alternative for treatment. Schema therapy does not require the resources of comprehensive DBT, and DBT skills can easily be woven into schema therapy to address suicidality/self-harm and in-the-moment, overwhelming emotional distress. Schema therapy has shown promising results for achieving deeper, long-term changes in BPD symptoms and overall recovery.
General Stages of Treatment
The father of schema therapy, Jeffery Young, has outlined three general stages of treatment for patients struggling with BPD symptoms:
Bonding and Emotional Regulation: the therapist works to establish an emotional bond with the client’s vulnerable child mode (part of self that feels the emotional pain of one’s schemas) by bypassing the person’s detached protector mode (part of self that detaches from emotions and pain) and therefrom providing limited reparenting, teaching emotional regulation, and conducting experiential work with the client’s childhood memories.
Schema Mode Change: the therapist models the healthy adult mode (part of oneself that can act in a way to meet one’s emotional needs, regulate emotions, balance other modes, and foster healthy decision-making and relationships) by reparenting the client’s vulnerable child mode, helping vent while setting limits on the client’s angry child mode (the part that has anger about emotional needs not being met), and banishing the client’s punitive parent mode (hypercritical, punitive part of self that represents the internalised voice of caregivers).
Autonomy: The therapist helps the client generalise changes in therapy to their life outside of therapy (e.g., relationships, decision making).
References: available upon request.
Authored by Brant Maclean, Clinical Psychology Registrar
Brant currently has capacity for new clients and offers sessions at True North Psychology on Monday to Thursday afternoons.
Comments