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 mode” and the “angry/impulsive child mode” are actually examples of such mergers (see Figure 3.1).
The feedback of the results of the questionnaires can best be integrated in the conversation about the complaints and experiences. By delving into an experience of the patient, the discussion of a schema or mode is more involving. Discussing the schemas must encompass more than just stating the names of the schemas or modes and the scores. Educating the patient on how an activated schema or mode feels, helps the patient to recognize the relevant schema or mode and she experiences that the therapist understands her (ST step by step 1.02 and 6.06).
Figure 3.1 Case conceptualization Nora
Information from the therapeutic relationship
In order to make the patient feel safe and understood from the very first session, the therapist takes a friendly, open, and not distanced position (see Chapter 4, “Limited Reparenting”). He spends a lot of time with the current problems of the patient and empathizes with her feelings. He examines, in conjunction with the patient, which situations trigger intense emotions. Further, he also looks at how she usually deals with her problems and in how far this is helpful in solving them. He informs himself about the patient's expectations toward the therapy and the therapist and asks for previous experiences with therapy. Often the patient has already had experience with a number of different therapies, which produced limited results or even a damaging effect, for instance broken trust (sometimes even sexual abuse) of the patient by the therapist. Therefore, the therapist must be aware that the patient might distrust him in advance. He explains how far the patient's expectations can be met in the therapy and what the general rules are (see discussion in Chapter 4).
The therapist is very attentive to the way the patient treats him. From the behavior of the patient he can gather information about the schemas, modes and the coping strategies of the patient.
The process of treating a BPD patient seldom begins with a calm conversation of information collection and case conceptualization. One should not be surprised when this process of information gathering is more of a rollercoaster as opposed to a quiet drive in the country. Often from day one it is clear that the patient is not comfortable or in a state to embark on a constructive relationship with the therapist. The development of a therapeutic relationship and the gathering of information will be discussed in the next chapter.
Experiential techniques
The patient's personal history is mapped and put into relation with the emergence of the schema modes. The therapist analyses which experiences in the past have contributed to the current problems. This is often not easy to find out in a more cognitive way. Here, it is recommended to use a short imagery exercise to examine the link between the past and the present (see Chapter 5) or a two chair technique (see Chapter 6).
We recommend using imagery at least one or two times