I Hate You--Don't Leave Me - Jerold J. Kreisman [83]
1. Sessions educate about BPD and schema (cognitive distortions about oneself and others, such as a sense of unlovability, mistrust, guilt, lack of identity, fear of losing control, etc.).
2. Skills to better control emotions, such as problem management, distracting, and improving communication, are taught.
3. The third component teaches basic behavioral skills, such as healthy eating, healthy sleep regimen, exercise, and goal setting.
A second phase of STEPPS is STAIRWAYS (Setting goals; Trusting; Anger management; Impulsivity control; Relationship behavior; Writing a script; Assertiveness training; Your journey; Schemas revisited). This is a twice-monthly one-year extension of skills-training “seminars,” which reinforce the STEPPS model. Unlike DBT, which is designed to be self-contained and discourages other therapy contributions, STEPPS is designed to complement other therapy involvement.
Schema-Focused Therapy (SFT)
SFT combines elements of cognitive, Gestalt, and psychodynamic theories. Developed by Jeffrey Young, PhD, a student of Aaron Beck’s, SFT conceptualizes maladaptive behavior arising from schemas. In this model, a schema is defined as a worldview developed over time in a biologically vulnerable child who encounters instability, overindulgence, neglect, or abuse. Schemas are the child’s attempts to cope with these failures in parenting. Such coping mechanisms become maladaptive in adulthood. The concept of schemas derives from psychodynamic theories. SFT attempts to challenge these distorted responses and teach new ways of coping through a process denoted as re-parenting.7
Multiple schemas can be grouped into five primary schema modes, with which borderline patients identify and which correlate with borderline symptoms:
1. Abandoned and Abused Child (abandonment fears)
2. Angry Child (rage, impulsivity, mood instability, unstable relationships)
3. Punitive Parent (self-harm, impulsivity)
4. Detached Protector (dissociation, lack of identity, feelings of emptiness)
5. Healthy Adult (therapist’s role to model for the patient—soothes and protects the other modes)
Specific treatment strategies are appropriate for each mode. For example, the therapist emphasizes nurturing and caring for the Abandoned and Abused Child mode. Expressing emotions is encouraged for the Detached Protector mode. “Re-parenting” attempts to supply unmet childhood needs. Therapists are more open than in traditional therapies, often sharing gifts, phone numbers, and other personal information, projecting themselves as “real,” “honest,” and “caring.” Conveying warmth, praise, and empathy are important therapist features. Patients are encouraged to read about schema and BPD. Gestalt techniques, such as role-playing, acting out dialogue between modes, and visualization techniques (visualizing and role-playing stressful scenarios) are employed. Assertiveness training and other cognitive-behavioral methods are utilized. A possible danger in SFT is the boundary confrontation in “re-parenting.” Therapists must be extremely vigilant regarding the risk of transference and countertransference regression (see chapter 7).
Psychodynamic Treatments
Psychodynamic approaches typically employ discussion of the past and present, with the goal of discovering patterns that may forge a more productive future. This form of therapy is usually more intensive—with sessions conducted several times a week—than the cognitive-behavioral approach. The therapist should implement a structured, consistent format with clear goals, yet be flexible enough to adapt to changing needs.
Mentalization-Based Therapy (MBT)
Mentalization, a term elaborated by Peter Fonagy, PhD, describes how people understand themselves, others, and their environment. Using mentalization, an individual understands why she and others interact the way they do, which in turn leads to the ability to empathize with