Borderline Personality Disorder 2020

Borderline Personality Disorder
Models and Treatments
ZABURZENIE OSOBOWOSCI Z POGRANICZA – MODELE

TEORETYCZNE I METODY LECZENIA
Prof. Eduardo Keegan

Universidad de Buenos Aires
Problems with Applying Standard CBT to
Personality Disorders
(Young, Klosko, Weishaar, 2003)
The patient does not comply with protocol

Standard CBT assumes that patients are motivated to
reduce symptoms, learn skills and solve problems and
that, therefore, with a little encouragement they will
comply with all treatment procedures.
The patient lacks the ability to identify and monitor his/her emotions
and communicate them to the therapist
Standard CBT assumes that patients can do this with minimum
training. But many patients use cognitive and affective avoidance
as a coping strategy for negative affect.
Standard CBT takes for granted that the patient can change his/her
problematic cognitions and behaviors through empirical analysis,
logic, experimentation, gradual steps and repetition.
This is not enough when dealing with PD patients.
Standard CBT assumes that the patient can relate effectively
with the therapist after a few sessions
Since interpersonal issues are normally the core of the
problem, this is not true with PD patients. The therapeutic
relationship is one of the best domains in which to assess
and treat these patients.
Patients with personality disorders are rigid
Therefore, they respond much less to cognitive-behavioral
strategies. They change more slowly.
Standard CBT assumes that the patient has problems that are
readily identifiable as targets for treatment
The problems of these patients are ill-defined, chronic and
pervasive.
Clinical Consequence
• As in any relationship, BPD patients may not mention
or manifest their problematic behaviors or
experiences at the beginning of therapy.
• Failing to recognize the presence of BPD usually
leads to the application of a standard CBT protocol for
a mood, anxiety or eating disorder.
• This may not work adequately, frequently leading to a
rupture of the therapeutic alliance.
• Careful diagnosis and conceptualization are essential.
• Even if you decide to (or have to) target the associated

emotional or eating disorder, it is of great importance to
understand its links with BPD.
Therapists’ Experiences with Borderline
Clients
• Is there anything these clients do that is different
from other clients?
• Do you find them interesting?
• Are borderline clients your favorite clients?
• Anything you would like to share?
• Can we learn anything from the history of
diagnostic criteria?
Schmideberg’s Criteria (1947)
• Unable to tolerate routine and regularity.

• Tends to break many rules of social
convention.
• Often late for appointments and unreliable
about payment.
• Unable to reassociate during sessions.
• Poorly motivated for treatment.
Schmideberg’s Criteria (1947)
• Fails to develop meaningful insight.

• Leads a chaotic life in which something
dreadful is always happening.
• Engages in petty criminal acts, unless
wealthy.
• Cannot easily establish emotional contact.
Rado’s Criteria (1956)
• Impatience and intolerance of frustration

• Rage outbursts
• Irresponsibility
• Excitability
• Parasitism
• Hedonism
• Depressive spells
• Affect hunger
Esser and Lesser (1965)
• Irresponsibility
• Erratic work history
• Chaotic and unfulfilling relationships that never become
profound or lasting.
• Early childhood history of emotional problems and
disturbed habit patterns.
• Chaotic sexuality, often with frigidity and promiscuity
combined.
DSM’s Criteria for BPD
• DSM’s criteria rely mostly on the “eclectic-descriptive”
approach by Chatham (1985) and the work of Gunderson
(1984).
• DSM’s criteria are more neutral, less judgemental about

the patient’s behaviour.
DSM-5 Criteria
A pervasive pattern of instability of interpersonal relationships,
self-image and affects, and marked impulsivity beginning by
early adulthood and present in a variety of contexts, as
indicated by five (or more) of the following:
(1) Frantic efforts to avoid real or imagined abandonment. Note:
Do not include suicidal or self-mutilating behaviors covered in
Criterion 5
Utrwalony wzorzec niestabilności relacji interpersonalnych, obrazu „ja” i emocji

oraz znacznej impulsywności, który pojawia się we wczesnej dorosłości i ujawnia w różnych kontekstach, na
co wskazuje co najmniej pięć z poniższych kryteriów:
(1) gorączkowe próby uniknięcia opuszczenia – rzeczywistego lub wyimaginowanego.

Uwaga: Nie uwzględniać zachowań samobójczych i samookaleczeń, o których mowa w kryterium 5;
DSM-5 Criteria
(2) A pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization and
devaluation
(2) wzorzec niestabilnych i intensywnych relacji interpersonalnych, który cechuje na przemian
skrajne idealizowanie i dewaluowanie innych;
(3) Identity disturbance: markedly and persistently unstable self-image or
sense of self
(3) zaburzenie tożsamości: znaczący i trwały brak stabilności obrazu lub poczucia „ja”;
(4) Impulsivity in at least two areas that are potentially self-damaging (e.g.,
spending, sex, substance abuse, reckless driving, binge eating). Note:
Do not include suicidal or self-mutilating behaviors covered in Criterion
5
(4) impulsywność w co najmniej dwóch potencjalnie szkodliwych dla jednostki obszarach aktywności (np.
wydawanie pieniędzy, seks, nadużywanie substancji psychoaktywnych, nieostrożna jazda, napady
obżarstwa). Uwaga: Nie uwzględniać zachowań samobójczych i samookaleczeń, o których mowa w
kryterium 5;
DSM-5 Criteria
(5) Recurrent suicidal behavior, gestures or threats, or self-
mutilating behavior
(5) powtarzające się zachowania, gesty lub groźby samobójcze bądź samookaleczenia;
(6) Affective instability due to a marked reactivity of mood

(e.g., intense episodic dysphoria, irritability, or anxiety
lasting a few hours and only rarely more than a few days)
(6) niestabilność emocjonalna spowodowana silną reaktywnością nastroju (np.
silne stany dysforyczne, drażliwość lub lęk, trwające zwykle kilka godzin, rzadko
dłużej niż kilka dni);
(7) Chronic feelings of emptiness

(7) utrzymujące się poczucie pustki;
DSM-5 Criteria
(8) inappropriate, intense anger or difficulty controlling
anger (e.g., frequent displays of temper, constant anger,
recurrent physical fights)
8) nieadekwatna, silna złość lub trudności z jej opanowaniem (np. częste wybuchy złości, stałe
odczuwanie złości, wielokrotne bójki);
(9) transient, state-related paranoid ideation or severe

dissociative symptoms
(9) przemijające objawy paranoiczne lub poważne objawy dysocjacyjne jako reakcja na stres.
Objections to DSM’s Criteria
• They do not pay too much attention to cognitive aspects
(e.g., black-and-white thinking) (Young, 2003)
• These criteria are a list of coping responses to the
pathological modes that are the core of the disorder
(Young, 2003).
• The name has been questioned. Emotional dysregulation
disorder has been proposed as an alternative.
Objections to DSM’s Criteria
• Comorbidity with other PD is the rule, not the exception.
• BPD, like all others PDs, is more a continuum than a
category (styles vs disorders, Millon, 1994).
• DSM criteria describe a prototypical patient rather than a
category.
Subtypes of Borderline Personality
Disorder
The Cognitive Perspective
Subtypes and Cognitive Profiles of BPD
(Layden, Newman, Freeman, Morse, 1993)
• Since there are so many ways in which criteria for BPD can
be met, it is reasonable to assume the existence of subtypes
of BPD.
• Their cognitive profile can be somewhat different. This helps
in achieving a more precise cognitive conceptualization.
• Two people with BPD can share the same abandonment
schema, but may develop different assumptions or
compensatory strategies.
Subtypes of BPD
• Assumption: I must not be too close to anybody, since
sooner or later that person will abandon me.
• Resulting behaviour: emotional and social avoidance.
• Assumption: I must make everything possible for
someone to love me, and I must also overwhelm him with
my presence and passion, since this is the only way to
keep him near me.
• Resulting Behaviour: Overtly seductive and histrionic
behaviour.
• The identification of the schema will be identical in both
cases, but the change strategy will be different in each
case.
• The goal, however, is similar: to reduce the expectation of
being abandoned, to moderate the emotional and
behavioral responses (maintaining factors) and to develop
healthier, more stable relationships.
Subtypes of BPD
• Avoidant/Dependent borderline personality
• Histrionic/Narcissistic borderline personality
• Antisocial/Paranoid borderline personality

Avoidant/Dependent BPD
• They are very anxious and have low self-esteem
• The incompetence schema prevails.
• They believe they can’t face the challenges of life, therefore they
avoid problems and challenges.
• Thus, they don’t mature, reinforcing the incompetence schema
and the feelings of hopelessness and helplessness.
• Their beliefs are: I can’t take care of myself, others must make
decisions for me, I can’t live alone.
• They are hypersensitive to criticism.
• Their high level of demand is a great burden for
their relationships.
• They are afraid of losing their identity and autonomy
if they relate to somebody.
• Thus, they can put an end to their relationships in
order to survive as individuals.
• They fear their ideas, needs and aspirations will be
overwhelmed by the assertive people around them.
• They repeat the same pattern in therapy, oscillating
between withdrawing and making excessive
demands on the therapist.
• They avoid thinking of sensitive material (cognitive
avoidance).
• Attempts at teaching them skills can be read as
“trying to get rid of them”.
• They have problems with homework, that makes
them anxious.
Histrionic/Narcissistic BPD
• Characterised by marked mood lability, stormy
relationships, overwhelming needs of care and
affection and extreme anger when their needs are
not met.
• They oscillate between and idealizing and vilifying
their therapists.
• They resort to exhibitionistic behaviors or
melodramatics to hold on to love and care.
• Their abandonment and unlovability schemas are
salient.
• They are the most likely of any subtypes to make suicidal
threats and gestures as cries for help or as ploys to
manipulate the therapists or others.
• They have serious difficulties in understanting boundaries
in interpersonal relationships.
• They think their needs are evident to others, that they
require immediate attention and that they are congruent
with the needs of the nurturer.
• They oscillate between demanding a symbiotic relationship
and believing that nobody will be able to help them
(punishing the other).
• They seek stimulation, excitement and novelty
around them intensely, but they hate to generate
changes within themselves.
• They seek continuous reassurance and approval to
support a fragile self-esteem. They think the love of
others will solve all of their problems.
• They idealize a person and become deeply
disappointed at the smallest hint that this person will
not be able to meet all their needs.
• Impulsivity, impatience and low tolerance of
frustration are the hallmark of this subtype.
• They readily express their anger to those who
have –in their perception- wronged them.
• They believe a lot in their emotions (they are
highly valued) and very little in sensible, rational
thinking.
Antisocial/Paranoid BPD
• Boys will be boys, bad boys, bad boys.
• They show a marked disregard for the formal and informal rules
that regulate social behavior.
• They break these rules to their own benefit, to gain money, power
and stimulation at somebody else’s expense.
• They have a grandiose view of their self-importance, together with

an attitude of open defiance.
• Their interests always come first; the need or desires
of others have no importance for them.
• They show a pervasive mistrust of others’ motives.

They are always alert to the potential threats of
others, whether real or imaginary.
• Jealousy and anger are extreme and easily

triggered. Criticism is taken with great animosity and
indignation.
• This grandiose presentation of self disguises a deep
feeling of self-doubt.
• They get involved in the same impulsive, hostile and
destructive behaviours of the “pure” antisocial or
paranoid person, but for different reasons.
• Antisocials seek self-benefit. BPDs tend to act out
their pain and hostility, hurting themselves and
others.
• “I don’t care what happens to me, so I can do as I
please”.
• Hostility, suspiciousness and recklessness
are the hallmark of the subtype. They have
a malevolent view of others (mistrust
schema) and a false sense of power.
• They tend to use and abuse those who

they love.
• They rarely have stable relationships.

• They do not feel close to anyone, but are
extremely possessive, demanding and
jealous in their relationships.
• Anger is the most common expressed

emotion, frequently under the form of
recklessness or physical attacks on others
(engaging in frequent fights).
• Gunderson and Zanarini (1987) have postulated
that this subtype would be typically male.
• A tendency to suicide could correlate with a

tendency to homicide.
• They cannot tolerate boredom and are thus inclined

to substance abuse, increasing their impulsivity and
lack of self-control.
• They show contempt for themselves (badness

schema) in the form of self-destructive behaviours.
Prevalence of BPD
(DSM-5, 2013)
• 0.8 - 2% of the general population (estimated)

• 1.1% in a recent Dutch study (Ten, Verheul,
Kaasenbrood, Tuithof, Kleinjan, 2016)
• 10% of psychiatric outpatients
• Up to 25% of psychiatric inpatients (Gunderson, 2009)
• 30% to 60% prevalence in clinical populations with
personality disorders
Prevalence of BPD
• 8-10% of people with BPD die by suicide
• Many more injure themselves
• Injuries to arms, legs and stomach are the most common
• Their prevalence is 2.5-7% in a teenage sample (12-
month period); 17% lifetime prevalence in American
college students (Franklin et al., 2010).
Course of BPD
• Chronic instability at the beginning of adulthood, with
episodes of intense emotional and behavioral
dysregulation, and intense use of mental health
resources.
• Deterioration and risk for suicide are greater in the
early years of adulthood, declining after 30 years of
age.
• They achieve more stability in their relationships and
work in the 4th/5th decade of their lives.
Family Pattern of BPD
BPD is five times more frequent in first-

degree relatives of BPD sufferers,
compared to the general population.
DBT and Multi-Problem Clients
DBT Perspective on Multi-Problem Clients
• Severe, dual, comorbid pathologies
• Diagnostic complexity
• Borderline clients as the paradigm of multi-problem clients
• Characterized by a generalized emotional dysregulation

Organization of DSM-IV Criteria (Linehan,
1993)
Self Dysfunction: inadequate sense of self,
sense of emptiness.
Behavioral Dysregulation: impulsive, self-
damaging, and/or suicidal behaviors.
Emotional Dysregulation: emotional lability,
problems with anger.
Interpersonal Dysregulation: chaotic
relationships, fears of abandonment
Cognitive Dysregulation: depersonalization,
dissociation, delusion.
Characteristics of BPD
(Linehan, 1993)
Emotional Vulnerability
Emocjonalna podatność na zranienie
Self-Invalidation
Samounieważnianie
Unrelenting Crises
Nieuniknione kryzysy
Characteristics of BPD
(Linehan, 1993)
Inhibited Grieving
Powstrzymywana żałoba
Apparent Competence
Pozorna kompetencja
Active Passivity
Aktywna bierność
• A pattern of pervasive difficulties in regulating negative
emotions, including high sensitivity to negative emotional
stimuli, high emotional intensity, and slow return to
emotional baseline, as well as awareness and experience of
emotional vulnerability.
• It may include a tendency to blame the social environment

for unrealistic expectations and demands.
Self-Invalidation
• A tendency to invalidate or fail to recognize one’s own
emotional responses, thoughts, beliefs and behaviors.
• Unrealistically high standards and expectations for self.
• May include intense shame, self-hate and self-directed

anger.
Unrelenting Crises
A pattern of frequent, stressful, negative

environmental events, disruptions and
roadblocks –some caused by the
individual’s dysfunctional lifestyle, other by
an inadequate social milieu, and many by
fate and chance.
Inhibited Grieving
• The tendency to inhibit, overcontrol or avoid

negative emotional responses, especially those
associated with grief and loss, including anger, guilt,
shame, panic and anxiety.
• Patients may seem to “survive” loss quite well, only

to experience difficulties later on.
Active Passivity
A tendency to passive interpersonal

problem-solving style, involving failure to
engage actively in solving of own life
problems, often together with active
attempts to solicit problem solving form
others in the environment; learned
helplessness, hopelessness.
Apparent Competence
• A tendency for the client to appear deceptively more

competent, capable or effective than she really is; usually due
to failure of competencies to generalize across expected
moods, situations and time, and failure to display adequate
nonverbal cues of emotional states, in many situations.
• Due to emotional instability, they can sometimes cope with
certain situations or challenges and sometimes they cannot.
• Some borderline patients perform well at work or are creative,
intelligent, and artistic, but they may not be so at times. This
creates confusion in people around them.
Biosocial Theory: A Dialectical
Theory of BPD Development
(Linehan, 1993)
BPD is primarily a dysfunction of the

emotion regulation system, resulting from
biological irregularities combined with
certain dysfunctional environments, as
well as from their interaction and
transaction over time.
Emotion Dysregulation and Borderline
Behavior Patterns. The Biosocial Theory
Emotion Regulation Dysfunction
Invalidating Environment
(Affective Instability)
Behavior Interpersonal Self Cognitive

Instability Instability Instability Instability
Emotion Dysregulation and Borderline
Behavior Patterns. The Biosocial Theory
Związek miedzy dysregulacją emocji a wzorcami zachowań
typowymi dla osobowości z pogranicza wg teorii biospołecznej
DYSFUNKCJA REGULACJI EMOCJI
UNIEWAŻNIAJĄCE ŚRODOWISKO
Emocjonalna podatność na zranienie

(Niestabilność afektywna)
NIESTABILNOŚĆ NIESTABILNOŚĆ NIESTABILNOŚĆ NIESTABILNOŚĆ

ZACHOWANIA INTERPERSONALNA Ja POZNAWCZA
Biosocial Theory of Emotional Dysregulation
Emotional Stimulus High Sensitivity High Reactivity Slow Return to Calm

Emotional
Vulnerability
Emotional Response
Biosocial Theory of Emotional Dysregulation
Emotional Stimulus High Sensitivity High Reactivity Slow Return to Calm

Emotional
Vulnerability
Emotional Response
Inabilty to regulate arousal when necessary Inability to withdraw attention from the Invalidation
emotional stimulus
Deficits in
emotion
Distortion in Information Processing Limitations in organizing and coordinating regulation
goal-oriented activities irrespective of
mood
Inability to control impulsive behaviors
related to strong negative emotions
Turn off, Freeze

Biosocial Theory
Biological dysfunction in the Emotion Regulation System
Produces a deficit in emotion regulation
Generalized Emotion Dysregulation

Biosocial Theory: A Dialectical
Theory of BPD Development
Teoria biospołeczna: dialektyczna teoria rozwoju
zaburzenia osobowości z pogranicza
Invalidating environments during childhood

contribute to the development of emotional
dysregulation, also failing to teach the
child how to tolerate emotional distress,
and when to trust her own emotional
responses as reflections of valid
interpretations of events.
Biosocial Theory
As adults, borderline individuals adopt the
characteristics of the invalidating
environment.
They tend to:
(a) invalidate their own emotional
experiences
(b) look to others for accurate reflections
of external reality
(c) oversimplify the ease of solving life’s
problems
Biosocial Theory
These behaviors leads to unrealistic goals, use of
punishment rather than reward, and self-hate following
failure to achieve these goals.
They become self-invalidating.

Clinical Implications of the Biosocial Theory
If we consider BPD as a dialectical failure,

then treatment must focus on overcoming
an either-or perception of reality and self,
enabling the patient to achieve a holistic
perception instead.
One basic principle in this endeavour is to

observe an adequate (and difficult)
balance between acceptance and change.
Temperament and Environment
Thomas and Chess have suggested that

goodness of fit or poorness of fit of the
child with the environment is crucial for
understanding later behavioral functioning.
Invalidating Environments
Unieważniające środowiska
An environment in which communication of private
experiences is met by erratic, inappropriate, and
extreme responses.
The expression of emotions is not validated, instead, it
is often punished, and/or trivialized.
The individual’s interpretation of his own behavior,
including the experience of the intents and
motivations associated with behavior, are dismissed.
It tells the individual that he is wrong in

both the description and analysis of his
own experiences, particularly in his views
about what causes his own emotions,
beliefs and actions.
• It attributes experiences to socially

unacceptable characteristics or personality
traits.
• The environment may insist that the
person feels, likes or has done something
different from what the person thinks he
feels, likes or has done.
Invalidating Environments
• They are generally intolerant of displays of negative
affect, at least when not accompanied by public events
supporting the emotion.
• The attitude communicated is that anyone who tries hard

enough can make it.
• This is similar to the pattern of high expressed emotion

(Leff & Vaughn, 1985).
Consequences
• An invalidating environment does not teach the
child to label private experiences, including
emotions, in a manner normative in the larger
community.
• By oversimplifying the ease of solving life’s

problems, it does not teach the child to tolerate
distress or to form realistic goals.
Consequences
• Extreme emotional displays often become necessary to
provoke a helpful response from the environment.
• It fails to teach the child when to trust his own emotional

and cognitive responses as reflections of valid
interpretations of individual and situational events.
Types of Invalidating Families
Chaotic Families
Little time or attention is given to the children; their needs
are disregarded and, therefore, invalidated.
“Perfect” Families
Parents cannot tolerate negative emotional displays from
their children. They tend to simplify the difficulties in
solving problems.
Invalidating Families
Typical Families
The individuated self in Western culture is defined by sharp
boundaries between self and others.
Mature persons are assumed to be controlled by internal
rather than external forces.
Self-control is expected, and defined as the ability to control
one’s behavior by using internal cues and resources.
Invalidating Families
• The emphasis on individual independence as normative
behavior is unique to, and pervasive in Western culture.
• It appears that there is a “poorness of fit” between

women’s interpersonal style and Western socialization
and cultural values for adult behavior (Linehan, 1993).
Sexual Abuse
• Sexual abuse is 2 to 3 times greater for females
than for males (Finkelhor, 1979).
• Childhood sexual abuse was reported by 86% of
borderline inpatients (34% in other psychiatric
patients) (Bryer et al., 1987).
• Childhood sexual abuse was reported in 67% to
76% of borderline outpatients (26% in other
psychiatric patients) (Herman et al., 1989, Wagner, Linehan
& Wasson, 1989)
Sexual Abuse
• Sexual abuse might be uniquely associated with BPD
(Linehan, 1993).
• A similar link has been found between childhood sexual
abuse and suicidal, parasuicidal behaviors. Up to 55% of
these victims go on to attempt suicide.
• Sexually abused women engage in more medically
serious parasuicidal behavior.
• Individuals with suicide ideation or parasuicide were 3
times more likely to have abused in childhood (Bryer et al,
1987).
Sexual Abuse and BPD
(Lambie, 2016)
Findings from one systematic review, one meta-analysis,
two cohort studies, two narrative reviews, and seven
primary studies identified in this report showed that:
· There is fair quality evidence that childhood sexual abuse is

moderately associated with BPD
· Fair quality evidence that the association between childhood
abuse and BPD traits may be mediated by common genetic
factors
(Lambie, 2016)
• Associations between childhood trauma and the development of
BPD are strong and consistently identified. However, childhood
sexual abuse may not be a specific/unique risk factor for BPD
• Instead, there appear to be more complex indirect relationships
between specific trauma types and later diagnosis of BPD.
• There is some evidence that those with early onset sexual abuse
are more likely to have a diagnosis of BPD than late onset, and
that severity of childhood sexual abuse is significantly related to
symptom severity in core sectors of BP psychopathology.
(Lambie, 2016)
• Given the identified limitations of the current literature and the
complex pathways linking childhood sexual abuse and BPD, it is
difficult to conclude whether childhood sexual abuse is a direct
and sufficient cause of BPD
• However, there is good quality evidence that childhood sexual

abuse is a likely risk factor for developing BPD symptomology
Sexual Abuse
• Abuse may not only be pathogenic for individuals

with vulnerable temperaments, it may “create”
emotional vulnerability by affecting changes in the
central nervous system.
• Chronic stress may have permanent adverse
effects on arousal, emotional sensitivity and other
factors of temperament.
Sexual Abuse
• It is a form of extreme invalidation. The victim is told that
abuse is O.K. but that they must not tell anyone else.
• If the child says something about the abuse she may be

disbelieved or blamed by family members.
Emotional Dysregulation and Invalidating
Environments
• A slightly vulnerable child, within a slightly
invalidating family can, over time, evolve into one in
which the individual and the family environment are
highly sensitive to, vulnerable to, and invalidating of
each other (Linehan, 1993).
• The child’s response to invalidation reinforces the

family’s invalidating behavior.
Environments
• Caregivers may expect more or different behaviors than the
child is capable of emitting.
• Excessive punishment and insufficient modeling, instructing,
coaching, and reinforcement follow.
• Needed help is not offered to the child. Unavoidable
punishment increases her negative emotions, leading to an
extreme expression of emotion.
• This is so aversive for caregivers that they stop attempts at
control.
Environments
Caregivers unwittingly reinforce the functional
value of extreme expressive behaviors, and
extinguish the functional value of moderate
emotional expression.
Appeasement after extreme emotional expression

may create the BPD pattern of behavior in adults.
Emotional Dysregulation
Most borderline behaviors are either

attempts on the part of the individual to
regulate intense affect or outcomes of
emotional dysregulation
(Linehan, 1993).
Emotional Dysregulation and Impulsive
Behavior
Suicide and other impulsive, dysfunctional
behaviors are usually maladaptive solution
behaviors to the problem of overwhelming,
uncontrollable, intensely painful negative
affect.
Borderline patients report substantial relief

from anxiety and intense negative affect
after cutting themselves (Leibenluft, Gardner
& Cowdry, 1987)
Emotional Dysregulation and Identity
Disturbance
Unpredictable emotional lability leads to
unpredictable behavior and cognitive
inconsistency, preventing the development
of a stable self-concept or sense of
identity.
The numbness associated with the inhibition

of emotional responses is experienced as
emptiness, that contributes to the absence
of a strong sense of identity.
Emotional Dysregulation and Interpersonal
Chaos
Successful relationships require a capacity

to self-regulate emotions in approppriate
ways, to control impulsive behaviors, and
to tolerate stimuli that produce pain to a
certain degree.
Principles of Learning
• Persistent problem behaviors are viewed as the result of
a deficit in skills and motivation
• DBT uses functional analysis or chain analysis to make

sense of a problem behavior
• Careful chain analysis is essential due to the central role

of emotion dysregulation in borderline personality disorder
Principles of Learning
It is useful to distinguish between:
a) Skills in a certain context, when people can do
something under ideal circumstances,
b) Compromised performance in certain contexts, the client

can do something under certain conditions,
c) Character trait, typical behavior across different contexts

Causes for the Absence of Skilled Behavior
Four factors for the absence of skilled behavior:
a) Deficit in skills
b) Reinforcement of problem behavior
c) Conditioned emotional responses
d) Beliefs and expectations
Skills Deficits
The therapists assesses whether the client is able to:
• Regulate emotions
• Tolerate distress
• Skillfully respond to interpersonal conflict
• Observe, describe, and participate without judging,
mindfully, and with a focus on effectiveness
• Manage own behavior by means of other strategies other
than self-punishment
Reinforcement of Problem Behavior
• Circumstances reinforce dysfunctional behavior or fail to
reinforce more adaptive behavior
• Dysfunctional behaviors may lead to positive results, or to

results sought by the client, or may permit other sought
behaviors or emotional states
• More effective behaviors may be followed by neutral

results or punishment, or reinforcement may be delayed
Conditioned Emotional Responses
• They may block more effective responses
• More effective behaviors may be blocked or inhibited by

fears, shame, guilt or intense, out-of-control emotions
• Client may be “emotion-phobic”; she may display avoidant

or escape response patterns in response to her own
emotional responses
Beliefs and Expectations
• Effective behaviors may be blocked by beliefs and
expectations
• Dysfunctional beliefs or expectations may precede the

problem behavior
• The person may not be aware of the rules operating in the

environment or in therapy
BPD as Dialectical Failure
(Linehan, 1993)
Borderline and suicidal individuals frequently

vacillate between rigidly held yet contradictory points
of view, and are unable to move forward to a
synthesis of the two positions.
They tend to see reality in polarized categories of

either-or, rather than all.
Borderline Behavioral Patterns:
The Three Dialectical Dimensions
Emotional
Vulnerability
Emocjonalna
Unrelenting podatność Active
Crises na zranienie Passivity
Nieuniknione Aktywna
kryzysy bierność
Biological
Wpływy biologiczne
Social
Wpływy społeczne
Apparent
Competence Inhibited Grieving
Pozorna Powstrzymywana
Self-invalidation żałoba
kompetencja
Samouniewaznianie
Dialectical Dilemmas in the Treatment of BPD
A group of three dimensions defined by

their opposite poles:
(1) emotional vulnerability versus self-
invalidation
(2) active passivity versus apparent
competence
(3) unrelenting crises versus inhibited
grieving
The Dialectical Dilemma for the Therapist
The therapist must strive for a dialectical balance

between validating the essential wisdom of each
patient’s experience (especially her vulnerability and
sense of desperation) and to teach the patient the
requisite capabilities for change to occur (Linehan, 1993).
Dialectical Dilemma 1 – Emotional
Vulnerability versus Self-Invalidation
• Emotional vulnerability is strongly linked to parasuicidal
behavior and therefore is a target in itself
• Increasing self-validation and decreasing self-invalidation

is a central secondary goal of DBT
• The explicit focus of on the need for an adequate self-

validation is a central point of DBT
Dilemma 1 – Emotional Vulnerability versus
Self-Invalidation
• Focusing on the acceptance of vulnerability and on the
limitations may lead the client to desperation, to the
feeling that her problems will always be what they are
• Focusing on change may push the client into panic

because she knows there is no consistent way in which
she may meet expectations
Dilemma 1 – Emotional Vulnerability vs
Self-Invalidation
RESOLUTION
• To negotiate this dilemma, the therapist must be flexible,
combining, moment by moment, the use of acceptance
and confrontational change strategies
• The therapist communicates that the client is doing the

best she can, but must nevertheless do better
Dilemma 2 – Unrelenting Crises versus
Inhibited Grieving
Unrelenting crises
• The secondary goal is to decrease crisis-generating
behaviors and to increase realistic decision-making and
good judgment
Inhibited Grieving
• The goal is to decrease inhibited grieving and increase
emotional experience
Dilemma 2 – Unrelenting Crises versus
Inhibited Grieving
• Unrelenting crises and inhibited grieving interfere with crucial tasks of
therapy (such as dealing with trauma)
• It is difficult to work with what is not resolved when avoidant reactions to

cues that evoke trauma and past losses are activated, particularly when
someone is in a permanent crisis
• Avoiding and escaping painful emotions through maladaptive behaviors

generates a new crisis, increasing the cues that evoke previous losses
and increasing the chance of new crises, thus generating a vicious circle
Dilemma 2 - Resolution
• Expect extreme displays of distress and complete
inhibition of affect
• Teach the necessary skills to tolerate the emotional

experience without involving in behaviors that may make
the situation worse
• At the same time, decrease the behaviors that lead to

future loss of relationships and other assets of the person
Dilemma 3 – Active Passivity versus
Apparent Competence
• When faced with difficulties at actively solving a problem,
help is sought from others
• It is a personality trait that leads to asking others to solve

one’s difficulties rather than personally facing the problem
• At the same time, borderline clients may seem to be more

effective, capable or skillfull than they really are
Dilemma 3 – Active Passivity vs Apparent
Competence
• Determine the level of help that must be offered and when the
client is able to do things by herself
• Occassionally, and for different reasons, the client will need more
help than the environment is willing to offer
• Apparent, intermmitent competence will drive people –including the

therapist- to expect more than the client can offer. It also leads
others to desensitize to low levels of expressions of distress
Competence
• “Doing something for” the client when the client is passive
but capable reinforces learned helplessness and blocks
the chance of learning to actively solve problems
• But “abandoning” the client without sufficient help blocks

the adequate learning of skills, and increases both panic
and the possibility of future dysfunctional behaviors
Competence
RESOLUTION
• Respond to the communication of low levels of distress
with active help
• Teach more effective behavior
• Insist on that the client solve problems on her own
Treatments for Borderline Personality
Disorder
Common Features of Effective Treatments for
BPD (Bateman & Fonagy, 2004)
• Well-structured
• They devote considerable effort to the enhancing of
compliance
• Clearly focused, be it on problem behavior (self-harm) or
on interpersonal relationship patterns
• Theoretically highly coherent to both therapist and patient
Common Features of Effective Treatments for
BPD (Bateman & Fonagy, 2004)
• They are relatively long term
• They encourage a powerful attachment relationship

between therapist and patient, enabling the therapist to
take an active rather than passive stance
• Well-integrated with other services available to the

patient
Dialectical Behavior Therapy
Dialectical Behavior Therapy
• A comprehensive cognitive-behavioral treatment for
complex, difficult-to-treat mental disorders.
• Originally developed for chronically suicidal clients, it has

evolved as a treatment for multi-disordered individuals
with BPD.
• It has been adapted for other behavioral disorders.

DBT
It is based on a combined capability deficit and motivational model
of BPD which states that:
(1) people with BPD lack important interpersonal, self-regulation

(including emotional regulation) and distress tolerance skills,
(2) personal and environmental factors often block and/or inhibit the
use of behavioral skills that clients do have and reinforce
dysfunctional behavior.
DBT
• It combines the basic strategies of behavior therapy with
eastern mindfulness practices.
• “Dialectical” refers both to the multiple tensions that arise
in the treatment of suicidal patients and also to the
emphasis on enhancing dialectical thinking to replace
rigid, dichotomous thinking patterns.
• The fundamental dialectics in DBT is between validation
and acceptance of the client as they are within the context
of simultaneously helping them change.
Basics of DBT

The therapist creates a validating, non judgemental context

Within that context he/she extinguishes or discourages maladaptive behaviors

Encourages the client’s adaptive behaviors

Finds the way to reinforce functional behaviors to foster their occurrence and
to discourage the use of dysfunctional behaviors

Combines cognitive-behavioral interventions, Zen meditative practices,
elements and interventions from psychodynamic, person-centered therapy,
Gestalt therapy, and paradoxical and strategic interventions

Dialectical philosophy influences and is present in every aspect of the
treatment
Five Functions of DBT
DBT is a comprehensive therapy that:
1) Enhances behavioral capabilities
2) Improves motivation to change (by modifying inhibitions

and reinforcement contingencies)
3) Assures that the new capabilities generalize to the

natural environment
DBT
4) Structures the treatment environment in the ways
essential to support client and therapist capabilities.
5) Enhances therapist capabilities and motivation to treat

clients effectively.
Origins of DBT
(Linehan, 2001)
• DBT grew out of a series of failed attempts to apply
standard cognitive and behavior therapy protocols of the
1970s to chronically suicidal clients.
• There were three main difficulties

Origins of DBT
Problems of Standard Approaches
1. Focusing on change procedures was frequently experienced
by the client as invalidating and often precipitated withdrawal
from treatment, attacks on the therapist or vacillation
between both poles.
2. Teaching and strengthening new skills was extraordinarily

difficult to do within the context of an individual therapy
session while concurrently targeting and treating the client’s
motivation to die and suicidal behaviors that had occurred
the previous week.
Origins of DBT
Problems of Standard Approaches
3. Individuals with BPD often unwittingly
a) reinforced the therapist for iatrogenic treatment (e.g., a
client stops attacking the therapist when the therapist
changes the subject from one the client is afraid to discuss
to a pleasant or neutral subject) and
b) punished them for effective treatment strategies (e.g., a
client attempts suicide when the therapist refuses to
recommend hospitalizations stays that reinforce suicidal
threats).
Origins of DBT
(Linehan, 2001)
• To overcome these difficulties, several modifications were
made that formed the basis of DBT.
• Strategies that reflect radical acceptance and validation of

clients’ functioning and current capabilities were added to
the treatment.
• The synthesis of validation, acceptance and change in

every intervention led to the term “dialectical”.
Origins of DBT
(Linehan, 2001)
• The dialectical emphasis brings together the technologies of
change, based on both principles of learning and crises theory,
and the technologies of acceptance, drawn from principles of
eastern zen and western contemplative practices.
• Treatment itself was split into many components (individual

therapy, group skills training, phone consultation, weekly DBT
team meeting).
DBT versus Standard CBT
• Focus on acceptance and validation of behaviors as they
are in every moment
• Emphasis on therapy-interfering behaviors
• The therapeutic relationship is the essential element of

the therapy
• Focuses on dialectical processes

Skills in DBT
• One of the key ideas of the model is that skills training
increases therapeutic efficacy in multi-problem clients with
emotional dysregulation
• DBT involves improving both the client’s and the

therapist’s skills
Two Groups of Skills
For the therapist For the client
Dialectical approachMindfulness
DBT case formulation Emotional modulation
Functional analysis Distress tolerance
Validation Surviving crises
Skills building Radical acceptance
Psychoeducation Validation, self-validation
Problem solving
Contingency management
Interpersonal effectiveness
Dialectical flexibility
Case Formulation – The Dialectical
Approach
A systemic interpretation of the client
Principle 1: The whole is the relationship between parts that are heterogeneous in polarity
(thesis and antithesis), resolved by a synthesis. Parts are in contradiction, forcing the
observer to focus on the interaction of parts towards resolution
Principle 2: Parts acquire their properties merely as components of that whole. No clinical
phenomenon can be understood out of the context in which it happens
Principle 3: The parts and the whole are interrelated. It is impossible for the client not to
alter the therapeutic system with which she interacts (and that would not exist without her).
Attending to parts other than the client is as important as to pay attention to the client
Principle 4: Change is the constant, stability is rare. It is not an ideal goal

Case Formulation. A Summary
1) The stage of therapy defines which is the primary objective of therapy, as
well as the goals on which to work
2) The biosocial therapy provides the key hypothesis about which variables
are fundamental for the development and maintenance of problem
behaviors
3) The principles of learning suggest both a method for the analysis of
behavior and for problem-solving
4) Behavioral patterns and dialectical dilemmas suggest secondary
behavioral patterns that are functionally related both to problem behaviors
per se as with the difficulties in changing these patterns
5) Dialectics between change and acceptance is the central dialectic of DBT
Assumptions of DBT
About Clients
1. People are doing the best that they can.
2. People want to improve
3. People must learn new behaviors both in therapy and in
the context of their day-to-day life
4. People cannot fail in DBT
Assumptions of DBT
About Clients
5. People may not have caused all of their problems, but
they have to solve them anyway.
6. People need to do better, try harder and be more
motivated to change.
7. The lives of people who are suicidal are unbearable as
they are currently being lived.
Assumptions of DBT
About Treatment
1. The most caring thing a therapist or treatment provider
can do is help clients change in ways that bring them
closer to their own ultimate goals.
2. Clarity, precision and compassion are of the utmost
importance.
3. The treatment relationship is a real relationship between
equals.
Assumptions of DBT
4. Principles of behavior are universal, affecting clinicians
no less than clients
5. Treatment providers need support
6. Treatment providers can fail
What do you think of these assumptions? Are any of them

contradictions? Can these assumptions still be true, despite
contradiction? Do these assumptions fit with your experience of
therapy?
Overview of Treatment
DBT for BPD consists of two basic interventions:
individual therapy and skills training, offered initially for a
one-year period, on a once-a-week basis for each
intervention.
The treating team also meets once a week for

consultation/supervision.
A Possible Ancillary Treatment Scenario in DBT
(Supervisor)
DBT
TEAM ST
(Pharmacotherapist)
(Physician)
(Supervisor) T (Inpatient Staff)

P
(Vocational
Counselor)
(Personal Therapist) (Case Manager) (Residential
Treatment Counselor)
Individual Therapy - Goals
• To increase motivation
• To decrease factors that inhibit effective behaviors
• To decrease factors that reinforce maladaptive behaviors
• To intervene in crises
Groups Skills Training – Goals
To learn and improve the necessary skills to change emotional, behavioral and
thinking patterns that are associated to life problems, i.e., those that generate
distress and sadness
Specific goals - Behaviors to decrease

• Conflictive interpersonal behaviors
• Emotional and mood instability
• Impulsivity
• Confusion in identity, cognitive dysregulation
Specific goals - Behaviors to increase

• Basic mindfulness skills
• Interpersonal effectiveness skills
• Emotion regulation skills
• Distress-tolerance skills
Phone Consultation – Goals
• Provides client the opportunity to reduce suicidal, parasuicidal
and maladaptive behaviors that are implemented to regulate
mood
• Teach client how to ask for help in a more adaptive way
• To facilitate the process of skill generalization
• To provide the opportunity to repair the therapeutic relationship

Weekly Meeting of the DBT Team – Goals
• To reduce the burnout of the therapist
• To reduce iatrogenic behaviors
• To give the therapist moral support

Structure of DBT
Stages of disorder, stages of treatment
The treatment frame is informed both by the
biosocial-transactional theory and by a model of the
stages of the disorder, creating a hierarchy of
interventions.
The central goal of DBT is creating a life worth living,
according to the core values of the patient.
The hierarchy of interventions is determined by this
goal.
Structure of DBT
Primary targets
The treatment focuses on the behaviors that interfere
most with the goals of each stage (e.g., cutting).
Secondary targets
These are patient behaviors, environmental events or
behaviors of others that are “on the chain” toward
the primary target (e.g., on the chain of the cutting
behavior)
Structure of DBT
Pretreatment
The patient is informed of the nature of treatment, including:
- how it is conducted and evaluated,
- the modes of treatment available,
- treatment target hierarchy,
- assessment procedures,
- agreed upon length of treatment (including factors that can
result in more or less tx),
- rules of the treatment setting
Structure of DBT
Pretreatment
Therapist and patient evaluate the pros and cons of
entering treatment. Clients complete daily monitoring
sheets, therapist demonstrates process of treatment.
Both evaluate factors that may interfere with active
participation and commitment.
Agreement is usually reached after 2 to 4 sessions in
an outpatient setting.
Structure of DBT
Individual Therapy
Stage 1
The main difficulty is behavioral dyscontrol. The goal for the
patient is to achieve behavioral control across all relevant
contexts.
This involves three domains:
- Life-threatening behaviors
- Therapy-interfering behaviors
- Severe quality-of-life interfering behaviors
Stage 1
Life-threatening behaviors
Suicidal and parasuicidal behaviors, aggression,
violence, child abuse and neglect.
Therapy-interfering behaviors
Absence from sessions, noncollaborative behaviors,
interfering with the treatment of other patients,
behaviors that can burn the therapist/team out or
decrease motivation-to-treat.
Stage 1
Severe quality-of-life-interfering behaviors
Severe drug abuse, a severe eating disorder, being
homeless or in jail, or any out-of-control behavior that
limits an acceptable quality of life.
Stage 1
• This stage involves teaching self-management skills,
strengthening them and generalizing them to the natural
environment.
• It also involves changing environments to make them

safer or more compatible with skillful living.
Stage 2
The main difficulty is emotional misery, thought to be related
to deficits in emotional experiencing (BPD patients are
emotion-phobic). The prototype problem in Stage 2 is
Posttraumatic Stress Disorder.
The client must learn to experience emotions effectively

(without escalating or blunting them).
Stage 2
• Treatment strategies in this stage may originate a
return to problematic behaviors addressed in Stage
1.
• If so, stage 1 strategies are applied again until

stabilization is achieved.
• Effective experiencing of emotions demands a

validating environment. A therapist may provide this
during exposure treatment for PTSD.
Stage 3
• The main difficulty in this stage is life problems. The target
is to ameliorate major life problems.
• The focus flows from problem solving (change) to
problem management (accepting problems in a way that
minimizes associated difficulties).
• Topics normally revolve around education, employment
and relationships.
• Summarizing what has been learned so far, increasing
self-respect and feelings of connectedness
Stage 3
The challenge is learning to live: defining goals of life, building self-respect,
finding peace and happiness, solving everyday problems and improving
enjoyment of living
The client explores common problems that make us happy/unhappy,
possibilities of improving relationships
Client is encouraged to develop a moderate self-confidence. Thus, the
therapist will focus less on the therapeutic relationship and more on the
client’s self-validation, self-care and problem solving
This stage is centered on improving quality of life by means of maitaining
progress and setting reasonable goals. The goal in this stage is the
promotion of happiness and stability
Stage 4
• The target in this stage is to enhance the capacity for
sustained contentment and joy; dealing with the
“incompleteness” of human experience.
• When basic problems have been solved, human beings

must still struggle with meaning, isolation, intimacy.
Stage 4
Finding a deeper meaning through spiritual existence. This

stage is specially meant for those clients who expect more
than a common life of happiness or unhappiness. It is an
additional goal leading to the connection with a greater whole
The goal is for the client to move from a feeling of

incompleteness to a life that involves the ability for sustained
freedom and joy. In this stage, the goal lies in achieving
trascendence and the building of the capacity for joy
Stage 4
These goals are achieved through a a therapy oriented to
the long-term understanding that is designed to integrate
the past, the present and the future. Therapists support
people in advancing their lives. In therapy, people may
improve the skills they have learned or work towards
spiritual achievement.
In sum, the goal is to help people achieve and maintain a

sustained capacity for happiness and success
Therapist Characteristics in DBT
Cechy terapeuty w DBT
Oriented to
Change
Orientacja
Unwavering na zmianę Benevolent
Centeredness Demanding
Niezachwiana Życzliwe
stabilność wymaganie
Nurturing Compassionate
Troskliwa Flexibility
Oriented to Współczująca
opieka Acceptance elastyczność
Orientacja na
akceptację
Dialectical Behavior Patterns:
Balanced Lifestyle
1. Skill enhancement vs. self-acceptance

2. Problem solving vs. problem acceptance
3. Affect regulation vs. affect tolerance
4. Self-efficacy vs. help seeking
5. Independence vs. dependence
6. Transparency vs. privacy
7. Trust vs. suspicion
Dialectical Behavior Patterns: Balanced
Lifestyle
8. Emotional control vs. emotional tolerance
9. Controlling/changing vs. observing
10. Attending/watching vs. participating
11. Needing from others vs. giving to others
12. Self-focusing vs. other-focusing
13. Contemplation/meditation vs. action
Treatment Strategies in DBT
STYLISTIC
CHANGE ACCEPTANCE
Irreverent Reciprocal
Problem Solving Validation
Consultation to Environmental
the patient Intervention
CASE MANAGEMENT
Therapist Supervision/
Consultation
Strategie terapeutyczne w DBT
STYLISTYCZNE
ZMIANA AKCEPTACJA
Bezceremonialne Wzajemme
Rozwiązywanie problemów Uprawomocnianie
Konsultacje z Interwencje
pacjentką środowiskowe
PROWADZENIE
PRZYPADKU
Superwizja/ Udzielanie
konsultacji terapeucie
Skills Training
Group Therapy
• Mindfulness skills
• Emotion regulation skills
• Distress tolerance skills
• Interpersonal effectiveness skills

Mindfulness Skills
Umiejętności uważności
• Training in attention control

• Awareness of self and others
• Reducing emotional reactivity
• Provides a foundation for self-validation,
reducing feelings of emptiness and self and cognitive
dysregulation
Emotion Regulation Skills
Umiejętności regulacji emocji
• Ability to identify and label emotions
• Reduction of vulnerability to negative emotion
• Reduction of suffering associated with negative
emotion
• Ability to change negative emotion, reducing
emotional lability, and problems associated with
anger and other negative emotions.
How DBT understands emotions
Emotional vulnerability
Changes
Nervous and Endocrine System
Expression
Body and face language
(neurochemicals and hormones)
Interpretations of the event (facial expression, poise, color
of skin)
Internal of body and face
(muscles, nervous signals, blood
pressure, cardiac rate, Name of the
Expression in words
Triggering Events temperature) Emotion
Sensation Action
(Experience) (doing something)
Secondary effects Action tendency
Activating event 2
How DBT regulates emotions
Reducing vulnerability with skills and

problem-solving
Psychopharmacological agents
Opposition body posture and
can improve neurological
facial expression
Challenging interpretations functions
Mindfulness of Emotions
Opposite action:
Reducing the occurrence of triggering Observe and
events with interpersonal effectiveness, To emotional urges both with describe emotions
distress tolerance and problem-solving Skills for distraction words and with facts
(but returning)
Till the end
Skills to accept reality
Using distress tolerance on secondary effects.
Repeat emotional modulation skills with
secondary emotions
Distress Tolerance Skills
Umiejętności tolerancji dystresu/ dyskomfortu
• Counterbalance of impulsivity
• Learning how to inhibit dysfunctional actions (substance

abuse, parasuicide)
• Learning to tolerate intense emotional pain and urges to

engage in problematic responses (not to exacerbate
misery or suffering)
Interpersonal Effectiveness Skills
Umiejętności interpersonalne
• Learning how to achieve interpersonal goals.
• Manage relationships effectively.
• Maintain self-respect in interpersonal situations.
• Learning the –difficult- balance between situational

objectives with relationship objectives while maintaining
self-respect.
Intervention
Mindfulness Emotion Regulation
Observe. Describe. Participate Identifying emotion
One thing at a time. Without judging Understanding the function of emotion
Being effective Reducing vulnerability
Wise mind Mindfulness of emotion
Opposite action
Tolerating distress
Tolerating without making the crisis worse Interpersonal Effectiveness
Distract with wise mind
Calming down with 5 senses Factors that reduce effectiveness
Improve the moment Modulating intensity
Pros and Cons Asking or saying no
Radical acceptance How to achieve my goals
Half smile How to maintain a relationship
Good will and disposition How to maintain my self-respect
Changing the mind
Basic Treatment Strategies
1. Dialectical Strategies
Dialektyczne strategie leczenia
2. Core Strategies Strategie zasadnicze
3. Stylistic Strategies Strategie stylistyczne
4. Case Management Strategies

Strategie prowadzenia przypadku
Dialectical Strategies
Two levels of therapeutic behavior:
 Alert to the therapeutic interaction
 Teach and model dialectical behavior

patterns out of the therapeutic interaction
Specific Dialectical Strategies
• Entering the paradox

Patient’s own behavior, the therapeutic
process and reality in general.
• Using metaphors, parables and stories
• The Devil’s Advocate Technique
• Extends the seriousness or
implications of patient’s comunication
Specific Dialectical Strategies II
5. Activating “Wise Mind”
6. Making lemonade out of lemons
7. Allowing natural change in therapy
8. Dialectical Assessment: examining both the

individual and the broader social context
Core Strategies
Strategie zasadnicze
1. Problem-solving strategies
Strategie rozwiązywania problemów
2. Validation strategies
Strategie uprawomocniania
Validation
• It is about accepting experiences without trying to modify them (by
adding or substracting anything)
• Adopting a stance of warm listening and holding, away from
advice, critical or judgmental interpretations
• It is not about agreeing on how the other person feels or reacts
• It is not about understanding, reinforcing, praising, solving or
comforting
• Validation strategies basically involve maintaining an non-
judgmental attitude and a continuous exploration of the essential
validity of the responses of others
Validation
https://www.youtube.com/watch?v=-KXJobu6TG8
Six Levels of Validation
1. Listen and observe. Genuine interest in the client
2. Comment accurately on what has been understood.

Communicate to the client understanding and reflection
on what was said
3. Put words to what is left unsaid. Communicate

understanding of aspects not communicated by the
client
Six Levels of Validation
4. Sufficient cause, historic vision of behavior. Validating behavior by
means of showing why it is caused
5. Reasonable in the moment. Show reasonable and well-based

aspects with respect to the environment’s response, avoiding
remarks on dysfunctional aspects
6. Treat the person with the respect due to every human being.
Believe in the client as an individual capable of changing, as a
person of equal status and deserving of respect
Defining Validation
UPRAWOMOCNIANIE
 The therapist communicates to the patient that her

responses make sense and are understandable
within her current life context or situation
 Validating the patient’s history is not the same as

validating her current behavior
 Three steps: Active Observing, Reflection, Direct

Validation
Validation
Active observing
Therapist observes the actual emotions, thoughts and behaviors of
the patient, letting go of theories, prejudice or any other bias.
With a “third ear”, the therapist listens to the unstated emotions,

thoughts, values, beliefs, trying to read the patient’s mind. Patient
will have to acquire this ability in therapy.
Validation
Reflection
Therapist reflects thoughts, emotions, assumptions and behaviors to
the patient in a non-judgmental manner and asks “is that right?”
Direct validation
Therapist attends to the aspects of the response of the patient that
are reasonable or appropriate in the context, even when he/she can
appreciate the dysfunctional nature of the patient’s response.
Validation Strategies
• Emotional validation strategies
• Cognitive validation strategies
• Behavioral validation strategies
• Cheerleading
Emotional Validation Strategies
1. Providing opportunities for emotional expression
2. Teaching emotion observation and labeling skills
3. Reading emotions: timing and offering multiple-choice

emotion questions
4. Communicate the validity of emotion

Behavioral Validation Strategies
Teaching behavior observation and labeling skills
Many times clients do not understand their own behavior
because other people explain it in terms of presumed
motives (e.g.,“you are trying to control me”) rather than in
purely behavioral terms (“you are changing the topic”).
Use Socratic questioning; discriminate between motives

and judgmental labels
Identifying the “Should”
Client has unrealistic demands on her own behavior (“I should have acted
differently”). Therapist identifies ineffective strategies for behavior modification,
describes uses of guilt, self-berating and other punishment strategies
Countering the “Should”

Any standard not realized is unrealistic in the present moment (wishing reality to
be different does not change reality)
Everything that happens “should” happen, given the context;
Discriminating between why something happened from approving the event.
Accepting the “Should”
Therapist responds to client’s behavior non-judgmentally and
explores the validity of her “should in order to”
Therapist looks for nugget of truth in patient’s behavior when
patient’s prediction is accurate.
Moving to the dissapointment

Events are understandable, but so is the patient’s disappointment
(both must be validated).
Cognitive Validation Strategies
1. Eliciting and reflecting thoughts and assumptions
2. Discriminating facts from interpretations
3. Finding the “Kernel of Truth”
4. Acknowledging “Wise Mind”
5. Respecting differing values

Cheerleading Strategies
1. Assuming the best
2. Providing encouragement
3. Focusing on the patient’s capabilities
(a) communicating that the patient has what it takes to
succeed,
(b) expressing belief in the therapeutic relationship,
(c) validating the patient’s emotions, behaviors, thinking
Cheerleading Strategies
1. Contradicting/modulating external criticism
2. Providing praise and reassurance
3. Being realistic, but dealing directly with fears of
insincerity
4. Staying near
Levels of Problem Solving
1. The entire DBT program can be seen as a
general application of problem solving
2. Figuring out which strategies and

procedures should be applied to this
specific patient, at this moment, for this
problem
3. Addresses specific problems: reviewing

diary cards, responding to questions about
suicide ideation or parasuicide
Behavioral Analysis Strategies
1. Defining the problem behavior (describing the problem
specifically): frequency, duration, intensity and
topography
2. Chain analysis :
a. Select one instance of problem to analyze;
b. Attend to small units of behavior in terms of emotions, bodily
sensations, thoughts and images, overt behaviors and
environmental factors.
3. Generate hypotheses about variables influencing or

controlling the behaviors in question: use the previous
analysis to guide the current one
Chain Analysis
Utility
It makes an effective intervention possible

If we are good at chain analysis, we will be able to make an accurate diagnosis of the situation
and perform an effective intervention
Steps
Identifying vulnerability factors
Identifying antecedents and triggering events
Identifying crises or problem behaviors
Identifying consequences
Instructions
Chain Analysis
One of DBT’s main techniques
Behavioral assessment, link by link, of problem behavior or crisis
Without judging, invalidating or pathologizing
Objectives
Find out what the problem is, what is causing it, what is interfering with problem-solving, and
what resources are available to help solve the problems
The aim is to see empirically what the therapist is guessing based on experience with a certain
client, in a certain way it is a counterpoint to the therapist’s bias
Insight (Interpretation) Strategies
5. Highlighting the patient’s behavior: the therapist gives
the patient feedback about some aspect. In the case of
negative behaviors, try to balance highlighting of a
patient’s strengths with a focus on problematic
responses
6. Observing and describing recurrent patterns (thoughts,

affective responses, behavioral sequences): look for
those relationships that will throw light on causal
patterns
Insight (Interpretation) Strategies
7. Commenting on implications of behavior: “if - then” rules or
relationships of which the patient may not be aware. Be particularly
careful about suggesting that consequences are painful or socially
unacceptable
8. Assessing difficulties in accepting or rejecting hypotheses:

recurrent pattern or implication that is not recognized by the patient;
the pattern or implication may be recognized, but the patient may
have difficulty either acknowledging it to the therapist or accepting
its reality
Didactic Strategies
1. Providing information about the
development, maintenance, and
change of behavior in general
2. Giving reading materials about

behavior, treatments, BPD
3. Giving information to family members

(handouts, group psychoeducation)
Solution Analysis Strategies
1. Identifying goals, needs and desires: help to
redefine wishes to engage in parasuicidal
behavior as expressions of desire to decrease
pain and improve quality of life; redefine lack
of desire to change or inability to generate
goals as an expression of hopelessness and
powerlessness
2. Generating solutions: brainstorm; specific

coping strategies to shortcircuit impulsive,
self-damaging behaviors
Solution Analysis Strategies
1. Evaluating solutions: focus on consequences, short-
and long-term; discuss problem solution criteria;
identify factors that might interfere with problem
solutions
2. Choosing a solution or implementing it: specific DBT

procedures (case management, skills training
strategies, exposure strategies, cognitive modification
strategies, contingency management strategies)
3. Troubleshooting the solution: review the patient’s ways

in which attempts to solve problem can go wrong
Orienting Strategies
1. Providing role induction: therapist

orients patient to DBT and to her role
in therapy
2. Rehearsing new expectations:

therapist rehearses with patient
exactly what she is to do in trying to
respond to the problem
Commitment Strategies
1. Selling commitment: evaluating the pros and cons
2. Playing the Devil’s Advocate
3. “Foot-in-the-door/Door-in-the-face” techniques
4. Connecting present commitments to prior commitments
5. Highlighting freedom to choose and absence of
alternatives
6. Using principles of shaping
7. Generating hope: cheerleading
8. Agreeing on homework
Contingency Procedures
Strategie kontyngencyjne/ Sterowanie uwarunkowaniami
• Rationale for contingency procedures

Uzasadnienie procedur sterowania uwarunkowaniami/ kontyngencyjnych
• The distinction between managing contingencies
and observing limits
Różnica między sterowaniem uwarunkowaniami a przestrzeganiem
granic
• The therapeutic relationship as contingency
Relacja terapeutyczna jako kontyngencja
Contingency Management Procedures
• Reinforcing target-relevant adaptive behaviors
Wzmacnianie adaptacyjnych zachowań istotnych ze względu na cel
• Extinguishing target-relevant maladaptive behaviors
Wygaszanie dezadaptacyjnych zachowań istotnych ze względu na cel
• Using aversive consequences … with care
Wykorzystywanie konsekwencji awersyjnych… z ostrożnością
Observing – Limits Procedures
Procedury przestrzegania granic
1. Monitoring limits
2. Being honest about limits
3. Temporarily extending limits when needed
4. Being consistently firm
5. Combining soothing, validating, and problem solving
with observing limits
Skills Acquisition Procedures
1. Instructions in skill to be learned: therapist specifies
necessary behaviors and their patterning in concrete
terms, breaks instructions down into easy-to-follow
steps, begins with simple tasks, provides examples
and gives handouts
2. Modeling skilled behavior: role-play, therapist uses

skilled behavior in interacting with patient, thinks out
loud (self-talk), tells stories illustrating skilled behaviors
Skills Strengthening Procedures
1. Behavioral rehearsal: role-play,
therapist guides patient in session
practice, imaginal (covert) practice and
in vivo practice
2. Reinforcement of new skills
3. Feedback and coaching

Skills Generalization Procedures
1. Generalization programming: variety of
skilled responses to each situation;
therapeutic relationship
2. Between-session consultation: apply skills

in vivo; therapist assists patient in applying
skills to problem situations via phone calls
3. Providing session recordings for review: to

listen to in-between sessions
Skills Generalization Procedures
4. In vivo behavioral rehearsal assignments: therapist gives
specific tasks to practice with skills training therapists and skills
training therapists give task to practice with individual therapist
(in standard DBT)
• Environmental change: therapist helps patient to create an

environment that reinforces skilled behaviors
Exposure-Based Procedures
1. Providing non-reinforced exposure to

cues that elicit problematic emotions
2. Blocking action tendencies associated

with problem emotions: escape/avoid,
hide or withdraw, repair or self-punish,
hostile and aggressive responses
Exposure-Based Procedures
3. Blocking expressive tendencies
associated with problem emotions:
therapist helps patient express converse
emotions to those he/she is feeling
(therapist differentiates “masking” from
expressing a different emotion).
4. Enhancing a sense of control over

aversive events
Cognitive Modification Procedures
1. Contingency clarification procedures:
Procedury wyjaśniania uwarunkowań/ zależności/ kontyngencji
1. Highlight current contingencies
2. Communicating future contingencies in therapy
2. Cognitive restructuring procedures:

Procedury restrukturyzacji poznawczej
3. Teaching cognitive self-observation
4. Identifying and confronting maladaptive cognitive content and style
5. Generating alternative, adaptive cognitive content and style
6. Developing guidelines for when to trust and when to suspect interpretations
Schema Therapy for Borderline
Personality Disorder
(Young, 1990; Young, Klosko & Weishaar,
2004; Arntz & van Genderen, 2009)
Schema Therapy
A General Overview
Schema Therapy
• ST integrates techniques
- Experiential (imagery rescripting, psychodrama)
- Cognitive (education, challenging, experiments)
- Behavioral (reinforcement, skills training)
- Relationship (limited reparenting, transference)
• Focus on:
- Past (processing of traumas)
- Present
- Therapeutic relationship process
Schema Therapy vs Regular CBT
(Arntz, 2017)
• Focus on needs
• Focus on childhood experiences and relationships
• Patients can switch into different emotional states (schema
modes)
• Experiential methods added to cognitive and behavioral methods
• Therapeutic relationship used to meet needs and repair early
relationship representations and safe attachment offered
Patients’ Perspective
• “Schema therapy is a lot more individually tailored. You
look at where are the main focus points, in what modes
are you most of the time, where do we have to work on
the most? In the others it was always only to look for a
skill! Those skills do not help me, I cannot look for some
skills the whole day” (P compares ST to DBT)
(Tan, Lee, Averbeck, Brand-de-Wilde, Farrell, Fassbinder, Jacob, Martius, Wastiaux,
Zarbock, & Arntz, 2018)
Patients’ Perspective
• 16 patients indicated that ST seems to delve deeper into possible
reasons for one’s unique way of thinking, feeling and behaving
compared to their past therapies, primarily DBT.
• “You just learn in DBT how to survive with skills, while in ST, you
come to think and therefore also could aim at changes, and not
only to distract, to stop injuring myself but also via the thinking
level” (patient 2219, Tan et al, 2018)
Early Maladaptive Schema
Wczesny schemat dezadaptacyjny
(Young, 1990, 1999)
A broad pattern or topic,

comprising memories, emotions, cognitions and
bodily sensations,
relative to the self and to one’s relationships with
others,
that develops during childhood or adolescence,
is elaborated along the life of the person,
and is highly dysfunctional
Obszerny, ogólny temat, wątek treściowy dotyczący Ja
jednostki, jej relacji z otoczeniem, sformułowany w
dzieciństwie, rozwijany w ciągu całego życia i w
znacznym stopniu dysfunkcjonalny dla jednostki
Early Maladaptive Schemata
• EMSs are cognitive and emotional patterns that
turn against the person, that develop from the
beginning of life and are repeated throughout that
person’s life.
• In Young’s model, the behavior associated to the

schema is not part of it; these behaviors develop in
response to the schema.
• EMSs develop as survival strategies. They are related to
the search for consistency. They are what the person
knows. Although it may cause suffering, they are
comfortable and familiar. They are considered to be self-
evident.
• The afflicted person would be attracted by the events that

trigger the EMS, this is why they are so difficult to change.
• EMSs are representations based on the
reality of the child’s environment. They
reflect with precision the tone of the early
environment (the attribution may be
biased, but the perceived tone is correct).
• EMSs are dimensional: they have different

levels of severity and pervasiveness.
• The more severe the schema, the greater the number of
situations that will trigger it.
• The more negative the schema, the greater the negative

affect caused by its activation and the greater the period
for which it will remain activated.
• The succesful or faulty solution to each

problem posed by the level of
development (Erikson, 1950) will generate
an adaptive or maladaptive schema.
Origin of EMSs
• EMS develop as a consequence of an early neglect
of basic emotional needs.
• These are:
Safe attachment to others (security, stability,
acceptance)
Autonomy, competence and sense of identity
Freedom to express valid needs and emotions
Spontaneity and play
Realistic limits and self-control
Origin of EMSs
• The dysfunctional interaction between the temperament
and the environment frustrates the child.
• The goal of schema therapy is to find adaptive ways of

attaining basic emotional needs.
Early Life Experiences
• Early toxic experiences are the main origin of EMSs.
• The strongest EMSs originate in the family.
Schemata developed later in life are not so
dominant.
• Four types of early life experiences:
toxic frustration of needs, excess, traumatization or
victimization, selective internalization.
• Toxic frustration of needs (the child receives little of
something good, developing a EMS of emotional
deprivation or abandonment)
• Traumatization, victimization (the child is hurt or

victimized, leading to a schema of mistrust/abuse,
shame/badness, or vulnerability to harm)
• Excess; the child experiences too much of a good thing
(leading to a EMS of dependence/incompetence, or of
entitlement/grandiosity)
• Selective internalization/identification with the other (the

child selectively internalizes thoughts, experiences and
behaviors of the other person).
Emotional Temperament
• The model postulates the existence of dimensions of
temperament that would be innate and relatively impermeable to
psychotherapeutic change. These are:
Lability -- Non reactive
Disthymic -- Optimistic
Anxious -- Calm
Obsessive -- Distracted
Passive -- Agressive
Irritable -- Cheerful
Shy -- Sociable
Emotional Temperament
• Temperament would result from the combination of each
position on each of these continua.
• Temperament interacts with the painful events of

childhood, leading to EMSs.
Origins of BPD – A Hypothesis
(Young, Klosko & Weishaar, 2003)
Biological Factors
The temperament of BPD patients is characterized by intense and
labile emotionality. This would represent a biological
predisposition to the disorder.
The higher frequency of BPD in women could be a result of

temperamental differences, or of the higher frequency of sexual
abuse, or of submission and restraint in the expression of anger.
It could also be that BPD is less diagnosed in men.

Environmental Factors
Family environment is unsafe and unstable
Family environment is characterized by emotional
deprivation
Family environment is harshly punitive and
rejecting
Family environment is subjugating.
Schema Domains
Domeny schematów
Non-attained basic needs are grouped into five

categories called schema domains:
Domain I Disconnection and Rejection

Domain II Impaired Autonomy, Performance
Domain III Impaired Limits
Domain IV Other-directness
Domain V Inhibition and Overvigilance
Disconnection and Rejection
Opuszczenie, odrzucenie
Patients with schemas in this domain lack the ability to establish a
safe and satisfactory attachment.
They believe their needs for stability, security, love and belonging
will not be met.
Families of origin are unstable (abandonment, instability), abusive
(mistrust/abuse), cold (emotional deprivation), contemptuous
(deffectiveness/shame) or isolated (social isolation/alienation).
The abandonment/instability schema is the instability
perceived in one’s connection with significant others.
People with the mistrust/abuse schema are convinced that,

given the opportunity, other people will use them for their
own selfish ends.
The schema of emotional deprivation involves the

expectation that one’s wishes for emotional connection will
not be adequately met. It may take the form of (1)
deprivation of affection, (2) deprivation of empathy, (3)
deprivation of protection.
The schema of deffectiveness/shame generates the
feeling that one if deffective, bad, mean, inferior, and that
therefore will not be lovable.
The schema of social isolation / alienation involves
feeling that one is different or does not fit in the social
world that exceeds the family.
Impaired Autonomy and Performance
Ograniczenie autonomii i funkcjonowania
Patients have expectations about themselves and the world that

interfere with their ability to differentiate from their parental
figures and to function independently.
The schema of dependence/incompetence involves feeling
uncapable of facing daily responsibilities without considerable
help from others.
Vulnerability to harm or to illness is the exaggerated fear of
facing unexpected, unmanageable catastrophes.
Fears may involve:
(1) health (AIDS, myocardiac infarction)
(2) emotional (losing control, going crazy)
(3) external (accidents, catastrophes)
Impaired Autonomy and Performance
• Patients with the emmeshment/underdeveloped self

schema relate to other person in an exaggerated way, at
the expense of their own development as individuals.
They believe they cannot cope on their own, and often
feel suffocated or fused with the other person, lacking a
sense of individuality and direction in their lives.
• The schema of failure involves the belief that one will

inevitably fail in the realm of life achievement.
Impaired Limits
Zachwianie granic
Patients have not developed adequate internal limits in terms

of reciprocity or self-discipline. They have problems with
respecting other people’s rights, cooperating, observing
commitments, or reaching long term goals. They are
narcissistic, selfish, spoilt or irresponsible.
The schema of grandiosity/entitlement involves the
assumption that one is superior to other people and therefore
is entitled to privileges.
Patients with insufficient self-control and self-discipline
cannot or will not exert sufficient self control and tolerance to
frustration in order to achieve their personal goals.
Other-directedness
ukierunkowanie na innego
Patients put an excessive emphasis in satisfying the needs of

others rather than their own. They do so to win approval, to
maintain connection or to avoid retaliation. They are often
unaware of their preferences and their anger.
• The schema of submissiveness is the excessive
submission to the other person because one feels coerced.
Its usual function is to avoid anger, revenge or
abandonment.
• It may take the form of:
(1) submission of own needs, or rather
(2) submission of emotions (e.g., suppression of anger)
Other-directedness
• The self-sacrifice schema leads people to willingly sacrify

their personal gratification to attend to the needs of others.
Its goal is to save others from pain, avoid guilt, maintain
self-esteem or mantain an emotional connection with
someone who is perceived as needy.
• Patients with the approval or recognition seeking
schema value being approved or recognized over the
development of a safe and genuine identity. Their self-
esteem depends on the reaction of others, rather than their
own. They worry about their social status, aspect, money or
success as indicators of social approval.
Overvigilance and Inhibition
Nadmierna czujność i zahamowanie
• The unrelenting standards/hypercriticism schema

involves believing that one must strive to achieve very high
internal standards, usually to avoid disapproval or shame.
It generates constant feelings of pressure on oneself and
others. It may take the form of (1) perfectionism, (2) rigid
rules (shoulds), (3) worrying about time and efficiency.
• The schema of punishment is the conviction that people
should be harshly punished for making mistakes. It leads to
being intolerant with those who do not meet our
expectations (including oneself).
• They suppress their spontaneous feelings and
impulses, and struggle to meet rigid internalized rules
at the expense of happiness, relaxation, health or
close relationships.
• As children, they were not encouraged to play and

experiment, but to expect negative events in a
hypervigilant way, and to have a negative view of life.
• The schema of negativity/pessimism is a pervasive and
lasting focus on the negative aspects of life, together with a
minimization of the positive aspects. They are characterized
by worrying, indecission, complaints and hypervigilance.
• Patients with emotional inhibition restrict their spontaneous

actions and feelings not to be criticized or not to lose control
over their impulses.
They inhibit (1) anger, (2) positive impulses, (3) have
problems with expressing vulnerability, (4) emphasize
rationality at the expense of emotionality.
They are perceived as cold, withdrawn, flat.
Unconditional and Conditional Sch.
Unconditional Schemata Conditional Schemata
Abandonment/instability Submission
Mistrust/abuse Self-sacrifice
Emotional Deprivation Approval and recognition seeking
Deffectiveness Unrelenting standards/hypercriticism
Emotional inhibition
Social Isolation
Dependence/incompetence
Vulnerability to harm or illness
Emmeshment/Underdeveloped self
Failure
Negativity/pessimism
Punitivenesss
Entitlement/grandiosity
Insufficient self-control and self-discipline
Detecting the Activation of a Schema
Abandonment
https://www.youtube.com/watch?v=kAQnMtk1xUU&t=1s
Emotional Deprivation
https://www.youtube.com/watch?v=cUCeQi9suJ4
Vulnerability to harm
https://www.youtube.com/watch?v=7e6YSrvHw1Q
PD and Dominant Schemata
(Sprey, 2002)
Paranoid Mistrust /abuse
Emotional deprivation
Social isolation / Alienation
Schizoid Social / Alienation
Schizotypal Social isolation / Alienation
Mistrust / Abuse
Antisocial Abandonment / instability
Mistrust /abuse
Entitlement
Insufficient self-control, self-discipline
PD and Dominant Schema
(Sprey, 2002)
Borderline Abandonment / instability
Mistrust / abuse
Deffectiveness / shame Dependence /
Incompetence
Vulnerability to harm / illness
Insufficient self-control, self-discipline Submission
Emotion inhibition
Punitiviness
(Sprey, 2002)
Histrionic Abandonment / instability
Entitlement
Narcissistic Entitlement
Deffectiveness / shame
Avoidant Social isolation / alienation
Social undesirability
(Sprey, 2002)
Avoidant Failure
Submission
Dependent Dependence / incompetence
Abandonment / Instability
Submission
Obssesive-Comp. Unrelenting standards / hypercriticism
Emotional inhibition
Passive-agressive Failure
Mistrust / abuse
(Sprey, 2002)
Depressive Mistrust / abuse
Social isolation / alienation
Social undesirability
Failure
Submission
Schema Processes
Procesy schematów
• Schema activation /aktywacja schematu
(When the patient’s “buttons get pushed.” When they “make
mountains out of molehills.”)
• Schema maintenance/ poddanie się
(The “self-fulfilling prophecy.” When patients keep bringing
about their own worst nightmares.)
• Schema avoidance/ unikanie
(“Out of sight, out of mind, out of touch.” When patients
structure their lives so as never to be able to test or disprove
their most destructive beliefs.)
Schema Processes (Cont’ed)
• Schema compensation/ kompensacja
(When patients try to solve an extreme problem by going
to the opposite extreme, thus causing a new problem
without ever solving the old problem)
• Schema antagonism and vacillation/ sprzeczność/ oscylowanie

(Cognitive and emotional “gridlock.” “Damned if you do,
and damned if you don’t.” When patients hold mutually
exclusive schemas at the same time, or in sequence, thus
leading to “roller-coastering.”)
Healing of the Schema
• It is the ultimate end of therapy.
• Healing reduces the intensity of the memories linked

to the schema, the emotional charge of the schema,
the strength of bodily sensations and dysfunctional
cognitions.
• Treatment includes, therefore, cognitive, emotional,

and behavioral interventions.
Healing of the Schema
• As the schema heals, it activates less easily, and when it
does, it generates a less overwhelming feeling, and the
patient recovers more rapidly.
• Complete healing is never achieved, since we cannot

erase the events associated to the trauma. Patients must
learn to respond to its activation in a healthier way.
Coping Styles and
Maladaptive Responses
• The behavior associated to the schema is not part of it, it is part of

the coping response. Although most coping responses are
behavioral, they can also be cognitive or emotional strategies.
• A differentiation between schema and coping response is made

because patients use different coping styles in different life
situations to deal with the same schemata.
Coping Styles and
• The three basic responses to danger (fight, flight,

freezing) correspond to three coping styles:
overcompensation, avoidance or surrender.
• Overcompensation relates to fighting, avoidance to

fleeing, and surrender to freezing.
• These styles normally operate without the person’s

awareness.
Coping Styles and
• The activation of the schema is a threat (frustration of a basic
need and associated emotions) to which the person responds with
a coping style.
• They were adaptive in childhood, but they become dysfunctional

as time goes by because the coping style perpetuates the
schema, even when conditions improve and the person has got
better options.
Coping Styles and
Surrendering to the schema
• Patients do not question the schema and cannot avoid, they just
accept it as being true.
• When they encounter the triggers of the schema they react with
disproportionate emotions. They choose partners that will treat
them like the “offending” parent did. They relate to these people in
a passive, obedient way, and this perpetuates the schema.
Coping Styles and
Avoidance of the schema
• Clients organize their lives so that the schema is never
activated. They behave as if the schema did not exist and
block the images that can activate it. They also avoid the
emotions associated to the schema.
• They may avoid complete areas of their lives, such as job

challenges or intimate relationships.
• In therapy, they “forget” to do homework, they only talk

about superficial issues, they are late for sessions or
abandon treatment prematurely.
Coping Styles and
Overcompensation of the schema
• Clients think, feel and act as if the opposite of the schema were
true. They struggle to be as different as possible from the child
they were when they developed the schema.
• They may seem very healthy (many successful people employ
this coping style), but they remain stuck in counter-attack mode.
• It offers an alternative the feelings of helplessness associated to
the origin of the schema.
Differences in temperament would determine the selection of the

dominant coping styles
Coping Responses
• They are the specific behaviors by which the coping styles
are expressed.
• The coping style is a trait, whereas the coping response is a

state (the response given by the person at a given
moment).
• Young’s model accounts for chronic, pervasive

characterological patterns, in terms of schemata as well as
in terms of coping responses, relating them to their early
origin, thus providing clear indications for treatment .
Young’s Model
Schemas and Modes
Model SCHEMATÓW i AKTYWNYCH STYLÓW SCHEMATÓW Younga
• Young’s original model (1990) posited that personality
disorders were the result of the prevalence of certain –and
different- schemas (unconditional, rigid, basic cognitive
structures).
• BPD patients scored high on almost all of the 16 schemas. It
became evident that a more inclusive unit of analysis was
necessary.
• The original model was a trait rather than state model. This
could hardly account for the ever-changing behavior of BPD
patients.
• Schema modes are the emotional states and the
coping responses –adaptive or maladaptive- that we
experiment at a given time. They are the schemas or
schema operations that are active in a person at a
given time.
• Schema modes are triggered by vital situations to
which we are hypersensitive.
• The object of the therapy is to move from a
maladaptive schema mode to an adaptive one (the
healthy adult).
• A mode is the conceptual answer to the question “what
group of schemas or schema operations is the patient
enacting at this present moment?”
• A dysfunctional schema mode is activated when

certain dysfunctional schemas or coping responses
have emerged, giving place to painful emotions,
avoidance or dysfunctional behaviours that take
control of a person’s functioning.
Schema Modes
Aktywne style schematów
• Young’s model is interested in adaptive and maladaptive
modes. The goal of therapy is helping the patient switch
from a maladaptive mode to an adaptive one (the healthy
adult).
• The mode is the conceptual answer to the question: “what

group of schemas or schema operations is the patient
showing at this moment?”.
Schema Modes as Dissociated States
• The schema mode is an aspect of the self composed by

schemata or schema operations that have not been fully
integrated with other aspects.
• Schema modes can be characterized in terms of the
degree in which they are dissociated from other aspects
of the self.
• They can be described in terms of the point of the
spectrum of dissociation in which they are found.
Dimensions of the Dissociation of Schema Modes
Dissociated – Integrated
Unrecognized – Recognized
Maladaptive – Adaptative
Extreme – Mild
Rigid – Flexible
Pure – Mixed
Schema Modes
Aktywne style schematów
Young’s model postulates 10 schema modes, divided into

four categories:
a) child modes, dziecko
b) dysfunctional coping modes,
nieprzystosowawcze radzenie sobie
c) dysfunctional parental modes,
dysfunkcjonalny rodzic
d) healthy adult mode.
zdrowy dorosły
Child Modes
• They would be innate and universal (all children may
manifest them)
• The vulnerable child wrażliwe dziecko

• The angry child rozgniewane dziecko
• The impulsive/undisciplined child
impulsywne/ niegrzeczne dziecko
• The happy child szczęśliwe dziecko
Child Modes
The Vulnerable Child
It is the schema mode that experiences most of the core
schemata.
It may adopt the form of:
the abandoned child
the abused child
the deprived child
the rejected child
Schema Modes in the BPD Patient
Young (2003) postulates five schema modes present in

borderline patients:
• The Abandoned Child opuszczone dziecko
• The Angry and Impulsive Child
impulsywne/ niegrzeczne dziecko
• The Punitive Parent karzący rodzic
• The Detached Protector brak obrońcy
• The Healthy Adult zdrowy dorosły
The Abandoned Child

• It is the part of the patient that suffers the pain and the terror
associated with most of the schemata (abandonment, abuse,
deprivation, badness and submission).
• The patient looks fragile and childish. They are sad,

desperate, frantic, lost. They feel terribly lonely and are
obsessed with finding a parental figure to take care of them.
They idealize carers and have rescue fantasies. They despair
about being abandoned by their carers.
The Angry and Impulsive Child

• This mode prevails when the patient is furious or acts
impulsively because his/her needs are not met. According to
Young, it is the less frequent one, but it is the one therapists
most frequently associate with BPD patients.
• Patients make demands that suggest that they feel entitled or

that they are spoilt (that alienates others), but in reality they
reflect desperate attempts to cover their emotional needs.
• It emerges as a consequence of the tension accumulated by

the unresolved issues generated by the activation of the
Punitive Parent and the Detached Protector.
The Punitive Parent

• It is the internalized voice of the parent, who criticizes or punishes
the child.
• The patient turns into a cruel self-punisher.
• The voice punishes the child for doing something “wrong”, such
as expressing needs or feelings.
• It is the internalization of the hate, anger, or contempt of one or
both parents, together with the submission of the patient.
The Detached Protector

• The patient blocks all emotions, disconnects from others and
functions in a quasi-robotic way. It is the default mode.
• They seem normal and “good” patients. They may act
appropriately but they do so by suppressing their needs and
feelings.
• Its presence is detected by depersonalization, feelings of
emptiness, boredom, binges, self-harm, being blank, and
performing robotically.
The Healthy Adult
• Very weak and underdeveloped in most BPD patients, since they
do not have a soothing parental mode to calm them down and
take care of them (hence their inability to tolerate separation).
• The therapist models the healthy adult until the patient learns to
do so by himself / herself.
How to Recognize a Mode?
• Through the affective tone, the patient’s tone of voice and the way
he/she expresses himself / herself.
• The tone of the Abandoned Child involves sadness, fright,
vulnerability and helplessness.
• The tone of the Angry/Impulsive Child is that of rage together with
an impulsive attack on the parent that does not fulfill emotional
needs.
• The tone of the Punitive Parent is rough, harsh, critical and
unrelenting.
• The Detached Protector sounds mechanic, devoid of emotion
• The tone of the Healthy Adult is the emotional tone provided by a
loving, strong parent.
Dysfunctional Coping Strategies
Each of these modes corresponds to one coping style
(surrender, avoidance, and overcompensation).
a) the obedient surrenderer (surrender)
b) the detached protector (avoidance)
c) the overcompensator (overcompensation)
Dysfunctional Coping Strategies
The Obedient Surrenderer

The patient submits to the schema, turning into the
passive and helpless child that must surrender to others.
The Detached Protector
The patient withdraws psychologically from the pain
generated by the schema, distancing emotionally ,
abusing substances, avoiding people or using other ways
of escaping.
The Overcompensator
The patient counterattacks, either by abusing others o
behaving in an extreme way to prove the schema wrong,
but in such a way that ends up being dysfunctional .
The Structure of Schema Therapy
(Young, Klosko & Weishaar, 2003)

Assessing and Changing Schemata
Stages of Schema Therapy
Education and Assessment Stage
• In this stage the therapist helps the patient identify his/her
schemata and to understand the origin of schemata in
childhood and adolescence.
During the assessment the therapist socializes the model.
• The assessment includes:
an interview on history of life
several schema questionnaires
self-monitoring exercises
imagery exercises
Stage of Assessment and Education
• This allows the patient to establish a relationship between
the childhood experiences and their present problems.
• The goal of this stage is to build a complete

conceptualization of schemata and a treatment plan
including behavioral, cognitive, and experiential
strategies, as well as the healing component of the
relationship.
Stage of Change
The therapist, without adhering to a rigid protocol, applies
cognitive, experiential, behavioral and interpersonal
strategies in a flexible way, according to the needs of the
patient, week after week.
Cognitive Techniques
• Patients learn to build an argument against the schema. They
disprove it at the rational level, through empirical analysis.
• The result of the analysis is included in a flash card,
ellaborated jointly. The patient carries the flash card, in order
to read it frequently, specially as they enter situations that
used to trigger the schema.
Stage of Change
Experiential Techniques
• Patients fight the schema at an emotional level. Through
imagery or dialogue, they express anger and sadness for
what happened to them as children.
• In imagery exercises they confront their parents or other
important figures of their childhood and protect and offer
consolation to the vulnerable child.
Stage of Change
Breaking Behavioral Patterns
• The therapist collaborates with the patient in designing the
tasks oriented to replace the dysfunctional coping strategies
with more adaptive ways of behaving.
• Therapist and patient use imagery and role-playing to try out
new behaviors and prepare the patient for new homework, in
which the patient will rehearse new behaviors.
• Many of the dysfunctional behaviors are dysfunctional coping
strategies, and they represent the main obstacle for modifying
schemata. Patients need to be ready to abandon these
behaviors if they want to change.
Stage of Change
The Therapist-Patient Relationship

Two important aspects of the relationship:
a) empathic confrontation
b) limited reparenting
Therapeutic Relationship
(Arntz, 2017)
• High on warmth and on directiveness
• ST has high scores on working alliance
• Specific for ST:
Limited reparenting
Therapeutic relationship offers corrective experiences (e.g., safety
and comfort when upset)
Personal connection, also through email (outside office hours)
Self Disclosure (therapist uses personal experience to educate and
to normalize things)
Therapeutic Relationship from the Patient’s
Perspective
“I somehow see this exaggerated now –but it was a little like parent-
substitution. And that was I think, extremely important for me
because what my therapist reflected or what she mirrored me in that
moment: that was what I did not get before…the relationship
between therapist and patient in my opinion is the most important
thing for the whole Schema Therapy to work” (patient 2018, Tan, Lee,
Averbeck, Brand-de-Wilde, Farrell, Fassbinder, Jacob, Martius, Wastiaux,
Zarbock, & Arntz, 2018)
Therapeutic Relationship: Risks
• Directiveness / dominance
Therapist is too dominant and is not attuned to P
Therapist does not reduce dominance in later phases
Therapist is not directive enough
• Limited reparenting
Not limited enough (e.g., T gives too much and neglects own boundaries)
Not caring enough: T is inhibited and does not offer corrective learning
experiences
Believing limited reparenting is enough
Believing reparenting does not involve frustration
The Schema Mode Model
“The structuring of schema therapy-the subdivision, how you
structure yourself, where you are at the moment and why it is like
that. I find that very helpful, to be able to analyze myself and say:
“Which schemas, modes are there, and where do they belong?”
That we first roughly looked at it then go into detail into every single
aspect. I found that helpful like a huge poster; what opened up
there. There were many aha-moments”
(Tan et al, 2018)
Borderline Personality Disorder Basic Modes
(Arntz, 2017)
• Detached Protector: reassure, make them less necessary
• Punitive Parent Mode: combat; get it out of patient’s
system
• Angry/Impulsive Child Mode: empathic confrontation;
develop functional ways to assert and get need met
• Abandoned/Abused Child Mode: Give safety and process
traumas
The Schema Mode Model
(Arntz, 2017)
• A framework to understand the patient’s problems and
their (childhood) origins
• Personalized
• Central in treatment: first detect the mode and then

choose a technique
Mode Model: Risks
• Pointing out modes and discussing them
-Not addressing a mode with a technique
• Being too directive
-Not tentatively saying that a mode might be activated
-Not inviting the patient to reflect on what mode might be
active
• Creating the Mode Model only on self-report (e.g., Schema Mode
Inventory, SMI)
Schema Therapy for Borderline
Personality Disorder
(Arntz & van Genderen, 2009)
BPD – The Rationale for EBTs
“Individuals who have BPD often experience crises with self-harm or suicide
attempts, and thus show an intensive use of health services and high costs [11,
15–17]. The direct health care costs that result from BPD are markedly higher
than those for depression (e.g., 11,817 € vs. 6058 € per patient two years after
an index diagnosis in a German study) [17].
A recent systematic review and cost offset analysis from economic evaluations
revealed that empirically supported psychological treatments for BPD can
massively reduce those costs [16].”
Fassbinder, E., Assmann, N., Schaich, A., Heinecke, K., Wagner, T., Sipos, V., ... Schweiger, U.
(2018).PRO*BPD: effectiveness of outpatient treatment programs for borderline personality
disorder: a comparison of schema therapy and dialectical behavior therapy: study protocol for a
randomized trial. BMC Psychiatry, 18, [341]. https://doi.org/10.1186/s12888-018-1905-6
Schema Therapy
• Outcome studies of DBT for BPD showed reductions in drop-out
rates, fewer hospitalizations and a greater reduction of self-
harming and suicidal behavior compared to treatment-as-usual
(Linehan, 1991).
• But there were no differences when comparted to other
interventions for other aspects of BPD psychopathology.
• Beck’s cognitive therapy showed a reduction of suicidal risk,
depressive symptoms and other symptoms of BPD, with a smaller
drop-out rate than usual (Arntz, 1999; Beck, 2002; Brown et al,
2004)
Schema Therapy
• Schema therapy was compared to Kernberg’s
Transference Focused Therapy (Giesen-Bloo et al, 2006)
in a study conducted in the Netherlands.
• ST showed more positive results than TFP in reducing

symptoms of BPD, as well as in other aspects of
symptomatology and quality of life.
Schema Therapy
• In a 4-year follow-up, 52% of patients treated with ST had
recovered from BPD, while over 2/3 showed significant
clinical improvement in the reduction of symptoms of
BPD.
• These results include drop-out rates (including those due
to medical problems).
Schema Therapy
• In a study conducted in Norway (Nordahl & Nysaeter,
2005), 50% of patients did not meet criteria for BPD at
post-treatment, while 80% seemed to have improved with
treatment.
• ST is not only superior to TFP in outcome, it is also less
costly (van Asselt et al., 2008).
Schema Therapy
• The reduction in social costs makes ST a treatment that
pays for itself.
• The duration of ST is of 1,5 - 4 years, approximately.
• It starts with two sessions a week, that can be reduced to
one session a week later in treatment.
Schema Therapy - Outcomes
“ST shows promise for treating BPD as it was effective in reducing all BPD
criteria and led to substantial improvements in quality of life [42, 43]. Two RCTs
[44, 45], one case series [46], five open pilot studies [47–49] and one
implementation study [50] demonstrated decreases in all nine BPD symptoms,
general psychiatric symptoms, and quality of life, as well as low treatment drop
out. In the first Dutch RCT ST was compared with transference focused
therapy (TFP), both offered in an individual design. ST showed better treatment
retention, and in the intention-to-treat-analysis it was clinically more effective
than TFP [45]. Also, ST was more cost-effective [51]. A pre-post comparison
demonstrated successful implementation of individual ST under routine clinical
care conditions [50] (…)”
“A group format (Group schema therapy, GST) was developed by Farrell and
Shaw [52] and was successfully tested in an RCT in the United States: Patients
who received GST showed no drop-out, high BPD remission rates, significant
reductions in BPD-typical and general psychiatric symptoms as well as
improvements in psychosocial functioning, with large effect sizes after only
8 months.
Two outpatient pilot studies on GST in the Netherlands [47] and Germany [48]
used GST in combination with individual ST and found substantial
improvements in BPD-symptoms, general psychopathology, quality of life and
happiness.” (…)
“To systematically investigate the clinical effectiveness and cost-effectiveness of
GST for BPD and to test different formats of GST (GST only vs. a combination
of GST with individual ST), a large, international, multicenter RCT on GST for
BPD is currently in progress [53].
A meta-analysis from 2013 (including all published outpatient studies through
2013, which are all mentioned above, except for [48, 49]) revealed an overall
effect size of d = 2.38 for pre-post change and an overall drop-out rate of 10%
for ST in BPD patients. This is a very low drop-out rate compared to the
average drop-out rate of 25% for BPD patients for interventions with a minimum
duration of 12 months [54].”
“In sum, there are promising findings on the clinical efficacy and effectiveness of
DBT and ST in treating BPD [20]. Moreover, both treatments lead to impressive
reductions in direct and indirect health care costs (approx. 10,000 € per patient
per year) [30, 51]. However, research has not yet compared these two methods.
A treatment comparison would be interesting for psychotherapy research
because both treatments have different approaches to treating BPD and focus
on different techniques, despite several common factors (see also methods and
a detailed overview in [55]).”
Fassbinder, E., Assmann, N., Schaich, A., Heinecke, K., Wagner, T., Sipos, V., ... Schweiger, U.
(2018). PRO*BPD: effectiveness of outpatient treatment programs for borderline personality
disorder: a comparison of Schema therapy and dialectical behavior therapy: study protocol for a
randomized trial. BMC Psychiatry, 18,[341]. https://doi.org/10.1186/s12888-018-1905-6
Schema Therapy – Patients’ Perceptions
“Schema therapy (ST) has been found to be effective in the treatment of
borderline personality disorder (BPD). However very little is known about how
the therapy is experienced by individuals with BPD including which specific
elements of ST are helpful or unhelpful from their perspectives. The aim of this
study is to explore BPD patients’ experiences of receiving ST, in intensive group
or combined group-individual format. Qualitative data were collected
through semi-structured interviews with 36 individuals with a primary diagnosis
of BPD (78% females) who received ST for at least 12 months. Participants
were recruited as part of an international, multicenter randomized controlled trial
(RCT). Interview data (11 Australian,12 Dutch, 13 German) were analyzed
following the procedures of qualitative content analysis (…)”
Schema Therapy – Patients’ Perceptions
“Patients’ perceptions of the benefits gained in ST included improved self-
understanding, and better awareness and management of their own emotional
processes.
While some aspects of ST, such as experiential techniques were perceived as
emotionally confronting, patient narratives informed that this was necessary.
Some recommendations for improved implementation of ST include the
necessary adjunct of individual sessions to group ST and early discussion of
therapy termination”
Tan, Y. M., Lee, C. W., Averbeck, L. E., Brand-de Wilde, O., Farrell, J., Fassbinder, E., ... Arntz,
A. (2018). Schema therapy for borderline personality disorder: A qualitative study of patients’
perceptions. PLoS ONE, 13(11), [e0206039]. https://doi.org/10.1371/journal.pone.0206039
Schema Therapy
• Some clinical situations need to be taken
care before implementing ST:
a) severe major depression
b) anorexia nervosa
c) severe substance abuse demanding the
implementation of detoxification
d) autism or Asperger syndrome
Stages of ST
• ST does not follow a session-by-session intervention
protocol, but it is a structured treatment.
• The crux lies in the therapist deciding which is the best
way to react before each schema mode according to the
stage of therapy.
• There are 7 clearly defined stages of therapy.
Stages of Schema Therapy
1. Initial stage and case conceptualization
2. Treatment of Axis I symptoms
3. Crisis management
4. Therapeutic interventions with schema modes
5. Treatment of childhood trauma
6. Change in behavioral patterns
7. Ending therapy
Initial Stage and Case Conceptualization
• 6 to 12 sessions in which a complete assessment is
made.
• The therapist assesses the relationship of parents and
caregivers with the child in search of events that may
have originated dysfunctional schemata.
• The therapist identifies the possible contraindications for
implementing ST.
• The therapist assesses level of impairment and severity of
BPD symptoms.
• Patient and therapist jointly generate a case conceptualization
based on the model of schema modes.
• The therapist adopts a friendly, open, non-distant stance.
• The discussion of the rules of treatment must include the
availability of the therapist.
• The therapist dedicates a lot of time to the present
problems of the patient and examines with him/her the
situations that trigger intense emotions.
• The therapist evaluates the patient’s expectations of
therapy, his/her previous therapeutic experiences, and
explains the characteristics and rules of ST.
• The history of the patient is analyzed in detail and is
related to the emergence of schema modes.
• Some assessment tools are used: the Young Schema
Questionnaire, the Young Parentalization Inventory, the
BPD Severity Index, the Personality Belief Questionnaire,
the Schema Mode Inventory, the Young-Atkinson Schema
Inventory.
Treatment of Axis I Symptoms
• In this stage the therapist targets Axis I
problems that represent a contraindication
for starting ST (severe MDD, AN, severe
substance abuse in need of urgent detox,
autism or Asperger syndrom).
Crisis Management
• If treatment does not begin in the context of a crisis this
stage can be skipped.
• The therapist may return to it at any time in which a crisis

emerges.
Therapeutic Interventions with Schema Modes
• This the core stage of treatment, and it may last for years.
• The initial stage of treatment ends when the patient can
explain adequately in his/her own words how schema
modes work in his/her particular case, and when the
therapist has explained how he/she will proceed with
therapy.
Therapeutic Interventions with Schema Modes
• At some point the therapist will have to put an end to
collecting data and generating explanations and will have
to proceed to modify thoughts and behaviors.
• Many therapists feel uncomfortable when beginning this

phase of therapy.
Treatment of Childhood Trauma
• In order to face this stage, the patient must first
strengthen his/her healthy adult schema mode, as well as
develop and strengthen functional interpersonal
relationships in and out of therapy.
• This stage must not be ommitted, even when the patient

seems to be doing well or when dealing with trauma may
seem unnecessary.
Changing Behavioral Patterns
• Young, Klosko & Weishaar (2003) hold that this is the
longest and also the crucial stage of ST.
• Implementing new behaviors is not easy, even when the

patient has managed to dominate the activation of their
problematic schema modes.
Ending Therapy
• Ending therapy is not considered until the patient ceases
to meet criteria for BPD, has built a reasonably stable
social network, and has found a valuable, meaningful way
of filling his/her days.
• Therapy must end if there has been no progress after one

year of ST.
Schema Therapy
• The process of change takes place through three different
paths: feeling, thinking and doing.
• These paths correspond to the three ways of representing

knowledge that are present in schemas: explicit
knowledge (thinking), implicit knowledge (feeling), and
operational representations (doing).
Schema Therapy
• There are three topics, to be treated by these three
pathways:
a) life outside therapy
b) experiences in therapy
c) past experiences
Experiential Techniques
“The chairwork I found really incredible that I could really
imagine where these extreme feelings of tension come from –
how they crash into you…oh, that is scary! And these
imagination exercises, especially for not-so-good memories I
think are really great, to rearrange them like that, that gives you
a completely different feeling…all of a sudden they are a lot
less hard to bear…and not so negatively loaded anymore”
(patient 2404, Tan et al, 2018).
Experiential Techniques: Risks
(Arntz, 2017)
• T avoids
-Rule of thumb: at least once every 2 sessions
• T postpones
-Rule of thumb: start within 10 minutes, talk afterwards
• T gives in to resistance or fears of patients
-Instead of addressing them
• Applied in a “wild” and unsafe manner (like in old-times
experiential therapies)
Experiential Techniques – An Example
• https://www.youtube.com/watch?v=1r7Jc3wwJeA
Cognitive Techniques
• Not specifically mentioned by P’s
-Apart from Schema Mode Model
“When I understand what is going on inside me, how these
processes are…I can structure all of that really well for myself and
then also deal with it better” (patient 2411, Tan et al, 2018).
• Education is important, patients might experience this as part of the

therapeutic relationship
-Education is also woven into experiential techniques
-Not about BPD, but about emotional needs, development, and
schemas
Cognitive Techniques: Risks
• Being too cognitive
• Assuming too much healthiness (Healthy Adult) in one’s
patient
-Actively bring in healthy perspectives
• Expecting / demanding regular homework (e.g., cognitive
diaries) which BPD patients often not comply with
Behavioral Techniques
(Arntz, 2017)
• Not specifically mentioned by patients
• But experiential techniques involve modelling skills
• And behavioral pattern breaking is important at later
phases of treatment
Behavioral Techniques: Risks
(Arntz, 2017)
• T avoids pushing patient to change dysfunctional behaviors
• T demands patient to change dysfunctional behaviors too early
-The emotional background should be addressed first
• T does not tolerate dysfunctional behaviors and uses limit setting
too early
-Restrict limit-setting to what is absolutely unacceptable at the
beginning
Therapeutic Techniques
Focus Channel
Emotion Thoughts Action
-------------------------------------------------------------------------------------------
-----
Out of Role-plays Socratic Behavioral Experiments
Therapy of situationsquestioning Role-playing skills
Imagining Formulate new Problem solving
situations schemas Trying out new
Practising Schema behaviors
feeling dialogue
emotions Flashcards
Exposure Positive Log
to showing
emotions
Focus Channel
Emotion Thought Action
----------------------------------------------------------------------------------------------------
In Limited Recognizing Behavioral experiments
therapy reparenting the patient’sStrengthening functional
Empathetic schema in the behavior
confrontation therapeutic Training in skills related Setting limits
relationship to therapeutic relationsh. Changing roles
QuestioningModeling by therapist
therapist/cilent ideas about
the therapist
Recognizing the
schemas of the
therapist
Self-disclosure
Focus Channel
-------------------------------------------------------------------------------------------
-----
Past Imaginary Reinterpreting Trying out new
rescripting past events behaviors in Role-play and
integration key persons of the past in new
schemas of the past
Two or more Historical testing
chair
techniques
Letter writing
Focus Channel
-------------------------------------------------------------------------------------------
-----
Out of Role-plays Socratic Behavioral experiments
Therapy of situations questioning Role-playing skills
Imagining Formulating Problem-solving
situations schemas Trying out new
Practising Schema behaviors
feeling dialogue
emotions Flashcards
Exposure toPositive log
showing emotions
Schema Therapy Sessions
• Sessions are recorded and the patient is asked to listen to
recordings before the next session, in order to strengthen
treatment.
• One of the reasons for doing this is that the patient might
not be in a receptive, listening mode during the session.
Imagery
• The patient tries to recreate a situation in his/her mind.
• The aim is to recreate what happened and what are his/her
emotions.
• Rescripting is added later, when the therapist believes something
must be changed.
• In the initial phase of therapy, imagery is used when the therapist
believes there may be a connection between a schema and an
event of the client’s childhood.
Imagery
As therapy progresses, imagery can be applied in the following
situations:
• Situations involving physical or sexual abuse (including traumatic
situations with peers such as bullying)
• Situations in which the emotional, physical or developmental
needs of the client were not met.
• Restriction of the possibility of expressing emotions.
• “Parentization”, when the patient takes the role of agent between
parents or carers, or when the patient has to take care of a parent
or sibling.
Image Rescripting – Initial Phase
• The aim is to modify the meaning assigned to the past
experience.
• We cannot change the past, but we can the conclusions we draw
about the past.
• Stage 1: Imagining the original situation
• Stage 2: Rescripting in charge of the therapist
Image Rescripting – Secondary Phase
• Once the client has developed a strong-enough Healthy Adult mode,
then she/he can be in charge of the rescripting, according to the
following sequence:
Stage 1 Client = child The original situation as was experienced
by the client Stage 2
Client = adult Situation is rescripted as evaluated by the
client as an adult. The client intervenes as an
adult
Stage 3 Client = child The client experiences as a child the
intervention of the adult. She asks for
and receives additional interventions from
the adult
Imagery Rescripting – Potential Problems
• The client doesn’t want to close her/his eyes
• Which childhood event should I choose?
• Continuous repetition of the same memory
• Inability to “find” memories
• Client does not want anybody to go against his/her
parents
• Client believes the intervention has not been carried out
properly
Imagery Rescripting – Potential Problems
• Client feels the intervention is not realistic
• Feelings of guilt
• Client only comments memories of his/her late childhood
• Client cannot adopt the perspective of the child
Two or More Chairs Exercise
• A chair is assigned to each mode of the patient.
• It is particularly useful with clients who find it hard to dal

with their Punitive Parent and Detached Protector modes.
• Once the client learns to deal with these, the exercise is

applied to other modes.
Two-Chair Exercise
Mode Location of Therapist Patient
Mode
Punitive Parent Empty chair Trains client as a Healthy adult
healthy adult
Punitive Parent Empty chair Healthy adult Abandoned child
Punitive Parent Other chair Healthy adult Punitive Parent
Protector Empty chair Trains client as a Healthy adult

healthy adult
Protector Empty chair Healthy adult Abandoned child
Protector Other chair Healthy adult Protector
Protector Other chair Abandoned child Protector first, then

abandoned child
Multiple-Chair Exercise
Mode Location of Therapist Patient
Mode
Punitive Parent Two empty chairs Trains client as a Healthy adult
alternates with healthy adult
Protector
Punitive Parent Two empty chairs Healthy adult Abandoned child

alternates with
Protector
Punitive Parent The other 2 chairs Healthy adult Punitive Parent or

alternates with Protector
Protector
Punitive Parent The other 3 chairs Healthy adult or Punitive Parent or

alternates with abandoned child Protector
Protector
Two-Chair Technique with Schemas and
Coping Strategies
Mode Location Therapist Patient

Schema The other chair Trains client as a Healthy adult
healthy adult
Coping strategy The other chair Trains client as a Healthy adult

healthy adult
Visual Analogue Assessment
• To question black or white thinking a visual analogue scale is used:
L C Pt. A X
0....X.....X......X....X....X.......100
Stupid Intelligent
L: mentally-handicapped cousin
C: friend who did not complete high school
A: friend from university
X: Nobel prize winner
Multidimensional Assessment
• If the person values her / his self on just one dimension, the
therapist may suggest to do so on different dimensions at
the same time.
• Several visual analogue scales are made to turn an abstract
concept into a more concrete issue:
0........................................................................................10
0
(lovable) (not lovable)
(no friends) (with many friends)
(does not get along with people) (gets along with everyone)
(does not do anything for others) (does whatever for others)
(cannot work with others) (can work with others)
(always in a bad mood) (never in a bad mood)
Bidimensional Representation of Supposed
Connections
• When the patient believes that two factors are logically linked (e.g., “success
in work leads to happiness) these graphs cand be used to put the theory to
test.
happy presumed association
unhappy
Pie Charts
• They are useful for viewing the level of influence that a fact or characteristic
have on the whole.
Court Method
• It is used to “blame” or “exonerate” a person in a given situation.
• It is a role play in which the patient takes the role of the prosecutor and the
therapist plays the defense.
• If it works, roles are inverted.
• The therapist may also ask the patient to play the role of the judge that must
pass a sentence.
• The difference with the two-chair technique is that the latter aims at
questioning modes and the court method is used for dysfunctional thoughts.
Flashcards
• They are used as memory helpers, in special in situations in
which the Punitive Parent is activated.
• On one side of the card the patient writes down the vision of the
Punitive Parent, while on the other side he / she will write the data
that provide a more balanced view of himself / herself.
Socratic Dialogue
• The goal is that the patient discovers there is more than one possible
interpretation for a given event.
• Typical questions:
what makes you think that?
what arguments support or question that vision?
how many times has that happened?
what does people around you think about that?
imagine the situation actually happens, what would be so bad about that?
if that happened, what could you do about it?
Changing Behavioral Patterns
Description of the behavioral pattern that I want to work on:
In what kind of situation does this behavior take place?
What do I do in those situations that leads to things not
going well?
What mode, rule of life or idea plays an important role in
that situation?
What are the arguments against this mode, rule of life or
idea?
What is the new behavior that would be more oriented to
my goal in this situation?
What happened when I tried this new behavior?
Formulate a new, healthier rule of life
Cognitive Mode Log
Activating Event (what caused my reaction?)
Feeling (How did I feel?)
Thought (what was I thinking?)
Action (what did I do?)

Cognitive Mode Log
The 5 aspects of my self
What aspect of myself came into play in the situation? Highlight the
aspect that you recognize and describe it
1. Abandoned/abused child
2. Impulsive/Angry Child
3. Punitive Parent
4. Detached Protector
5. Healthy Adult
Cognitive Mode Log
Justified Reaction (what part of my reaction was justified?)
Excessive Reaction (what part of my reaction was too strong?

Did I overreact or saw things that were not there? What did the
different aspects of myself do to make things worse?)
Desired Reaction (what would a better way of seeing the

situation for me, that would allow me to better deal with it?) (what
could I do to solve this problem in a better way?)
Feeling
Positive Event Log
Try to write down one or more activities or small (or big) experiences that
contribute to a more positive vision of you or of others. All this information
can be used to weaken the Punitive Parent mode and strengthen the Healthy
Adult mode
________________________________________
Date:
Topic:
_______________________________________________
Date:
Topic:
Historical Testing
Write down experiences that took place in different phases of your life that show
that the Punitive Parent is wrong and that support the little child
______________________________________________
0-2 years
______________________________________________
3-5 years
______________________________________________
6-12 years
_______________________________________________
Historical Testing
13-18 years
_______________________________________________
19-25 years
_______________________________________________
26-35 years
_______________________________________________
36-50 years and later
_______________________________________________
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Borderline Personality Disorder 2020

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Borderline Personality Disorder

Models and Treatments

ZABURZENIE OSOBOWOSCI Z POGRANICZA – MODELE

Prof. Eduardo Keegan

The patient does not comply with protocol

• Even if you decide to (or have to) target the associated

• Unable to tolerate routine and regularity.

• Fails to develop meaningful insight.

• Impatience and intolerance of frustration

• DSM’s criteria are more neutral, less judgemental about

Utrwalony wzorzec niestabilności relacji interpersonalnych, obrazu „ja” i emocji

(1) gorączkowe próby uniknięcia opuszczenia – rzeczywistego lub wyimaginowanego.

(6) Affective instability due to a marked reactivity of mood

(7) Chronic feelings of emptiness

(9) transient, state-related paranoid ideation or severe

• Histrionic/Narcissistic borderline personality

• Antisocial/Paranoid borderline personality

• They have a grandiose view of their self-importance, together with

• They show a pervasive mistrust of others’ motives.

• Jealousy and anger are extreme and easily

• They tend to use and abuse those who

• They rarely have stable relationships.

• Anger is the most common expressed

• A tendency to suicide could correlate with a

• They cannot tolerate boredom and are thus inclined

• They show contempt for themselves (badness

• 0.8 - 2% of the general population (estimated)

BPD is five times more frequent in first-

• Borderline clients as the paradigm of multi-problem clients

• Characterized by a generalized emotional dysregulation

• It may include a tendency to blame the social environment

• Unrealistically high standards and expectations for self.

• May include intense shame, self-hate and self-directed

A pattern of frequent, stressful, negative

• The tendency to inhibit, overcontrol or avoid

• Patients may seem to “survive” loss quite well, only

A tendency to passive interpersonal

• A tendency for the client to appear deceptively more

BPD is primarily a dysfunction of the

Emotion Regulation Dysfunction

Behavior Interpersonal Self Cognitive

DYSFUNKCJA REGULACJI EMOCJI

Emocjonalna podatność na zranienie

NIESTABILNOŚĆ NIESTABILNOŚĆ NIESTABILNOŚĆ NIESTABILNOŚĆ

Emotional Stimulus High Sensitivity High Reactivity Slow Return to Calm

Emotional Stimulus High Sensitivity High Reactivity Slow Return to Calm

Turn off, Freeze

Generalized Emotion Dysregulation

Invalidating environments during childhood

They become self-invalidating.

If we consider BPD as a dialectical failure,

One basic principle in this endeavour is to

Thomas and Chess have suggested that

It tells the individual that he is wrong in

• It attributes experiences to socially

• The attitude communicated is that anyone who tries hard

• This is similar to the pattern of high expressed emotion