Schema Therapy for Borderline Personality Disorder(BPD)

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Schema therapy is one of the treatments for personality disorders, especially borderline personality disorder. It is also used to treat other conditions, such as major depressive disorder, eating disorders, and interpersonal difficulties. It was developed by Jeffrey E Young, who found the method helpful in treating personality disorders and other chronic psychological conditions.

It has been proven to be effective when patients fail to respond to other forms of treatment or when they have relapses. Schema therapy combines and borrows from a range of therapeutic modalities, from cognitive behavior therapy to psychodynamic object relations theory and attachment theory. 

Although it seems like an eclectic approach that combines multiple therapeutic approaches, schema therapy’s central focus is to understand and unlearn maladaptive patterns of thoughts and behavior, which precipitate and maintain different psychological conditions. 

This article takes a detailed look at schema therapy and how it can help individuals with borderline personality disorder.

Development of schema therapy: Differentiating from pure cognitive therapy

Schema therapy, as mentioned above, was developed by Jeffrey E Young when he was working at the Center for Cognitive Therapy, University of Pennsylvania. In a paper that he published alongside Aaron Beck, the pioneering cognitive behavior therapist, Dr. Young noted that although 60% of individuals with depression saw positive results with cognitive behavior therapy (CBT), almost 30% of them relapsed within a year. Young understood that those who relapsed or did not respond to CBT often had more profound problems, such as personality disorders. 

CBT does not focus on childhood experiences

While CBT identifies deep-rooted belief systems and core beliefs, Young felt a need to go back into the patient’s childhood. CBT focuses on the “here and now” and discourages dwelling on childhood experiences that may or may not have affected an individual. Dr. Young felt that those with personality disorders developed deeper patterns of thoughts during their early childhood, which he labeled “schemas .” These dysfunctional and negative schemas pose severe obstacles to accomplishing therapeutic goals when CBT alone is used. At this point, it is necessary to point out that psychodynamic theory emphasizes early childhood experiences. 

Schema therapy places a greater focus on schemas developed during childhood

The focus on schemas, or patterns of thinking, feeling, and behaving, differentiates it from cognitive therapies, which do quite the same but do not dwell on early childhood experiences. These toxic childhood experiences, which give rise to negative schemas, can persist throughout adulthood and cause various psychological disorders, including personality disorders. Young termed these schemas “Early Maladaptive Schemas,” also known as EMS.

Understanding Early Maladaptive Schemas (EMS)

EMSes tend to be broad and pervasive and have a specific pattern. They consist of emotions, cognitions, bodily sensations, and memories. In other words, they are not limited to thoughts and beliefs but go much deeper. They develop during childhood and adolescence and persist through one’s lifetime unless explored and replaced with healthy coping skills learned during therapy. 

They are dysfunctional and cause significant impairment in the person’s life. It is important to note that according to schema therapy, behaviors occur due to schemas, and they are not part of the schemas themselves. These schemas provide context for schema therapy, and the therapist uses various techniques to explore and replace them with healthier ones. 

As you can see, schema therapy borrows from cognitive theories but differentiates itself from CBT by going deeper into childhood experiences. It is more suitable for pervasive disorders such as personality disorders and for those who are relapse-prone. In particular, it is well suited for treating and managing BPD. 

Understanding BPD and its management

Borderline personality disorder is a serious mental health condition that causes hypersensitivity to rejection and instability in interpersonal relationships, self-image, mood, and behavior. It is also characterized by impulsivity, dissociation, and other significant problems. 

Twin studies indicate that there is a 50% heritability when it comes to developing borderline personality disorder. However, environmental factors such as childhood maltreatment, which includes physical and sexual abuse, and neglect, may cause BPD as well. There is also a high correlation between parental substance abuse and psychopathology and the offspring developing BPD. 

At this juncture, it must be noted that women and LGBT individuals are overrepresented in BPD samples, which may reflect clinicians’ bias. Heterosexual men are underrepresented or underdiagnosed when it comes to BPD. As individuals with BPD are at high risk of completing suicide attempts, it is a serious mental health issue that cannot be taken lightly. 

How BPD manifests

According to a study, Borderline Personality Disorder is found in 20% of the clinical population and 1.6% of the general population. Individuals with BPD experience chronic emptiness, mood swings, anger outbursts, fear of abandonment, impulsive behavior, dissociative mental states, suicidality, and many other symptoms. BPD is usually comorbid with other psychiatric and psychological conditions such as eating disorders, depression, anxiety, body dysmorphic disorder, and substance use disorders. 

The most common psychological treatments for BPD are Mentalization Based Therapy (MBT), Schema Therapy (ST), Transference Focused Therapy (TFP), and Dialectical Behavior Therapy (DBT). 

Borderline personality disorder and substance use disorders

People with BPD are at a high risk of using different substances as coping mechanisms. As individuals with BPD often have traumatic experiences, they use alcohol, tobacco, and other drugs to self-soothe. Unfortunately, these substances are highly addictive. 

To make things more complex, people with BPD tend to be impulsive and easily bored. As a result, they may find an escape from boredom and feeling numb by abusing substances. Their impulsivity may also cause binge-drinking episodes, leading to various physical and emotional problems. It is always important to address substance use disorders while treating individuals with BPD. 

The study concerning schemas and borderline personality disorder symptoms in incarcerated women

Spect, Chapman, and Cellucci (2009) examined the relationship between BPD symptoms and early maladaptive schemas (EMS). They used a sample of 105 incarcerated women to assess BPD symptoms through semi-structured diagnostic interviews. The study found that Disconnection/Rejection (DR) and Impaired Limits (IL) were schemas that independently predicted BPD severity. Although the study was conducted on incarcerated women, these findings may also apply to the general population. 

Disconnection/Rejection (DR) consists of schemas related to safety, security, stability, empathy, acceptance, and respect. Those who develop dysfunctional DR schemas tend to grow up in cold, abusive, lonely or abusive environments. 

DR consists of the following schemas: 

  1. Abandonment / Instability (AB) – This schema revolves around the belief that the significant others (parents or guardians) will not be able to provide physical or emotional safety. Parents and caregivers tend to be unpredictable and emotionally unstable. The child might begin to believe that they may die or abandon him/her in favor of someone else. 
  2. Mistrust / Abuse (MA) – This schema revolves around believing the individual will be betrayed, cheated, or humiliated. Extreme negligence and intentional harm may reinforce these belief patterns. 
  3. Emotional Deprivation (ED) – When parents cannot provide nurturance, empathy, or protection, the child may internalize feelings of emotional deprivation, which persist into adulthood. 
  4. Defectiveness / Shame (DS) – This schema involves the feeling that one is defective in some manner and that they have flaws that are either private (unacceptable sexual desires, violent thoughts, etc.) or public (social awkwardness or a perception of being physically unattractive). 
  5. Social Isolation / Alienation (SI) – This schema focuses on the individual’s inability to connect with others and feeling disconnected from the immediate surroundings and the rest of the world. 

Impaired Limits consist of two major schemas — entitlement/grandiosity (ET) and insufficient self-control/self-discipline (IS) schemas. 

  1. ET leads to the belief that one is somehow superior to others and that he/she is entitled to special privileges. 
  2. IS leads to impulsivity and self-control issues, typical among borderline personality disorder-diagnosed individuals, who are also at a higher risk for developing substance abuse disorders. 

What is the most common schema in clients with BPD?

According to Young, the core schemas experienced by people with BPD are:

  1. Abandonment: The individual feels they will be rejected or left alone by those who care for them. This typically manifests as anxiety within interpersonal relationships and may affect romantic and platonic relationships. Unfortunately, fear of abandonment often results in behaviors that become self-fulfilling prophecies. For example, a person with BPD may fear their best friend will abandon them because they are too clingy and may end up texting or calling their best friend repeatedly to ensure they are not abandoned. 
  2. Abuse: The second core schema suggested by Dr. Young includes abuse, which relates to the belief that the individual will be abused, humiliated, cheated, or betrayed by others. This worldview usually develops when parents or caregivers fail to respond to the child’s needs, neglect them, or commit sexual or physical abuse. It is important to note that parental neglect and abuse are highly correlated with BPD in later years of life. 
  3. Emotional Deprivation: The person with BPD typically feels their emotional needs will not be met by anyone. These feelings often stem from being overprotected during childhood or being neglected. Emotional Deprivation schema causes interpersonal conflicts, especially within the context of romantic relationships and friendships. However, this may also manifest as expectations of being mistreated by others. 
  4. Defectiveness: This schema develops when the child feels invalidated or unloved. The individual grows up to believe that there is something inherently wrong with them and that they do not deserve to be loved or cared for. This schema may also be related to abandonment and emotional deprivation schemas. 
  5. Subjugation: A person with this schema may avoid confrontations to such a degree that they surrender to others or become submissive. They may engage in clingy behaviors to avoid perceived abandonment, anger, and retaliation from others. Unfortunately, individuals with BPD who develop this schema tend to remain in toxic relationships, further aggravating their symptoms. 

What is the goal of schema therapy in BPD?

According to schema therapy, individuals with BPD respond to triggering or stressful situations with the following schema modes

  1. Abandoned child mode: When this schema mode is at play, the patient relives traumatic experiences that made them feel helpless, needy, and left alone. They may remember moments when they felt they were abandoned by their parents and reenact this trauma in the current context. This may lead to the person behaving in a clingy manner or fearing abandonment by loved ones. Some people with BPD may abandon or reject others before others do it to them out of anxiety. 
  2. Angry and impulsive child mode: Impulsivity and anger outbursts are core BPD symptoms. This mode is activated when the individual feels frustrated or cannot communicate their needs to people around them. Impulsive child mode may get activated when the individual feels bored or experiences emptiness. This may lead to risky behaviors such as binge drinking, engaging in unsafe sex, or driving recklessly. 
  3. Punitive parent mode: Self-harm is a classic symptom of BPD, and the person may punish themselves for all their imagined faults. Self-harm may also occur as a response to stress and as a form of distraction. In addition, punitive parent mode may get activated when the individual feels the need to be sarcastic and punish people for perceived wrongs. 
  4. Detached protector mode: People with BPD often find it challenging to connect intimately with others. This may result in communication issues and the activation of detached protector mode. For example, the individual may genuinely care about their children or spouse but may remain detached and aloof while taking care of their loved one’s needs. This causes emotional hurt to those around them. 

The goal of schema therapy is to recognize when these schema modes are activated and replace them with healthy adult mode. Healthy adult is a schema mode in which the individual learns to validate and support themselves while moderating EMS as and when necessary. The therapist may offer limited reparenting and empathetic confrontation and teaches cognitive, behavioral, and emotional strategies to cope with situations when early maladaptive schemas are activated. 

Is schema therapy good for BPD?

A study conducted by Arntz, Jacob, and Lee sought to explore if group schema therapy is more effective than combined individual and group schema therapies. This study was a randomized clinical trial that recruited 495 adult participants across five countries. The study found that combining individual and group schema therapy is more effective in reducing the severity of borderline personality disorder. 

It must be made clear that schema therapy can be delivered both in group and individual therapy sessions. However, due to logistical reasons, many clinical psychologists find it challenging to organize group therapy sessions for BPD-diagnosed clients. In such situations, individual schema therapy is quite effective too. 

Very few studies have been conducted comparing schema therapy with dialectical behavior therapy (DBT), which is the gold standard for BPD treatment. However, schema therapy has empirical evidence of being effective and is one of the many possible treatment options if you have been tackling borderline personality disorder. 

Sempértegui et al conducted a comprehensive review of the literature to determine the efficacy of schema therapy on borderline personality disorder. The authors conclude that there is sufficient evidence for schema therapy as a valid form of treatment for BPD. 

However, they add a note of caution that DBT and mentalization-based therapy (MBT) have more evidence in terms of treating BPD. They also add that this does not discount schema therapy as an effective treatment for BPD, but more studies need to be conducted to prove that it is as effective as DBT or MBT. 

Benefits gained and difficulties faced in Schema Therapy

Schema therapy can help people with BPD to recognize schemas that trigger their symptoms. They also learn how schema modes get activated during stressful situations and learn to find better coping mechanisms. 

The therapist provides limited parenting, another word for validating a client’s unmet emotional needs without crossing professional boundaries. Finally, the client also learns how to activate the healthy adult mode and reduce the severity of symptoms associated with BPD. 

While Schema therapy has many benefits and is quite successful in treating BPD, there isn’t enough research to compare it with DBT or MBT. In addition, schema therapy takes multiple sessions, and clients may drop out of treatment when they do not see quick results.  

How to Find a Schema Therapist 

Most clinical psychology programs do not offer schema therapy as part of their training, and psychologists often train themselves in schema therapy. Finding a schema therapist can be challenging, especially if you live outside the US or the UK. You may have to inquire with individual clinical psychologists if they are trained in schema therapy or if they are familiar with its techniques. 

However, The International Society of Schema Therapy (ISST) is an organization that brings together a community of trained professionals in schema therapy. It also offers training and workshops and engages in research. You may use the organization’s “Find a Therapist” feature to find a therapist specializing in schema therapy near you. 

Strengths and limitations of Schema Therapy

Schema therapy has many strengths. First and foremost, it is an evidence-based treatment approach to manage BPD symptoms. Second, it helps people with BPD to learn coping strategies that are helpful and healthy. Third, it reduces the distress associated with BPD and allows people to live more fulfilling lives.

While schema therapy has its strengths, it also has some limitations. It can be challenging to find a therapist who is a certified schema therapist. The therapy sessions may last for weeks to months, but BPD is a pervasive and enduring disorder. Hence, most therapeutic modalities take a long time to address and treat BPD. 

If you have been diagnosed with BPD, there is help available in the form of therapy and medicines. Speak to a mental health care provider near you to find your needed help. 

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