You know I won’t leave you – Abandoment

Hello and good morning! I can’t believe it but I actually kind of look forward to coming in to work. Craziness. Sheer craziness. I’m productive. I enjoy my co-workers. I’m awake and alert. I really think this Pristiq is helping me lift my mood enough that my life feels more easily manageable.  This is just, unheard of. I’m kind of waiting for the other shoe to drop but for now I’m just going to try to enjoy feeling reasonably decent for a change.

Alright. I wanted to get back into my discussions of SchemaTherapy. I’ve introduced you to all the difference schemas, coping styles and modes, but there’s still a lot of depth and useful information. Over the next few weeks I want to take a detailed look at each of the schemas, go over behavioral pattern breaking, look at some easy exercises to increase introspection and self-awareness and a plethora of other things. For now though, let’s start with detailed schema treatment strategies. Each of these will have a pattern of Typical Presentation of the Schema, Goals of Treatment, Strategies Emphasized in Treatment, and Special Problems with This Schema. I just want to emphasize that I’m only presenting information as I’ve uncovered it. There will always be facets and exceptions that I miss or am not aware of. I can’t diagnose or treat anyone.  Strategies that work for some people may not work for others. Etc. My goal is to present as much information as I can and hope that it enables self-reflection and understanding. I also find it reassuring that there is proof that people have found ways of successfully dealing with so many of the issues that we struggle with. So here we go. Let’s taking a deeper look at one of the core issues of Borderline Personality Disorder.

Domain I: Disconnection and Rejection Domain

Abandonment

Typical Presentation of the Schema

These patients constantly expect to lose the people closest to them. They believe these people will abandon them, get sick and die, leave them for somebody else, behave unpredictably, or somehow suddenly disappear. Therefore, they live in constant fear and are always vigilant for any sign that someone is about to leave their lives.

The common emotions are chronic anxiety about losing people, sadness, and depression when there is an actual or perceived loss, and anger at the people who have left them. (In more intense forms, these emotions become terror, grief, and rage.) Some patients even become upset when people leave them for short periods of time. Typical behaviors include clinging to significant others, being possessive and controlling, accusing others of abandoning them, jealousy, and competitiveness with rivals – all to prevent the other person from leaving. Some patients with an Abandonment schema avoid intimate relationship altogether, in order to avoid experiencing what they anticipate to be the inevitable pain of loss. (One patient with this schema, when asked why he could not make a commitment to the woman he loved, answer: “What if she dies?” Consistent with the schema perpetuation process, these patients typically choose unstable significant others, such as uncommitted or unavailable partners, who are highly likely to abandon them. They usually have intense chemistry with these partners, and often fall obsessively in love.

The Abandonment schema is frequently linked with other schemas. It can be linked with the Subjugation schema. Patients believe that if they do not do what the other person wants, then he or she will leave them. It can also be linked with the Dependence/Incompetence schema. Patients believe that if the other person leaves, they will be unable to function in the world on their own. Finally, the Abandonment schema can be linked with the Defectiveness schema. Patients believe the other person will find out how defective they are and will leave.

Goals of Treatment

One goal of treatment is to help patients become more realistic about the stability of relationships. Patients who have been successfully treated for an Abandonment schema no longer worry all the time that reliable significant others are about to disappear. In object relation terms, they have learned to internalize significant others as stable objects. They are far less likely to magnify and misinterpret behaviors as signs that other people are going to abandon them.

            Their linked schemas are usually diminished as well. Because they feel less subjugated, or dependent, or defective, abandonment is not as frightening to them as it used to be. They feel more secure in their relationships, so they do not have to cling, control, or manipulate. They are less angry. They select significant others who are consistently there for them, and no longer avoid intimate relationships. Another sign of improvement in patients with this schema is that they are able to be alone for extended periods of time without becoming anxious or depressed, and without having t o reach out immediately and connect to somebody.

Strategies Emphasized in Treatment

            The more severe the Abandonment schema, the more important the therapy relationship is to the treatment. Patients with BPD typically have Abandonment as one of their core schemas, and, therefore, the therapy relationship is the primary source of healing. According to our approach, the therapist becomes a transitional parent figure – a stable base from which the patient can venture into the world and form other stable bonds. First, the patient learns to overcome the schema within the therapy relationship, and then transfers this learning to significant others outside of therapy. Through  “limited reparenting,” the therapist provides the patient with stability, and the patient gradually learns to accept the therapist as a stable abject. Mode work is especially helpful (I’ll talk about this some other time). Through empathic confrontation, the therapist corrects the patient’s distorted sense that the therapist is constantly about to abandon the patient. The therapist helps the patient accept the therapist’s departures, vacations, and unavailability without catastrophizing and overreacting. Finally, the therapist helps the patient find someone to replace the therapist as the primary relationship – someone stable, who is not going to leave – so the patient is not dependent forever on the therapist to be the stable object.

            Cognitive strategies focus on altering the patient’s exaggerated view that other people will eventually leave, die, or behave unpredictably. Patients learn to stop catastrophizing about temporary separations from significant others. Additionally, cognitive strategies focus on altering the patient’s unrealistic expectation that significant others should be endlessly available and totally consistent. Patients learn to accept that other people have the right to set limits and establish separate space. Cognitive strategies also focus on reducing the patient’s obsessive focus on making sure the partner is still there. Finally, cognitive strategies address the cognitions that link to other schemas – for example, changing the view that patients must do what other people want them to do or else they are going to be left; that they are incompetent, and need other people to take care of them; or that they are defective, and other people will inevitably find out and leave them.

            In terms of experiential strategies, patients relive childhood experiences of abandonment or instability in imagery. Patients re-experience through imagery memories of the parent who left them, or of the unstable parent who was sometimes there and sometimes not. The therapist enters the image and becomes a stable figure for the child. The therapist expresses anger at the parent who acted irresponsibly, and  comforts the Abandoned Child; then, patients enter the image as Healthy Adults and do the same. They express anger at the parent who abandoned them and comfort the Abandoned Child. Thus, patients gradually become able to serve as their own Healthy Adults in the imagery.

            Behaviorally, patients focus on choosing partners who are capable of making a commitment. They also learn to stop pushing partners away with behaviors that are too jealous, clinging, angry, or controlling. They gradually learn to tolerate being alone. Countering their schema-driven attraction to instability, they learn to walk away from unstable relationships quickly and to become more comfortable in stable relationships. They also heal their linked schemas: They stop letting other people control them; they learn to become more competent in handling everyday affairs, or they work on feeling less defective.

Special Problems with This Schema

            Abandonment often comes up as an issue in therapy when the therapist initiates a separation – such as ending a session, going on vacation, or changing an appointment time. The schema is triggered, and the patient becomes frightened or angry. These situations provide excellent opportunities for the patient to make progress with the schema. The therapist helps the patient do so through empathic confrontation: Although the therapist understands why the patient is so scared, the reality is that the therapist is still bonded to the patient while they are apart, and the therapist is going to return and see the patient again.

            Alternatively, patients may be overly compliant in therapy to make sure the therapist does not ever leave them. They are “Good patients,” constantly seeking reassurance or cling between sessions in order to reconnect. Avoidant patients may miss sessions, be reluctant to come on a regular basis, or drop out of therapy prematurely because they do not want to become too attached to the therapist. Patients with the Abandonment schema may also repeatedly test the therapist – for example, by threatening to stop therapy or accusing the therapist of wanting to stop. (Eventually I’ll go back and talk more about how therapists address these issues for someone with Borderline Personality Disorder.) Briefly, the therapist approaches the problem through a combination of settling limits and empathic confrontation.

            Another risk is that patients with the Abandonment schema may make the therapist the central figure in their lives permanently, instead of forming stable, primary connections with other people. The patient never terminates therapy, but just o continues to let the therapist be the stable connection. Becoming dependent upon the therapist becomes the unhealthy solution to the schema. The ultimate goal of therapy is for patients to connect with others in the outside world who can meet their emotional needs.

I may change up my writing strategy of these schemas as I go along. These posts are pretty darn long and I have so much I want to interject and expound on.  Regardless, I think there’s a lot of good information here. I recognize so much of myself in this. For me at least, when I can recognize my behavior as something that’s defective, it makes it easier for me to recognize it when I’m living my life and try to remember to act differently. After all, how can you fix something if you don’t know it’s broken, right?

Second Time’s the Charm – Limited Reparenting

The Schema concept of “limited reparenting” means that the therapist provides the support that the parents failed to provide, enabling patients to internalize the therapist and eventually provide their own support.

The process of limited reparenting is the heart of the treatment in schema therapy and is one of its most unique and defining elements. Through treatment the therapist uses the relationship built in therapy as a partial antidote to the patient’s schemas. This limited reparenting provides something of a corrective emotional experience specifically designed to counteract the patient’s Early Maladaptive Schemas. Limited reparenting flows directly from schema therapies assumption that early maladaptive schemas and modes arise when core needs are not met. Schema therapy’s aim is to meet these needs by helping the patient find the experiences that were missed in early childhood that will serve as an antidote to the damaging experiences that led to maladaptive schemas and modes. Limited reparenting, paralleling healthy parenting, involves the establishment of a secure attachment through the therapist, within the bounds of a professional relationship, doing what she can to meet these needs.

In order to do this the therapist will use childhood history, reports of interpersonal difficulties, questionnaires, imagery exercises… pretty much anything that gives insight into what the person with BPD was missing early in life. It takes the form of simultaneous tenderness and firmness through what is called “empathic confrontation”.

The more I learn about Schematherapy the more I believe that it takes a special kind of person to be this kind of therapist. Since this type of depends entirely on the individual with BPD the therapist has to be very flexible to adjust to their patients  unique history. It’s the goal of the therapist to become something of a ‘good parent’. Now that does not mean they’re going to become a substitute parent. But within the reasonable limits of therapy a therapist will try to meet those basic emotional needs: (1) Secure attachment; (2) autonomy and competence; (3) genuine self-expression of needs and emotions; (4) spontaneity and play; and (5) realistic limits.

This technique works because treatment parallels child development in some ways. Think of it as the person with BPD growing up in therapy. The patient begins anew (as an infant or very young child) and under the influene of the therapist’s reparenting, can gradually mature into a healthy adult. This is also one of the reasons why therapy for someone with a Borderline Personality Disorder cannot be short. It takes a long time to grow up and mature. These things can’t be rushed and require putting in real effort to grow into a healthier person.

For this to be truly effective the relationship with the therapist has to be one of mutual respect and genuineness. The therapist should genuinely care about the patient. A lot of people with BPD are hypersensitive which makes them very aware of how other people interact with them. If the therapist doesn’t genuinely care that falseness isn’t hard to pick up on and it makes it really difficult to form a trusting therapeutic bond. It’s funny. My therapist often reminds and reassures me of this. That she cares. I don’t understand why she cares though. I don’t believe she has reason to because I’m essentially a random person in her life with no cause for an emotional bond. This is probably my failing though, not hers. Like I said, it takes a special kind of person to care about people like this. Or maybe I’m just so detached and dissociated from my own emotions that this only feels like a foreign concept to me. Maybe for an emotionally healthy person it’s not that difficult.

The overall goal of therapeutic treatment is to help incorporate that Healthy Adult mode, modeled after the therapist. Relating to all those modes we’ve been talking about the therapist tries to:

1.      Empathize with and protect the Abandoned Child

2.      Help the Abandoned Child to give and receive love.

3.      Fight against, and expunge, the Punitive Parent.

4.      Set limits on the behavior of the Angy and Impulsive Child and help patients in this mode to express emotions and needs appropriately.

5.      Reassure, and gradually replace, the Detached Protector with the Healthy Adult.

Limited reparenting involves reaching the Vulnerable Child Mode and reassuring, being firm with or setting limits on the avoidant and compensatory modes or coping styles that block access to the Vulnerable Child Modes or schemas. In the midst of this, the therapist helps to provide constructive outlets for the Angry Child Mode. In addition, it often requires that the therapist help the patient fight punitive, demanding, or subjugating parent modes or schemas. These steps are usually facilitated by the use of guided imagery; an experiential technique that allows the therapist to establish more direct contact with the various modes and schemas.

People with BPD often expect other people to treat them the same way their parents treated them (or whomever it was that most affected them most growing up). It seems completely natural that everyone else would take on the worst aspects of the person you internalized most. This is part of the Punitive Parent schema. It’s necessary to go through a process of understanding why the parent mistreated the patient. Once patients are able to understand the parent’s reasons for mistreating them, they are more likely to break the emotional tie between their parent’s treatment of them and their self-esteem. It’s possible to learn that, even though their parent mistreated them, they were worthy of love and respect. By becoming a stable, nurturing base, the therapist provides stability, enabling us to let go of or stand up to the dysfunctional parent figure and eventually all the dysfunctional schemas we embody. In being able to do this a level of autonomy and independence is achieved. Essentially the therapist is trying to lead by example; by demonstrating what a healthy adult thinks, acts, and feels, eventually, in time, that will become what seems normal as old habits and ways of living become things of the past.  

It’s not an overt thing though. I can definitely see how my therapist does this, but it’s not like she sets out to ‘be a parent’. It’s really not like that at all. She does what (I assume)  most therapists do, she listens, and works through my issues with me, but while doing this she also puts an emphasis on creating a safe place and building the relationship between us. Limited reparenting isn’t one large overlying program. It’s all the little encouragements, positive affirmations, repeated reminders, subtle guidance, and appropriate corrections in addition to your standard therapy. Like I said, it takes a special kind of person to be good at this.

Thinking about it, I get down on therapist for being so positive and telling me I’m a good person when I don’t feel like I am. I’ve heard my entire life that I’m not good enough and can always be better, so when she tells me that I am a good person and I don’t need to be so hard on myself this just seems contrary to what deep down I know because it’s what I’ve always been told. Just because I’ve always been told that, doesn’t make it true though. Geezus her patience is outstanding because no matter how much I fight her some days, she holds steady with the reality that she sees in me. Some days I even believe her too.