超然分离保护者的图式治疗
作者: Arnoud Arntz / 6181次阅读 时间: 2014年5月22日
来源: 陈明翻译 标签: BPD 图式治疗
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The detached protector

When the patient is in the detached protector mode, the patient seems relatively mature and calm. A therapist could assume the patient is doing well. In fact, the patient uses this protective mode in order to avoid experiencing or revealing her feelings of fear (abandoned child), inferiority (punishing parent) or anger (impulsive child). Underlying assumptions that play important roles here are those of: it is dangerous to show your feelings and/or desires and to express your opinion. The patient fears losing control of her feelings. She attempts to protect herself from the alleged abuse or abandonment. This becomes particularly evident as she becomes attached to others. The protector keeps other people at a distance either by not engaging in contact or by pushing them away. Should others discover her weaknesses, the patient would face potential humiliation, punishment and/or abandonment. Therefore, for her it is better to not feel anything at all and keep others from getting too close to her.

Sample dialogue with a patient in the protector m ode

(In this example and following dialogues, ‘ t ’ is therapist and ‘p ’ is patient.)

t : How are you doing?

p : (with no emotion) Good.
 : How was your week, did anything happen that you would like to talk about?
 

p : (looks away and yawns) No, not really.

t : So, everything ’ s OK?

p : Yeah, everything ’ s OK. Maybe we could have a short session today?

Should simple methods of avoiding painful emotions prove ineffective, she may attempt other manners of escape, such as substance abuse, self - injury (physical pain can sometimes numb psychological pain), staying in bed, disassociation or attempting to end her life. BPD patients often describe this mode as an empty space or a cold feeling. They report feeling distanced from all experiences while in this mode, including therapy.

If the patient is not successful at keeping people at a distance, she can become angry and cynical in an attempt to keep people away from her. It is important for the therapist to recognize these behaviours as forms of protection and not be put off by them. If this angry state is very pronounced, it can be distinguished as a separate ‘ angry protector ’ mode.

It is difficult to distinguish the angry protector from the punitive parent, especially during the initial stages of the therapy. One manner of distinction is to observe the direction of the patient ’ s anger. While the angry protector ’ s rage is directed towards the therapist (or someone else), the punitive parent ’ s anger is directed towards the patient herself. If the therapist is unsure of the mode he is presented with, he can simply ask the patient if she is able to disclose which ‘ side ’ of her personality is currently active.

Sample dialogue with patient in the angry protector and the punitive parent mode

t : When I told you that I have the next few days off, your reaction was pretty angry. What mode do you think that reaction came from?
Response from angry protector:

p : Oh No! We're going to have another lecture about that stupid borderline model of yours? You couldn't wait, could you? Can't think of anything better can you?

Response from punitive parent:

p : I don ’ t know which ‘ side ’ of me this is. I only know that I must have been a complete idiot to trust you and that is one mistake I won ’ t make again. It doesn ’ t matter anyway, I ’ ll never get better.

In the beginning of the therapy, the subtle differences between the angry protector and the angry child can also be difficult to distinguish.

The differences are primarily evident in the level of anger that is paired with the reaction (see the section ‘ Angry/Impulsive Child ’ ).
These examples involve the protector expressing herself in a demonstrable, interactive manner.

 The completely opposite form in which the protector may express herself is by exhibiting tired or sleepy behaviour. In this case the therapist must assess whether or not the patient is actually tired or whether she is in the protector mode.

There is the risk that while in the protector mode, the patient may avoid therapy and not work on her problems with a serious chance of her stopping therapy all together. The patient can also have problems with dissociative symptoms, self - injury, addiction to numbing substances (e.g. drugs or alcohol) or may attempt suicide. Because of this, it is important to identify when the protector role is present and circumvent it. This will give the patient an opportunity to work on her actual problems.

Treatment Methods for the Detached Protector

Therapeutic relationship

In the beginning of the therapy the therapist must often deal with the detached protector. The patient is frightened by the strong emotions of the abandoned or angry child. She also fears punishment and/or humiliation from the punitive parent. The therapist must regularly reassure the detached protector that he will support his patient when this happens and help her deal with these strong and often unpleasant emotions. He encourages her to express her emotions. He speaks to the detached protector in a friendly yet firm voice. During each session, the therapist must continually try to bypass the detached protector even if this takes a great deal of effort. While the patient is in her detached protector mode, it is not possible for the therapist to reach the abandoned child with limited reparenting (see Chapter 4 ). At times the protector can even become aggressive, often as a result of the patient not having enough trust in her therapist. Because of this, the protector is prepared to do, and does, anything and everything to ensure the therapist does not get near the abandoned child. The protector does this with the aim of protecting the patient from further abuse. This means that the therapist must have patience and continue to earn the patient\\\'s trust in him. If the patient is mistrusting, her therapist must make it clear that the fact that she does not trust him is evidence that she is in the protector mode and he must show understanding for her inability to trust. He must express empathy with her, let her know that learning to trust someone takes time, particularly if one has a past of putting their trust in untrustworthy individuals. The therapist can choose to increase the frequency and/or length of the sessions in trying to bypass the protector because usually the protector will back down in this situation. Outside of the session the protector can show their side by means of self - injury or suicide attempts. To an extent, physical pain protects the patient from emotional pain. In this case, all attention must first focus on putting an end to self - injury and/or suicide attempts. The therapist must ensure that he is easily accessible to the patient in this situation and that a crisis centre is available when he is not.

Feeling

The best method for removing the detached protector from the situation is the two - chair technique. The therapist asks the patient to sit in a different chair and from this new position put into words why the protector is needed. While in this other chair the patient can put her fears into words without immediately becoming emotional. Then, the therapist can have a discussion with the protector. During this discussion he emphasizes that the protector had a functional role in Little Nora\\\'s past when she was unable to escape her difficult situation.However, now Noras situation has changed and she can allow Little Nora to be protected by the therapist and he will teach her how to handle emotions in another (more adult) way. When the relationship between therapist and patient is strong and trusting, the patient often becomes emotional by this reassurance and moves into the abandoned child mode. The therapist can then ask her to return to her original chair and continue the discussion with the abandoned child. When the protector agrees that the therapist continues with the abandoned child, he asks her to return to her chair even if she is not visibly emotional. 

Another possibility is to avoid the protector all together by asking the patient to close her eyes and imagine Little Nora. If this is successful, then the therapist can try to reach the abandoned child in this manner and encourage her to express her feelings.

Thinking

The therapist can write down the pros and cons of the protector on a board. In practice, it is the patient who will think of pros and the therapist must help to find cons.He must explain why it is in her best interest to learn to deal with her feelings and emotions. This is an important skill for future intimate relationships and/or having children. Further it will help her with her general development as a person (see Table 9.1 ). This cognitive technique helps the patient to lessen the detached protector mode. 

The other cognitive techniques described in Chapter 6 are less useful in this situation. This is because what appears to have changed on a cognitive level is often not assimilated at an emotional level. The new insights have not sunk in.

Table 9.1 Examples of the pros and cons of the detached protector.

 
ProsCons
I feel quietI feel empty
I don't feel the urge to cut myselfIf I suppress my feelings too long, I ’ ll end up hurting myself
I don't have conflicts with other peopleI don't connect with other people (or my therapist)

 

I don't have to talk about difficult issues in the sessionI cannot start a new relationship when I stay detached
I don't have to try new things like working or studyingI don\\\'t learn how to handle emotions, so I should better not raise children. Otherwise they\\\'ll get the same problems as I have

I don't learn how to overcome my problems

If I don't find new work or a training course,I will never get a normal income

If I stay in the detached protector mode, my life will be boring

Doing

The patient must learn to spend less time in the protector mode both during sessions and outside of sessions. She can only be successful in doing this outside of sessions once she is able to do so during sessions. Further, the patient also needs to have built up trust in others outside of the therapeutic framework. The therapist encourages her to share her feelings with others more and more often. If she has little contact with others, he can encourage her to participate in activities where she is likely to meet people regularly. Once she has developed relationships with a few good friends, it is helpful to invite them for one or more sessions to stimulate the patient by encouraging her to practise expressing her emotions towards them.

Pharmacotherapy

The use of psychopharmacology has been suggested if the patient\\\'s level of fear and panic reaches a point that she can no longer tolerate. Antidepressive drugs can be used in this case. However, there are at least two reasons to be extremely careful with the use of psychopharmics during ST. First, there are indications that pharmacological agents interfere with the emotional and cognitive change processes during treatment, so that recovery is delayed (Giesen - Bloo et al ., 2006 ). Secondly, their application might actually strengthen the detached protector mode, the opposite ST aims for. Should everything go well, after about a year the protector will be much less present. Further, the times that the protector is present, it will be much easier to set him on the sidelines.

Obstacles

• If the patient appears tired or sleepy, it is almost impossible to get through to her. The therapist must first find out if this is due to an actual lack of sleep and if so, which mode is responsible for her insomnia. Once this is established, the therapist and patient can work together to improve her sleep patterns. However, if there appears to be no physical explanation for her being tired, it is more than likely the result of the protector. In this case the therapist can try different methods to ‘ wake her up ’ such as opening a window, talking louder or even (gently) shaking her.Often it is helpful to begin with a difficult subject, which is more likely to force the patient to become more alert. When the patient\\\'s ‘ absence ’ begins to take the form of a dissociative state, the therapist can attempt to remove her from this state by means of concentration exercises such as controlled breathing, focusing on a certain point in the room, and having her describe where she is and with whom. He continues to reassure her that he will protect her from her punitive side. While doing this the therapist tries to discover what made the patient so frightened that she went into this dissociative state. He further tries to connect the results of this search to traumatic experiences from the patient\\\'s past.

• Large amounts of stress combined with serious fear can result in short - term psychotic symptoms. These psychotic symptoms often have a paranoid content. For example, the patient may think that her therapist is about to hit her or she sees him looking at her in an aggressive manner. In these situations it is as if the therapist becomes the abusive parent. Just as when a patient becomes dissociative, the therapist must also slowly, and in detail, reassure her and try to bring her back to reality when she shows psychotic symptoms. As the stress levels decrease, these psychotic symptoms will also decrease. The therapist need not worry about a full - blown psychotic episode based on these symptoms. Temporary use of antipsychotic drugs is sometimes indicated (the ability to counteract illusions is limited).

• At times the therapist does not know whether or not he is dealing with the protector as the patient makes apparently sensible statements while at the same time asking the therapist to come up with practical solutions for her situation. He may think that he is dealing with the healthy adult. To clarify the situation the therapist can ask his patient about her feelings. If she appears to have a flat emotionless reaction, then he knows he is dealing with the protector. Looking for practical solutions while the patient is in the protector mode is seldom a good idea, as this mode is not focused on the needs of the young child. On the other hand, if she responds in a nuanced manner, then the therapist knows he is dealing with a healthy adult mode. Even when she is in the abandoned child mode, if the patient feels that she has enough support from the therapist it is possible for her to think of practical solutions herself without the protector.

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