The Subjective Experience of the Punitive Parent Mode in Individuals With Borderline Personality Disorder Following Schema Therapy: A Qualitative Study

Abstract

Borderline personality disorder (BPD) is often characterized by self-critical and punitive thoughts, emotions, beliefs and behaviours, conceptualized in schema therapy (ST) as the punitive parent mode (PPM). This mode involves internalized punitive messages from childhood from the behaviour and reactions of significant others, leading to self-hatred, guilt and self-denial. Although patients with BPD frequently report auditory verbal hallucinations (AVHs) as manifestations of the PPM, this phenomenon is often overlooked in ST studies. We conducted semistructured interviews with 16 (ex)patients (63% female) from two Dutch mental health institutions to explore their experiences with the PPM before, during and after ST. An independent, double-coded systematic content analysis was performed. Approximately half of the participants reported AVHs linked to the PPM before therapy. The patients characterized the PPM by pervasive self-critical messages, contributing to intense emotional and physical distress and maladaptive coping strategies. Participants reported that ST techniques, including group therapy, imagery rescripting (ImRs) and the empty chair technique (ECT), effectively reduced the power and credibility of the PPM, including AVHs. The self-reported improvements included more adaptive coping mechanisms, increased social support and a general experience of reduced PPM. This study highlights the prevalence of the PPM as AVHs in individuals with BPD and demonstrates the efficacy of ST in reducing the impact of PPM, including in cases involving AVHs. Clinical implications include the need for relapse prevention plans and further exploration into how ST's effects can be enhanced. Future research should explore the broader spectrum of psychotic experiences in BPD and consider integrating PPM-related AVHs into the assessment and treatment of BPD.

Keywords: auditory verbal hallucinations; borderline personality disorder; empty chair technique; imagery rescripting; punitive parent mode; schema therapy.