Addressing the punitive parent mode in schema therapy for borderline personality disorder: Short-term effects of the empty chair technique as compared to cognitive challenging.

Background and objectives: In Schema Therapy (ST) for Borderline Personality Disorder (BPD) patients the empty chair technique (EC) is often used to diminish the ‘punitive parent mode’ (PP). The present study is a first attempt to assess whether EC is more effective in reducing the PP than a standard Cognitive Behavioral Therapy technique (CT). 

Methods: We utilized a counterbalanced, crossover design comparing one EC session to one CT session in twenty patients with a primary BPD diagnosis who had started ST. Before and after each intervention we assessed credibility, power, and valence of the PP-associated core belief and how much power patients felt over this core belief (dominance). Patients also completed a working alliance inventory. An interview was conducted to explore subjective views regarding the interventions. 

Results: Both techniques reduced power and credibility of the PP-associated core belief and increased dominance. CT reduced credibility more strongly than EC. Still, patients preferred EC as they felt it was better able to elicit feelings during the session and believed it would be more effective than CT when administered repeatedly. 

Limitations: A complex technique was tested early in treatment and only once, effects might be different later in treatment and when applied repeatedly. Moreover, only short-term effects were assessed in a rather small sample. 

Conclusion: Both EC and CT help combat the PP in BPD patients, with CT being more effective in reducing credibility after one session. However, patients preferred EC and suggest multiple sessions might be needed to truly elucidate differences between both techniques.