来源：《边缘型人格障碍的图式治疗》
作者：Arnoud Arntz and Hannie van Genderen
翻译：陈明
愤怒/冲动儿童
边缘型人格障碍的另一种图式是愤怒/冲动儿童。在治疗初期经常被抑郁（小诺拉）和害羞（惩罚性父母）所遮盖。正因为如此，在治疗初期愤怒/冲动儿童不常见。
愤怒的娜拉是狂怒、沮丧和不耐烦的幼儿，丝毫不考虑或为别人着想（约4岁）。在这种模式下，患者通常是口头的，间或身体攻击和刻薄的对待他人，包括她的治疗师。 她被激怒，她的需求得不到满足，她的权利都没有得到确认。
愤怒的诺拉相信要得越多越好，或者是根本一无所得。她相信她会被占便宜。她不仅狂怒，同时也希望大家看到她曾经被多么糟糕的对待过。她通过攻击他人（口头或身体上），伤害自己，企图自杀，甚至杀人，来作为报复的形式。这些当然是愤怒的诺拉的极端形式。愤怒诺拉对治疗师的一个温和的方式可能是不参加会谈或同时停止治疗。
愤怒儿童和愤怒的保护者之间的不同未必总是很明确，在愤怒呈现时，他们通常可以被观察到。愤怒儿童是冲动和不合理的。她所指的问题是完全不相关的和无关紧要的。愤怒的保护者越是控制，就越玩世不恭而不是狂怒（参见第九章“愤怒/攻击儿童的治疗方法的案例对话”）。
愤怒的爆发是受感情驱使并不可预期的。在会话中应该会发生这样的事，治疗师应该尝试保持冷静并容忍愤怒。他唯一要克制的是呈现出愤怒，当患者威胁要伤人、破坏财产的时候，或者她的愤怒的表达是如此丢脸，治疗师觉得他的界限受到侵犯。
治疗的目的是教患者，她当然可以生气，但也有其他的方式来表达她目前粘附着冲动与极端方式的情绪。
尽量让其需求得到满足的冲动方式，是BPD患者这一模式的第二个特点。患者可能，比如，与她根本不认知的人发生性接触，以试图感到被关心、有价值。其他的例子是冲动性的购物，酗酒的冲动或使用毒品，冲动性进食。这些行为都与他们冲动时的这个模式相关（病人并没有真正考虑长期风险），这些往往被一种反对惩罚性模式的反叛所激发，并带有需求满足之目标。酒精和苯二氮平类药物的使用，尤其是结合使用，可能会导致（已经有问题的）这类冲动的抑制缺损。治疗的总体目标是让病人学会承认他们的需求（而不是试图远离他们），并发展促使他们的需求得到满足的健康方式。
愤怒/冲动儿童的治疗方法
治疗关系
愤怒儿童需要一个安全的治疗性的关系，在那里，治疗师设置了清晰的边界（参加第4章设置限制）。愤怒儿童在此界限内将能够表达他的愤怒（参见第五章“愤怒”）同时学习适当的自信（参见第七章，技能培养和角色扮演）。愤怒的整个主题通常会在稍后的治疗中遇到，因为患者出于对惩罚性父母或被治疗师拒绝的恐惧而在治疗早期不敢表达这些情绪。有时，患者非常害怕自己的那些根本不会表露的侵略性的部分。在这种情况下，治疗师当时就可以打电话给她，告诉她应该参与会谈，并与她讨论她的恐惧。他可以试着打消她的疑虑，当她变得愤怒的时候，他不会打击或惩罚她，反而会帮助她表达她的情绪。如果患者的畏惧变的不可控并且意外的伤害治疗师，如果她失去了控制，他们可以同意她临时离开治疗室，当她的愤怒减弱之后再回来。更好的方法是向她展示她是如何发泄愤怒的，例如，打枕头。治疗师通过实际的身体击打枕头和喊叫来演示。与此同时鼓励她也这么做，她的愤怒发作时，始终保持一个枕头在身边。如此，患者就得到启示，无论愤怒多么强大，是可以接受的。然而，这种愤怒的表达必须以非破坏性的方式进行。这会促使患者越来越频繁的，足够安全的表达自己的愤怒。
如果患者无法触及她的情感或愤怒，帮助她是治疗师的工作（参见第五章‘愤怒'）从患者的既往中使用意象重构情景时，她会非常的愤怒，但又对她的愤怒无法做任何事情，治疗师要确保惩罚性父母不会伤害患者。他可以做到这一点，例如，创建一个牢不可破的透明的墙或篱笆，将愤怒儿童与惩罚性父隔离开。另一个可能的解决方案是他绑住或阻止惩罚性父母。通过这些，他给予了愤怒儿童或健康成人表达其愤怒的机会。如果她无法做到，治疗师也可以替她做这些。他以有形的方式展示愤怒（比如击打枕头）并鼓励她和他一起这么做。
这类意象训练之后，重要的是与患者讨论应急预案，并决定不同选择,以应对在会谈之外，可能会回来的惩罚父母，并寻求报复。有时候，参与这种类型活动后不久，患者会感到一些伤害自己或企图自杀的需求，来惩罚她表达了愤怒的情绪。当这些威胁发生时，患者可以打电话给治疗师或其他的卫生保健人员。然而，如果治疗师怀疑她积极呼救的能力，他可以通过使用电话预约并询问通话中的情况来“核查”之。
想法
BPD患者经常有很多不合理的想法包围着情感和/或愤怒的表达。这些不合理的想法是认知疗法的绝好治疗材料。观察普通人如何处理愤怒，对如何建立以正常的方式表达愤怒是有帮助的。
行为
首先，患者必须练习表达轻度的恼怒和愤怒，先在会谈中进行，之后在会谈之外（参见第七章“技能训练和角色扮演”）。这可以采取结合挑战不正常的想法的形式来体验。如果她看起来对她的愤怒有烦恼、在家里躁动不安，不能直接处置来上述情况下的愤怒，这很可能是来自于、她还没有准备好去处理的过去愤怒的残留。体育锻炼对遏止这一不安很有帮助。有些患者发现打枕头或拳击袋有帮助，有些则用运动来作为发泄的形式。当一个病人可能更喜欢用运动来释放这种愤怒，另一位病人可能会疯狂地打扫房子。治疗师可以在随后的会谈中探讨引起这种愤怒的各个方面。
药物疗法
愤怒会导致部分患者失眠。偶尔使用苯二氮左类药物可以帮助患者打破这种枯竭的恶性循环风险，而当她过于疲惫时，处理惩罚性父母模式的能力就会大打折扣。然而，在大多数情况下，不推荐使用苯二氮左类，因为它们有松弛患者的副作用，而且实际上增加了愤怒不可控配的机会。抗组胺类作为睡眠药物可能是一个更好的选择。
障碍
人们不应低估惩罚性父母的存在风险，尤其是一节会谈结束后。在愤怒儿童出现后的一节会谈的最后部分，治疗师必须永远不要忘记讨论这一可能性。
与其他模式相比，愤怒儿童可以从治疗师哪儿唤起更多的负面反应。正因如此，治疗师必须注意让自己的反应在控制之中，尤其是当愤怒儿童的侵略是针对他的时候。他必须尽其所能把患者视为勃然大怒中的、在愤怒中跺的脚的一个孩子。如果他控制自己的愤怒不成功，并用以暴治暴的方式回应，病人无疑会开始感到被拒绝（遗弃儿童）。另一种风险是治疗师希望远离患者，因为他受不了她的愤怒。这并不是说治疗师不应该对患者的攻击行为设置限制。 当他必须容忍她的情绪愤怒时，他需要不去容忍所有的愤怒表达形式。这样做的时候，他不拒绝她的愤怒，而是与她讨论哪些部分是现实的，哪些是不现实的。另一方面，如果治疗师确实变的害怕于他的患者，他必须调查他是否正在应对愤怒儿童孩或愤怒的保护者。在这两种情况下，为了让他再次感到安全，他必须确保必要的边界和限制是清晰的。
愤怒的诺拉也会掉头自伤或自杀，以这种方式展示愤怒。在这一模式下，她不打算惩罚自己，而是报复她身边那些不公正对待她的人。在极少数情况下，病人可能也威胁要杀死这些冤枉了她的人。当患者威胁自杀和/或杀人，治疗师处在了巨大压力之下，同时必须重新设置非常清晰的边界并赢得同僚的支持（参见第八章“自杀和自伤行为”）
The angry/ impulsive child
The other child mode in BPD is that of the ‘ angry/impulsive child'. The beginning of therapy is often overshadowed by desperation (Little Nora) and shame (punitive parent).Because of this, one does not often see the angry/impulsive child in the beginning of the therapy.
Angry Nora is a furious, frustrated and impatient young child (approximately four years of age) who has no regard or consideration for others. When in this mode, the patient is often verbally and, at times, physically aggressive and acrimonious towards others including her therapist. She is incensed that her needs are not met and her rights go unacknowledged.
Angry Nora is convinced it is better to take all you can or you will end up with nothing at all. She is convinced she will be taken advantage of. She is not only furious, but also wants everyone to see just how badly she has been treated. She does this by attacking others (verbally or physically), hurting herself, attempting to kill herself, or even others, as a form of revenge. This, of course, is the extreme form of Angry Nora. A milder way in which Angry Nora may show the therapist her anger is by not attending sessions or stopping therapy all together.
While the differences between the angry child and the angry protector are not always clear, they can usually be observed in how the anger is presented. The angry child is impulsive and unreasonable. She refers to issues that are completely unrelated and irrelevant. The angry protector is more controlled and more likely to be cynical than furious (see Chapter 9 ‘ Treatment Methods for the Angry/Impulsive Child'for a sample dialogue).
Outbursts of rage are impulsive and unexpected. Should these take place during a session, the therapist should attempt to remain calm and tolerate the anger. He should only limit the display of anger when the patient threatens to damage persons or property, or when the expression of her anger is so humiliating that the therapist feels his limits are violated.
The purpose of therapy is to teach the patient that she can be angry, but that there are other ways to express this emotion than the impulsive and extreme manner she currently adheres to.
A second characteristic of this mode is the impulsive way BPD patients try to get their needs met. The patient may, for instance, have sexual contacts with people she doesn't really know, in an attempt to get a feeling of being of value and cared for. Other examples are impulsive buying, impulsive alcohol or drug use, and impulsive eating. Such behaviours are related to this mode when they are impulsive (the patient did not really contemplate the long - term risks), often motivated by a sort of rebelliousness against the punitive mode, and have the aim of need satisfaction. Alcohol and benzodiazepine use, especially in combination, might lead to a loss of (the already problematic) inhibition of these kinds of impulses. The general aim of the treatment is that patients learn to acknowledge their needs (instead of trying to detach from them) and develop healthier ways of getting their needs met.
Treatment Methods for the Angry/Impulsive Child
Therapeutic relationship
The angry child requires a safe therapeutic relationship in which clear boundaries are set by the therapist (see Chapter 4 , ‘ Setting Limits'). Within these boundaries the angry child should be able to express her anger (see Chapter 5, ‘ Anger') and also learn appropriate assertiveness (see Chapter 7, ‘ Skills Training and Role Play'). This entire topic of anger is usually faced later on in therapy, as the patient does not dare to express these emotions early in therapy out of fear of the punitive parent or rejection by the therapist. At times, the patient is so frightened of her own aggression that she does not show up for the session at all. In this case the therapist can call her at the time she should have had her session and discuss her fears with her. He can try to reassure her that he will not be shocked or punish her when she becomes angry, but rather help her express her anger. If the patient fears becoming uncontrollable and accidentally hurting the therapist, they can agree that if she loses control, she can temporarily leave the room only returning once her rage has diminished. A better method is to show her how to vent her anger by, for example, hitting a pillow. The therapist demonstrates this by actually physically hitting a pillow and shouting. In doing so he encourages her to do the same, always keeping a pillow close at hand should her anger fl are up. In this way the patient gets the message that anger, no matter how strong, is acceptable. However, the expression of this anger must take place in a non - damaging manner. This allows many patients enough security to express their anger more and more often.
Feeling
If the patient is unable to get in touch with her feelings of anger, it is the job of the therapist to help her (see Chapter 5 , ‘ Anger').
When using imagery rescripting situations from the patient's past, in which she was very angry but was not able to do anything about this anger, the therapist makes sure that the punitive parent cannot harm the patient. He can do this by, for example, creating an unbreakable see - through wall or bars separating the angry child from the punitive parent. Another possible solution is that he ties up or holds back the punitive parent. By doing this he gives the angry child or healthy adult the opportunity to express her anger. If she is unable to do so, the therapist can also do this for her. He can physically show anger (e.g. hitting a pillow) and encourage her to do so with him.
After this type of imagery exercise it is important to discuss an emergency plan with the patient and decide on different alternatives for dealing with the punitive parent should it return and seek revenge outside of the sessions.
Sometimes, soon after participating in this type of exercise, the patient will feel the need to hurt herself or possibly attempt suicide as punishment for expressing her angry emotions. Should this threaten to happen, the patient can call her therapist or other health care workers. If, however, the therapist has doubts about her ability to actively call for help, he can ‘ check up'on her by making telephone appointments and asking how she is doing during these calls.
Thinking
BPD patients often have a number of irrational thoughts surrounding feeling and/or expressing anger. These irrational thoughts are excellent material for treatment with cognitive therapy. Observing how ordinary individuals deal with anger is helpful in building an understanding of how to express anger in a normal way.
Doing
First the patient must practise expressing mild irritations and anger during sessions and later outside of the sessions (also see Chapter 7 , ‘ Skills Training and Role Play').
This can take the form of an experiment in combination with challenging dysfunctional thoughts. If she appears to have problems with anger and restlessness at home and cannot directly place where this anger comes from, it is likely to be residual anger from her past which is not yet ready to be processed. Physical activity is helpful in curbing this unrest. Some patients find hitting a pillow or boxing bag helpful while others use sports as a form of release. While one patient may prefer using sports to release this anger, another patient might frantically clean the house. The therapist can use the following session to explore aspects that elicited this rage.
Pharmacotherapy
Anger leads to insomnia in some patients. Occasional use of benzodiazepines can help break this cycle as the patient runs the risk of exhaustion, and when she is overly tired her ability to deal with the punitive parent mode is compromised.
However, in most cases the use of benzodiazepines is not recommended as they have the side effect of unbridling the patient and can actually increase the chances of uncontrollable fits of rage. Antihistamines may be a better alternative as sleep medication.
Obstacles
One should not underestimate the risk of the presence of the punitive parent, particularly once the session is completed. The therapist must never forget to talk about this possibility at the end of a session in which the angry child was present.
The angry child can evoke more negative reactions from the therapist than the other modes. Because of this, the therapist must take care to keep his own reactions under control particularly when the angry child's aggression is directed towards him. He must do his best to view the patient as a child in the middle of a tantrum, stomping her foot in anger. Should he not succeed in controlling his own anger and respond to her attack with a counter - attack, the patient will no doubt begin to feel rejected (abandoned child). Another risk is that the therapist wants to pull away from the patient because he cannot stand her anger. This is not to say that the therapist should not set limits to the patient's aggressive behaviour. While he must tolerate her feeling angry, he need not tolerate all forms of expressing this anger. In doing so he does not reject her anger, but rather discusses with her which part of it is realistic and what is unrealistic. On the other hand, if the therapist actually does become frightened of his patient, he must investigate whether he is dealing with an angry child or an angry protector. In either case, he must ensure that the necessary boundaries and limitations are clear in order for him to feel safe again.
Angry Nora can also turn towards self- injury and suicide as a way of showing anger. In this mode she does not intend to punish herself, but to take revenge on those around her who have unjustly hurt her. In rare cases the patient may also threaten to kill these individuals who have wronged her. When a patient threatens suicide and/or murder, the therapist is put under an enormous strain and must again set very clear boundaries and enlist the involvement of a colleague (see Chapter 8 , ‘ Suicide and Self- Injury').
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