SCHEMA THERAPY

threeSchema therapy is one of the latest advances in psychotherapy, having been developed in the mid-1980s by Dr. Jeff Young in an effort to help patients with chronic issues that were not being adequately helped either with traditional psychodynamic/pyschoanalytic therapy or CBT. It is an integrated therapy that attempts to synthesise the key benefits of three classic therapeutic models.

Schema Therapy has a certain amount of overlap with Cognitive Behavioral Therapy (CBT) in that it focuses on bringing about changes in thoughts and behaviour for concrete, current life problems, whilst adding to this extra layers from Depth psychology which recognise that psychological problems may sometimes have their origins in experiences in childhood and youth.

Alongside cognitive strategies are experiential techniques taken from Psychodrama and Gestalt therapy which offer us ways to address emotional issues in session as well as heal developmental trauma. These techniques enable us to work in a more direct, “live” way while also focusing on the core needs and values that drive your life (a key aspect of Humanistic, Existential and Client-centred therapy).

MODES/PARTS

34602053943_12886925be_bA central concept in schema therapy is that of schema Modes or Parts.  A Mode/Part is a persistent pattern of behaving, thinking and feeling that always causes the same type of problems in our lives. We could think of these Modes/Parts as that aspect of ourselves or our identity which is primed or active at any given moment and which drives the way we anticipate, see, and respond to the world around us. I like to see these Modes/Parts as different members of an inner team (think David Brent, Gareth, Dawn, and Tim from The Office) who are all working for a similar cause but may have at times different agendas or perspectives.

There are four main types of modes:
(a) Child modes
(b) Maladaptive coping modes
(c) Dysfunctional internalized parent modes, and
(d) The Healthy Adult mode.

The Wounded Core: The Vulnerable Child mode

6642495487_58d4156a1a_oThe first and possibly most important mode we focus on is the Vulnerable Child mode. This is the mode that usually experiences most of the core schemas. When we are in a Vulnerable Child mode, we are like lost or wounded children. We may appear sad and hopeless, or be anxious, overwhelmed, and helpless. As the name implies, we often feel weak, vulnerable, exposed, and defenseless. The Vulnerable Child is a remnant of the time when as a child we needed the care of adults in order to survive, but were not getting the care we required, or maybe not in the manner we needed.

The specific nature of the wound to the Vulnerable Child depends upon the needs that went unmet. Based on the specific nature, a more specific name (other than “Vulnerable Child”) might be used for the mode. For example, if a child was often left alone or had parental figures whose presence was unpredictable, the Abandonment schema may predominate and we might decide to refer to this vulnerability as the “Abandoned Child.” Loneliness, sadness, and isolation may be the key feelings in this case. If the child was subjected to direct cruelty or violence, the Mistrust/Abuse schema may predominate and the vulnerability will take the form we call “The Abused Child.” In this case, feelings of fear, fragility, and victimization may be the key feelings.

Other forms of the Vulnerable Child mode (e.g., the Deprived Child, the Defective Child, the Lost Child) reflect other predominant schemas (e.g., Emotional Deprivation, Defectiveness, and Enmeshment schemas, respectively). Indeed, most schemas are part of the Vulnerable Child mode.

The ultimate objective of Schema Therapy is to help adults get their own needs met, even though these needs may have not been met in the past. The Vulnerable Child mode provides the clearest and most unequivocal manifestation of our unmet needs and of the emotional consequences of not having these needs met. So it is this mode that we are most concerned with accessing and helping in therapy. In a nutshell, we are trying to heal the Vulnerable Child mode—and provide you with the Life Skills you need to gradually provide such self-nurturance for your own Vulnerable Child.

Angry Child mode

angryThe Angry Child mode is the side of us that feels and expresses anger or rage in response to unmet core needs. The Angry Child mode is evident in uncontrolled, or poorly controlled, expressions of anger. More extreme manifestations might include screaming, shouting, swearing, throwing things, banging on things, or breaking things. Less extreme manifestations include having an angry or agitated facial expression or body language, or speaking in a loud or angry voice.

Such reactions might seem in the eyes of other people who don’t know what has triggered our Angry Child, disproportionate to the events which our Angry Child is getting upset about.

The Angry Child mode may be triggered by feelings of mistreatment (Mistrust/Abuse schema), abandonment (Abandonment schema), neglect (Emotional Deprivation schema), or humiliation (Defectiveness/Shame schema).

The Angry Child mode may also be triggered by feelings of frustration related to a sense of entitlement or poor self-control.

When the Angry Child mode is triggered, it can sometimes look as if we are having a temper tantrum: balled-up fists, red face, foot stomping, and so forth. As a result, such reactions are often counterproductive, which we generally recognise later, but not when we’re “fused” with the Mode itself.

temper-tantrum-girlOther people will often perceive our outbursts as childish and inappropriate, or as threatening and frightening, and this can have negative consequences for relationships and in the workplace. In contrast, more healthy expressions of anger involve the constructive expression of angry feelings within appropriate limits. It is a common misconception that anger per se is destructive. In fact, the healthy expression of anger can help to bring problems or conflicts to light, making it possible to resolve them. However, an Angry Child mode often lacks a strong Healthy Adult side that can modulate these reactions and channel them in constructive ways.

If we have a very active Angry Child mode even if we are able to contain angry reactions in the moment, we may continue to harbour resentments and ruminate over perceived wrongs, suggesting that the schemas (the patterns of angry thinking and feeling) involved in these reactions remain active.

Impulsive Child mode

056f5b7The Impulsive Child mode is the side of us that behaves impulsively, and has difficulty tolerating frustration. The Impulsive Child “wants what s/he wants when s/he wants it.” We experience these needs as urgent and find it intolerable to wait to have our needs met or to have them denied.

When the Impulsive Child wants something, s/he immediately springs into action without stopping to think about the possible consequences. If we have a very active Impulsive Child mode, we might also lack a Healthy Adult side that can reflect on the pros and cons of these behaviours, while simultaneously inhibiting impulses.

The Impulsive Child inevitably runs into conflicts with people in positions of authority.They becomes frustrated and angry when they can’t have their way, and experiences limits as unfair, arbitrary, or punitive. If we have a strong Impulsive Child mode we might have grown up in a family that lacked firm and consistent limit setting. Such a family may have been overly indulgent, chaotic, or neglectful, and might have been lacking in parental supervision and control.

Coping Modes

16826154838_fd6e68ee0b_hSchema Therapy distinguishes three types of main coping modes: the Detached Protector, the Compliant Surrenderer, and the Overcompensator.

The Detached Protector is a state of emotional avoidance. When in this state, we may feel cut off from our feelings and problems, acting in ways that are emotionally detached, distant, and numb, or are intellectualized and super-rational.

Another variation on the Detached Protector is the The Detached Self-soother in which we attempt to calm or soothe our feelings through compulsive, repetitive, or addictive behaviours, such as drug or alcohol use, food, shopping, gambling, tv, or internet/smart phone addiction. When in this state, we may feel a pleasant sense of buzz, high, or numbness, which serves to block out painful feelings. Time passes without being noticed and problems are temporarily forgotten.

Alternatively, in a Detached Self-stimulator mode, we may pursue sensations and thrills, and take risks, culminating in a state of excitement that also serves to avoid painful emotions. For example, we may pursue extreme sports, drive at high speeds, or engage in other dangerous pursuits, as if addicted to the risk itself.

The Compliant Surrenderer mode is a state of compliance. It involves attempts to conform to others’ expectations or demands, often at the expense of one’s own needs. When in this state, we may act passively, helplessly, or in a submissive manner. This can sometimes be done as a way of

The Overcompensator mode refers to a number of specific emotional states, which all involve overcompensatory forms of coping. In essence, doing the opposite of what our vulnerable child is feeling in order to avoid the painful emotions associated with being in a Vulnerable Child Mode. So the Overcompensator might act in a way to feel POWERFUL (by dominating others) rather than powerless; AGGRESSIVE (acting harshly towards others) rather than weak; IN CONTROL (trying to control other people) rather than helpless.

Internalized parent modes

Matilda-Bad-Blood-1The two internalized parent modes that are often referred to in Schema Therapy as the Punitive Parent and the Demanding Parent. These modes have in common an internalized parental “voice” that we experience either consciously or unconsciously as criticizing or denigrating us (Punitive Parent) or placing almost impossible demands on us (Demanding or Critical Parent).

In Schema Therapy, these modes are thought to be based on our memories of actual criticism, punishment, or abuse by parents or other caregivers. This does not mean that Schema Therapy views the Punitive/Critical mode as an exact representation of our actual parents though. Our personality and sensitivity to others and our own internal states can also have a part to play in creating these Modes.

As I have remarked above the Vulnerable Child mode is often the focus of therapy and that access to it is a key part of the healing process. Another key part of the process involves the strengthening of the two healthy modes—the Healthy Adult and the Contented Child.

Healthy Adult mode

15847266449_36f6b81103_kThe Healthy Adult mode is the part of the self that is capable, strong, and well-functioning. It includes those functional cognitions and behaviors that are needed to carry out appropriate adult functions such as working, parenting, taking responsibility, and committing to both people and actions. This part of the self is also the one that pursues pleasurable adult activities such as intellectual, aesthetic, and cultural interests, sex, health maintenance, and athletic activities.

The Healthy Adult mode, like an internalized therapist or good-enough parent, tries to respond flexibly to the various other modes. It nurtures, protects, and validates the Vulnerable Child mode, sets limits on the impulsivity and the angry outbursts of the Angry and Impulsive Child modes, and combats the effects of maladaptive coping modes and dysfunctional parent modes.

It is important (but sometimes difficult) not to confuse our Detached Protector modes and our Healthy Adult mode. At times, when we feel detached we can come across as rational, functioning, and in control. What helps distinguish a bona fide Healthy Adult mode from the false health that characterizes a Detached Protector mode is that the former involves a genuine experience of the full range of emotions, while the latter usually involves restriction of emotion and affect. As a consequence, being in a Healthy Adult mode allows us to engage with and compassionately acknowledge all of our myriad feelings, while being in a Detached Protector mode may leads us to deny or invalidate certain parts, especially the Vulnerable Child and its neediness.

Contented Child mode

14628822635_29e94032eb_kA second and related adaptive mode is the Contented Child. When in this mode, we feel at peace because our core emotional needs are currently met. We experience others as loving and appropriately protective, and they feel connected to them, nurtured, and validated. Because of this sense of security, we feel fulfilled, worthwhile, and self-confident, and are able to have a sense of optimism, spontaneity, and contentment.

As is true with other child modes, every child is born with the innate capacity to experience contentment. The degree to which it is actually experienced depends on the frequency and regularity with which childhood needs are adequately met and the life skills we learn to deal with the strengths and weaknesses of our personalities.

The Contented Child mode represents the capacity to experience and express spontaneity, glee, and playful happiness. In its original form (i.e., in children), it is a care-free mode, but its existence requires much care, either from external adults (parents) or from one’s own Healthy Adult mode. If the Healthy Adult is strong and functioning, it creates the freedom necessary for the Contented Child to thrive.

Limited reparenting

8090901158_be48a451de_hSchema Therapy involves two fundamental therapeutic stances—limited reparenting and empathic confrontation.

The central project of Schema Therapy is to help us as adults get our own emotional needs met, even when these needs may have never been met in the past. To achieve that, the therapy relationship itself needs to be one in which your needs are recognized, articulated, validated, and—within certain boundaries—fulfilled. The most important fulfillment is of those needs that were not met by the your parents when you were a child. This bounded fulfillment of needs is known as “limited reparenting”.

Which needs are fulfilled in a given therapy relationship depends to a large degree on the schemas or modes most active for you. For example, someone with strong Abandonment and Mistrust/Abuse schemas (and with an unmet need for safety and stability) will most benefit from a therapeutic relationship which emphasizes constancy, reliability, honesty, and availability. Someone else, who has the schema of Unrelenting Standards or a strong Critical Parent mode, will gain the most from a therapeutic relationship in which their therapist is generous with (authentic) praise and acceptance.

Schema therapists take great pains to provide limited reparenting in a caring and respectful way, rather than in a condescending one. Your core needs are seen as essential and universal requirements and not as frivolous fantasies; their fulfillment is therefore quite different from sheer gratification. When done correctly, limited reparenting can easily be immune to two critiques of this therapeutic stance: that it is paternalistic or denigrating, or that it is a form of counterproductive gratification of a client or patient’s fantasies.

32597403711_4ce16c681e_hSince the therapist can only provide the patient with “limited” reparenting, it is inevitable that there will be a gulf between what the patient wants and what the therapist can give. Rather then using impersonal explanations of limits (i.e., “It is the policy of our center to prohibit any behavior that might lead to suicide”), the schema therapist always tries to communicates in a personal manner (i.e., “For the sake of my own peace of mind, I have to know that you’re safe”).

Empathic confrontation

Empathic confrontation, along with limited reparenting, is one of the two central “pillars” of the Schema Therapy treatment approach (Young et al., 2003). In empathic confrontation, I might bring attention to some of your coping modes, but in an empathic, non-judgmental way. This technique only works if the therapist is able to access genuine compassion and show an ability empathize with the reasons for which you might engages in certain behaviours, but at the same time acknowledging the self-defeating nature of these responses and the necessity of changing them. The Schema Therapy language of schemas, coping responses, and modes facilitates empathic confrontation by giving the us a common set of concepts and vocabulary with which to understand the ways in which we all attempt to cope with the challenges of life. These concepts are morally and emotionally neutral, in that they view all forms of behaviour as a consequence of (sometimes) self-defeating patterns rather than as stemming from moral flaws.

Empathic confrontation can be used to confront the patient with his self-defeating behavior outside or inside of the therapy session. A therapist’s in-session empathic confrontation can be extremely powerful because it gives both parties the chance to examine the patient’s behavior as it is occurring in the “here-and-now” of the therapy relationship. This enables the therapist to demonstrate to the patient the obstacles being put in the way of intimacy and of getting the patient’s emotional needs met.

An illustration of this is given by the schema therapist Eshkol Rafaeli working with a young man “Robert”, who had been physically and emotionally abused as a child, and now would get into frequent heated arguments with his boss.

Because of the way he had been mistreated as a child, Robert expected that other people were out to hurt or humiliate him and had similar expectations towards his boss. Empathically confronting Robert with this understanding, Eshkol might say:

“When your boss criticizes you there is a side of you, the ‘Abused Child’ side, which feels that he is being abused all over again, just like you were by your parents. It’s no surprise that you become angry, and turn the tables on your boss by going on the attack with your ‘Angry Child’. When you were a child, fighting back was the only way that you could preserve your self-respect. However, when you get into a fight with your boss now, he doesn’t see the side of you that feels abused or mistreated. He just sees the ‘Angry Child’ side and feels attacked. As a result, you don’t get what you need, which is empathy and understanding. That’s what you want from your boss; it’s what you really needed from your parents, too.”

Eshkol uses the the concepts of schemas and coping responses with Robert to confront this self-defeating behaviour. By framing the conflict with his boss in terms of schemas and coping responses, Eshkol and Robert are able to look at Robert’s behaviour in a caring and non-judgmental way, while at the same time recognising its downsides. This approach enables Robert to view his interactions with his boss in more realistic and less schema-driven terms, and to adopt a less confrontational style in these interactions.

 

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