Theme Article. The schema mode model for personality disorders

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1 78 The schema mode model for personality disorders E. Fassbinder 1 ; U. Schweiger 1 ; G. Jacob 2 ; A. Arntz 3 1 Universität zu Lübeck, Klinik für Psychiatrie und Psychotherapie; 2 GAIA AG, Hamburg; 3 University of Amsterdam, Department of Clinical Psychology, Amsterdam Keywords Personality disorders, schema mode model, schema therapy Schlüsselwörter Persönlichkeitsstörung, Schema-Modus-Modell, Schematherapie Summary Schema therapy (ST) based on the schema mode approach is currently one of the major developments in the treatment of personality disorders (PD). ST is a transdiagnostic approach, but also provides disorder-specific models for most PDs. The mode model gives a clear structure for the development of an individual case conceptualization, in which all current symptoms and interpersonal problems of the patient and the connection with their biographical context can be accommodated. The therapeutic interventions are adapted to the present mode in the specific situation. In addition to cognitive and behavioral techniques there is a special focus on experiential techniques (especially chair dialogues and imagery rescripting) and on specific features of the therapeutic relationship ( limited reparenting ). This paper provides an overview of the theoretical background and practical application of schema mode-based ST for PDs. An individual case conceptualization and the therapeutic techniques are illustrated with a case example of a patient with histrionic PD. Zusammenfassung Schematherapie (ST) mit dem Schema-Modus-Ansatz ist derzeit eine der wichtigsten Entwicklungen in der Behandlung von Persönlichkeitsstörungen (PS). ST ist zwar grundsätzlich als transdiagnostischen Ansatz zu verstehen, bietet aber auch störungsspezifische Modelle für die meisten PS. Das Modusmodell bietet eine klare Struktur für die Erarbeitung eines individuellen Störungsmodells, in dem alle aktuellen Symptome und zwischenmenschliche Probleme des Patienten und die Verbindung mit dem biografischen Kontext eingeordnet werden können. Die therapeutischen Interventionen werden dem jeweils aktiven Modus angepasst. Hierbei stehen neben kognitiven und behavioralen Techniken insbesondere emotionsaktivierende Techniken (v.a. Stuhldialoge und Imaginationstechniken) und eine spezifische Gestaltung der Therapiebeziehung ( limited reparenting ) im Vordergrund. Der folgende Artikel gibt einen Überblick über die theoretischen Grundlagen und die praktische Anwendung des schematherapeutischen Modus-Modells. Eine schematherapeutische Fallkonzeptualisierung sowie die schematherapeutischen Techniken werden mit einen Fallbeispiel einer Patientin mit histrionischer PS illustriert. Das schematherapeutische Modusmodell für Persönlichkeitsstörungen Die Psychiatrie 2014; 11: Eingegangen: 17. Februar 2014 Angenommen nach Revision: 19. März 2014 Schema therapy (ST) based on the schema mode model is one of the major current developments in the field of psychotherapy for personality disorders (PD). For most PDs a specific mode model has been described (1, 2). The first and best evaluated is the mode model for Borderline Personality Disorder (BPD) (3, 4). Several studies have shown that treatment based on that model is very effective for patients with BPD (5 8). But also for other PDs results are encouraging: In a randomized controlled trial in six other PDs with a majority of patients with cluster-c-pds (avoidant, dependent, and obsessive-compulsive) ST based on the mode model was superior to comparison conditions (9). Recent reviews summarize current research findings on ST for BPD (10) and PDs in general (11).

2 79 This paper provides an overview of the theoretical background and practical application of the schema mode model for PDs. Case conceptualization and therapeutic techniques are illustrated with a case example. As most publications on ST so far focus on BPD and to a lesser extent on cluster-c-pd, narcissistic and antisocial PD we present an example of a patient with histrionic PD. What characterizes schema therapy? ST derives from cognitive behavior therapy (CBT) and was originally developed by Jeffrey Young for patients, who did not respond to standard CBT. These patients typically showed chronic, rigid, complex psychological problems and in many cases had comorbid PDs (12, 13). ST is characterized by a combination of typical CBT techniques with a special focus on experiential techniques (especially chair dialogues and imagery rescripting) and a specific conceptualization of the therapeutic relationship as limited reparenting. The mode model gives a highly structured frame. It helps both the patient and the therapist to understand current symptoms and interpersonal problems and guides the treatment. The main advantages of working with the mode model are: Focus on essentials: The mode model summarizes all problems and symptoms even in patients with very complex problems and high comorbidity in one clear, plausible model. This way therapists and patients do not get lost and rapidly reach a meta-understanding of essential problems and can directly address them. Individual case conceptualization: At the start of treatment an idiosyncratic case concept is worked out with every patient. The individual mode model explains the patient s problems and symptoms and puts them into context with pathogenic childhood experiences. In the further course of therapy all problems and symptoms are linked to this mode model. If necessary the model can be easily adapted to incorporate issues that were not clear at the beginning. Transparent guide to mode specific interventions: Treatment goals are derived from the mode model, transparent for patients. Each mode is linked with specific goals, resulting in a roadmap for the whole therapy. This roadmap guides therapeutic interventions and can be transferred to everyday life by the patient. Validation and change: Current emotions, cognitions, and behaviours can be conceptualized in the mode model and thus be validated. At the same time patients can be empathetically confronted with problematic consequences of their behaviour and with the need to change. Normalization of psychological problems: The mode model incorporates both a broad spectrum of psychopathology, but also healthy emotions, cognitions and behaviours. The idea that everyone has maladaptive and adaptive modes is a relief for most patients and can be fostered through skillful self-disclosure by the therapist. Corrective emotional and interpersonal experiences: The intensive use of experiential techniques in the safety of the therapeutic relationship is a special focus of ST and leads to corrective experiences with regard to emotions, needs and interpersonal relationships and has the potential to break through dysfunctional, chronic patterns. Schemas, coping styles, needs and the development of the mode model ST states that everyone develops schemas during childhood. Schemas are defined as broad patterns of information processing comprising thoughts, emotions, memories and attention preferences (12, 13). Healthy schemas develop when core emotional needs are met in childhood. This enables children to develop positive views about themselves, relation to others and the world as a whole. The basic needs of children include (3, 4, 12, 13): Safety (secure attachment, stability, care) Connection to others, social inclusion Autonomy, competence, identity Expression of needs, emotions, and opinions Acceptance and praise Realistic limits Love and attention Spontaneity, play When these needs are not met, maladaptive schemas may develop. Young described 18 maladaptive schemas, e.g. abandonment, mistrust or emotional deprivation (12, 13). When a maladaptive schema gets activated, it provokes aversive emotions such as fear, sadness, shame, or anger. People cope with these emotions by three major coping strategies: overcompensation, avoidance, or surrender. The plurality of schemas and coping strategies (18 schemas x 3 coping styles = 54 different possibilities) leads to an inappropriate complexity, overwhelming both patient and therapist. Young discovered especially for patients with BPD, that it is hard to keep an overview as many different schemas and coping reactions are present. Thus, Young developed the mode approach first for patients with BPD, later for narcissistic PD (12, 13). Arntz et al. completed and empirically tested the mode model with other modes and with specific mode models for most PDs (1, 2, 14, 15).

3 80 What is a mode? A mode is a combination of activated schemas and coping and describes the current emotional-cognitive-behavioral state. It is therefore transient, while a schema is enduring (schema = trait, mode = state) (12, 13). Modes are typically triggered by specific stimuli, and influence emotions, cognitions, behaviors and the attentional focus in the respective situation. Similar to the mind-set construct a mode could be explained with the metaphor of a DVD: If a DVD is loaded in a DVD-player, the screen automatically shows a specific sequence of pictures and music. The loading of the mode DVD is triggered by specific external conditions or internal stimuli like thoughts, feelings or bodily sensations ( emotional buttons ). Once loaded a mode-typical pattern of feelings, thoughts, bodily reactions and behavior is processed. The attention focusses on mode-congruent information and all information is processed in the light of the mode. Everyone has adaptive and maladaptive modes. Adaptive modes are flexible and help to process information in a healthy way. Maladaptive modes are inflexible, reinforce dysfunctional schemas and lead to enduring intra- and interpersonal problems. Mostly people are not aware of their active mode ( the loaded DVD ). In therapy this automatic process is interrupted. Thus patients learn to recognize their current mode DVD (mode-awareness) and its biographical backgrounds. Thus, they gain a better understanding of their cognitions, emotions and behaviors. If the mode is problematic, patients learn in the next step how to change the mode ( insert a new mode DVD ), so that they get their needs met in a healthier way (16). Modes are divided into 4 broad clusters (Fig. 1): 1. Dysfunctional child modes develop when major needs, particularly attachment needs were not adequately met in childhood. Child modes are associated with intense negative emotions, e.g. fear or abandonment, helplessness, sadness (vulnerable child modes), anger, or impulsivity (angry/impulsive child modes). 2. Dysfunctional parent modes (punitive or demanding) are characterized by self-devaluation, self-hatred, or extremely high standards. We regard them as internalizations of dysfunctional parental responses to the child. They reflect internalized negative beliefs about the self, which the patient has acquired in childhood due to the behaviour and reactions of significant others (e.g. parents, teachers, peers). 3. Dysfunctional coping modes serve to mitigate the emotional pain of child and parent modes and describe the excessive use of the coping strategies surrender, avoidance, or overcompensation. These modes are usually acquired early in childhood to protect the child from harm, devaluation and make the emotional pain more bearable ( survival strategies ). 4. The healthy modes include the healthy adult mode and the happy child mode. In the healthy adult mode, people can deal with emotions, solve problems and create healthy relationship. They are aware of their needs, possibilities and limitations and act in accordance with their values, needs and goals. The happy child mode is associated with joy, fun, play, and spontaneity. The healthy modes are usually weak at the beginning of therapy. Healthy modes Parent modes Punitive/ Demanding Coping modes Overcompensation Avoidance Surrender Child modes angry/impulsive/ vulnerable Figure 1 The mode model basic structure

4 81 Healthy modes Strengthen Give safety, review pros and cons, replace by healthy strategies Fight & Reduce Parent modes Punitive/ Demanding Coping modes Overcompensation Avoidance Surrender Figure 2 Mode-specific goals of the therapy Get aware of needs, soothe & comfort, set limits if required Child modes angry/impulsive/ vulnerable For a detailed description of all schema modes see Arntz & Jacob (17, 18). Modes can be assessed by self-report with the Schema Mode Inventory (SMI), though there are limitations in the degree to which people can report their modes (15). The development and maintenance of modes Unmet basic needs, traumatic experiences, educational factors, and vicarious learning in combination with biological factors lead to the development of dysfunctional schemas and coping styles, hence to parent and child modes. To mitigate the resulting emotional pain, coping modes develop early and are applied also in later life. Later in life the coping modes protect the person from painful activation of the vulnerable child modes, but on the other hand they also block access to emotions and needs and hinder the development of healthy relationships. This way the coping modes often cause further suffering and interpersonal problems. Moreover, corrective emotional experiences are not possible. No alternative to deal with emotions and interpersonal difficulties can be learned. Thus, even in adult life needs are not met, leading to a life of low quality and lack of self-fulfillment. Therapy goals For every mode there are specific goals, resulting in a roadmap for the whole therapy: For the child modes it is important to find out unmet needs, and get aware of needs in the here and now. Child modes are supported and comforted in therapy; thus frustrated needs are met and new healthier schemas can be learned. Dysfunctional parent modes are reduced, we even fight against punitive parent modes. Coping modes are questioned and replaced with healthier strategies. An important goal is to strengthen the healthy adult mode in every possible way. Figure 2 shows the goals of treatment. To achieve these goals, mode-specific cognitive, experiential, and behavioural interventions are used. In addition, the therapy relationship is conceptualized as limited reparenting. Within the professional boundaries the therapist behaves towards the patient like a good parent and fulfills some of the needs the patient missed in childhood. This serves as an antidote to traumatic experiences and leads to corrective interpersonal experiences. Limited reparenting includes warmth, care, protection and empathy. However, it can also mean to set limits or to encourage more autonomous behaviour. Structure of the therapy There are three overlapping phases in therapy: 1. In the first phase (mode awareness) we work on the therapeutic alliance, investigate current problems and the biography of the patient, and educate about modes and needs. A major aim of this phase is the development of the individual case conceptualization. 2. The second phase (mode change) starts when the mode model is well established. All arising problems and be-

5 82 haviours are classified in the model mode and mainly processed by experiential techniques. Usually coping modes have to be addressed first to get access to the underlying child modes. The therapist helps the patient to identify coping modes and discusses pro and cons as well as the way they initially developed in childhood. Only when there is sufficient safety in the therapy relationship the patient can usually reduce his coping modes. When the child modes are activated, they should be supported in particular with imagery exercises, through the therapeutic relationship and the development of other useful relationships, e.g. in group therapy. After that the dysfunctional parent modes are antagonized and reduced. 3. Over the entire treatment process the healthy adult mode is strengthened, so that patients themselves can take on these tasks and finally can pass into the third phase, the autonomy phase. Here the patient has to take more and more responsibility and develops other helpful, healthy relationships outside the therapy relationship. Therapy contacts are gradually reduced, a contact after the end of the treatment is possible, but not required. Disorder specific and transdiagnostic approach The mode model includes both a transdiagnostic and a disorder-specific approach. Within the transdiagnostic approach, all symptoms, problems and problematic interpersonal patterns, as well as healthy behaviours and attitudes are conceptualized within the framework of applicable modes. In the disorder-specific mode models the typical modes of a particular diagnosis are summarized. Disorder specific mode concepts are available for most PD and forensic patients (1, 2). However, these disorder-specific models can only be viewed as a rough frame. An individual mode model always needs to be adapted to the patient s individual problems and history. It can be extended with additional modes if necessary. As stated above we aim to present the mode model of histrionic PD, since it is one of the mode models that were less well described so far. For examples and further explanation of all other mode models we refer to Arntz & Jacob (17, 18) or Fassbinder et al. (16). Mode model of histrionic PD Figure 3 gives an overview of the typical mode model of histrionic PD: In the vulnerable child modes patients with histrionic PD feel unloved, lonely, abandoned, helpless, and needy. As in childhood major needs were not satisfied they crave for attention, appreciation and praise and would do anything to get it. Moreover they have a very low tolerance to frustration and difficulties with discipline. In the impulsive, undisciplined child modes, they therefore often act impulsively, without thinking, if they feel unseen or a task is boring. In the punitive parent mode patients with histrionic PD devalue themselves sharply, e.g. to be inadequate, unattractive, worthless, stu- Healthy modes Punitive parent mode Coping modes Overcompensation: Seeking Attention Impulsive/ undisciplined child Vulnerable child Figure 3 Mode model of histrionic personality disorder

6 83 Healthy adult mode Grown up Conny Comes to therapy Girlfriend Completed education as secrtary Messages from father and mother Coping strategy to receive attention, and not to be alone, observational learning from the mother Punitive mode Chaotic circumstances, emotional needs of safety, attention, love and guidance are not met You are not lovable You screwed it up Loser Nobody will ever put up with you You are lying Attention seeking mode Drama Queen dramatic behaviour (e.g. nervous breakdown) exaggerated expression of emotion flirting, going out dress provocatively, heavy make-up having affairs Impulsive/ undisciplined child Problems to be punctual Vulnerable child mode Little Conny Feels unloved, lonely, unseen Need for attention and love Figure 4 Conny s mode model pid, or lazy. The main coping mode of people with histrionic PD is the overcompensating attention-seeking mode, in which they do anything to get attention for their lost and emotional deprivated child mode. This includes typical histrionic behaviour such as flirting, being very extroverted, loud and charming, overly sexualized behaviour, or exaggerated expression of emotion. The healthy adult mode is mostly week at the start of therapy. Bamelis et al. only found significant associations between histrionic PD and the attention-seeking mode. None of the above mentioned child or parent modes was significantly associated with histrionic PD. One explanation is the core function of overcompensating modes is to keep up the appearance that the opposite of the schema is true and to keep painful modes out of awareness. Thus, people with strong overcompensating modes might be unaware of, deny, or be unwilling to report vulnerable experiences. Similar patterns are seen in antisocial, narcissistic or even obsessive-compulsive PD (1). Case example: Histrionic PD Conny, a 41-year-old secretary, is 10 minutes late for her first appointment. She is provocatively dressed and wears a lot of make-up. She complains: I need your help very urgently. Something has to happen immediately. I ve had several nervous breakdowns at work and have a terrible stomach when I think of tomorrow. I had an affair with my boss and now he does not want to meet me anymore. He just used me and wanted to have sex, like all the men before. They are all the same. But with this man, I will not survive it. I cannot understand. Why he doesn t love me (sobbing, crying) I tried to get an answer from him, but he did not react. Even not, when I had this awful breakdown in the office and just could not stop crying. He did nothing, as if I was not there. Do I need to jump from a bridge to show him, that he has destroyed me? I tried to forget him and I cannot stand being alone, so I went out with my girlfriend to meet

7 84 other men. But it always ends up the same way I just want somebody to love me, but all they want is sex I am already 41, my best years are over How can I ever find someone?... I screwed it up nothing in my life has worked out I am a loser and nobody will ever put up with me that is exactly what my father said With regard to her childhood she reports: Oh, this was very chaotic. My father drank a lot of alcohol, he was in jail several times. My mother worked as a secretary, too, so she did not have too much time for me and my younger brothers. Only if we messed something up, we got at least some attention, even when it was a slap on the face. She had lots of affairs and there were always new men in our flat. Some of them were nice, but it was not worthwhile to get used to them, as they were only there a short time. Other men were very aggressive and one was sexually abusing me. I told my mother, but she did not believe me. Conny s mode model is shown in Figure 4. The case concept is developed in interaction with the patient on a flip chart. If possible, individual names for the respective modes are chosen. A name like Drama Queen for the attention-seeking mode in this example should only be selected, if the patient herself mentioned it. Otherwise it would be invalidating. A limitation of four to seven problematic modes is recommended, as the human working memory is limited to a maximum of seven items. The therapist has the task to select the relevant modes for the patient. With the increasing number of modes, disorder-specific concepts and an exploratory survey with the SMI (15) may be helpful. Table 1 Pros and Cons of the Seeking Attention Mode Pros of Drama Queen I get attention to me I am in the focus Exiting, not boring Flirting feels good I do not feel so lonely and empty Others have to look for me, listen Men find me attractive At least I have some connection I can express my emotions Con s of Drama Queen I feel lonely Often I feel ashamed afterwards I get on other s nerves and they withdraw from me, than I feel even more not seen and lonely (vicious circle!) I do not have the chance to find a nice man or at least a good friend I have sex with too many men I feel used afterwards Others do not take me serious, and I feel misunderstood I do not have good contact with myself, my emotions and needs Therapeutic Techniques Cognitive techniques Cognitive techniques are used to educate patients about their modes and why they developed. For each mode, identifying features like emotions, thoughts, bodily reactions, memories, behaviour impulses, and situational triggers are worked out to foster mode awareness. Psychoeducation on basic needs of children, normal development, and emotions also plays an important role. In this context, all CBT techniques can be used, such as focusing on long-term consequences, analysis of selective attention processes or behavioural analyses. Especially for coping modes, discussing pros and cons is a major issue in therapy. Various suggestions for the use of cognitive techniques such as mode cards, mode diary or mode analysis, and materials for psychoeducation can be found in Fassbinder et al. (16). For Conny the pros and cons list displayed in Table 1 has been worked out. Experiential techniques Experiential techniques and emotional processing of aversive childhood memories are an important focus of ST and aim at validating and healing the child modes. At any time patients are encouraged to express emotions, such as sadness or anger. The main techniques are chair dialogues and imagery techniques, primarily imagery rescripting. In chair dialogues different modes are placed on different chairs and dialogues between them are performed. The goal is to get more distance from modes, to illustrate different perspectives, and to activate emotions. Moreover, the therapist or the healthy adult mode can address every mode. Content, tone and action are adapted to the specific mode by following the above explained mode-specific objectives (see Figure 2), e.g. fight the punitive parent mode or soothe the vulnerable child mode. An example of a chair-dialogue with Conny: After the pros and cons of the Drama queen have been discussed, Conny comes in the attention seeking mode to the therapy session again. The therapist proposes a chair dialogue to better understand the Drama Queen. He asks Conny to take place in a chair, provided for the Drama Queen, and take over the perspective of the mode and answer to all questions out of the modes view. He says: You re extremely important for Conny, I d like to better understand you. Can you tell me, why you are here today? He asks for the development of the mode (e.g. Do you know, when you first came in Conny s life? Why did Conny need you? ). If Conny answers, the therapist validates her: Oh yes, I can imagine, Conny told me, that she often felt lonely and not

8 85 seen. And that the only way to get attention, was to act extremely. So, it makes pretty much sense, that you came to help her to get at least some attention. And that is what you still do now, don t you? After that the therapist aims to work out disadvantages of the Drama queen mode by using self-disclosure in the therapeutic relationship I have the impression that something happened to little Conny, and that she feels lonely, but at the moment I cannot see what it is, because of that dramatic behavior. To be honest it overwhelms me and pushes me away. And I think this is absolutely not, what little Conny needs. What do you think? The patient switches to the vulnerable child mode and is placed on another chair for little Conny. She tells that she had birthday last week, but that nobody called her, even her girlfriend forgot about it, and that she feels very lonely and sad. The therapist soothes and comforts her. A popping up of a punitive parent mode ( You are just not lovable ) is fought by the symbolic action of placing the chair of the dysfunctional parent mode out of the therapy room. In imagery rescripting exercises (19), a stressful childhood memory is imagined and modified in a way, that the needs of the child are satisfied. For this purpose, a helper can be introduced into the image, for example the therapist, other helpful persons, or the patient himself in his healthy adult mode. An example in Conny s case is imagery rescripting of the situation after the sexual abuse by one of the mother s boyfriends, when the mother did not believe her. In the rescripting part the therapist comes into the image, protects Conny and rebukes the mother. After that the boyfriend is brought to jail, so that he cannot harm Conny anymore. Finally, the therapist takes Conny and, at her request, also her brothers to the house of her best friend s family. This was the only secure place in Conny s childhood. At the end of the image they play all together with the families dog and Conny feels safe and connected. The patient feels strengthened by this exercise and gets the homework, to repeatedly listen to an audio recording of the exercise. Behavioural Techniques It is important for therapists to consider, that behavior does not change automatically in most patients. Patients need support to translate emotional and cognitive insights into behaviour and their everyday life. All techniques known from behavioural therapy can be used to develop and strengthen new healthy behaviours. These include role plays, homework, exposure exercises, behavioural experiments, skill training, behavioural activation, or relaxation techniques. These techniques are always set in relation to the mode model. The main goal is spending more time in the mode of healthy adult. For Conny it was important to learn, how her Drama queen mode affects others. Together with her therapist she worked out, how to change her behaviour in a way, that she is not primarily seen as a sexual object any more. On the other side they developed a list of criteria, how Conny can recognize that a man has serious long-standing interest in her. The therapist and she agreed on a No Sex before the third date -rule, which was very helpful for Conny. After one year of therapy Conny had a relationship for already four months. About her partner she said: I would never have felt attracted by this man before, but now I really do feel comfortable with him. She has found a new job and is busy in getting adjusted with her new colleagues, but feels much better as she did in the job before. For further information to work with the mode model we refer to the detailed manuals, specifically for BPD (3, 4), general application (17, 18), and for ST in group therapy (20, 21). Conclusions for clinical practice ST with the mode model is a new therapeutic technique particularly for patients with PD or complex chronic emotional problems. However, this model is also well applicable to other patient groups or therapists in self-therapy. The mode model gives a clear structure for the development of an individual case conceptualization and guides the treatment. Clear treatment goals can be derived from the mode model. Special attention is paid to experiential interventions and the specific design of the therapy relationship as limited reparenting. Previous studies show very good efficacy in patients with borderline personality disorder in individual (7, 8) and group therapy settings (5, 6) and for other PDs (9). Good results are also reported for chronic depression (22). Studies for forensic patients and chronic Axis I disorders are currently underway. Acknowledgements Our studies on ST are supported by the Else-Kröner-Fresenius-Stiftung in Germany, and by ZonMW, the Netherlands Organization for Health Research and Development in the Netherlands. Eva Fassbinder is supported by a grant from the University of Lübeck. Conflict of interest The authors report no conflict of interest. References 1. Bamelis LL, Renner F, Heidkamp D, Arntz A. Extended Schema Mode conceptualizations for specific personality disorders: an empirical study. J Pers Disord 2011; 25 (1):

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