Schema Therapy II (2016) PDF
Schema Therapy II (2016) PDF
Schema Therapy II (2016) PDF
BACKGROUND AND THEORY directly observable and measurable, because they represent
the moment-to-moment emotional and cognitive states and
The term “Emotional regulation” refers to a series of strategies coping responses that are active at a given point in time.
aimed at modulating and adjusting unpleasant emotional Modes are triggered by emotional events and an individual
experiences (John and Gross, 2004; Gross, 2011). Emotional may shift from one mode into another very rapidly (oscillating
regulation is a multidimensional construct composed of the dyads in psychodynamic terms). Modes were introduced to
following traits: (1) awareness and acceptance of emotions; (2) ST in order to explain the abrupt changes in thoughts,
skills to engage in behaviors aimed at a target; (3) flexible feelings and behaviors displayed by patients with severe PD
use of appropriate strategies to modulate the context’s intensity (Young, 2002). In this way, the mode concept describes
and the duration of the emotional response (Pedersen et al., the rapid shifting in emotion and behavior demonstrated
2014). Deficits in these areas are considered indicative of by patients suffering from severe PD (Young et al., 2003;
emotional dysregulation and are an indicator of psychopathology Lobbestael et al., 2007). Compared to standard CBT, ST
(John and Gross, 2004). Adopting effective strategies of assigns a central role assigned to the concept of reparative
emotional regulation is considered one of the fundamental therapeutic relationship (e.g., limited reparenting) and emotion-
aspects of individual adaptation. In fact, different scientific focused experiential techniques (e.g., imagery rescripting and
evidence demonstrated that emotional dysregulation is one chair work). These relational and experiential techniques can
of the main important factors in different disorders as, overcome some of the limitations of the standard CBT
for example: cluster b personality disorder, bipolar disorder, approach such as the poor attention given to elaborate and
interpersonal trauma, anxiety disorder, mood disorder, and problematic emotional states. Improved cognition does not
post-traumatic stress disorder. Schema Therapy (ST) is a necessary mean improved emotion regulation (Grecucci and
relatively new treatment approach to treat chronic Axis I Job, 2015; Grecucci et al., 2015a, 2016). Greenberg and Safran
and Axis II disorders (Young et al., 2003). According to (1984) provided evidence that rational cognitive language-
this model, stable and enduring Early Maladaptive Schemas based systems are independent from emotion based systems.
(EMSs) are at the core of chronic Axis I and Axis II To understand this, the model of Interacting Cognitive
disorders (Young et al., 2003). The term “schema” is derived Subsystems was proposed (ICS; Teasdale, 1993; Waltz and
from the theory of information processing, which maintains Rapee, 2003), which distinguishes between two systems: the
that the information is sorted in human memory by theme propositional coding system of meanings – that is based on
(Williams et al., 1997; Vonk, 1999). The idea is that the language, which can be assessed and directly influenced by
experiences are stored in our autobiographical memory by sensory information – and the implicational coding system of
means of diagrams from the early years of life (Zajonc, meanings – that elaborates experiences from a wide variety
1980, 1984; Conway and Pleydell-Pearce, 2000). The patterns of sources, including specific patterns of indirect sensory
consist of sensory perceptions, experience, emotions, and input -. It follows that, if a therapist wants to change
the meaning attributed to them, so that early childhood dysfunctional behavioral patterns, he/she has to work on
experiences are stored at a non-verbal level (Freeman, 1981; the level of this implicational coding system and activate
Greenberg and Safran, 1989; Christianson and Engelberg, target emotional states. Following other psychotherapeutic
1999; Young, 2005; Rijkeboer and Huntjens, 2007). Schemas approaches (Bowlby, 1969; Singer, 1974; Samuels and Samuels,
act as filters through which individuals order, interpret and 1975; Pope and Singer, 1978; Singer and Pope, 1978, 1980;
predict the world. EMSs have been shown to mediate the Shorr, 1983; Sheikh, 1984; Burke et al., 1992; Frankel, 1993;
relationship between adverse childhood experiences and adult Guntrip, 1995; Field and Horowitz, 1998; Fonagy, 1998), ST
psychopathology (Carr and Francis, 2010). Because EMSs are implements several emotion focused techniques rather than
considered ego-syntonic, therapists believe that clients with simple cognitive techniques, to foster emotion regulation.
chronic difficulties lack the motivation to change them. Young There is now empirical evidence that imagery work can have
incorporated a range of technique from Gestalt and Emotion- more impact than rationalist methods in fostering emotional
Focused Therapies (Perls and Baumgardner, 1975; Safran et al., change (see for example, Holmes et al., 2007). Another key
1988; Greenberg and Safran, 1989), particularly imagery work factor in ST is the role of the therapeutic relationship. ST
and empty chair dialogs (Kellogg, 2004) for treating and focuses on painful childhood experiences that were central
changing EMSs. Recent insights have lead to the view that to the development of the patient’s EMSs. Thus, ST involves
complex Personality Disorders (PD) are not characterized by the endeavor to re-experience and communicate the most
one set of pathogenic EMSs, but by different sets of EMSs vulnerable states of childhood, those in which the child
activated by the same trigger, and having the same purpose, desperately needed the care of adults but was not getting it
that can be activated as a group of schemas. In therapy, (Young et al., 2003). The aim of this paper is to summarize
dealing with many schemas at the same time can result theoretical implications of this model, empirical evidence and
very difficult. For this reason, Young introduced the concept clinical application of ST in the management of emotional
of Schema Modes in 2002. Schema Modes (from here, we dysregulation, and to build bridges with the science of emotion
will simply name them Modes), are relatively independently regulation. We believe ST holds the promise to provide
organized patterns of thinking, feeling and behaving that means to modulate severe dysregulated emotions as shown
underlie the different states of consciousness; they can be by PDs.
SCHEMA THERAPY MODEL OF parents (or other significant persons or even social and peer
EMOTION DYSREGULATION AND groups) toward the patient as a child. Parent modes are the
primary source of dysregulated emotions. In terms of emotion
EMOTION REGULATION regulation science, these Modes are dysregulatory mechanisms
that generate the most severe dysregulated emotions (for
In the last decades, emotion regulation has been increasingly
example, a Punitive parent Mode that induces self-hate and
considered as a focal point to address psychological disorders.
contempt toward the self). The last macro-category of modes is
In ST emotions and emotion regulation are strictly linked to the integrative adaptive modes, that encompasses the Healthy
the concept of schema mode. This concept is the essential Adult mode, which includes functional cognitions, thoughts
and most complex aspect of the theoretical model proposed and behaviors (Arntz et al., 2012), and the Happy Child, which
by Young et al. (2007; Lobbestael et al., 2005, 2008, 2009). feels at peace because all core emotional needs are currently met
A mode is an intense predominant dysregulated emotional state (Simeone-DiFrancesco et al., 2015). In terms of the science of
linked to a pattern of thinking, feeling and behaving based emotion regulation, Happy Adult may be viewed as a collection
on a set of specific frustrated needs. Usually the modes are of self-soothing, positive reappraisal like-, and acceptance based-
activated by external stimuli or internal states, are transient by regulatory strategies that regulate emotions and produce a Happy
definition and may comprise both adaptive and maladaptive Child state of mind.
responses (Young et al., 2007; Lobbestael et al., 2010). In socio- The first macro-category, concerning the Child modes,
cognitive terms, the modes are the conception of the self that includes different emotional states. It includes three categories
are active at a given time. They are the part of the self, or the (Arntz et al., 2012).
identity of that person, that leads the way in which the subject The first category of Child Modes is named Vulnerable Child
him/herself anticipates, sees, and responds to the world around mode. It encompasses most EMSs and most of the suffering felt
him/her (Kellogg and Young, 2006). In psychodynamic terms, by patients. From this mode many modes that belong to the other
a mode can resemble the concept of the object relation dyad two categories of child modes can derive, as well as dysfunctional
active in the interpersonal situation (Clarkin et al., 2007). In coping modes (Arntz and Jacob, 2012). Exaggerated emotions
particular, a dysfunctional mode is characterized by maladaptive of sadness, anguish, and shame characterize the mode of this
schemas or coping responses erupting into distressing emotions, category.
avoidance responses or self-defeating behaviors that influence an
individual’s behavior and control his/her emotional functioning. • Lonely Child. In this mode the patient feels emotionally empty,
The mode theory’s basic concept is that different mental states lonely and socially unacceptable, not worthy of being loved.
have different purposes and are related to different basic needs. Dysregulated sadness characterizes this mode.
The therapist’s first goal is to understand and conceptualize the • Abandoned and Abused Child. In this mode the patient feels
subject’s model of functioning. This is done to simplify the work sad, scared, alone, unworthy and unlovable: he/she feels the
with the patient without being simplistic, helping him/her to enormous pain and fear of abandonment caused by his/her
understand his/her way of functioning. In the next paragraphs we abusive history, which expresses itself through depressive,
show how every Mode is associated with either (1) Dysregulated fearful, desperate, and inferiority feelings. This mode can be
emotions, or with (2) Dysregulatory strategies. evoked by perceptions of threatened abandonment and abuse.
There are four Mode macro-categories (Young, Severe anguish characterize this mode.
2002). The first macro-category of modes is the • Humiliated and Inferior Child. In this mode the subject feels
maladaptive Child Modes that developed when certain incapable of managing responsibilities. The person in this
basic emotional needs were not adequately met in mode shows strong regressive tendencies, he/she wants to
childhood. In terms of the science of emotion regulation, be taken over. Usually we observe this mode in people who
Child Modes are characterized by specific dysregulated emotions have developed poor autonomy and poor self-sufficiency.
(anger, shame, sadness, etc.). With dysregulated Dysregulated shame characterizes this mode.
emotions we indicate an exaggerated aspect of
Dysregulated anger, with different levels of expression,
on of the components of the emotional response
characterizes the second category of Child modes:
(onset, duration, strength, type or expression). The
second macro-category of modes is the dysfunctional • Angry Child. This mode is characterized by feelings of anger,
Coping Modes that reflect dysfunctional regulatory strategies frustration and impatience because the patient’s needs have
or coping styles (overcompensation, avoidance or surrender). neither been considered nor satisfied. He/she may rebel against
In terms of the science of emotion regulation, Coping modes this alleged grievance, making pretentious or flawed demands,
are problematic regulatory strategies that may produce a but does not attack others.
momentary relief on the short run (for example, avoiding a • Stubborn Child. This mode is a subtype of the Angry Child.
situation that triggers the emotions associated with the EMS), Individuals feel angry but do not show anger openly. Instead,
but cause and maintain dysregulated emotional states on the they persist passively, so stubborn in their positions or requests
long run (lack of interpersonal intimacy and attachment). The that they are deemed unreasonable by others.
third macro-category of modes is the dysfunctional Parent • Enraged Child. In this mode the subject experiences stronger
modes that reflect internalized attitudes and opinions of the levels of anger that lead to uncontrolled aggression like hurting
people or damaging objects. Aggression is out of control, distracting and soothing activities, such as eating, watching TV,
and its goal is to destroy or eliminate the alleged assailant. abusing drugs and having promiscuous sex.
The patient shows affectivity similar to that of a furious and • Angry Protector. In this mode the patient usually covers what
uncontrollable child. he/she is really feeling with a stream of resentment and anger.
They use a ‘wall of anger’ to protect themselves from others
Dysregulated impulsivity characterize the third category of who are perceived as threatening. Displays of anger serve to
Childs modes: keep others at a safe distance to avoid being hurt.
• Avoidant Protector. In this mode the patient usually avoids
• Impulsive Child. This mode refers to a person in which triggering by behavioral avoidance; he/she keeps away from
all locked emotions discharge impulsively, immediately and situations or cues that trigger distress. The difference between
directly in order to meet his/her needs or desires, without being Detached Protector and Avoidant Protector is that the former
able neither to postpone their gratification nor to predict the tends to inhibit or decrease the feeling of emotions, whereas
consequences of his/her actions. the latter is characterized by interpersonal and situational
• Undisciplined Child. This mode describes an extremely avoidance.
frustrated person, unable to make efforts in order to fulfill
routine or boring tasks, who, consequently, easily decides to In terms of emotion regulation science, these coping strategies
give up. belong to the class of “distancing” strategies, and produce an
excessive down-regulation of (positive and negative) emotions
See Table 1 for a summary. (Grecucci et al., 2013, 2015a).
The second macro-category focuses on maladaptive coping See Table 2 for a summary.
modes. Parallels can be made with the concepts of defense The second category of dysfunctional Coping modes,
mechanisms in psychodynamic terms, and with dysfunctional diametrically opposed to the Avoidance coping strategies, is the
regulatory strategies (Gross, 2011; Grecucci et al., 2013; Grecucci Overcompensation that is composed of six modes:
and Job, 2015). It includes three categories.
The first category of dysfunctional Coping modes concerns the • Self-Aggrandizer. In this mode the patient acts egoistically,
Avoidance strategy: shows little empathy for the needs and feelings of others and
thinks he/she should not follow the rules like others do. He/she
• Detached Protector. This mode is characterized by emotional behaves competitively, hatefully, abusively. The subject is quite
and psychological withdrawal of the individual, who self-absorbed, craving the admiration of others, and showing
suppresses his/her feelings, depersonalizes him/herself and superiority. Usually the emotion associated with this mode is
does not feel linked to or in contact with others. Therefore, anger, activated when someone threatens his/her status.
feelings of emptiness, boredom and abulia are typical in this • Bully/Attack. This mode is characterized by the will to
context. strategically harm others physically, psychologically, verbally
• Detached Self-soother. This mode refers to an emotionally and through antisocial or criminal actions. The emotion that
detached person, who tries to suppress and silence his/her characterizes this mode is often anger and the feeling of
emotions by compulsively and excessively committing to pleasure experienced when others are harmed.
TABLE 1 | Categories of dysregulated emotions in relation to modes and therapeutic strategies: child modes.
Vulnerable Child (Lonely Child, Exaggerated Self blame Vulnerability Imagery rescripting
Abandoned and Abused Child, sadness Anxiety Fragility Reparenting in and extra-session
Humiliated and Inferior Child) Deprivation Cognitive or behavioral techniques
Exclusion Limited reparenting
Angry Child (Angry Child, Stubborn Exaggerated anger Blame others Impulsivity Venting anger
Child, Enraged Child) Interpersonal problems Limiting destructive expressions of anger or
rage
Increase ability to tolerate frustration
Limited reparenting
Cognitive techniques (e.g., using a diary to
identify mode triggering situations)
Behavioral techniques (e.g., role playing present
situations etc.)
Impulsive Child Undisciplined Child Emotions displayed Attack Impulsivity Increase ability to find a realistic way to meet
with no control Interrupt Frustration hedonistic needs
Blame others Spoiled behavior Increase ability to tolerate frustration
Ignore others Impatience Therapeutic relationship
Lack of control
TABLE 2 | Categories of dysregulated emotions in relation to modes and therapeutic strategies: dysfunctional coping modes.
Compliant Surrender Reduced anger Passivity Self Abuse acceptance Chair work to bypass and overcome
Assertiveness defeating Submission avoidance coping mode
Masochism Validation and empathic confrontation
Identification and reappraisal of the
mode through cognitive and
experiential techniques
Detached Protector (Detached Protector, Down regulation of Interpersonal Detachment Chair work to bypass and overcome
Detached Self-soother, Angry Protector, every emotion detachment Not caring avoidance coping mode
Avoidant Protector) Isolation of Withdrawal Validation and empathic confrontation
affect Emptiness Identification and reappraisal of the
Passive Depersonalization mode through cognitive and
aggressive Self soothing experiential techniques
stance behaviors
Over-compensator (Self-Aggrandizer, Exaggerated Devaluing Arrogance Chair work to bypass and overcome
Bully/Attack, Attention Seeker, grandiosity others Control overcompensator coping mode
Over-Controller, Manipulator, Predator) Anger Sense of Attack others Dominance Validation and empathic confrontation
dominance Manipulation Identification and reappraisal of the
Exploitation mode through cognitive and
Attention seeking experiential techniques
Limit placing
• Attention Seeker. In this mode the patient attempts to of others’ controlling behavior. Both these modes usually
get the attention and approval of others, with extravagant, face the demanding parents’ attempts to make the child feel
inappropriate or exaggerated behaviors. Usually he/she tries to incompetent and not good enough.
compensate for feelings of sadness and loneliness. • Manipulator. This mode manipulates, lies and frauds to obtain
• Over-Controller. In this mode the patient tries to protect a specific goal that is usually to damage others or to avoid
him/her-self from danger, real or perceived, by focusing on punishment
external details and brooding. There are two distinct subtypes: • Predator. This mode is focused on the elimination of a
the Perfectionist Over-Controller, focused on perfectionism threat, a rival, an obstacle, in a merciless, cold and calculating
to gain control and prevent critical or misfortunes, the way. Unlike the bully attack mode that is a hot mode
Paranoid Over-Controller, which is suspicious and focuses of expressing anger, the predator instead is very cold and
on supervision and is concerned by the malicious intent ruthless.
TABLE 3 | Categories of dysregulated emotions in relation to modes and therapeutic strategies: dysfunctional parent modes.
Punitive Parent Exaggerated guilt Self attack Self directed abuse Chair work to deal and overcome punitive parent mode
Shame Self devaluation Imagery rescripting to become aware of emotional
Contempt Self punishment needs and help the patient modify the situation in order
Disgust Self blame to adequately meet needs
Helping to express emotions and needs using healthy
ways to deal with emotions
Identification and reappraisal of the mode through
cognitive and experiential techniques Active
confrontation by the therapist to deal and overcome
punitive parent mode using limited reparenting
Demanding or Exaggerated Striving for high status Chair work to deal and overcome punitive parent mode
Critical Parent sense of Self neglect Imagery rescripting to become aware of emotional
responsibility Humility needs and help the patient modify the situation in order
Guilt Efficiency to adequately meet needs
Rigidity Helping to express emotions and needs using healthy
Work addiction ways to deal with emotions
Lack of spontaneity Identification and reappraisal of the mode through
Lack of pleasant cognitive and experiential techniques
activities Active confrontation by the therapist to deal and
overcome punitive parent mode using limited
reparenting
In terms of emotion regulation science, these coping strategies Happy Child’s functionality; fights to replace the maladaptive
may be seen as variations of reappraisal strategies (Gross, 2011), coping strategies and, finally, neutralizes or limits the influence
as the individual reinterpret himself in an excessively positive way of his/her dysfunctional parents. Moreover, this mode also
and interpret others in a devaluing way. This causes excessive accomplishes appropriate adult functions, such as working,
emotions of power, dominance attributed to the self, as well as adopting care-giving behaviors and taking responsibilities.
excessive negative emotions toward others (e.g., disgust, rage Furthermore, it engages in pleasant and stimulating adult
etc.). activities, such as sex, cultural and esthetic interests and sports.
The third category of dysfunctional Coping modes is the • Happy Child. This mode allows a person to feel loved, accepted,
Surrender strategy: understood, safe and spontaneous because his/her core needs
are been fulfilled.
• Compliant Surrender. This mode refers to a passive, servile,
submissive behavior of someone constantly looking for When the patient is in these modalities, no dysregulatory
everyone’s approval. Fearing conflict or refusal, the individual strategies, nor dysregulated emotions are observed.
could even tolerate abuse and silence his/her needs or desires. Another aspect to be considered when analyzing modes is
the degree of dissociation they have between each other. This
In terms of emotion regulation science, this coping strategy
concept is extremely important in determining the severity of
causes excessive fear of abandonment; often it causes also rage,
the patient’s pathology. The dissociation between modes in ST
that in this mode can be expressed only in a passive way.
might be described in terms of structural organization of the
See Table 3 for a summary.
personality and concerns the divisions and the organization of
The third macro-category of modes includes the figures
the personality or consciousness (i.e., structural dissociation),
concerning the Dysfunctional Parent: the Punitive Parent and the
as originally advocated by Janet (1907). Dysfunctional schema
Demanding Parent. These modes usually derive from parents or
modes are essentially ‘facets of the self ’ that have not been
other attachment figures (Young et al., 2003). Nevertheless, they
integrated into a cohesive personality structure and therefore
can derive also from internalized social or religious authority,
operate in a dissociated manner (Johnston et al., 2009). The
peers, etc. (Simeone-DiFrancesco et al., 2015). They intrude as
constant alternation of the modes is directly related to their
negative automatic thoughts (Beck and Emery, 1985) and can be
dissociated nature. The higher the dissociation between modes,
theorized as toxic parental introjects (Freud, 1917), that patients
the higher the emotional instability of the person. Moreover, the
hear as “voices inside the head.”
higher the dissociation between one mode and the others, along
• Punitive Parent. This mode represents the interiorized voice with the dissociation between modes and healthier aspects of
of very critical and punitive attachment figures. This mode the Self, the more they become increasingly maladaptive (Young
makes the patient afraid he/she did something wrong, sees et al., 2003). For example, some patients with Narcissistic PD
him/herself as evil and worthless because of his/her feelings show a constant activation of the Self-Aggrandizer mode. When
and desires. As a consequence, self-directed anger and hate alone, they activate the Detached Self-soother mode. These coping
develop and the patient punishes him/herself in one or another modes try to avoid contact between the subject and the Lonely
way. Child mode. If the subject is aware and capable of accessing the
• Demanding Parent. This mode represents the interiorized latter mode, this is a sign of low levels of dissociation, meaning
voice of very demanding and impossible to please attachment the subject understands his/her needs and how to satisfy them.
figures. This mode makes patients constantly feels under Individuals that have a higher awareness of their modes’ way
pressure, for he/she aims at reaching excessively high standards of functioning don’t show pathological symptoms, even if their
and goals. This mode constantly tells to you that you have to personality structures are quite similar to ones seen in some PDs.
be perfect in order to be accepted by others. Moreover, others’ Another problematic aspect of dissociation is when dysfunctional
needs are almost always considered as more important and dissociated modes are integrated each other. In particular, for
overriding than their own. While Demanding Parent makes emotional dysregulation, when the Impulsive Child mode is
one feel always wrong, Perfectionist Over-controller makes associated with the Abandoned and Abused Child mode. In this
one feel loved and accepted. case the trigger events are able to evocate a disruptive behavioral
reaction and the person is not able to have an emotional control
These Parent modes are in our view the source of primary over behavior.
emotion dysregulation in the patient, and may be seen as a class of
self-attacking/self-blaming strategies (in psychodynamic terms)
that creates unbearable negative affects inside the patient.
The last macro-category of mode encompasses Healthy Adult A STRATEGY TO REGULATE EMOTIONS
and Happy Child modes:
Based on the assumption we made in paragraph 2, every
• Healthy Adult. This mode presents significant adaptive and Mode is associated with dysregulated emotional states or a
mediation functions between the different identified elements. dysregulatory strategies, the therapist works with Modes, in
It harbors and embraces the Vulnerable Child’s vulnerability; order to foster emotion regulation. The overarching strategy
sets strict limits and boundaries on the Angry and the and steps to regulate emotions in ST are the following: (1)
Impulsive Child’s behaviors; encourages and supports the Mode identification. If the patient experiences a dysregulated
emotional state in the session (but also outside the session), the sadness is felt before anger, because the patient did not feel seen,
therapist tries to find out the Mode responsible for that state (for heard or understood.
example, “Punitive Parent”). (2) Mode work. Once the Mode is On the other hand, the anger of the Bully and Attack mode is
recognized, the therapist uses a series of specific techniques to a rage with the purpose of annihilating the person the patient is
resolve that Mode (“Chair work” to fight the Punitive Parent). facing. This type of mode can be found in patients with severe
(3) Mode change. Once the Mode is deactivated, the experience PDs or forensic patients. This rage usually serves the purpose of
of a more functional modality is facilitated (for example, the ending the ongoing relationship, typically when the subject feels
activation of the “Happy Adult”). As an effect of step 2, the like his/her rights haven’t been respected. In this last case this
patient experiences a down-regulation of negative emotions, and mode is quite similar to the Angry Child mode, with the difference
as an effect of step 3, he/she experiences an up-regulation of that the latter never actually harms others, since it reflects a need
positive, self-soothing emotions. The techniques belonging to to be seen, not a need to break relationships.
Steps 2 and 3 are different and depend on the Mode that is Along with modes that share the same emotion, there are also
active in that moment. Every Mode is characterized by up- or modes that imply a deletion or modification of emotions. This is
down-regulation of specific emotions. When intervening, the the case of the Detached Protector and the Detached Self-soother
clinician must monitor the presence of exaggerated or blunted modes. Those two modes have the purpose of keeping the subject
emotions or even their apparent absence (say for example, an away from emotions. This doesn’t allow him/her to use emotions
excessive distant and cold attitude of the patient). This can as a feedback, therefore hindering the comprehension of his/her
guide the clinician to understand which Mode is active in needs.
that moment (in this example, the Coping Mode “Detached A telltale sign to spot the Detached Protector mode is
Protector”). Sometimes the type of emotion is not sufficient to when, during the session, traumatic or strongly depriving life
distinguish between Modes. The therapist has to also assess the events are narrated without the subject showing any emotions
way that emotion is expressed and its function. Some examples about them. If asked to explain this lack of emotion, the
follow: Anger is an indicator of the Angry Protector mode or patient usually answers with statements like: “Yes, it was very
of the Angry Child mode. To disambiguate between the two, sad at the time. But it’s all over now.” When this mode
the clinician must observe the way anger is expressed. The activates the therapist usually feels boredom, detachment and
Angry Protector mode is an avoidant coping style, aiming, for coldness in the therapeutic relationship. Everything is filtered
example, to keep the psychotherapist away from accessing certain through rationality, the Detached Protector’s sharpest tool. This
experiences. During a psychotherapeutic session, the therapist detachment doesn’t allow the patient to activate some incorrectly
may ask the patient to explore a specific traumatic life experience. elaborated traumatic memories.
If the Angry Protector mode is active, the patient may react in This protector is one of the most frequently seen coping
aggressive manner, saying for example: “Why do we have to modes in Borderline PD (BPD). BPD is one of the first PD
talk about this bullshit all the time? It’s useless! You still can’t on which ST efficacy has been tested (Giesen-Bloo et al.,
understand how I feel? What kind of therapist are you?” The 2006). The Detached Self-soother mode has the Detached
patient usually feels fear to face certain traumatic memories that Protector mode’s same goal, i.e., to keep a safe distance from
were not correctly elaborated because of their nature. In this way, emotions and emotional needs. It reaches this objective by
this avoidance coping strategy prevents re-experiencing and re- occupying the subject’s mind with repetitive activities. Subjects
elaborating these memories. Consider that the Angry Protector that report substanceless addiction (e.g., compulsive shopping,
mode activates a sense of bewilderment, guilt or inadequacy in pathological gambling, Internet addiction, work addiction) show
the therapist, sometimes even activating his/her coping strategies. an active Detached Self-soother mode when they act out the
The activation of the therapist’s coping strategy could be followed addiction-related ritual. Compared to the Detached Protector
by a “dysfunctional interpersonal cycle.” The result of this mode, the Detached Self-soother mode also employs a finer
vicious circle is that painful issues are pushed away from the strategy for emotional control. The former silences emotions
session – this does not allow a further processing of these with logic and emotional detachment. The latter, on the
memories. other hand, proposes a different emotion associated to the
The Angry Child’s anger, instead, is reactive to frustration of activity it uses to distract the patient’s mind from the feeling
a basic need. For example: the patient has an explosion of anger of vulnerability. As an example, a subject who has often
when the therapist arrives late to the session: “I’ve been waiting felt loneliness and abandonment in childhood may try to
for 15 min, is this the care and attention you have for your stop the feeling of emptiness and sadness with pornographic
patients? I wonder what the one before had to say! I knew I material when alone. So, in this example, the Detached
couldn’t trust you, I refuse to pay for the whole session!” In this Self-soother mode replaces the negative feelings with sexual
case the anger is reactive to the frustration of a specific need: excitement.
the need to be respected, seen and considered by the therapist.
The Angry Child’s reaction might be understandable, if it were
not so excessive. The patient’s anger is one of the few emotional TECHNIQUES TO REGULATE EMOTIONS
strategies that the patient is able to use to meet his/her needs
in this situation. The patient does not want to create a distance Once the Mode has been clearly detected (Step 1), the clinician
like in Angry Protector mode. If this mode is to be investigated, may want to use one or more specific techniques designed to
TABLE 4 | Categories of dysregulated emotions in relation to modes and therapeutic strategies: functional modes.
rework the active Mode. In this work, the main techniques are an individual encounters negative stimuli or situations,
grouped in three main clusters (see Tables 1–4). such as the emotions, bodily sensations, and cognitions
from his/her childhood, such as abandonment, abuse,
(A) Cluster 1: Relational techniques. One of the major neglect, or rejection, the amygdala is activated (Pynoos
techniques used to convey emotional regulation during et al., 1999). The activation of the amygdala is very
treatment is the relationship between the therapist and
fast and automatic, occurring through memory channels
the patient. This set of techniques follow psychodynamic
(Phelps and LeDoux, 2005). Although the amygdala is
principles derived from object relation theory and Self
connected with prefrontal areas, it is poorly affected
psychology (Clarkin et al., 2007; Maroda, 2009). This
by purely cognitive areas (Gray et al., 2002; Gerdes
kind of relationship is designed to contrast the abusive
et al., 2010; Shiba et al., 2016). For this reason, these
or punitive relationship that the patient experienced
memories are hard to change by the simple activation
during his/her childhood. The therapy situation becomes
of cognitive areas. In schema therapy the therapist
a safe place in which the patient can affirm and express
helps the patient activate these memories, in order
his/her needs, desires, and feelings. It also provides an
to satisfy the unmet needs related to these memories
emotional-relational corrective response (an extension
(Martin and Young, 2010). Emotional memories are then
of the emotional corrective response, Alexander and
rewritten and changed. We hypothesize that this happens
French, 1946). This kind of relationship helps the
because of a memory reconsolidation process (Nader,
Child to experience and express feelings or desires that
2003). When the patient reactivates past experiences, the
were banished or frustrated by the Punitive Parent.
neural system of the amygdala is no longer activated
This corrective relationship is experienced inside most
in the same way. After this, a positive alteration in
sessions as the therapist explores the present interpersonal
behavioral and emotional response can be observed
difficulties of the patient. After the exploration of present
(Fink et al., 1996). The recognition and satisfaction
life, the discussion goes to the childhood and adolescence;
of these needs in these situations, through different
a link between present and past situations is made. During
exercises and therapeutic relationship, allows the patient
these explorations, the goal is to help the patient to access
to create a restorative experience against those damaging
and elaborate the problematic child modes, thanks to the
experiences that have created his/her schemas and modes
therapist’s figure limited reparenting (Kellogg and Young,
(Rafaeli et al., 2010). The core therapeutic process
2006).
involved in limited reparenting is based on a secure
(1) Limited reparenting. Limited reparenting is the heart attachment between therapist and patient. In fact, we
of ST (Behary and Dieckmann, 2013). The core know that the development of a healthy attachment
concept of limited reparenting can be defined as a is a prerequisite for normal psychological functioning.
wide range of responses, behaviors, and attitudes of Limited reparenting uses the therapeutic relationship as a
the therapist designed to respond to patient’s core secure base that meets the deep needs that the patient has
needs (Arntz and Jacob, 2012). This process helps never seen fulfilled by his/her parents, such as security,
the patient recognize and meet unacknowledged needs stability, acceptance and autonomy. The first step of
from his/her early childhood, so that he/she can limited reparenting is to teach to patient how to regulate
recognize and satisfy the present ones (Arntz, 2014). his/her emotions. This is done by using modeling
This experiential process is able to reach emotional techniques, in which the patient follows the therapist’s
structures of the brain such as the amygdala, in which method of emotional regulation, within the limit of
emotional memories are stored (LeDoux, 1995). When therapeutic framework. The emotional regulation carried
out by the therapist will then be internalized by the (B) Cluster 2: Experiential techniques. Experiential techniques
patient and subsequently form a part of the Healthy are focused on emotions, and are designed to deal with
Adult mode. The Healthy Adult is able to see his/her own emotions related to the activation of specific EMSs. They
needs, understand reality, and become autonomous. In derive from emotion focused therapy (Greenberg, 2015),
fact, the main goal of the therapy is to teach the patient and take partial inspiration from the CBT tradition. These
how to strengthen the Healthy Adult mode, giving more techniques give the patient the possibility to experience
and more space to it, thanks to the internalization of anger and sadness in a more adaptive way, or to build
the therapist’s healthy adult model. To maintain this, new systems of meaning and behaviors related to those
the therapist has to reach the Vulnerable/Abused Child emotions. In ST experiential techniques can be grouped
mode to try and meet the needs of this mode with into two main categories: imagery rescripting and dialog
different psychotherapeutic instruments. Reaching the with the chairs. These techniques are then appropriately
Child mode helps the therapist create a healthy and used depending on which mode the therapist is faced with,
essential bond with the patient. Direct access to the in the sessions.
Vulnerable Child is the cornerstone to give the therapist
the possibility to meet those needs, and is the mainstay (1) Imagery rescripting. In the imagery rescripting exercises,
of treatment. This can only occur after a long process schemas and modes are activated with their associated
in which he/she has managed to overcome dysfunctional unpleasant emotions. These emotions are related and
modes to reach the Vulnerable Child mode. Usually, in connected to biographical traumatic memories (Marieke
order to do this the therapist needs to confront and et al., 2011). The psychotherapist asks the patient to find
dismantle these dysfunctional coping modes. Limited in his/her imagination, through an emotional bridge,
reparenting simulates a real reparenting and may provide a situation in which, as a child, he/she experienced
a patient with warmth, empathy, compassion, as well an emotion similar to the present negative emotion.
as firmness, reciprocity, respect for limits, and the In these exercises, the traumatic childhood experiences
recognition of the patient’s rights. Naturally, it also are changed, and acquire new meaning through the
depends on the therapeutic stage that has been reached. therapist’s support in the imagery. The therapist (or
Dealing with the dysfunctional coping modes is the first another adult protective person chosen by the patient)
stage of therapy. Once the coping modes are overcome, will take part at the scene and will help the patient
both Vulnerable Child modes and Punitive/Demanding in meeting the needs of the child. During imagery
Parent modes will emerge. The second stage of therapy rescripting, negative emotions (anxiety, sadness, disgust,
is to delete the punitive/demanding modes and to fear...) are changed, in the first instance thanks to the
protect the Vulnerable Child. At this point, however, intervention of the therapist that, entering in the scene,
the interaction with the therapist has already been is able to meet the need of the child (see Table 5). The
internalized; this is realized in Healthy Adult mode. In fact that the patient’s needs are recognized and protected,
fact, the third stage of therapy is building a Healthy Adult in a situation where no one did it, creates two effects
mode. It is fair to say that in the therapeutic process of in the patient. The first is that the patient realizes that
ST the “validation process” becomes the key step in all he/she deserves to be recognized and protected. The
techniques used. The patient should never be perceived second is that the healing experience felt gives the patient
as wrong. a different viewpoint of that traumatic situation, a new
(2) Empathic confrontation is often used to deal with possibility to experience similar situations in a safe way.
dysfunctional ways of coping. This technique With the continuation of treatment, the relationship with
allows a balance between the emotional validation the therapist – and the modeling that is created during
of dysfunctional coping modes and the push for the imagery – creates a healthy pattern in the patient,
change. When the patient adopts dysfunctional an adult mode (i.e., internal working model), that is able
patterns based on his/her schemas during a session, to see the patient’s needs and to have a realistic and
the therapist shows understanding toward him/her practical vision of reality. In fact, in a more advanced
and stresses how those patterns derived from his/her stage of therapy the patient’s Healthy Adult enters the
childhood experiences. At the same time, however, scene and tries to meet these needs, during imagery
the therapist draws attention to the fact that those rescripting exercises. It is often observed that when the
patterns may very well not be accurate and that the patient returns to a past experience, in which he/she has
patient’s behavior can lead to an unhappy life (empathic felt a similar emotion to that of the present, he/she begins
reality testing). Therefore, empathic confrontation to understand the meaning of the emotion experienced
requires a constant switching between empathy in the present. The therapist enters the scene and takes
and reality check: the therapist validates schemas care of the child patient, trying to meet his/her needs,
and coping styles as an understandable outcome allowing the patient to begin to recognize them, and
of the life history of patient and at the same time figure out how to satisfy any of them, whatever they are;
brings his/her attention to their current negative the subject needs to be seen, protected, unconditionally
consequences. accepted, loved, validated and limited.
(2) Chair Work. In chair-work (Kellogg, 2004), dialogs vulnerability. Having the opportunity to differentiate
between the patient’s different modes are conducted these modes is the first step to cope with them in a
in order to help him/her to develop awareness about functional way.
his/her mode activation and lack of integration. As a
final step the chair-work leads to potentiate the Healthy (C) Cluster 3: Cognitive techniques. In ST the therapists also
Adult that should be able to contrast maladaptive modes, uses some CBT techniques, but only after the first stages
nurturing Vulnerable Child modes and let Happy Child of therapy are done. In fact, using CBT before having
express him/herself. For example, patients are supported dismantled maladaptive coping strategies might reinforce
to get in touch with feelings of anger and rage in the them rather than reduce them. These techniques are
Angry Child Demanding and Punitive Parent modes, derived from more standard CBT approaches and help
in Healthy Adult’s chair. The dialogs with the chairs, the patient to cognitively understand their modes, coping
then, are good tools to deal with the coping modes. strategies, function of emotions and to restructure eventual
At the start of the trial the therapist underlines the thinking patterns or break dysfunctional behavioral
importance of these modes, forming, in this way, the patterns. Writing flash cards, in which the patient report
foundations for a more critical discussion. In fact, Modes activation and associated beliefs, and their effects, is
validating, comparing, limiting the dysfunctional coping an example.
modes, the therapist can make the patient more aware
Although some parallels can be made between ST strategies
of the role that these modes have always had from
and techniques and Gross cognitive model of emotion regulation
childhood, how they developed, and then why the patient
(CER) (see Fassbinder et al., 2016), we believe a Dynamic-
perceives them as ego-syntonic. It also allows seeing the
Experiental model of Emotion Regulation model (EDER,
disadvantages that these modes have today, in terms of
Grecucci et al., 2015b, in press) may better fit ST methodology.
negative interpersonal consequences. Subsequently, this
According to the CER model, emotions are generated according
work gives the opportunity to the patient to recognize
to a precise sequence in which an individual exposed to a
them in everyday life, and allows him/her to limit the
situation: (1) engages it; (2) attends to a particular aspect of the
effect of these modes in his/her life. In chair-work, it is
situation; (3) interprets the event; (4) experiences an emotional
important that the patient enters fully into the mode’s
response with a behavioral (action tendency), emotional,
perspective, and only speaks to the therapist from that
and physiological arousal; and (5) modulates that response.
perspective. In the same way, the therapist addresses the
Following this model, emotion regulation or dysregulation can
patient with the mode’s name, as if he/she were only
happen at any step in this sequence and every emotion can
speaking to this part of the patient. The chair-work is able
become dysregulated. The main mechanism of dysregulation
to correct two different maladaptive phenomena in the
is the lack of, or failure to apply, an appropriate regulatory
patient’s mind: one is the dissociation, perceived in terms
strategy. Cognitive Behavior Therapy (Beck and Fernandez,
of process (i.e., breakdown in integrated processing;
1998), and Dialectical Behavior Therapy (Linehan, 1993) use
Van der Hart et al., 2006; Dorahy and Van der Hart,
interventions for emotional regulation that fit with CER model.
2007; Steele et al., 2010), and the other is the excessive
Within this model and these therapies, emotion dysregulation
integration among different maladaptive modes. When a
is treated through behavioral methods, attentional methods,
patient enters a dissociated mode, he/she can experience
cognitive methods and mindfulness and acceptance methods.
a wide array of experiences, from low dissociation to
The Experiential-Dynamic Emotion Regulation model (Grecucci
high dissociation state. In the former, the patient is able
et al., 2015b, in press; see also Campos et al., 2004 for a
to remember different events or life themes related to
similar account) claims that events trigger: innate emotional
different modes. In the latter case, the patient is not
responses with inborn adaptive action tendencies which precede
able to remember or to be aware about situations with
cognition (temporal and neuroanatomical primacy) (Grecucci
different emotional value experienced in his life when
et al., 2016). Once elicited, emotions have a duration and intensity
other modes were active. In this way, the chair-work is
proportional to the stimulus and automatically self-regulate.
able to enhance the metacognitive ability to recognize
different modes, to be aware about it and about related
memories.
Moreover, this exercise can also maximize the ability to TABLE 5 | Imagery rescripting: steps of the process.
differentiate different modes when they are integrated. (1) Relaxation and creation of a safe space
Usually, we observed the co-activation of different (2) Accessing a difficult image from the present
modes, such as Vulnerable Child and Punitive Parent. (3) Creating an emotional bridge from the difficult present image
In this case, the patient experienced strong feelings of (4) Accessing a past image with a similar emotional correlate, focusing on
guilt, vulnerability and sadness. With chair-work, the needs and emotions of the child
patient becomes aware about the fact that feelings of (5) Introducing a figure who will care for the needs of that child (therapist or
guilt are caused by a Punitive Parent, an internalization healthy adult), so that the situation may change
of past interactions with the caregiver that blames (6) Stabilize a sense of security and positive attachment
the Vulnerable Child, causing feelings of sadness and (7) Translate the new emotional meaning to the initial situation
The conscious control or regulation is therefore not required. during sessions. The patient lived strong emotions that changed
Emotions are generated, expressed, and channeled into healthy in just a few seconds. This is typical in cases of BPD. For example,
actions and automatically return to baseline. Thus, emotions when talking about her affective relationship, Linda feels a terrible
are not inherently dysregulated. Dysregulation derives from need to open up and feel loved for the person she is. At the same
the combination of emotions plus conditioned anxiety, or of time, she’s terrified of showing herself, because in her experience
emotions with a dysregulatory strategy (for example, sadness she has always been criticized and judged by her parents in a very
for failing in an exam plus the intervention of a maladaptive negative way, regardless of what she did.
Parent mode that creates shame, guilt, and contempt toward To highlight modes, the therapist utilized the Schema Mode
the self; in psychodynamic terms, a defense mechanism of self- Inventory (SMI, Young et al., 2007) and ecological observation
attack) leading to dysregulated emotional states. To regulate these of what happened during the session, paying special attention
states, the clinician must remove the pathological Modes. Once to the emotions that emerged and their somatic manifestations.
removed, automatic emotion regulation follows. For this reason, For example, when Linda claims to be very angry, the therapist
ST rarely teaches explicit regulatory strategies (such as in CBT asks: “How does this emotion make you feel?”, “Where do
or DBT), but works on the underlying cause that creates the you feel it on your body?”, “What do you do to manage it?”
observed dysregulation. “Where is it coming from, what triggered it?”, “How do you
feel afterward?” By doing this, the following modes have been
identified: Detached Protector, Abandoned and Abused Child,
APPLICATION Enraged Child, Punitive Parent and the Healthy Adult, although
the latter was very weak.
We are going to present a clinical case to give an example When Linda feels she’s being criticized by an external
of strategies and techniques used in ST for the treatment of agent, the Punitive Parent mode, along with the Abandoned
emotional dysregulation. When the therapist1 met the 36 year and Abused Child mode, are activated. Those two modes are
old Linda in May 2014, she had the impression of having a sad, deeply set in Linda’s personality. This makes Linda feel like she
impulsive, angry and emotionally unstable woman in front of her. is profoundly wrong, inadequate, inferior, unworthy of other
She was also 15 min late. Linda had decided to see a therapist people’s love. When this happens, the Enraged Child comes
because she was suffering from strong mood swings, fits of anger, out, only to be inhibited by the strong Detached Protector.
agitation, central insomnia characterized by waking up frequently This mode does not allow her to feel any emotions, making
and anhedonia. These symptoms had taken a turn for the worse her act like a robot and making her avoid situations that
after the end of the relationship with her boyfriend, with whom trigger these emotions. A strong sense of derealization is seen
she had been for 19 years. in this mode, reality appears to be muffled. If the protector
Linda says “I’ve always been a bit moody, sometimes I feel doesn’t act, a strong rage is triggered, and Linda vents all her
good around people, other times I argue furiously. I don’t know frustration verbally and physically, sometimes throwing objects.
what’s happening to me,” “When someone criticizes me I can’t This happens when criticism is seen as something final and
stay quiet. I get really angry, I feel a heat surging from my chest unchangeable.
and just coming out!” Linda grew up in an environment that During therapy the patient was taught how to identify and
ignored every need for care, affection, attention, listening, and recognize different modes and needs, while also being taught
understanding. Her parents were often absent, physically and that modes are an adaptive response to attachment needs that
emotionally. have not been satisfied in childhood, adolescence, and the
As a consequence of her personal life Linda shows, current period. In order to effectively give Linda this knowledge,
as is the case with many BPD patients, several EMSs: the therapist openly asked her questions about her childhood
Mistrust/Abuse, Abandonment/Instability, Emotional and adolescence, maintaining as much eye contact as possible,
Deprivation, Defectiveness/Shame, Failure, Self-sacrifice, showing sincere interest for her life story, and validating her
and Unrelenting Standards. The first 4 EMSs we mentioned emotional experiences.
imply that the needs for safety, nurture, empathy and security The only moment in which the patient does not receive
were not adequately satisfied, Failure implies that the patient validation is when the Punitive Parent emerges: in this case, the
lives with strong feelings of guilt for not meeting her family’s therapist makes the patient notice how this part is based on
exaggerated expectations. Thus, the last 2 EMSs (Self Sacrifice interiorized negative experiences, how this part does not belong
and Unrelenting Standards) are developed: both are based on an to her. Thus, the therapist asks “Does Linda really need to feel like
excessive focus on the desires and needs of others, at the expense this?”, “Is this really what Linda thinks about herself?”
of personal needs. The third phase in therapy is designed to modify emotional
The ST therapist must always try to validate the patient’s dysregulation with limited reparenting: the therapist uses this
experience, so in this first phase no action must be taken to technique to pose as a new safe and accepting attachment figure,
restructure the processes behind emotional dysregulation: the so that a new, healthy operative model can be created for Linda.
focus is on validation. Therefore, instead of working on EMSs, the By doing this, Linda started getting in touch with her
first step in Linda’s therapy was focusing on modes that emerged emotions, and started, albeit with much effort, labeling different
parts of her with names like “Small Linda,” “Angry Linda,”
1
Also one of the article’s authors. “Warrior Linda,” “Top-of-the-class Linda”: respectively the
Abandoned and Abused Child, the Enraged Child, the Detached emotions. In this way, the patient interiorizes a new, healthy
Protector and the Demanding Parent. model for a relationship. In a more advanced therapeutic phase
With limited reparenting the therapist tries to satisfy the these imaginative exercises are designed to allow the adult patient
patient’s emotional needs by giving warmth, nurturing and care, to intervene, so that she can protect and validate the needs of her
being truthful, honest and straightforward, empathizing with the child Self.
patient and validating his/her emotional states and feelings. To This is an important passage in the path of consolidating the
put it briefly, the therapist acts as a model for a healthy adult internal operational model of the Healthy Adult. The patient
by behaving like a healthy adult that satisfies a child’s needs. For therefore becomes capable of recognizing her emotions, of
example, when Linda started sessions in a detached and cold way, connecting them to her childhood experiences, of expressing and
the therapist made her notice that the Detached Protector mode satisfying her needs in the present, self-regulating her emotions
was activated. To bypass it and reach the Abandoned and Abused in an adaptive way. This happens because Adult Linda puts limits
Child, chairwork was used. The therapist made the patient sit on to Angry Linda’s behavior and excludes Top-of-the-class Linda
the Warrior Linda chair and told her “I realize that right now and Warrior Linda, while creating an emotional connection to
Warrior Linda is here with us, and that she’s trying to protect you. I Small Linda’s needs. During therapy the patient often jumps from
would like to thank her for protecting you, I know how painful it is one mode to the other very rapidly (i.e., flipping). This often
for you to talk about these things, so I understand that a part of you begins when a critical or hostile mode emerges, such as Top-of-
tries to protect you from feeling that deep sadness and that sense of the-class Linda, that makes Small Linda feel wrong and alone.
emptiness and abandonment again. I know your life, I know what This emotional state activates Angry Linda, in order to avoid
happened to you, you were a small child and you should have had feeling the sadness and sense of powerlessness that Small Linda
somebody who took care of you. Unfortunately, nobody was there. brings. However, this mode inevitably reactivates Top-of-the-
I remember when you told me about that time your father was class Linda, and Little Linda is humiliated again: “See? You’re
hitting you and your mother was standing there, looking at you getting angry again, you’re the same old spoilt brat!” In order to
without doing or saying anything. No child can bear this anguish, break this vicious cycle, Warrior Linda is activated and muffles
this fear, you had to find a way to avoid feeling it, and Warrior all emotions. The therapist uses chair-work to make Linda notice
Linda helped you with this. It’s normal, and I understand that even how all these parts activate, what triggers them, how long each
now that there’s a person who wants to help you and take care of part is active for. This work has the purpose of enhancing the
you Warrior Linda is trying to protect you and to keep emotions patient’s awareness of these different parts by acting on her meta-
hidden. But exactly because I understand what you felt, I have to cognitive capability. Another focal point of chair-work is working
ask Warrior Linda to let me talk with the part that is suffering, so on the Top-of-the-class Linda mode, stripping it of legitimacy.
that I can ask what she needs.” Top-of-the-class Linda says: “See? Small Linda is wrong; she’ll
Once contact has been made with the Abandoned and Abused never be able to be like the others.” The therapist answers: “Here’s
Child, the therapist starts a rescripting exercise that involves Top-of-the-class Linda, always trying to convince you that you’re
reparenting. Linda has to close her eyes to visualize her safe space, not like the others, that you’re wrong, but we now that this is
where her tolerance to emotions is heightened. By doing this, a useless part that doesn’t see what you really need. I think we
the triggering of dissociative mechanisms is avoided. When the should send her away immediately, you don’t deserve to sit here
therapist sees that Linda is in a stable and relaxed mood, she and believe what she says.”
asks her to visualize the past situation that triggered those strong By weakening the punishing part, the integration between
emotions. Once the situation is visualized, the therapist focuses the Healthy Adult and the Abandoned and Abused Child is
on what Linda is feeling, allowing her to feel what she needs and strengthened. The patient manages to recognize the punishing
the related emotion. Emotion is used as a catalyst for childhood part and shut it out, letting the healthy part that recognizes
situations in which Linda has felt a similar emotion. At this point, her emotions and needs talk. This constant co-activation of her
the therapist asks Linda where she is, how old she is, what is vulnerable part and her healthy part enhances her emotional
happening, what she looks like, and how she feels. The patient regulation capability.
starts to slowly take on the facial expression of a frightened child, During therapy the patient says she feels connected to Small
her voice has changed, it’s softer, and she whispers what she sees Linda, that she needs to protect her and listen to her real life
behind her eyelids. In this case, the Little Linda mode is fully needs and necessities, acting like a Healthy Adult. Linda has
accessible. The therapist validates the emotions that the child often referred effort and difficulty in having to take on negative
feels, and uses rescripting to stop any aggression, so that Linda emotions.
can know what being protected feels like. One of the fundamental parts of this therapy has been the
Once Linda’s need for a sense of safety, genuine interest, and therapeutic relationship. The therapist has always been sincere,
value is satisfied, the therapist takes her back to the initial scene. straightforward, and empathetic. This has allowed Linda to
Now that Linda has felt protection and care, she does not feel experiment what has probably been her first healthy relationship,
wrong anymore; instead, she sees her needs and acts to satisfy along with allowing her to trust the therapist and show her
them in a functional way. vulnerable side, in order to share it and work with it through
This work is at the roots of the development of a new mode work.
relationship, based on trust and attachment with a healthy figure Sessions lasted for 10 months: twice a week for the first
that sees needs and acts to satisfy them, validating the patient’s 6 months, once a week for the last 4 months. At the end of this
therapy, Linda shows a high level of tolerance for situations that understand their own behaviors and feelings. Parallel with these
used to trigger dysfunctional modes and emotions. The patient studies, some studies have compared the effectiveness of ST with
also managed to feel emotionally involved with people who know TAU in group therapy, on patients with BPD (Farrell et al.,
how to give her what she needs and that don’t constantly criticize 2009). In particular, in this study Farrell et al. (2009) observed
her. She has also learned to make difficult choices, reducing from 2 to 3 months into the 8 months of treatment not only
her fear of abandonment and tolerating negative feedback. She meaningful reductions in impulsive, self-injurious behavior or
doesn’t feel the presence of Top-of-the-class Linda when she loneliness and emptiness but also an increase in mood, affective
relates to others, at least not as much as she used to. All the features, quality of life issues, and global functioning. Nadort
symptoms that brought her to start a therapy are gone. At the et al. (2009) demonstrated that ST efficacy in recovering from
time being, her level of social functioning has allowed her to meet six types of PDs (avoidant, dependent, obsessive–compulsive,
friends and have a relationship of healthy sharing with them. She paranoid, histrionic, narcissistic). Its effect was superior to TAU
has also started a new relationship, in which she feels loved and and COP. ST had fewer dropouts, and superior cost-effectiveness.
seen. A randomized controlled trial comparing ST for forensic patients
with PDs to usual treatment suggests strong effects of ST even
in patients with high psychopathic traits (Bernstein et al., 2012).
EMPIRICAL EVIDENCE AND FUTURE In these last years the research on the effectiveness of ST moved
DIRECTION from PDs to other disorders like depression. In these studies,
researchers using a single case series study design (Renner et al.,
In the last decades, ST efficacy has been tested in different studies. 2013, 2016; Renner, 2014; Porter et al., 2016) or using RCT
Giesen-Bloo et al. (2006) using a multicenter randomized control (Carter et al., 2013) showed that ST is not less effective than CBT.
trial, compared ST with Transference Focused Psychotherapy Studies have been conducted to test not only the effectiveness of
(TFP), a psychodynamically based psychotherapy. In this paper, ST, but also the effectiveness of specific techniques used in ST. In
the researchers tested the efficacy of ST compared to TFP particular, some imaginative techniques, like imagery rescripting,
on a population of patients with BPD. After only 12 months were evaluated in several disorders or conditions (Grunert et al.,
of treatment, ST showed its effectiveness in reducing BPD 2007; Arntz, 2011; Stopa, 2011). Although ST was shown to be at
symptoms. After 3 years of treatment, ST showed to be superior least equal and for some measurements, if not superior to other
to TFP in some of the measures. In Van Asselt et al. (2007) types of therapies (Perry et al., 1999; Leichsenring and Leibing,
evaluated the cost-effective ratio between ST and TFP, finding 2003), we do not have an empirical demonstration of its power in
that ST dominates over TFP in many items. In particular, logistic regulating emotions yet.
regression analysis with the treatment group and BPD baseline
score as covariates showed a significant effect in favor of ST.
Societal and informal care costs in the ST patients were lower CONCLUSION
and recovery rate was higher compared with the TFP group. In
The literature up to now indicates that ST is an effective treatment
addition, another important result was replicated in this study:
for BPD. We believe ST efficacy is due to the structural change in
the proportion of patients who had recovered after 4 years
the patient’s personality that every ST therapist aims to, and not
was 52% for the ST group and 29% for the TFP group. From
only to symptomatic improvements. As a result of the structural
2008 ST has been recommended as one of the evidence based
changes, the initial emotional dysregulation due to maladaptive
treatments in the Dutch Guidelines on Personality Disorders
regulatory strategies (pathological Modes), gives way to (adult)
(2008), and insurance companies reimburse for treatment. After
emotional regulation. We think that the features of ST and the
this date the efficacy of ST has been demonstrated also in
need of new treatments, that are able to bring about a full recovery
other PDs. Bamelis et al. (2014), with a multicenter Randomized
for patients, will be a major propulsive boost in exploring new
Controlled Trial (RCT) design compared the ST with Treatment-
clinical applications of this model. This is quite probable, not only
as-Usual (TAU) and Clarification-Oriented Psychotherapy (COP)
regarding ST’s effectiveness, but also regarding what is effective
in cluster C, paranoid, histrionic, and narcissistic PDs. This study
in ST and if it can be further enhanced to better understand and
lasted 3 years and was conducted on 323 patients. All analyses
treat various ailments. Along this paper we provided theoretical
consistently revealed that ST was superior to other treatments
and clinical implication of ST as a way of treating emotional
on greater recovery from PDs, as well as when recovery was
dysregulation in a wide range of patients. Indeed, ST gives the
defined more stringently, and when controlled for assessment
therapist a set of instruments and techniques to foster emotional
instrument. Moreover, the lower dropout rate in ST suggests
regulation through the therapeutic relationship and experiential
higher acceptability by patients. The number of patients still in
emotion focused methods. Future studies will test this fascinating
treatment after 3 years was lowest in the ST group (13% vs. 26% in
hypothesis.
TAU and 36.6% in COP), pointing to the ability of ST to achieve at
least comparable results in less time. An adjacent qualitative study
assessing patient and therapist perspectives on ST (Bamelis et al., AUTHOR CONTRIBUTIONS
2014) revealed that working with the mode model was highly
appreciated by patients and therapists since it guided therapists HD, AG, and MP contributed equally to this work. HD, AG, and
in choosing adequate techniques and helped patients to better AC substantially contributed in the conception of the work. HD,
EU, and IG drafted the work. HD, AG, and MP give the final ACKNOWLEDGMENT
approval of the work. HD, AG, and MP agree to be accountable
for all aspect. Thanks are due to Daniele Caponcello for English revision.
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