The Official Publication of the
International Society of Schema Therapy
In This Issue
In this February Issue by Chris Hayes & Lissa Parsonnet
Working on the Healthy Modes and Cluster-C Personality Disorder (PD) by Guido Sijbers
Dealing with Pathological Worry and Rumination: Proposing a new "Over-Analyser" Coping Mode by Robert Brockman and Adele Stravopoulos
The Problems with Modes and their Measurement by Eamon Smith
Interview with David Edwards (ISST President) by Vivian Francesco
THE PROBLEM WITH MODES AND THEIR MEASUREMENT
Dr Eamon Smith,
Clinical Psychologist in Private Practice
Lecturer in Psychology, National University of Ireland, Galway, Ireland
(Based on a paper presented at the ISST Vienna Conference 2016)
The concept of modes is one of the central pillars of schema therapy and, for many, has become the primary focus of therapy. The different definitions of the concept encompass a range of theoretical positions from cognitive therapy to object relations. Young et al. (2003) defined modes as ‘those schemas or schema operations-adaptive or maladaptive- that are currently active for the individual’ and as ‘a facet of the self involving specific schemas or schema operations that have not been fully integrated with other facets’. Flanagan (2014) defined modes as ‘adaptive strategies for satisfying needs, having behavioural, affective and cognitive components’ and are conceived to be ‘roles’ rather than traits. Others have commented on their theoretical similarity to concepts such as ‘ego states’ and ‘splitting’ from other therapeutic models (Edwards & Arntz, 2012). What the different definitions have in common, however, is that modes are not unidimensional constructs but contain a number of theoretically related components. I believe that there is a misalignment between our theoretical understanding of modes and our knowledge derived from empirical studies, which thus raises the following concerns.
Although clinically specific early maladaptive schemas (EMSs) have been observed to be associated with certain modes (e.g. Emotional Deprivation, Abandonment and Vulnerability with the Vulnerable Child Mode) particular EMSs are not exclusively associated with individual schema modes (Young et al. 2003). Little attention has been given to the specific mechanism by which EMSs and modes are related.
Modes comprising EMSs, various coping responses and behavioural dispositions can be expected to change over the course of treatment by the deactivation of the EMSs and modification of the coping response. Again, the mechanism by which modes are expected to change has received very little theoretical or empirical attention.
Likewise, there are few theoretical studies that specifically address the issue of modes and psychopathology. Increased mode activation has been related to severity of psychopathology and specific modes have been associated with certain personality disorders. However, evidence for these assertions comes, in the main, from studies using the Schema Mode Inventory (SMI). Even when clinically determined, there appears to be little integration with theory.
From an original ten, the number of modes has now approached thirty, with the ever-increasing list of schema modes cited as an attempt to grapple with the complexity of clinical presentations. It is hardly surprising that a mode titled ‘Self-Aggrandiser’ might be required to describe a narcissistic presentation or that Conning and Manipulative mode and Predator mode might be required in forensic settings. Modes, instead of being perceived as ‘unintegrated facets of the self’, are being increasingly used as broad behavioural descriptors of presenting behaviour and symptoms. This point has been well made by Flanagan (2010), who also questions the utility of the ever-growing lists and observes that the original purpose of the concept was to simplify the schema model.
The reciprocal relationship between the theoretical understanding of modes and results from studies using the SMI can be problematic. There is a danger that theory will be modified on foot of the SMI in a similar manner to that of the Young Schema Questionnaire (YSQ), where, based on studies of the reliability and validity of the instrument, changes have been proposed regarding the basic model. In this case, Lockwood & Perris (2012) proposed a shift from the five- to a four-domain model, which was subsequently endorsed by Young (2014). More recently, based on their reliability and validity exploration of the SMI, Panzeri et al. (2016) made a theoretical jump by concluding that the theoretical structure of the model was strong and, therefore, that schema therapy itself as an approach in evolution is a promising treatment for personality disorders. While the over-interpretation of an instrument such as the SMI may be problematic, the very instrument itself is questionable from both a conceptual and technical perspective.
The proliferation of modes raises a basic question about the feasibility of measuring modes as the SMI assesses, at best, just fourteen. If the number continues to grow we will be left with an inventory of indeterminable length! More importantly, however, there are conceptual issues around the use of the SMI. Firstly, how can a measure be developed that will reflect the situational triggering of a specific mode and simultaneously assess the characteristic modes utilized by an individual, given that modes are said to contain EMSs which are conceived as traits? Pilot studies carried out on earlier instruments found that subjects had difficulty in separating, on the one instrument, currently active modes from general modes (Lobbestael, 2012.). Secondly, can an instrument measure both the intensity and presence of a mode given the theorized relationship between intensity of mode activation and the level of psychological distress? Indeed, Lobbestael (2012) cautions against the use of a non-clinical sample in studies of modes because they are more likely to score low on the ‘pathological modes’.
Despite its widespread use, there have been relatively few studies that have examined the factor structure of the SMI. Some studies have confirmed the fourteen-factor structure (Lobbestael et al. 2010; Reiss et al. 2011, 2016; Panzeri et al. 2016). However, other than making assumptions regarding the intercorrelations among the various modes, there have been no studies that have examined the different categories of modes as independent models.
Smith et al. (2016) tested the modes as unifactorial models to examine the convergent validity of the items. The modes and their individual items were brought together in their various categories, i.e. innate child, coping, parent and healthy, which tested their discriminant validity. The modes were then fitted into a full model, firstly, as correlated categorises and then as third-order factors. With some questionable modifications to the item content of the individual modes, the confirmatory factor analysis largely confirmed the structure of the modes in terms of their items. When included in their respective categories, there is some question of overlap, as the fit indices were not overly convincing, although using more lax criteria (CFI index >0.85) and incorporating the item modifications, the fit might be regarded as adequate. However, the overall fit of the model, being poor, suggests that the categories of modes may not be sufficiently discriminating because of significant overlap among the modes.
All the modes were moderately to strongly correlated with measures of general psychological distress and well-being. Intercorrelations among the different categories of modes is cited as evidence of their cohesion and, indeed, Smith et al. (2016) did find significant correlations among the modes within the various categories. However, all the maladaptive modes regardless of category were significantly correlated. That the correlations among the modes did not reach r= 1.0 cannot be regarded as evidence for their individual integrity, as suggested by Panzeri et al. (2016).
In summary, Smith et al. (2016) found some evidence for the fourteen-factor structure but only following significant modifications to the items initially and the further use of a questionably lax interpretation of some of the goodness-of-fit indices. The modes were also significantly correlated with each other regardless of category and, furthermore, all the so-called maladaptive modes were significantly related to degrees of psychological well-being.
The results raised some fundamental questions for the authors (Smith et al. 2015; Smith, 2016). For example, have we fully explored and explained the nature of the concept? Is the scale not just a further measure of distress or lack of well-being? Do we understand the unnecessary reductionist position that can be adopted when using such instruments? Can a unitary score on an inventory reflect the multiple components of the concept? Does the SMI measure what we theorise as modes?
If modes are indeed theorized to be the situational responses to triggered EMSs and only exist within the context of an external or internal relationship with another and if schema therapy is a relational therapy, then surely the patient’s interpersonal narrative and the therapeutic relationship itself is the ‘royal road’ to unearthing the self–other dyads, the connecting affect, and the characteristic coping strategies or defences. To prematurely provide the patient with a personal understanding of constructs, which, may in part, be based on the interpretation of a questionable instrument is a violation of the ‘not knowing’ stance, which is an essential ingredient in the therapeutic encounter. Vulnerable patients are often acquiescent and eager to please the therapist and will often acknowledge interpretations as representing the true contents of their minds. While schema therapy does not solely rely on the YSQ or the SMI, nevertheless the provision of a simple instrument that will short-circuit more in-depth exploration can be attractive, particularly for the more novice therapist. Are they ever told that the SMI may not measure what they assume it measures?
Maybe it is time to get back to the basics again and look afresh at the whole structure of the modes and rather than attempting to describe them according to results of studies using the SMI, we should examine the theoretical structure in terms of the interpersonal relationship and decouple the concept from notions of psychopathology.
Another course of structural exploration may be to examine the relationship between concepts such as ‘internal working models’ and EMSs/modes, and, subsequently, assess what self–other representations and coping strategies are associated with specific modes. At a broader level, perhaps the relationship between these core constructs may be examined by reference to other related clinical approaches, such as the Core Conflictual Relationship Theme of Luborsky and Crits-Christoph (1990) or the interpersonal affect focus (IPAF) of Lemma, Target, and Fonagy (2011). Should modes and EMSs be operationalized in terms of a broad template such as these, then there can be as many mode operations as there are different minds and mental operations. Flanagan (2014) has, from a more cognitive therapy stance, proposed a matrix model for modes as one possible structure which deserves further attention.
While the above comments refer to modes and the SMI, similar observations can be made about the nature of EMSs and their measurement using the YSQ (Smith, 2015). To monitor progress through the course of therapy by using measures of symptom severity is acceptable but, when the instrument purports to measure concepts that are integral to the theory of the therapeutic endeavour itself, we should proceed with caution.
Want more? Watch the interview with Eamon Smith
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