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The Schema Therapy Bulletin

The Official Publication of the 

International Society of Schema Therapy

TREATING DISSOCIATION: MODE WORK AND BEYOND 

ROBIN SPIRO & JUDITH MARGOLIN (USA)

Dissociation has been conceptualized as a normal, defensive, survival related response to a severe threat or danger. This mechanism becomes a habitual way of coping under conditions of chronic abuse and relational disruptions. As a result, many chronically traumatized children are unable to develop a unified sense of self across behavioral states, resulting in the development of alternate identities. Similar to schema modes, these organized patterns of thinking, feeling and behaving based on a set of schemas, represent different facets of personality that have not been integrated into a whole.  This lack of integration gives rise to a functional dissociative self, with relatively independent schema modes (Arntz, Klokman & Sieswerda, 2005, p.227). As Young et.al. (2003) stated the more extreme the dissociative personality, the greater degree of pathology and the more separated maladaptive schema modes are from each other and from healthy aspects of the personality”.

During the recent conference in Vienna (June/July 2016), Judith Margolin and Robin Spiro presented the clinical case of Diane”, demonstrating the blend of Schema Therapy, and the mode model, with approaches drawn from the fields of Trauma and Dissociation.  This approach to the Phase Oriented Treatment of a patient with Dissociative Identity Disorder (DID) identified adaptations to ST and the mode model that can be used to effectively enable resolution of trauma.

A phase oriented treatment of DID was presented, highlighting the functions of mode management and mode awareness. Mode management serves to diminish maladaptive schema and schema modes (alternate identities) by helping alters function in an integrated, collaborative and cooperative manner, and by increasing safety and stability. Risk assessment, grounding and containment are some of the techniques used throughout treatment for effective mode management.

Psychoeducation about DID, and increasing mode awarenesshelps patients understand the experience of DID in a depathologizing way, recognize that individual alters/parts may have multiple modes, and identify and name different alters and the functions they serve. Different techniques for mode management and increasing mode awareness, some of which were developed by Joan Farrell and Ida Shaw, were noted.  These include the Safety Bubble, Circle Monitor, Alter Questionnaires, Mode Information sheets, Alter/Mode Monitoring, and reorganizing alters /modes in order to stabilize the system (Pairing Alters, Grouping and Mapping Alters). As shame is reduced via the limited reparenting relationship and trauma processing, the modes often spontaneously develop cooperative and compassionate internal relationships.

Margolin and Spiro identified particular challenges in working with DID. Extensive dissociation, with larger gaps in awareness and memory, adds difficulty to treatmentbut can also enable trauma work with an alter, without overwhelming the main personality. Alters are more differentiated, separate and less transient than modes. There is less access to the Healthy Adult. Alters provide a sense of identity, and loss is often experienced with change. As re-experiencing of trauma is more intense, greater rescripting is often necessary.

The integration of trauma processing interventions, drawn from the trauma and dissociation field, was illustrated.  Reframing the apparentlypunitive parent mode as a protector mode, and aligning with the self-destructive modes/alters were demonstrated as necessary healing interventions.  Dissociation as an extreme detached protector needs to be respected to prevent decompensation, and is sometimes used therapeutically via distancing techniques.  This enables trauma processing within a window of tolerance.  Other techniques, including fractionation and pendulation, were demonstrated, along with methods of mode work for rescripting, with short vignettes from actual sessions with Diane.

The case of Diane” demonstrated one of the central trauma healing interventions, limited reparenting.  As Richard Chevetz said during his keynote address at this conference, IT IS ALL ABOUT THE RELATIONSHIP”. Being a good parent”, establishing a safe, trusting relationship involves active engagement, providing a therapeutic holding environment, bonding with a system of multiple alters, and open discussion of schema activation within the therapeutic relationship.  Limited reparenting is considered one of the most powerful tools to change the maladaptive character of the schemas and to meet the needsof the patient (Sempertequi, et. al., 2013).  Developing a limited reparenting relationship with a DID patient is complex and challenging but ultimately rewarding process.  Relationships develop differently with the main personality vs. vulnerable child parts and angry protectors, and require a sturdy, consistently caring presence throughout periods of testing and mistrust.

This clinical case presentation clearly demonstrated the bridge between Schema Therapy and the Schema Mode Model, and best practices from the fields of trauma and dissociation in the treatment of DID.  As one participant stated, it was a deep, clear presentation that balanced well between theory and clinical material, also allowing room for short demonstrations of actual sessions”.  

Why Schema Therapy?

Schema therapy has been extensively researched to effectively treat a wide variety of typically treatment resistant conditions, including Borderline Personality Disorder and Narcissistic Personality Disorder. Read our summary of the latest research comparing the dramatic results of schema therapy compared to other standard models of psychotherapy.

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