The Official Publication of the International Society of Schema Therapy
In This May Issue
Healthy Adult Mode:
Ways to Strengthen the Healthy Adult of Our Patients
by Remco van der Wijngaart, The Netherlands
As schema therapists we all strive for the same common goal in treating our patients, to strengthen the healthy adult part of the patient by validating basic core needs. We often explained this therapy goal to patients and for most of them this explanation was clear and sufficient. Some patients however, have questions about this healthy adult part of them. Questions like ‘How do I connect to that Healthy side of me?’ or ‘
What does a healthy adult do?’. These questions let us think about ways to make the concept of the Healthy Adult less abstract for our patients. Although some authors describe different aspects of the Healthy Adult (Artnz &Jacob, 2012, Farrell&Shaw, 2012, Van, Jacob, Genderen & Seebauer, 2012) our patients were in need of even more simple guidelines to learn Healthy Adult behaviour. This article describes these methods and techniques and will enable the schema therapist to explain the concept of the Healthy Adult in an easy to understand manner. It also will give a simple step-by-step training of that Healthy Adult.
Visualizing the Healthy Adult
The patient needs to learn to visualize the Healthy Adult to make it a less abstract concept. The way to do that is to start with the therapist explaining about his own Healthy Adult. The therapist self discloses on a memory where he was able to deal with a difficult situation in a healthy way. The therapist mentions all the different aspects of the Healthy Adult; emotional- cognitive and behavioural aspects. He might say things like: ‘That moment I felt confident. And that confidence felt strong; I was holding myself straight, head held high and shoulders straight. And I felt calm, a calm feeling in my belly but at the same time connected, as if I could focus on my feelings but also be aware of the reality that I was facing. And just talking about it now makes me feel that same way. If I had to draw myself being in that mode I would look tall, looking calmly but strong. If I’m now confronted with an upsetting situation, standing up straight with my head held high and my shoulders straight, I do connect to my Healthy Adult, connecting me to that calmness and strength.”
The therapist then explains that the patient needs similar gateways to their Healthy Adult as well as a vivid visual image of their Healthy Adult. The therapist asks the patient to close her eyes and get a memory of a situation in which she was connecting to that healthy part. In our experience every patient will have such a memory or more then one; rare moments like deciding to break up a bad relationship. Visualizing the Healthy Adult they were in that situation is a way to identify the different aspects of their Healthy Adult. The homework assignment at the end of that session will be to practise visualizing that Healthy Adult daily in non-challenging situations.
This is the start of internalising a sense of the Healthy Adult of the patient. Next, we need to explain healthy adult behaviour in looking after the needs of the Vulnerable Child. We explain this using a simple plan called ‘the 3 steps of the Healthy Adult’.
The ‘3-steps of the Healthy Adult’
In our experience, patients really love this simple 3-step plan; it gives them clear instructions and it easy to remember. The first step is to acknowledge the feelings and distress of the Vulnerable Child. A healthy Adult says things like “I see you’re upset”, “I totally understand that this is painful”, “If I was in that situation I would feel bad myself”. So the patient has to learn to say things like “I’m upset and that’s understandable, I never learned to feel safe in these situations. It’s my Vulnerable Child that has been triggered”. This acknowledgement of the suffering is a soothing way of connecting.
The second step is to offer hope, a different perspective. Acknowledgment is a necessary first step but if it would just be acknowledgment then it wouldn’t be enough. Words like “This will go away, that’s a fact”, “It will change” give a clear and healthy message that distress can be overwhelming but that it will not stay that way, how strong that overwhelming feeling may be. It’s important that the patient learns remind themselves of this message and make it more then just hollow words.
The third and final step of the Healthy Adult is to deal with reality. Dealing with reality may mean different things. It often relates to deal with parent modes or coping modes that were triggered and were part of the reason why the patient was in so much pain. Dealing with reality also means making healthy behavioural choices how to solve a problem or cope with a difficult situation.
The three steps have to be taken in this specific order. One common pitfall is that a person immediately tries to solve things when faced with an upsetting situation, to take action. Although action is a necessary step it’s only effective if it is first acknowledged how much the other is in pain. In some way we’re all aware of that necessary first step. Just imagine that you feel bad because of what happened at work, return to your home and talk about these difficulties with your loved ones. When these loved ones immediately start to give advice how to deal with that situation (“What you should do is…”, “What I would do is…”) that might feel irritating. Although these solutions may be very wise, it’s too soon. First we need to hear that our pain is acknowledged, understood, before we can be open to suggestions how to take action.
Depending on the pathology of the patient we tend to start to visualize the Healthy Adult during the middle phase of the therapy. Next, that Healthy Adult of the patient is present in imagery exercises while the therapist does the rescripting. Then we start to explain about the 3 steps so the patient will cognitively understand what she needs to learn to do for herself. The therapist may still do the rescripting but will also explicitly point out these 3 steps to the patient. In the last phase of therapy the patient is coached to practise the Healthy Adult herself. The therapist will ask questions like “Did you do the 3 steps?’ and thereby coaching the patient to strengthen her Healthy Adult.
Arntz, A., & Jacob, G. (2012). Schema therapy in practice: an introductory guide to the schema mode approach. New York: Wiley.
J. M. Farrell & I. A. Shaw (2012). Group schema therapy for borderline personality disorder—A step-by-step treatment manual with patient workbook. West Sussex, UK: Wiley-Blackwell.
Genderen, H. van, Jacob, G. & Seebauer, L. (2012). Patronen doorbreken, Negatieve gevoelens en gewoonten herkennen en veranderen. Amsterdam: Uitgeverij Nieuwezijds.
Special thanks to my colleagues of the day time clinic in Maastricht, specifically Judith van Hommerig who was the first to mention the 3 steps of the Healthy Adult.
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