The Schema Therapy Bulletin

In This May Issue

Message from the ISST President

Self-pity/Victim: A Surrenderer Schema Mode by Dave Edwards 

Ways to Strengthen the Healthy Adult by Remco Van der Wijngaart

Face to Face With “Anger Modes” Sturdy and Secure In The Treatment Room by Wendy Behary 

New Directions for Working with Dysfunctional Parent Modes by Offer Maurer and Eshkol Rafaeli

Upcoming Bulletins

Bulletin May 2015 PDF

New Directions for Working with Dysfunctional Parent Modes

by Offer Maurer and Eshkol Rafaeli, The Israeli Institute for Schema Therapy

It is a well-known fact that some individuals are their own worst enemies. This phenomenon has been recognized by many approaches which described the dynamic using various terms. Common to all these approaches is the recognition that through identification and introjection, children learn to treat themselves in just the same ways their parents treated them – ways that are at times quite dysfunctional. Although the terms introduced by Young to label hurtful internalized self-states in the Schema Therapy (ST) model point directly to the parents as their source (e.g., the Punitive Parent or the Demanding Parent Modes), neither we nor Young himself take it to imply that all critical, punitive, or demanding modes must always be the result of direct internalization of parental figures (Young, Klosko & Weishaar, 2003). At times, these modes echo the words and actions of other influential sources like siblings, peer groups or even broader society’s messages.  

One of the most important goals in ST is to help the client identify these modes, view them as ego-alien voices, assertively stand up to them, and learn to protect and shield the Vulnerable Child mode from their destructive effects. Various tools can be employed in ST for this purpose, yet ST’s most powerful tools for combatting the Dysfunctional Parental Modes (DPM) are experiential strategies, particularly chairwork (Kellogg, 2004) and Imagery Rescripting (ImRS; Arntz & Jacob, 2012, Rafaeli, Bernstein & Young, 2011). 

When therapists request permission and enter an image, they typically do so with four broad goals in mind. They want to (1) bypass the various coping modes which often block feeling. They aim to (2) nurture or re-parent the child modes, especially the Vulnerable Child. By doing so, they hope to (3) model adaptive parenting so that the patient’s own healthy adult mode is strengthened. Often times, this involves (4) confronting or combating the internalized parent or perpetrator modes. 

Of these goals, we find the first three incontrovertible. This is not the case, however, with regards to the fourth goal – the one tied to addressing parent or perpetrator modes. In recent years, we have begun to doubt whether directly and forcefully “taking on” the internal hurtful self-states of our patients is the only clinical avenue possible. We have no doubt that this avenue should exist, nor that there is convincing evidence for its utility (e.g., Arntz, Klokman & Sieswerda, 2005; cf., Bamelis, Giesen-Bloo, Bernstein, & Arntz, 2012). Still, our own clinical impressions, those of our supervisees, and those of therapists from various (quite compatible) schools of therapy point to other clinical options, ones which might hold promising merits (Rafaeli, Maurer & Thoma, 2014).

To illustrate our thinking about this issue, we would like to share an instructive experience one of us (OM) had while studying with Dr. Suzette Boon, an internationally renowned trauma expert who’s best known for her work with patients suffering from Dissociative Identity Disorder (DID). After watching some video clips from real patients’ sessions she presented at a workshop, I was struck by the tremendous amount of respect (and even what I felt to be genuine gentleness!) she showed towards pretty horrific malevolent self-states within her dissociative patients. This, of course, stood in stark opposition to the ST model’s approach. Curious, I came up to her during the break and asked her about this discrepancy. Dr. Boon told me about her own experience with ST, during which she had attempted to confront malicious self-states in the manner prescribed by the model. The results, she said, were at times problematic. In particular, though patients seemed to be experiencing some relief in session, the internal attackers came back to haunt and punish the patients later at home with even more vengeance then before. Some patients, she said, would then need even more care and protection due to an increase in their suicidality. These experiences and others led her, she said, to change the way she worked with critical or punitive self-states to a one that’s more respectful and gentle to them (S. Boon, personal communication, May 18, 2011). 

This and other clinical observations have served as an important starting point for us in our search to expand our own (and our supervisees’) toolbox for engaging and working with DPMs. Today, when we encounter these modes, we often view them as internal representations of parents (and others) who just did not - and maybe still do not - know how to treat their children right, mainly because of their own deficient upbringing. After realising we’re not against them, these modes often come out, with some tentativeness, and seek counsel with us. Many of them agree to change their ways after getting enough reassurance and guidance (Maurer, 2015).

One way to think about this style of work is by analogy to the therapeutic stance adopted when working with real parents in parental-guidance sessions. In many instances, parents enter hoping to be discuss their child’s symptoms, only to discover that the clinician conceptualizes things quite differently; in particular, it often becomes evident (at least to the clinician) that the underlying cause of the presenting problems resides with the unmet (or inadequately met) needs of the child. With forthcoming families, a discussion focused on the child’s needs and the parents’ responses to it often leads to a recognition of the parents’ schemas and modes and to their developmental origins; such recognition later leads to personal growth and change both in the parents and in the child. 

Sensible therapists typically wouldn’t begin parent training interventions with forceful confrontation, but instead would try to empathize or understand the parents, even as they attempt to correct problematic behaviours. We propose that the same principle applies to work with a DPM. As we’ve seen repeatedly, most parents who were overly demanding, strongly critical or mercilessly punitive were so not because of a wish to hurt their child (although sadly this might indeed be the case in the minority of cases) but because they themselves were activated into a Maladaptive Coping Mode or a DPM of their own, making it impossible for them to respond to their child’s needs in a good enough manner. 

A related point has to do with the notion that treating the violence of the DPM with violence could prove to be quite problematic in the long run. When we strive to to ‘banish’ the parental modes, or when we treat them harshly, we may be just repaying them with the same old coin. Although the Vulnerable Child Mode may actually value this (and at times really need this, especially when it’s done to save or protect her/him from severe maltreatment) he/she is actually missing out an important chance to learn new ways of interacting and negotiating, ways marked by compassion and empathy.

To conclude, we’d like to reiterate that these new directions involving a softer response to the DPMs are proposed here not as replacement of the established ST way, but rather as a variant to it. Developing this variant could expand the diversity of tools available to present-day schema therapists. Over time, we hope to elaborate on the specifics of this line of intervention: when should it be used in the course of therapy, how should it be combined with the more classic approach, and how should one determine which is superior in any particular juncture in therapy.   

Bibliography

Arntz, A., Klokman, J., & Sieswerda, S. (2005). An experimental test of the schema mode model of borderline personality disorder. Journal of Behavior Therapy and Experimental Psychiatry, 36(3), 226-239. 

Arntz, A., & Jacob, G. (2012). Schema therapy in practice: an introductory guide to the schema mode approach. New York: Wiley.

Bamelis, L., Giesen-Bloo, J., Bernstein, D., & Arntz, A. (2012). Effectiveness studies of schema therapy. In M. Vreeswijk, J. Broersen, & M. Nadort (Eds.) The Wiley-Blackwell Handbook of Schema Therapy: Theory, Research and Practice (pp. 495-510). New York: Wiley.

Kellogg, S. (2004). Dialogical encounters: Contemporary perspectives on ‘chairwork’ in psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 41, 310–320. 

Lobbestael, J., Arntz, A., Cima, M., & Chakhssi, F. (2009). Effects of induced anger in patients with antisocial personality disorder. Psychological Medicine, 39, 557-568. 

Maurer, O. (2015). A Failure with a Capital F. In: Rolef Ben Shahar, A. & Shalit, R. (Eds.) Therapeutic Failures.London: Karnac. (In Press)

Rafaeli, E., Bernstein, D. P., & Young, J. (2011). Schema therapy: Distinctive features. New York: Routledge. 

Rafaeli, E., Maurer, O., & Thoma, N. (2014). Working with modes in schema therapy. In N. Thoma & D. McKay (Eds.), Engaging Emotion in Cognitive Behavioral Therapy: Experiential Techniques for Promoting Lasting Change. NY: Guilford. 

Van der Hart, O., Nijenhuis E.R.S. & Steele, K. (2006). The Haunted Self. New York: Norton.

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner's guide. New York: Guilford.