17

Schema Therapy
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Eva Fassbinder and Arnoud Arntz

O ver the last 2 decades, schema therapy (ST), developed by Jeffrey Young
(Young et al., 2003), evolved as one of the major current treatments for
patients with personality disorders (PDs) and chronic mental health prob-
lems. ST has its roots in cognitive behavioral therapy (CBT) but also integrates
ideas and techniques of other theoretical orientations (e.g., attachment the-
ory, psychodynamic and experiential therapies). Practitioners of ST assume
that traumatization in childhood and frustration of basic childhood needs
lead to the development of early maladaptive schemas (i.e., basic mental repre-
sentations of the self, the relationship to others and the world) and dysfunc-
tional schema modes (i.e., negative emotional-cognitive-behavioral states),
which cause psychological problems in adult life. Thus, a strong emphasis in
treatment is placed on early development. In addition to cognitive and
behavior-oriented techniques, ST extensively uses experiential techniques to
process memories of aversive childhood experiences. The therapeutic rela-
tionship is conceptualized as limited reparenting, meaning that the therapist,
within the boundaries of a professional therapy relationship, behaves like a
“good parent” toward the patient.
ST is basically a transdiagnostic approach. However, it also comprises disorder-
specific models for most PDs. A number of studies demonstrate effectiveness for
treatment based on these models, especially for borderline personality disorder
(BPD; Dickhaut & Arntz, 2013; Farrell et al., 2009; Fassbinder, Schuetze, et al.,
2016; Giesen-Bloo et al., 2006; Nadort et al., 2009) and Cluster C PDs (i.e.,
avoidant, dependent, and obsessive-compulsive PD; Bamelis et al., 2014). In

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Handbook of Cognitive Behavioral Therapy: Overview and Approaches, edited by A.  493

Wenzel
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 494  Fassbinder and Arntz

this chapter, we provide an overview of the background, underlying theory,

practical application, and outcome data of ST. Case formulation and therapeutic
techniques will be illustrated with case examples of a patient with BPD and a
patient with chronic depression and avoidant PD.1

HISTORY AND DEVELOPMENT OF SCHEMA THERAPY

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In the 1980s, Young developed ST as an extension of Beck’s cognitive therapy

for patients who did not respond fully to treatment (Young et al., 2003). These
patients showed very complex, pervasive, enduring psychological problems
(called “characterological problems” by Young) and dysfunctional behavioral
patterns, which in most cases could be followed back into their childhood. In
many of these patients, a PD was evident. The characterological problems also
lead to problems in psychotherapy and often interfere with the therapeutic
process. In order to develop helpful treatment strategies, Young tried to under-
stand the characteristics of these patients and potential pitfalls of CBT tech-
niques. Major aspects were the following (Young et al., 2003):

• Patients learned early in life to suppress and avoid emotions and other inner
experiences as a coping strategy that they developed in response to adverse
experiences. Thus, they had problems and showed resistance to expressing
emotions or thoughts. This caused problems for CBT, as sufficient access to
and willingness and ability to report thoughts and emotions are usually
needed to ensure success in therapy. Consequences could be that patients
avoided doing their homework or rejected trying techniques the therapist
proposed. This often led therapists to doubt patients’ compliance.

• Patients had difficulties in forming a collaborative relationship with the ther-

apist, such that they remained distant, mistrustful, or hostile. Other patients,
on the contrary, became too reliant on the therapist. These interpersonal
problems were often mirroring the problems patients had in their relation-
ships in everyday life.

• Patients’ complaints were often vague and hard to capture, whereas stan-
dard CBT aims for clarity and focuses on clear, measurable treatment goals.

• The belief system of these patients and their coping strategies were very
rigid. Thus, even if they committed to trying CBT techniques, their patterns
of thinking and feeling seemed to be deeply rooted and were very resistant
to change.

To address these problems, Young enriched CBT techniques with elements

and insights from attachment, interpersonal, and object relation theory and
integrated experiential techniques from gestalt and emotion-focused therapy.
This integration led to the following distinctive features of ST, which distinguish
ST from other CBT approaches:
Case examples are disguised to protect patient confidentiality.
1
 Schema Therapy  495

• A strong emphasis is placed on the patient’s early development. The patient’s

current problems are brought into context and explained from adverse
childhood experiences and frustration of basic childhood needs.

• Experiential techniques are used extensively. They aim at processing aversive

childhood memories and experiencing emotions and needs in a safe way
and bringing them in a healing process by emotional restructuring. Through
the use of these techniques, coping strategies (such as experiential avoid-
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ance) are reduced, and dysfunctional schemas and the dysfunctional mean-
ing of emotions and needs are changed.

• The therapeutic relationship serves as an antidote to adverse interpersonal

experiences and is conceptualized as limited reparenting. This means that
within professional boundaries the therapist creates an active, caring,
parent-like relationship with the patient. At the same time—as good parents
would do with their child—the therapist empathically confronts the patient
with the problematic consequences of their behavior and the need to change
and promotes change.

• The major goal in ST is helping patients understand their emotional core

needs and learn adaptive ways of getting needs met better. This requires
breaking through long-standing emotional, cognitive, and behavioral pat-
terns, meaning change of dysfunctional schemas, coping strategies, and
schema modes.

UNDERLYING THEORY
Early Maladaptive Schemas

A central assumption of ST is that aversive experiences and frustration of basic

childhood needs lead, in interaction with biological and cultural factors, to the
development of early maladaptive schemas. Young et al. (2003) defined early mal-
adaptive schemas as broad pervasive life themes or patterns of information pro-
cessing composed of memories, emotions, cognitions, bodily sensations, and
attention preferences. Schemas strongly influence individuals’ views of them-
selves (e.g., “I am a terrible person”), their relationships to others (e.g., “Others
will leave me anyway”), and the world as a whole (e.g., “The world is a danger-
ous place”). Besides explicit and verbal knowledge accessible to consciousness,
schemas also contain implicit and nonverbal knowledge. Schemas are devel-
oped during childhood or adolescence and elaborate throughout one’s lifetime.
They act as filters of incoming information and have a self-sustaining character,
as information is processed in a way that fits the schema. Thus, they are very
stable and resistant to change.
It is important to consider that everybody develops schemas in childhood and
that there are maladaptive and adaptive schemas. Adaptive (healthy) schemas
develop when core emotional needs are met in childhood. This enables children
to develop positive pictures about themselves and their connection to other
 496  Fassbinder and Arntz

people. That there is a relation between the development of maladaptive sche-

mas and negative childhood experiences and that these schemas mediate the
association between childhood experiences and personality disorders, is sup-
ported by research (Carr & Francis, 2010; Specht et al., 2009; Thimm, 2010).
Basic emotional needs of children include the following (Arntz & van Genderen,
2009; Young et al., 2003): (a) secure attachment, stability, and care; (b) protec-
tion from harm and abuse; (c) connection to other people and social inclusion;
(d) love, nurturing, and attention; (e) acceptance and praise; (f)  autonomy,
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competence, and identity; (g) expression and validation of emotions, needs, and
opinions; (h) realistic limits; and (i) play and spontaneity.
Young et al. (2003) described 18 maladaptive schemas, grouped into five
domains, each domain reflecting a theme of frustrated needs (e.g., disconnec-
tion and rejection; see Table 17.1). The 18 maladaptive schemas were derived
from clinical experience. Psychometric research with the Young Schema Ques-
tionnaire, which assesses the presence or absence of 16 core maladaptive sche-
mas, has shown stable factor structure in clinical samples (Baranoff et al., 2006).
Early maladaptive schemas are activated automatically by internal or external
triggers, especially if triggers show parallels with the situations that have led to
the development of the schema. Activation of the maladaptive schema leads to
psychological distress associated with painful emotions. In order to deal with this
psychological distress, an individual may use one of the following three coping
styles: (a) surrender (i.e., giving in to one’s schema), (b) avoidance (i.e., avoiding
full activation and awareness of one’s schemas), and (c) overcompensation (i.e.,
fighting one’s schema by believing and doing the opposite of the schema).

TABLE 17.1. Early Maladaptive Schemas and Schema Domains Identified by Young
et al. (2003)

Schema domain Schemas

Disconnection and rejection • Abandonment/instability

• Mistrust/abuse
• Emotional deprivation
• Defectiveness/shame
• Social isolation/alienation

Impaired autonomy and achievement • Dependency/incompetence

• Vulnerability to harm and illness
• Enmeshment/undeveloped self
• Failure

Impaired limits • Entitlement/grandiosity

• Insufficient self-control

Other-directedness • Subjugation
• Self-sacrifice
• Approval seeking

Overvigilance and inhibition • Negativity/pessimism

• Emotional inhibition
• Unrelenting standards
• Punitiveness
 Schema Therapy  497

For example, patients with a mistrust/abuse schema are convinced that oth-
ers will betray, abuse, humiliate, cheat, lie to, or manipulate them intentionally.
These expectations reflect their experiences in childhood, when they experi-
enced that it is not advantageous to trust others. Patients with this schema
often experienced severe abuse in childhood, including sexual, physical, and
emotional (including verbal) abuse. If the schema is activated, which often
occurs in interpersonal situations, patients experience strong anxiety, threat,
and a sense of mistrust. The three ways of schema coping are as follows:
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• If patients surrender to their mistrust schema, they might choose relation-

ships with abusive partners and allow others to mistreat them; thus, they
repeat history from childhood. Although this leads to emotional pain, it
might somehow feel familiar for these patients. Often, these patients do not
see any alternative to the schema, or they believe that it would cause even
more pain and is hopeless for them to try an alternative. Thus they give in
and stay in abusive relationships.

• If patients avoid their mistrust schema, they might avoid relationships

entirely, or they will not show themselves to be vulnerable, and they will
not disclose personal information or trust other people. This way they can-
not be hurt; thus, painful emotions do not arise in the short run. In the long
run, these patients experience loneliness without close relationships. They
do not provide themselves with opportunities to experience corrective expe-
riences, and their schema stays stable.

• If patients overcompensate their mistrust schema, they might abuse and mis-
treat others. This way they are in control, they feel strong and powerful
instead of weak, and they cannot be hurt by others (e.g., “If I beat them first,
they cannot beat me”). The schema is often not conscious to the overcom-
pensating patients, or they deny it; thus, the emotional pain is not felt
directly. However, overcompensating behavior also causes problems in rela-
tionships. Corrective experiences are impossible, and the underlying schema
remains uncorrected.

Coping strategies typically develop in childhood as attempts to adapt to a

distressing environment. As such, they have an adaptive value and can help
the child attenuate painful emotions. However, they often become very rigid,
inflexible, and automatically triggered over time and impair adaptive interper-
sonal and self-regulatory behavior, leading to many difficulties in essential life
areas. Rigid coping prevents the needs that were frustrated in childhood from
being fulfilled in adult life and serves to maintain the maladaptive schema.

Schema Modes

While working with BPD patients (as well as with other patients with severe
personality pathology), Young discovered that many competing schemas were
apparent and that these patients manage these schemas with different coping
 498  Fassbinder and Arntz

strategies. The plurality of possibilities (18 schemas × 3 coping styles = 54 pos-

sibilities) leads to a high level of complexity, which makes it hard to maintain an
overview for both patient and therapist. Moreover, the schema concept was not
optimal to explain and work with the quick mood and behavior changes of
these patients. Thus, Young extended the schema theory with the mode model
approach, a major development in the evolution of ST. Young et al. (2003)
developed the schema mode approach first specifically for BPD, then for narcis-
sistic PD. Later, the schema mode approach was further developed and empiri-
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cally tested for most other PDs (Bamelis et al., 2011; Lobbestael et al., 2008, 2010).
A schema mode (“mode” to simplify) is a combination of an activated schema
and a coping strategy and describes the momentary emotional-cognitive-behav-
ioral state that is active at a given time point. Patients can flip from one mode to
another mode very quickly, whereas a schema is rigid and enduring (i.e.,
schema = trait, mode = state; Young et al., 2003). It is, therefore, a convenient
concept in clinical practice, as it helps patients and therapists track and explain
the frequent and sometimes sudden shifts in emotion, cognition, and behavior.
Also, specific treatment strategies and goals for each dysfunctional mode have
been developed, which help patients learn healthier ways of coping with them.
Most outcome studies on ST are based on the mode model (Jacob & Arntz,
2013), and modern ST works almost exclusively with the mode model. Thus, in
this chapter we focus on the mode model.
It is, however, important to keep in mind that schema modes are related to
schemas, in the sense that the activation of a schema leads to a way of coping
with the activation, which results in a schema mode:
activated schema → coping → schema mode

This model has received empirical support in two studies so far (Rijkeboer &
Lobbestael, 2012; van Wijk-Herbrink et al., 2017). Interestingly, the ST model
predicts that the same schema can underlie very different types of modes,
depending on the way the individual coped with the schema activation there-
fore, both externalizing and internalizing psychopathology can be based on the
very same schema. For instance, the activation of a mistrust/abuse schema can
lead to depression and anxiety (via surrender type of coping, resulting in a vul-
nerable child mode activation) or to aggression (via overcompensating type of
coping, resulting in an angry-enraged child mode activation; see van Wijk-
Herbrink et al., 2017, for an empirical test). This implies that when a schema
mode is addressed in treatment, the associated schema is automatically
addressed.
In the basic approach of the mode-model there are four broad categories of
modes (see Figure 17.1, modified from Arntz & Jacob, 2012):

• Dysfunctional child modes develop when major emotional needs were frus-
trated in childhood. In these modes, patients experience intense aversive
emotions, such as fear or abandonment, loneliness, helplessness, and sadness
or mistrust (vulnerable child modes), but also anger, rage, impulsivity, or lack
of discipline (angry/enraged/impulsive/undisciplined child modes).
 Schema Therapy  499

• Dysfunctional parent modes (punitive, demanding) are characterized by internal-

ized negative beliefs about the self, which the patient has acquired in child-
hood due to the behavior and reactions of significant others (e.g., parents,
teachers, peers). They are associated with self-devaluation and a sense of
self-hatred, guilt, shame, or extremely high standards.

• Dysfunctional coping modes serve to reduce the emotional pain and distress of
child and parent modes and describe the excessive use of the coping strate-
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gies of surrender (e.g., compliant surrender mode), avoidance (e.g., detached

protector mode or self-soother mode), or overcompensation (e.g.,
self-aggrandizer mode or bully-and-attack mode). These modes are usually
acquired early in childhood to protect the child from further harm and are
therefore considered as “survival strategies.”

• The healthy modes of the healthy adult mode and the happy child mode represent
functional states. In the healthy adult mode, people can deal with emotions,
care for their needs, solve problems, and create healthy relationships. In this
mode, people are aware of their needs, possibilities, and limitations and act
in accordance with their values, needs, and goals. The happy child mode is
associated with joy, fun, play, and spontaneity. In severe psychopathology,
the healthy modes are usually weak at the beginning of therapy.

Table 17.2 displays the most important modes in more detail and specifies
for each mode the PD that is typical. For more information and a detailed
description of all modes, see Arntz and Jacob (2012).

FIGURE 17.1. Basic Structure of the Mode Model

 500  Fassbinder and Arntz

Modes can be assessed by self-report with the Schema Mode Inventory

(SMI), though there are limitations in the degree to which patients can report
their modes, due to lack of insight, strategic reporting, or unwillingness to
report (Lobbestael et al., 2010). We later address other ways to assess modes
during treatment.

TABLE 17.2. Schema Modes

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Child modes

Lonely child mode

Feels like a lonely child that only gets attention and love if they do everything
that is expected by the parents or other important persons. Core emotional
needs are not met; thus, the child has a sense of being alone, socially
unaccepted, unloved, and unlovable.
Typical mode in narcissistic and obsessive-compulsive PD (however, often
denied and not conscious in the beginning of treatment) as well as in
avoidant PD (especially in combination with a sense of inferiority).
Vulnerability

Abandoned, abused child mode

Has a sense of being abandoned, sad, anxious, helpless, hopeless, and
threatened; has extreme fears of being left alone, mistreated or neglected;
appears fragile, vulnerable, needy like a child, looking for a parent figure
that helps.
Typical child mode in BPD and dependent, avoidant, and histrionic PD.

Dependent child mode

Has a sense of being like a helpless child, incapable and overwhelmed by adult
responsibilities; searches urgently for someone for help and to take over
responsibility.
Typical child mode in dependent PD.

Angry/enraged child mode

Feels angry, enraged, frustrated, and inpatient because core emotional (or
physical) needs of the vulnerable child are not being met; expresses anger
in inappropriate ways (e.g., by making demands that seem entitled or
Anger

spoiled, shouting, or even being physically aggressive). With the enraged

child mode, there is loss of control not only over the feeling of anger and its
verbal expression but also over aggressive behavior. Thus, there is severe
aggression in a “hot” emotional state.
Typical child mode in BPD as well as antisocial and histrionic PD.

Impulsive child mode

Acts impulsively to get needs and desires met, without thinking about
Lack of discipline

long-term consequences or taking care of others; often has difficulty

delaying short-term gratification to concentrate on long-term goals.
Typical child mode in BPD as well as antisocial; and histrionic PD.

Undisciplined child mode

Has difficulties with rules, discipline, and finishing routine or boring tasks; is
frustrated quickly and gives up soon.
Typical child mode in antisocial and histrionic PD.

Happy child mode

Happiness

Feels happy and contented because core emotional needs are met; has a sense
of being loved, connected to others, valued, understood, hopeful, resilient,
optimistic, and spontaneous.
 Schema Therapy  501

TABLE 17.2. Schema Modes (Continued)

Dysfunctional parent modes

Punitive parent mode

Reflects internalized punitive messages of significant others (e.g., parents,
teachers, siblings, or peers); shows in self-devaluation, self-contempt,
Punishment

self-hatred, shame, and guilt. Patients think they are bad, stupid, lazy, ugly,
or invalid; punish themselves or do not allow space to take care of them-
selves or to do something good for themselves; and believe that they must
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be punished for expression of needs or emotions and for any mistake.

Present in all PDs; however, often denied or not conscious to patients with
strong overcompensating modes, such as narcissistic, histrionic,
obsessive-compulsive, and antisocial PD.

Demanding parent mode

Has extremely high standards and pushes patient to do everything perfect,
without mistake, to be effective and efficient, not to lose time, to strive for
the high achievement, to be modest, and/or to put others’ needs before
Criticism

one’s own. The patient feels that it is wrong to express feelings or to be

spontaneous.
In patients with narcissistic and obsessive-compulsive PD, there is often a
demanding parent mode with focus on achievement, while in dependent
and avoidant PD, the demanding parent mode focuses more on social
behavior and the needs of other persons.

Maladaptive coping modes

Compliant surrender mode

Acts in a passive, submissive, reassurance-seeking way without caring for their
Surrender

own interests to avoid conflicts, disharmony, or rejection by others; behaves

as they think others wish them to behave, allows others to take over the
control of their life and to mistreat them, and stays in invalidating,
sometimes even violent, relationships.
Major coping mode in dependent PD.

Detached protector mode

Distances themself from other persons and emotions by shutting off all
emotions (e.g., by consuming drugs or alcohol, through dissociation or
distraction), withdrawing from relationships, and keeping others at a
distance.
Major coping mode in patients with BPD.

Avoidant protector mode

Uses situational avoidance as the primary coping strategy; avoids social
contacts, challenging situations, and conflicts as well as emotions in
Avoidance

general, intensive sensations, or activities that are in any way arousing.

Major coping mode in patients with avoidant PD.

Angry protector mode

Keeps others at a distance with cynism, irritation, or angry behavior
often found in BPD patients.

Detached self-soother mode

Shut off their emotions by engaging in activities that will somehow soothe,
stimulate, or distract them from feelings (e.g., addictive or compulsive
behaviors such as workaholism, gambling, dangerous sports, eating,
watching TV all day, engaging in fantasies, promiscuous sex, drug abuse).
Typically found in narcissistic patients.

(continues)
 502  Fassbinder and Arntz

TABLE 17.2. Schema Modes (Continued)

Self-aggrandizer mode
Behaves in a grandiose, over-self-confident manner; is very competitive,
arrogant; highlights own strengths and achievement; points at others’
mistakes or weaknesses; shows little empathy for others’ needs or feelings;
expects to be treated as special.
One of the main coping modes in narcissistic and obsessive-compulsive PD.

Attention- and approval-seeking mode

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Tries to get other people’s attention and approval by extravagant, inappropri-

ate, and exaggerated behavior. Usually compensates for underlying
loneliness.
Major coping mode of histrionic PD.
Overcompensation

Perfectionistic overcontroller mode

Attempts to protect themself from making mistakes or a perceived or real
threat by focusing attention, ruminating, worrying, increased planning, and
controlling Focus lies on perfectionistic behavior to prevent criticism,
misfortune, mistakes, or guilt and to prove capability.
Major coping mode of obsessive-compulsive PD.

Suspicious overcontroller mode

Attempts to protect themself from threat by being vigilant, scanning other
people for signs of malevolence, and controlling others’ behavior out of
suspiciousness.
Major coping mode of paranoid PD.

Bully and attack mode

Bullies and intimidates others, behaves aggressively toward others, and
threatens others and tries to frighten others in order to have the control
and not be harmed by others.
Major coping mode of antisocial PD.

Healthy adult mode

Performs appropriate adult functions, such as working, parenting, taking

responsibility, and committing; pursues pleasurable adult activities such as
sex; intellectual, esthetical, and cultural interests; health maintenance; and
athletic activities. Has functional attitudes toward emotions and needs and
uses appropriate assertiveness when functional.
Note. BPD = borderline personality disorder; PD = personality disorder. From Schema Therapy in
Practice: An Introductory Guide to the Schema Mode Approach (p. 42–46), by A. Arntz and G. A.
Jacob, 2012, Wiley. Copyright 2012 by Wiley. Adapted with permission.

Treatment Goals of Schema Therapy

The ultimate goal of ST is helping patients find adaptive ways to get their needs
better met in their everyday life and helping them deal with the frustration if
their needs cannot be met in a certain situation. This requires changing mal-
adaptive schemas, coping styles, and modes that underlie patients’ symptoms
and problems.
With respect to the mode model, there are mode-specific goals for each
mode providing a central “red thread” to follow at each point of therapy. These
goals are connected with specific therapeutic tasks for each mode (see Fig-
ure 17.2):
 Schema Therapy  503

• Child modes are healed and corrected. The patient should get in contact with
their vulnerable core and become aware of their emotions and frustrated
needs. Needs and emotions are validated and taken care of to foster emo-
tional processing of childhood maltreatment and enable corrective experi-
ences. This way, early maladaptive schemas can be healed. In the angry,
impulsive child mode, patients need to learn adequate ways to deal with
their anger and desires; sometimes this also requires setting limits to these
modes. The major aim, however, is to reach and soothe the vulnerable child
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mode, which is underneath the angry child mode. Memories of childhood

experiences related to child modes are emotionally processed mainly by
experiential techniques such as imagery rescripting, multiple chair, and
drama techniques, as is done with trauma processing.

• Parent modes are abolished as much as possible. The therapist “fights” the puni-
tive and demanding parent modes and helps the patient learn healthier
views of themself and develop more self-compassion.

• Coping modes are made less necessary by replacing them with healthier, more flexible
strategies. However, because these modes have functioned as “survival strate-
gies” to protect the vulnerable child mode, first their adaptive value needs to
be accordingly honored. Their reduction is to take place gradually as the
healthy adult mode has to develop more functional ways of coping.

• The healthy adult mode should become the dominant mode so that the patient can
take over all the above-named tasks by themself and become able to create healthy
relationships more and more. Thus, the therapist is not needed anymore at the
end of treatment. The happy child is also enhanced. Joy and spontaneity
should get more space in patients’ lives and protect them from psychological
distress.

FIGURE 17.2. Mode-Specific Therapeutic Tasks

 504  Fassbinder and Arntz

The mode-specific goals are achieved by means of cognitive-oriented, expe-

riential, and behavior-oriented techniques and through the work with the
therapeutic relationship. Each set of techniques is explained in the following
passage in more detail.

FOCI OF TREATMENT AND CHANNELS OF CHANGE

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ST has three general areas on which the treatment focuses:

• childhood experiences, which lie at the root of the development of the

problems

• the therapeutic relationship, to offer corrective experiences and to address

issues that become apparent in this relationship

• present problems and the future, to address the problems the patient strug-
gles with outside the therapy

The focus on the etiology of the problems in ST is a distinctive feature com-

pared with other forms of CBT, with the exception of trauma-focused CBT for
posttraumatic stress disorder (PTSD) related to childhood trauma. The reason
for the focus on the childhood experiences that contributed to the development
of the current disorder is that emotionally processing the memories of these
experiences leads to a change in their (implicational) meaning, which, in turn,
causes a change in the related schemas. Thus, successful processing of memo-
ries of abandonment experiences in childhood leads to a reduction of the aban-
donment schema (and thus the abandoned child mode), which in turn, is
associated with a reduction of the associated problems in the present (e.g.,
abandonment fears and dysfunctional attempts to prevent or cope with these
fears). Moreover, understanding the relation between childhood experiences
and present problems helps the patient understand the present problems and
promotes a metacognitive grip on them (Tan et al., 2017).
A second distinctive feature is the focus on the therapeutic relationship. Per-
sonality pathology has a strong interpersonal aspect and will, therefore, also
become manifest in the therapeutic relationship. This offers the chance for the
therapist to directly offer corrective experiences (i.e., the expression of negative
emotions, including anger toward the therapist, is followed not by rejection
from the therapist but by empathy and support). Schema therapists are warm
and more personable to foster a safe and corrective experience, but at the same
time, they are also directive (especially at start of treatment), as warm and per-
sonal directiveness matches the needs of the patient that has missed this form
of care in childhood. This concept of limited reparenting, such that the therapist
tries to meet the needs that were not adequately met in childhood, within pro-
fessional boundaries, is further discussed later.
The third focus is on problems outside the therapy room, in the present and
future. ST shares this focus with most (other) CBT approaches. However, when
 Schema Therapy  505

indicated, the therapist might more actively put issues on the agenda like (dys)
functional partner choice, choice of education and work, or hobbies to prevent
patients from remaining caught in a repletion of dysfunctional choices and to
promote their future well-being.
In addition to the three foci, ST integrates three channels of change:

• Experiential: changing by experiential techniques

• Cognitive: changing by thinking (reasoning, information) techniques

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• Behavioral: changing by behaving differently

Experiential techniques are generally inspired by techniques used in experi-

ential therapies like gestalt therapy, and an important reason to use them is that
they are so powerful in getting emotions activated and in bringing about a
change that goes further than cognitive insight (i.e., a change on a felt level).
This is, in particular, important in the treatment of personality problems, as
these patients often report, after the use of cognitive therapy techniques, that
they see what is meant but do not feel it. Experiential techniques also allow one
to go back to the developmental level of the child that experienced the negative
events that contributed to the problems and offer corrective experiences and
information on a developmentally appropriate level, so that these are better
integrated in the memory representations of these events. The cognitive tech-
niques used in ST not only are those that are common in traditional CBT (dom-
inated by a Socratic dialogue approach and challenging negative thoughts) but
also involve extensive psychoeducation about universal emotional needs and
emotions, the etiology of psychological problems, the effects of abuse and
neglect, and the intergenerational transmission of psychopathology.
The behavioral techniques can involve most of those known in CBT. One
specific technique to emphasize is behavioral pattern breaking, which usually takes
place at the end of treatment if dysfunctional patterns are still apparent. It occurs
when patients are stimulated to change the way they behave and make choices
to stop with dysfunctional patterns and start with trying out more functional
options. All ST techniques are explained in detail in the following section.

DESCRIPTION OF MAIN PROCEDURES

Main Treatment Plan

After assessing current problems, symptoms, important relationships, and the

developmental history of the patient, an individual case conceptualization with
the mode model (see below) is worked out. This normally happens within the
first five sessions. In the following treatment process, all occurring problems
and interpersonal disturbances are put into context, explained, and worked
with in this individual mode model. This means that for each situation or prob-
lem, the patient and therapist find out which modes are involved and how
their interplay contributes to the problem, and then they intervene according
to the above-named mode-specific goals.
 506  Fassbinder and Arntz

First, a rule of thumb, coping modes must be addressed and reduced because
they block access to the vulnerable child mode and the associated schemas,
often from the first domain. It is important for therapists to keep in mind that
these modes have served as a “protective shield” for many years; thus, they
have to proceed with caution. Patients will only reduce their coping modes if
they feel safe enough in the therapeutic relationship and if the adaptive func-
tion of these modes has been acknowledged sufficiently. At the same time,
patients also need to understand the disadvantages these modes cause in their
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current life and why it would be important to learn healthier strategies. The
therapist, thus, motivates the patient to reduce their coping mode stepwise,
first in the therapeutic relationship and later in other situations outside the
therapy room. Second, once there is access to the vulnerable core of the patient,
the therapist aims at validating needs and emotions of the child modes and
helps heal the deeply rooted and long-standing emotional pain by means of
experiential methods and through the therapeutic relationship. Simultane-
ously, dysfunctional parent modes are reduced, and their influence in the
patient’s life is weakened. Implicitly, the patient builds healthier schemas (e.g.,
“I am a loveable person,” “I can trust others”). Throughout the whole therapy
process, the healthy adult mode is strengthened and the patient takes over
more and more responsibility by themself.
Only very general information about the duration of treatment can be pro-
vided because ST is used with very different patients and settings. For patients
with severe PD, a length of at least 1.5 years with weekly individual sessions is
recommended. For patients with less severe PDs, around 30 weekly sessions
followed by five monthly booster sessions is recommended as a minimum. In
less severely ill patients or in self-therapy of therapists, only a few sessions
might already lead to pronounced changes.
In the following section, we present a case conceptualization as well as
cognitive-oriented, experiential, behavior-oriented, and therapy relationship
techniques and illustrate them with two patient examples. We have chosen a
patient with BPD and a patient with a Cluster C PD to demonstrate the variety
of ST techniques and the adjustment of ST to the specific patient group and the
individual patient. These PDs are quite common and have been studied in ran-
domized controlled trials of ST, which are described later in the chapter. All
techniques are presented in line with the original manuals for ST in general
(Arntz & Jacob, 2012; Young et al., 2003) and for the treatment of BPD (Arntz
& van Genderen, 2009), which we recommend for further reading.

Case Conceptualization With the Mode Model

At the start of treatment, an individual case conceptualization with the mode

model is developed through interaction with the patient. Major current symp-
toms and interpersonal and emotional problems of the patient are conceptual-
ized within the relevant modes and put into context with their developmental
background.
 Schema Therapy  507

In most patients with PDs, a specific pattern of dysfunctional modes can be

observed. These patterns are summarized as disorder-specific mode models. Such
specific models exist and have been empirically tested for most PDs (all but
schizotypal and schizoid PD) and forensic patients (Bamelis et al., 2011; Lobbes-
tael et al., 2008, 2010). These disorder-specific mode models provide therapists
with a rough frame for case conceptualization in the respective PD. However
they always have to be adapted to the individual patient, their symptoms, and
their history. The disorder-specific approach can be extended by adding addi-
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tional modes to capture all major problems easily. Thus, even in very complex
patients with high comorbidity rates and many problems, it is possible to work
with one clear, plausible model. When there is no disorder-specific mode model
available, such as for patients with chronic depression or other Axis I disorders,
the therapist uses the general mode approach (as shown in Figure 17.1 and Table
17.2) and chooses the relevant modes for the patient. It is the therapist’s respon-
sibility to concentrate on the most relevant modes and to keep the model as
simple as possible. Thus, it is recommended to work with four to six problem-
atic modes so that patient and therapist do not get lost and so they can focus on
essential problems. To reduce the complexity of the model, one can often chunk
modes with similar functions, such as combining the angry and the impulsive
child modes into one mode.
We now present two case examples to explain the way in which an idiosyn-
cratic case conceptualization is developed. The examples are partly based on
German publications and DVD sets on ST and chair dialogues (Fassbinder,
Erkens, & Jacob, 2016; Fassbinder & Jacob, 2014; Jacob & Seebauer, 2013).

Case Example 1: Patient With Borderline Personality Disorder

Linda, age 23 years, comes to treatment because she is afraid to lose her
boyfriend:

I just can’t trust him; although he does not give me any reason. I just can’t
believe that he really loves me as horrible as I am. I am always afraid that he
might cheat on me and will leave me for another woman. When he is out and I
am alone at home, I freak out and call him several times. If he does not answer
I check his Facebook account and emails. We had so many fights. I am totally
out of control then. I shout and throw things at him. I even beat him. If he then
withdraws from me, it even gets worse.

Asked for other symptoms, she says that she smokes cannabis or drinks alcohol
at least three times a week and that she has binge eating attacks several times a
week. “This happens mostly when I am alone and feel sad. I can’t bear that. I
always try to have something to do. If this does not work out, I smoke pot,
drink alcohol, or eat . . . and I am already fat enough.” Besides the relationship
to her boyfriend, she has one close friend, “Steph.” Steph has been very reliable
and supporting in the past, so the therapist values that relationship as a healthy
one. From other people, Linda withdraws herself totally. She even keeps Steph
at a distance most of the time.
 508  Fassbinder and Arntz

With regard to her developmental history, it becomes clear that circum-

stances in her childhood were very chaotic: Both parents had an alcohol depen-
dency; her father was in jail several times. At a young age, she was often left
alone at home and did not know when, if, and how her parents would come
back. She felt very anxious and lonely and did not know what to do. Both of
her parents had several affairs and were lying to and cheating on each other
very often. She often witnessed their arguments connected with physical
assaults. Her parents were also violent toward Linda; most of the times, she did
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not understand for what she was being punished. Harsh insults and devalua-
tion took place every day. As a young child, she often tried to protect herself by
hiding under her bed or by saying nothing. Later, she fought back, mostly with-
out success. To soothe herself, she dreamed about another family that loved her
and would come to rescue her; in fact, going into fantasy world is something
she still does today. At the age of 10 years she drank alcohol for the first time;
by age 13, she consumed it daily and had begun to smoke cannabis.
Figure 17.3 shows Linda’s mode model that her therapist has worked out in
collaboration with her. As usual in ST, Linda chose individual names for each
mode. Linda shows the BPD-typical mode combination, such that the vulner-
able child mode is named “little abandoned Linda” and is connected with her
anxiety of being abandoned and her feelings of loneliness, sadness, and mis-
trust. Linda’s rage attacks and fights with her boyfriend and associated control-
ling behavior (e.g., calling him several times, checking his emails) are
conceptualized in the angry, impulsive child mode “little wild Linda.” These
modes developed because major childhood needs have been frustrated and cir-
cumstances have been so chaotic. Verbal and physical abuse by her parents
fueled the development of Linda’s strong punitive parent mode, called her

FIGURE 17.3. Linda‘s Mode Model

 Schema Therapy  509

“punitive side.” This mode consists of self-devaluating messages, feelings of

self-hatred, shame, and guilt.
Additionally, Linda has two coping modes. In the “detached protector mode”
called “the wall,” she avoids contact with other people and distracts herself
from painful emotions by smoking cannabis, drinking alcohol, binge eating, or
having something to do. The “detached self-soother mode” (i.e., “the soother”)
helps Linda soothe herself, when she feels lonely and sad, by going into fantasy
world, smoking cannabis, or eating. It can be seen that smoking cannabis and
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eating are present in both modes because they have both a detaching and
soothing function. Linda developed both coping modes at young age because
these strategies helped her soothe herself when nobody took care of her and
protected herself from further emotional pain by hiding. “Grown-up Linda” is
her healthy adult mode and shows in Linda’s commitment in therapy and her
friendship with Steph.
After developing the mode model, Linda is very relieved. She says that the
mode model is like an inner “road map” for her and that it helps her under-
stand her “inner chaos.”

Case Example 2: Chronically Depressed Patient With an Avoidant

Personality Disorder
George is 43 years old, single, and working as a teacher. He comes to treatment
because he feels overworked and exhausted. Apart from his job, he is active in
his church community and organizes the church choir. He reports slowly with
many breaks and without eye contact:
I can’t take it anymore. It is too much. I thought about going to my doctor and
asking him for sick leave, but then my colleagues will have to do all the work. I
am inferior anyway and they will be angry at me, if they have to do my work.
That’s not possible.

During the conversation, it becomes clear that George has strong fears of being
rejected and criticized by others. He often takes over unpleasant tasks and has
problems saying no if someone asks him to do something. Many times, others
have used him because of this. George prepares his lessons for school, often
very detailed, until late at night to run as little risk as possible to get attacked by
his pupils. The pupils laugh at him nevertheless, which reinforces his sense of
inferiority and shame. Outside school and church, he has no personal contacts
and feels very lonely. He has never had a romantic relationship and feels very
ashamed for that.
Asked for his information about his childhood, he reports that both parents
have been strict Catholics. They were both very demanding and emotionally
distant. His mother was suffering from a chronic inflammatory gut disease but
nevertheless was very engaged in the church community. At home, she often
blamed George for not supporting her enough. George’s central emotions
toward her were guilt and anxiety that her disease might get worse. His father
was very rigid and demanded obedience without questioning. If George failed
to fulfill his demands, he punished him hard and criticized him harshly.
 510  Fassbinder and Arntz

George’s mode model is shown in Figure 17.4. George also chooses names
for each mode. In the case conceptualization, the therapist uses the disorder-
specific mode model for avoidant PD as an orientation and detects the respec-
tive modes:

• A lonely/inferior and an abandoned/abused child mode. To simplify George’s case

conceptualization, the therapist decides to bring both modes into one vul-
nerable child mode with George (“little George”).
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• A punitive parent mode, which in George’s case was strongly influenced by the
father. The mother gave more emotionally demanding messages, and thus a
demanding parent mode is also apparent in George. Again, to keep a better
overview, the therapist decides to work with only one parent mode (“the
guilt inducer”).

• An avoidant and detached protector mode as avoiding coping modes (“the

avoider”)—always strongly present in avoidant PD—and compliant surrender
as surrendering coping mode (“the surrenderer”), also a frequent mode in
avoidant PD, although not seen as regularly as the avoiding coping modes.
George also shows some traits of obsessive-compulsive PD and, in line with
this, has a perfectionistic overcontroller mode (“the perfectionist”), which is not
typical for avoidant PD but the major coping mode in obsessive-compulsive PD.

• A healthy adult mode (“grown-up George”).

FIGURE 17.4. George’s Mode Model

 Schema Therapy  511

Cognitive Techniques

On the cognitive level, psychoeducation on schemas, coping styles, modes,

needs, emotions, and the normal development of children takes place espe-
cially in the beginning of treatment. Moreover, all CBT techniques can be used
(see Exhibit 17.1). These techniques are always adapted to the frame of the
mode-model and follow the typical ST goals.
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EXHIBIT 17.1

Cognitive Techniques
Psychoeducation on schema, modes, coping styles, needs, emotions, interpersonal reac-
tions, and normal development of children

• Increasing awareness of modes by working out typical trigger situations and mode-
related cognitions, body reactions, emotions, and behaviors
• Working out development and function of specific modes and schemas in the light of
traumatic experiences and frustration of basic childhood needs
• Testing the validity of schemas and modes using evidence from all periods of life
• Identifying and reappraising of schemas and mode-related distortions (e.g., identify “I
am a loser!” as a cognition from the punitive mode, restructuring from the healthy adult
mode perspective)
• Reviewing pros and cons, especially for coping modes
• Considering long-term consequences, such as from the impulsive child mode or staying
in the coping modes
• Using flashcards for relevant mode and schemas that helps patients remind themselves
of healthy views and behaviors in difficult situations
• Analyzing problematic situations in light of the mode model
• Writing schema or mode diaries to increase mode awareness and mode change
• Analyzing selective awareness processes
• Shifting attention to other perspectives (e.g., to the vulnerable child mode or the
healthy side)
• Looking up and considering relevant information, such as about the emotional needs of
children and their importance for childhood development or about the rights of chil-
dren to receive care and love
• Investigating the assumed causal relation between two concepts (e.g., between work
achievement and being liked by others) with the two-dimensional drawing technique,
such that the x-axis represents the assumed cause, the y-axis the effect, and the diago-
nal the assumed relationship; persons varying in achievement success and in being (dis)
liked are placed in the two-dimensional space, and the relationship is reconsidered
given where these people are placed (see Arntz & van Genderen, 2009)
• Pie chart drawing with all factors given a part to investigate the degree to which one is
responsible or guilty (see Arntz & van Genderen, 2009)
• Reducing dichotomous thinking by using visual analogue scales (see Arntz & van Gen-
deren, 2009)
• Countering one-dimensional evaluation by evaluating on multiple dimensions (see
Arntz & van Genderen, 2009)
 512  Fassbinder and Arntz

Continuation of Case Example 1: Use of Cognitive Techniques

For Linda, it was, first of all, important to understand her symptoms and inter-
personal problems in light of the mode model and to see how they originated,
as an important focus of treatment would be on the origins of the problems. It
was central to recognize that her rage attacks and impulsive acts in the “little
wild Linda” mode were preceded by fears of abandonment, helplessness, and
mistrust in her vulnerable child mode. This mode was quite pronounced
because Linda had often experienced loneliness and abandonment and had
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lacked secure attachment and other major core needs in childhood. Moreover,
her parents’ relationship model was characterized by cheating on and lying to
each other; thus, Linda expected relationships to be like that.
Although Linda understood the origins and developed good awareness to
recognize “little wild Linda,” it was hard for her to deactivate this mode and
focus on long-term consequences. The therapist and Linda worked on these
aims with many interventions, including the following flashcard that Linda
wrote for her angry impulsive child mode:

Hello little wild Linda, you are going wild and out of control
again. Stop right now, and breathe two times. If you call John
right now, you make it even worse. Remember, you want to
trust him. I know that this is hard for you because of your
previous experiences and your mistrust and abandonment
schemas. However, you can trust John. He is different from
your father. He has said that he loves you and has shown it to
you often enough. He will come back to you. If you can’t
stand being alone right now, call Steph.

Continuation of Case Example 2: Use of Cognitive Techniques

A central cognitive technique is reviewing advantages and disadvantages, espe-
cially in the work with coping modes. Table 17.3 shows the advantages-
disadvantages list of George’s compliant surrender mode, which he developed
with his therapist.

Therapeutic Relationship Techniques

Because early maladaptive schemas develop in particular through early inter-

personal traumatization by significant others, especially parents, the work with
the therapeutic relationship is a central focus of ST throughout the whole ther-
apy process. The therapeutic relationship has been conceptualized to serve as
an antidote to these adverse experiences in childhood and is an important
source of corrective interpersonal and emotional experiences, and through this,
 Schema Therapy  513

TABLE 17.3. Pros and Cons of George’s Compliant Surrender Mode

Advantages of “surrender” Disadvantages of “surrender”

• Others are thankful when I take over • I have a lot of work, and because of
unpleasant things from them; I get at that I feel exhausted and depressed.
least some attention. • My needs are not important and do
• I do not have such strong feelings of not get fulfilled, which detracts from
guilt and do not feel so egoistic. quality of life.
• Fewer arguments and less criticism. • No awareness of my limits and
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• More harmony, leading to less anxiety. borders.

• If I take care for others, I have • Other people use me.
something to do, which gives me the • The fear of doing something wrong
sense of being worthwhile and persists, and I go on with a sense of
decreases the sense of inferiority and being inferior and unloved, which
shame. does not allow for corrective
experiences in relationships (creating
a vicious circle).
• Some other people do not like my
submissive behavior.

it aims to change early maladaptive schemas. The two major techniques are
limited reparenting and empathic confrontation, which have been described as the
“two central pillars” of ST by Young (Young et al., 2003).

Limited Reparenting
Limited reparenting means that the therapist behaves toward patients as if the
therapist were a “good” parent figure and determines the central therapeutic
attitude at any time of the therapy process. The therapist, of course, respects the
limits of a professional therapy relationship. It is a limited and “as if” takeover
of the parent role, in which the therapist models appropriate parental responses
and behaviors, helping patients become aware of their needs and emotions and
express them. The therapist validates them and fulfills, to a limited extent, the
needs that were frustrated in childhood. At the same time, the therapist also set
limits and helps patients process the frustration that might result from limita-
tions of the therapist.
On the one hand, limited reparenting is characterized by support, warmth,
empathy, attention, praise, and providing secure attachment. On the other
hand, a therapist practicing limited reparenting also might set appropriate limits
or encourage or push patients toward autonomy and growth. These needs
might also have been frustrated and have to be fulfilled. The therapist adjusts
their relational style to the specific frustrated needs, schemas, and modes of the
individual patient. Thus, they always behave a little bit different with each
patient. It might be that they react differently to the very same behavior in two
different patients (e.g., being late for session with a patient with obsessive-
compulsive PD affords a different reaction than in a patient with antisocial PD).
The two case examples serve to illustrate this individual adjustment to each
patient in more detail. With each individual patient, the therapist adjusts their
relational style to each mode in line with the mode-specific goals of ST, which
we demonstrate in Figure 17.5 for Linda’s case.
 514  Fassbinder and Arntz

Continuation of Case Example 1: Design of the therapeutic relationship

In her childhood, Linda experienced much chaos, unreliability, and violence,
and she received little love, praise, and support. For these reasons, it is particu-
larly important that the therapist offer a reliable, warm-hearted, and caring
relationship. She needs self-soothing skills to apply in times of difficulty and to
reinforce herself for even the slightest progress. At the same time, due to the
chaotic circumstances in her childhood, Linda needs a reliable structure and
clear limits, especially when she is in her angry, impulsive child mode. Fig-
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ure 17.5 illustrates the mode-specific design of the therapeutic relationship.

Continuation of Case Example 2: Design of the therapeutic relationship

In contrast to Linda, George comes from a very structured, authoritarian, and
emotionally cold family environment. His parents placed precise requirements
on him regarding how he should behave, feel, and think. If he did not fulfill
these requirements, expressed his own needs, or verbalized an “unsuitable”
opinion, he was punished. His mother induced feelings of guilt in little George
by being disappointed or sad in him or by accusing him of being selfish. His
father produced massive shame and a sense of inferiority through devaluation.
As an antidote, George’s therapist offers a very warm, open, caring, and sup-
portive relationship. She promotes the expression of needs and emotions and
validates them. She shows interest in George’s opinions and judgments and
helps him deal with situations in which there are different opinions. The thera-
pist encourages George to sense and verbalize his own limits and reduce feel-
ings of guilt when he does so or expresses his own needs. She praises him for
progress, shows him that it is not bad if something does not work out right
away, and promotes his autonomy.

FIGURE 17.5. Mode-Specific Work With the Therapeutic Relationship in the Case
of Linda
 Schema Therapy  515

Empathetic Confrontation
In empathic confrontation, on the one hand, the therapist empathizes with the
intentions and emotions underlying problematic behavior or views of the
patient, explicitly connecting them with the patient’s modes and schemas as
well as with the childhood origins. On the other hand, the therapist confronts
the patient with the consequences of their behavior and the need for change.
The therapist does that in a friendly but very clear manner. It is important that
therapists also address their own emotions that were evoked through the
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patient’s behavior, after checking that their reactions are not connected with
their own dysfunctional schemas. By doing so, the therapist always makes clear
that the patient’s behavior and not the patient themself is meant and checks the
emotional reaction of the patient (careful self-disclosure).

Continuation of Case Example 2: Empathetic confrontation with George’s

avoidant coping mode
George is, in the beginning of treatment, very often distant and silent. He only
answers with a few sentences and tries to avoid eye contact.

THERAPIST: George, I recognize that it is hard for you to talk to me and that
you are very silent. I think this is your avoider-mode. Remem-
ber, this was the mode that came to protect you. When I think
back, what you told me about your father and his harsh criti-
cism, it was very important that you developed this mode to
protect you. There was nothing that you could do right in the
eyes of your father. I think the “avoider” was the only solution
for little George and protected him from feeling even more
ashamed. Does this make sense to you? [George nods, but still
avoids looking at the therapist and seems to be very ashamed.
Thus, the therapist goes on validating George.]

THERAPIST: I have the impression that your vulnerable child mode still feels
that shame and anxiety and hears these punitive voices, even
here in therapy. I can imagine that that is awful.

GEORGE: [nodding more] Yes, it is always like that. I always feel shame
and have so many fears about doing something wrong.

The therapist supports George opening up by looking at him in a

friendly manner and with compassion (as with children, nonverbal
behavior is sometimes even more important than verbal behavior).
She makes a connection between the schema and the coping mode.

THERAPIST: [with warm voice] Yes, that is your shame/inferiority schema

that you feel with all that pain . . . and the ‘avoider’ still comes
to rescue. [Then she starts softly with the confrontation part.] At
 516  Fassbinder and Arntz

the same time, the avoider does not allow little George to get in
contact with other people, and little George continues to feel
lonely and sad and does not get what he really needs. Also, he
can’t learn other things about himself and these feeling of shame
and inferiority stay with him. What do you think about that?
GEORGE: Hmm, I never looked at it this way, but I guess that is true. I
really feel lonely and have looked at myself as inferior for all my
life, but it is true others can’t get in contact with me when the
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avoiding side is always there.

THERAPIST: Yes, and here in therapy, the same happens: The avoider also
puts me at a distance, and I can’t reach little George. I think that
little George would need my support, connection, and someone
he can talk to so that he does not feel so lonely .  .  . but the
avoider blocks me out.
GEORGE: Oh, I really do not want to block you away, but this happens
automatically.
THERAPIST: Yes, I understand. See, good thing is that we can change that
automatic pattern together and that you can practice here with
me in a safe environment.
GEORGE: That sounds good, but what should I do?
THERAPIST: Pretty much, what you did today. Try to tell me what you are
thinking and feeling. I am really interested in that because I get
to know you better. There is nothing that you can do wrong.
Let’s just give it a try.

It can be seen that the therapeutic relationship in ST provides a safe haven

with much validation, caring, and support, while being a source of change,
such as by offering the patient the possibility to try new interpersonal behavior
in the safe environment of the therapeutic relationship.
One major aim of the relational work in ST is that patients internalize the
reactions toward their needs and emotions modeled by the therapist in their
healthy adult mode, and through these new experiences, they are able to fulfill
their needs themselves without support of the therapist. Limited reparenting is
very dynamic and flexible. Besides adjustment to the frustrated needs and
schemas of the patients, the therapist also adjusts their relational style to the
patient’s skills as well as to the phase of treatment: Normally, the therapist is
very active and caring at the start of treatment, and as treatment proceeds they
step back more and more and foster the patient’s autonomy and indepen-
dence—again showing the parallels with real parenthood.

Experiential Techniques

Experiential techniques, including emotional processing of aversive childhood

memories as well as work on current emotional problems, are of high signifi-
 Schema Therapy  517

cance in ST, which is an important difference from traditional CBT. Often,

patients reach an intellectual understanding of their problems quite quickly;
however, strong emotions connected to dysfunctional schemas or modes still
remain (e.g., “I know it from my head, but I can’t feel it in my gut”). Experien-
tial techniques aim at changing how the patient feels, or the emotional core of
the schema, which is often not stored verbally and is more deeply rooted. The
major experiential techniques are chair dialogues, imagery work (especially
imagery rescripting), and historical role play.
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Chair Dialogues
In this technique, different chairs are used to express different sides of a patient,
emotions, or perspectives of other persons (see overview in Kellogg, 2014). In
ST, most often the chairs symbolize the different modes and dialogues between
them that are initiated. The patient changes chairs and expresses in each chair
the perspective of the respective mode as well as connected needs and emo-
tions. If a new mode emerges, the therapist normally asks the patient to switch
to a new chair, which represents the new mode (e.g., “That sounds pretty much
like your punitive side; would you please switch chairs to this chair, which
stands for your ‘guilt inducer,’ and tell me what he is saying?”). The therapist
can also demonstrate the interplay of the modes, such as by helping the patient
to see the effect one mode has on another (e.g., “These were very harsh mes-
sages from your ‘guilt inducer.’ Could you please sit here in the chair for ‘little
George’ and tell me how he feels when he gets these messages?”). The therapist
helps patients express their emotions and needs, and if patients have difficulties
doing so, the therapist might also model expression of the emotions and needs
(e.g., “I see that it is very difficult for you to tell me what ‘little George’ feels. Is
it okay with you if I sit down in ‘little George’s’ chair and tell you what I feel as
him?”) The therapist addresses the modes in line with the mode-specific goals
(see Figure 17.2) and adjusts content, tone of voice, and other nonverbal
behaviors to the respective mode.

Continuation of Case Example 1: A chair dialogue with “little wild Linda”

Linda becomes very upset in “little wild Linda” mode in the session. She is very
angry at her partner and thinks, again, that he is having an affair. She speaks
very loudly and quickly and urges the therapist to call John: “You need to tell
him that he has to tell me the truth and that he must come here immediately.”
The therapist says clear and loud, “Stop,” to limit Linda. She asks Linda to hand
over her cellphone to make clear that they will not call John in the “wild Linda”
mode. Finally, she can bring Linda to do a chair dialogue with her. Here, Linda
first sits on the chair for “wild Linda” and expresses her anger and her inten-
tions: “I am so angry. I want to go to John, crash the door, and see if another
woman is there with him. I have a right to know that.” The therapist stops
“wild Linda” and asks Linda to sit down in the chair for “grown-up Linda.”
Linda sits in the chair with some resistance. The therapist places herself next to
Linda and encourages her to inhale and exhale twice to regulate her ten-
sion. Linda does so a bit reluctantly. The therapist praises Linda for every step
 518  Fassbinder and Arntz

in the right direction. She guides in small steps and remains active throughout
the process. In the next step, the therapist helps Linda look at the situation
from the perspective of the healthy adult mode. While doing so, emotions of
“little abandoned Linda” come to light; thus, the therapist takes a new chair for
the vulnerable child mode. She helps Linda express her sense of anxiety,
despair, and powerlessness and validates these experiences in light of Linda’s
childhood experiences. She soothes “little abandoned Linda” and expresses her
care and support. Afterward, the ideas of “wild Linda” are reflected upon again
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from the healthy adult mode. “Grown-up Linda” recognizes that these propos-
als will lead to even more problems in the long run and that she might actually
lose John if she follows “wild Linda.” Together with the therapist, “grown-up-
Linda” thinks about how she might bridge the time until John will call her and
how she can best take care for the needs of “little abandoned Linda.” She rec-
ognizes that being alone is currently too difficult and therefore decides to con-
tact Steph after the session.

Imagery Work
Imagery exercises can be used for diagnostic reasons (diagnostic imagery) or to
foster change of early maladaptive schemas and the meaning of adverse child-
hood events (especially imagery rescripting). Diagnostic imagery exercises are usu-
ally performed at the start of treatment and serve to clarify the origin of
dysfunctional emotional and behavioral patterns. Most often, diagnostic imag-
ery exercises start from a current situation, which is emotionally disturbing for
the patient. The patient is asked to imagine that situation with eyes closed, as if
it is currently happening, and to describe the scene in present tense. While
patients describe what they or other persons in the image are doing, thinking,
and feeling, emotions become more vivid and intense. The therapist focuses on
the emotions and asks the patient where in the body they can feel the emotion.
When the emotion is clear enough, the therapist asks the patient to let go of the
current situation but to stay with the feeling (i.e., affect bridge) and “float back”
to childhood and see whether an image that is somehow associated with their
feelings has been activated. The childhood image is, then, considered in the
same way, and the patient is prompted to express their feelings and needs.

Continuation of Case Example 2: Diagnostic imagery with George

George reports that he often oversteps his boundaries at work. He has problems
with saying no if someone asks him for something at work. His therapist sug-
gests doing an imagery exercise to better understand that pattern. George
agrees, and they imagine a situation that George has experienced—the last day
with a female colleague, who was asking him to do some copy work for her
lesson. This copy work is normally done by the secretary, but George perceived
that he could not say no.

THERAPIST: What do you think?

GEORGE: [with eyes closed] I have to do it. She has so much to do, and I
am on break now. She needs my help.
 Schema Therapy  519

THERAPIST: What do you feel?

GEORGE: I feel pressure to help her. It is egoistic that I want to have my

break. I am an awful and lazy person.

THERAPIST: How does that feel emotionally?

GEORGE: Pretty much under pressure. I feel ashamed and guilty. I need to
help her.
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THERAPIST: Can you feel that in your body?

GEORGE: Yes, there is pressure on my shoulders and a peak behind my

sternum.

THERAPIST: Okay, George, could you please wipe out that current image as if
you see a black television screen, but stay with the emotions and
the feeling in your body, and perhaps also enlarge them a bit.
And now travel back to your childhood and see if an image pops
up that is somehow connected. Do not force yourself, just take
your time and see if something comes up.

GEORGE: Hmm, that is strange. I have a picture of me with my mother.

THERAPIST: Very good. How old are you in that picture?

GEORGE: I must be 8 or 9.

THERAPIST: What happens in the image? Please tell me what you see when
you look out of little George’s eyes.

GEORGE: I am with my mum in the living room. She is lying on the sofa
and she looks as if she has pains.

THERAPIST: What do you feel?

GEORGE: I am anxious that she might get worse again. But I am also look-
ing forward since James, a classmate, has said he would come
around to play soccer with me. I am so excited because nobody
has asked me before. I think nobody is interested in me in school
. . . but I feel bad because my mother is so ill and I have to stay
with her.

James rings the doorbell, but little George is too afraid to open. He asks
his mother cautiously if he can go out to play. His mother reacts in a
disappointed manner and accuses George by saying, “Oh, George, I
have such strong pains; how can you even think about going to play
soccer?” George feels ashamed, guilty, and selfish, and he is also sad
that he cannot go out and play with James.
 520  Fassbinder and Arntz

In the debrief of that imagery exercise, George and the therapist

examine the parallels between his current situation and the childhood
images and focus on their connection within the mode model. The
desire for play and connection with other children and relaxation in
his current situation are normalized, as are his sadness when these
needs get frustrated (in the vulnerable child mode). His mother’s
demanding messages and behaviors are connected with George’s pro-
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found guilt and shame, “guilt-inducing mode” being activated by the

demand of his colleague in the current situation. Thus, the compliant
surrender mode emerged immediately to reduce these feelings of guilt
and followed the demands of the parent mode.

Diagnostic imagery exercises can also be performed without an affect bridge,

such as by imagining memories with both parents or other significant people.
Diagnostic imagery serves to gain an emotional understanding of schemas and
modes and does not involve emotional processing by changing the memory,
unlike imagery rescripting (described next). Sometimes, especially in severely
traumatized patients, this leaves the patients with strong, overwhelming emo-
tions, which they are not able to regulate themselves at the start of treatment.
Thus, in some groups of patients, such as patients with BPD, diagnostic imagery
alone (without rescripting) is not recommend or should be performed with
caution.
In imagery rescripting (Arntz & Weertman, 1999), an emotionally disturbing
situation, usually an unpleasant memory, is imagined in a way in which the
course of the event is changed to a positive outcome. Imagery rescripting is a
flexible, creative technique, and it is hard to predict the exact course. However,
for imagery rescripting in ST, there is a structured guideline leading the thera-
pist and patient step by step through the emotional process. Imagery rescripting
incorporates two phases: (a) Phase 1, imagery of the unpleasant situation, and
(b) Phase 2, the rescripting part, changing of the situation to have a better
ending.
In Phase 1, patients select a focus for the exercise, most often an aversive
childhood memory with a strong association with the patient’s maladaptive
schema. Such memories can be found through affect bridges, as explained pre-
viously, or can be directly taken from patient report. The therapist instructs the
patient to describe the situation from the perspective of the child using “I” and
present tense and then asks for the sensory experiences, emotions, cognitions,
and needs of the child. When the traumatic memory is sufficiently activated,
and the patient clearly feels the related emotions and needs, Phase 2, the
rescripting part, is started.
In Phase 2, a helping figure is introduced in the image and modifies the situ-
ation into a more pleasant ending for the child, in which the needs of the child
are better met. The helping figure can be the patient themself in their healthy
 Schema Therapy  521

adult mode, if they are already strong enough. For patients with a PD, this is
often not the case in the beginning of therapy. Thus, the therapist is initially the
helping figure. The helping figure first creates safety for the child, then stops
the perpetrator and confronts them. Then the helping figure takes care of the
other needs of the child, comforts the child, and soothes the child. The child is
encouraged to express all emotional needs. Besides fulfillment of these needs,
the child receives explanation and corrective information on needs and emo-
tions suited to children, which often relieves aversive emotions such as anxiety,
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loneliness, helplessness, shame, or guilt, while a sense of safety, secure attach-

ment, warmth, love, joy, and other pleasant emotions is promoted. The aim of
this exercise is not to suppress aversive emotions but to bring them in a func-
tional emotional process, to promote awareness, and fulfill the connected need.
For example, in the case of sadness, it is important that this feeling can be fully
experienced (i.e., as a “mourning process”) and that the patient is helped to
regulate it. To meet a central need associated with sadness, the therapist ensures
that the patient is soothed and comforted. To deepen the feelings of safety and
connection and to foster other pleasant emotions like happiness and fun, the
therapist can decide to proceed with a pleasant situation (e.g., going to the cin-
ema, playing together with a dog) if this is suitable for the situation and matches
the patient’s needs.
Unlike in typical CBT, the aim of imagery rescripting is not habituation and
extinction as a primary goal. Instead, the primary goal of ST is changing mal-
adaptive schemas and the original meaning of the trauma, including the mean-
ing of emotions and needs, through emotional processing. Thus, from an ST
perspective, it is not necessary that the patient relive the entire trauma in detail
in imagery rescripting.

Continuation of Case Example 1: Imagery rescripting with Linda

Through an imagery rescripting exercise, Linda and her therapist work on Lin-
da’s mistrust schema. Linda imagines herself as a 10-year-old girl. She received
a bad grade in math; she is afraid to get punished by her father; and she, thus,
decides to talk first to her mother. Her mother promises not to tell her father.
When her father comes home, he is drunk and starts a fight with her mother.
Her mother tells him about Linda’s bad grade to distract his attention away
from her to Linda. The father starts shouting at Linda and wants to hit her. The
therapist enters the image because Linda is frightened, and she does not want
her to relive the full trauma. She steps between her father and Linda to protect
Linda and says, “Stop immediately. You are not allowed to hit Linda and say
those awful things. It’s a shame how you treat Linda. That is not what children
need.” Linda’s father is very aggressive and wants to hit the therapist too. In
response, the therapist creates a wall of bulletproof glass between Linda and
her and her father and calls the police. Linda sees that four policemen arrest the
father, but she is still upset by her mother’s behavior. The therapist confronts
her mother by saying, “Your behavior was unfair. If you give a promise, you
must keep it, and you need to protect Linda. Children need someone to rely
 522  Fassbinder and Arntz

on.” Her mother apologizes to Linda and says that she was so frightened, indi-
cating that she did not think that her father would not attack Linda. The thera-
pist explains that Linda needs a safe and warm place to live and reliable people
around her and that her mother at the moment is not able to provide these
needs for Linda. Her mother says that she wants to work on these problems and
to take better care. Because Linda wants to stay with her mother, the therapist
organizes that the two of them move to a mother-children residential establish-
ment. Here, the mother receives support for her emotional problems and learns
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adaptive parenting skills, and Linda is cared for as well. The therapist promises
that she will visit Linda twice a week to check how she is doing.

Continuation of Case Example 2: Imagery rescripting with George

In the diagnostic imagery description presented previously, George had strong
emotions of shame, guilt, and sadness; thus, his therapist suggests that they
rescript his memory in a later session. The therapist recreates the picture with
little George and his mother lying on the sofa and inducing guilty feelings in
little George. After a short search for an adequate helping figure, the former
family doctor, Dr. Miller, is introduced, as George trusted Dr. Miller very much,
and Dr. Miller’s opinion was even accepted by George’s mother. Dr. Miller
rebukes the mother and states, “Mrs. Smith, I see that you have pain. However,
it is not okay that George has to take over the responsibility for that. He is just
a child. He has a right to play and have fun. That does not make him a bad boy.
That is just normal and healthy. I will take care of your pain now, and George
can go out and play with James.” George is relieved and happy. He opens the
door and runs out with James and the others to play soccer.

Historical Role Play

Historical role play (Arntz & Weertman, 1999) originates from drama therapy.
The therapist and patient examine an adverse childhood memory together as a
role play. The patient switches roles by playing their own role (most often as a
child) in the first round and the role of the other person (most often a parent)
in the second. This structure helps the patient experience both their own feel-
ings and needs as a child and the perspective of the other person. The insight
from the perspective of the other person can especially help the patient under-
stand the motivation and causes for the perpetrator’s behavior and, thereby,
the meaning of the situation.

Continuation of Case Example 2: Historical role play

The therapist and George identify a situation in which George has been criticized
by his father after he had dropped the candles on the floor at a church service for
his first holy communion. In the first round (George playing himself as a child and
the therapist playing the father), George views himself as inferior, unloved, and a
disappointment for his father, as his father posed very high demands on him and
was criticizing him harshly. In the second round, George plays the father, while the
therapist takes over the role of little George. By adopting the perspective of the
 Schema Therapy  523

father, George can see that the father posed high demands on himself also and
that he does so because he has learned that from his father, who also put high
demands on him. He sees that his father was very much under pressure because
church was so important for him, and he wanted to protect George from behav-
ing in a way that would be embarrassing. Through this exercise, George can
understand that it is not him being inferior or unlovable but that the experiences
his father has experienced in the past have contributed to his father’s actions.
For all experiential interventions, therapists should keep in mind that
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intense unpleasant emotions can be activated in patients. Especially at the

beginning of treatment, patients have intense fears of emotions, as they often
believe that they cannot control emotions and will be overwhelmed by them,
and, as a result, they demonstrate a great deal of experiential avoidance. There-
fore, the aim for this exercise is that patients experience emotions in a safe way
without being overwhelmed. The therapist adapts the intensity of emotions to
the individual patient and the phase of treatment. They set up emotional work
in small steps and balance emotional activation by means of the therapeutic
relationship. Despite the strong activation of emotions, ST shows very low
dropout rates and a high degree of acceptance in patients (de Klerk et al., 2017;
Jacob & Arntz, 2013).

Behavioral Techniques

Behavioral techniques aim at breaking through behavioral patterns displayed

as a function of unhelpful coping modes and spending more time in the healthy
adult mode. All techniques from behavior therapy to learn new behavior can
be applied, such as role play, homework, behavioral experiments, skill training,
behavioral activation, problem solving, and relaxation. All techniques are
adjusted to the mode model and follow mode-specific aims (see Figure 17.2).
Therapists are encouraged to consider that, at the beginning of treatment,
behavior change is quite challenging for patients due to maladaptive schemas
and the resultant coping mechanisms that have become habitual and rigid over
time. Thus, these techniques assume greater focus in the later stages of treat-
ment and are prepared by the other ST techniques.

Continuation of Case 1: Example of Behavior-Oriented Technique

After 1 year of treatment, Linda and her therapist work on Linda’s educational
aspirations. For homework, the therapist encourages Linda to inform herself
about possible educations in the job center and to do some career-related inter-
net research. In the next session, Linda has completed her homework in a
thorough manner and reports that she wants to complete an education as a
carpenter. She has already found three joineries where she would like to apply
for an internship, but she is afraid to call there.

THERAPIST: First of all, I must say I am very proud on you. You did all that
research and decided to do an internship first, which will help
 524  Fassbinder and Arntz

you to see if you really like that job. It’s terrific that you looked
into places where you can do that internship. [Linda smiles.]
Very good job, Linda.

LINDA: Yes, but I did not call there because I did not know what to say.

THERAPIST: That is quite normal. This is the first time you have applied for
an internship, and nobody has ever showed you how one does
something like that. Typically, parents or teachers show you how
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to do those things.

LINDA: Really. I thought I was stupid and a scaredy cat because I do not
know what to say.

THERAPIST: That is your punitive side speaking. You are definitely not stupid.
This is quite normal, feeling afraid and not knowing what to say.
You know what is funny: My daughter was in the same situation
last month. She wanted to do an internship in a kindergarten
and was also afraid to call.

LINDA: Really, but what did she do then?

THERAPIST: We prepared the call, then did a role play together, and then she
called. [Therapist smiles.] And we can do it here the same way,
if you want.

LINDA: [smiling] Okay, if you think that works also for me.

THERAPIST: I am sure. Okay, let’s start. What do you want to say when you
call? And remember, Linda, like always, no answer is wrong. We
will just give it a try.

LINDA: Okay. I guess, I will say hello and my name and that I want to do
an internship.

THERAPIST: Great. Please use direct speech.

LINDA: Hello. My name is Linda Myers. I am very interested to do an

internship in your joinery and would like to ask you if this is
possible.

THERAPIST: Okay. Very, very good. This is grown-up Linda! We can directly
jump into the role play. I am the boss of the joinery now, okay?
[Linda nods.]

THERAPIST: [with deep voice, imitating to speak in a phone] Hello, Miss

Myers. Thank you for your interest. Indeed, we are looking for
an intern at the moment. But in our company interns stay for at
least 3 months. Is this possible for you?

LINDA: Yes, I would like to stay 3 months or even longer.

THERAPIST: Okay, that is good. Do you have any experience as carpenter?

 Schema Therapy  525

LINDA: [getting unsecure, shaking a bit] No, aehm . . . not really. . . . Oh
gosh, I am a complete failure! No one will ever give me a job.

THERAPIST: [uses normal therapist voice, leans over to Linda] Okay, Linda,
that is not a problem. Most people who want to do an internship
do not have experience. Breathe two times and let go of the
punitive voices. [Linda breathes and relaxes herself.] Very good,
Linda. Please sit upright, so that your body helps you to get back
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in contact with grown-up Linda again. . . . Very good. Okay, I will
ask that question again, and you go back to your healthy side and
answer. You can just say “No, I don’t have experience, but I am
very interested” or you can express why you want to do the
internship. Okay? [Linda nods.] Okay, what do you want to say?

LINDA: I can say that I would like to do training to become a carpenter,

and maybe that I like to work with woods and with my hands.

THERAPIST: Great. That sounds very good. Can we restart the role play so
that you can say these things? [Linda nods.] Good, so I am the
boss again. [Therapist speaks again with deep voice, imitating
speaking on a phone.] Do you have any experience as carpenter?

LINDA: No, I have no experience, but I would like to do the training to

become a carpenter, and that is why I want to do the internship
first to gain experience. Yes, and I like to work with woods and my
hands. And I have good manual skills and spatial imagination.

THERAPIST: [as carpenter] That sounds good. Why don’t you write me a
short application, and then we’ll meet and get to know each
other to determine whether this will be a good match.

LINDA: Yes, that would be great. I will send you my application in the
next few days. Should I, then, call again that we can make an
appointment?

THERAPIST: I will give a call then.

LINDA: Okay, that is great. Do you need anything else from me?

THERAPIST: Please include your résumé, and then I will give you a call.

LINDA: Yes, I will do that. Thank you.

THERAPIST: Thank you. Hope to see you soon.

LINDA: Yes, me too.

THERAPIST: Goodbye.

LINDA: Okay, goodbye.

THERAPIST: [stops role play, in therapist voice] You did a great job. How was
it for you?
 526  Fassbinder and Arntz

LINDA: Not as hard as I expected. I just need to ignore the punitive

mode, then it seems to play out . . .

THERAPIST: Yes, you did a very good job. And it is true the punitive side
doesn’t help you; it blocks you. It worked out fine to let it go and
to shift into grown-up Linda, didn’t it?

LINDA: Yes, that is true. . . . I hope he will be as nice as you.

THERAPIST: [smiling] Of course, we do not have a guarantee that the person

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you are calling will react nicely. However, most of the time, peo-
ple are at least cordial on those occasions, and the most impor-
tant thing is that you call and give it a try. Only who dares, wins,
and there are three chances because you found three joineries.

LINDA: Yes, that is true. Nothing to lose.

THERAPIST: Great, so when will you make the calls?

LINDA: Directly after the session.

THERAPIST: Great. I cross my fingers for you.

Directly after the session Linda calls a joinery and receives a good answer.
While working out her CV, the punitive voice comes again, and thus, in the
next session Linda and the therapist do some chair work, where grown-up
Linda finally throws the chair of the punitive side out of the therapy room. As
homework the therapist prompts Linda to send her CV and make an appoint-
ment for a job interview.

Continuation of Case 2: Example of Behavior-Oriented Technique

After 15 sessions, George reports that he is interested in pursuing a romantic
relationship and that he does not want his parent and avoiding modes to keep
him away from that anymore. A new female teacher has started at school, and
George thinks that she is very attractive and nice. After all these years in his
coping mode, he feels insecure and does not know how he should show that he
is interested. The therapist uses problem solving to help George identify steps
for initiating a romantic relationship and acquire relevant interpersonal skills.
The therapist recognized that, in George’s case, it is also important for him to
learn to be aware of his nonverbal behavior (e.g., body language and friendly
mimics). George and his therapist do work in a café so that George can learn to
maintain eye contact with people, to smile at them, and to engage in small talk.
Finally, George’s therapist initiates a role play so that George can practice asking
the new teacher out on a date.

POPULATIONS TO WHICH ST IS APPLICABLE

ST is particularly suitable for patients with long-standing maladaptive emo-

tional, interpersonal patterns and complex chronic problems. It was primarily
 Schema Therapy  527

developed not to treat a specific disorder but rather as a universal approach to

treat a variety of problem constellations that are related to characterological
factors. Thus, ST is a transdiagnostic approach. However, through the evolution
of ST, prototypical models for case conceptualization and treatment of most PDs
have been developed and elaborated (Arntz & Jacob, 2012; Bamelis et al., 2011;
Lobbestael et al., 2005, 2008; Young et al., 2003). Thus, ST comprises both a
transdiagnostic and a disorder-specific approach for most PDs. Randomized
controlled trials (RCTs) demonstrate good treatment effects for ST in PD, espe-
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cially in BPD and Cluster C PDs (Bamelis et al., 2014; Jacob & Arntz, 2013;
Sempertegui et al., 2013; see also the section on outcome data below). Thus, ST
can be seen as a treatment of first choice for PDs. There are also encouraging
data for various syndromal disorders, such as chronic depression, eating disor-
ders, complex PTSD, and complex obsessive-compulsive disorder (Malogiannis
et al., 2014; Renner et al., 2016; Simpson et al., 2010; Thiel et al., 2016).
ST should not be used in patients with an acute, circumscribed, and/or sim-
ple problem that is not a part of a persistent pattern. Such disorders should be
treated with a less complex treatment method. As with all psychotherapies,
limited efficacy is to be expected in states that prevent emotional learning, such
as severe medical or neurological diseases, pronounced substance abuse, or low
body mass index in anorexia nervosa. Treatment-disabling psychosocial cir-
cumstances (e.g., dependency of a perpetrator) must also be considered. These
states, however, are not to be regarded as absolute contraindications. The
degree to which psychosis and (untreated) bipolar disorder are contraindicated
is not known yet.

OUTCOME DATA

Most studies into efficacy and effectiveness of ST were done for the treatment
of BPD. Two RCTs (Farrell et al., 2009; Giesen-Bloo et al., 2006), one case series
(Nordahl & Nysaeter, 2005), five open pilot studies, and one implementation
study (Dickhaut & Arntz, 2013; Fassbinder, Schuetze, et al., 2016; Nadort et al.,
2009; Reiss et al., 2014) demonstrated large improvements in reduction of all
nine BPD symptoms, general psychiatric symptoms, and quality of life as well
as low treatment dropout. In the first RCT, a Dutch multicenter trial (N = 86),
ST was compared with transference-focused therapy (TFP). Both treatments
consisted of two individual sessions per week over the course of 3 years. Both
groups improved significantly regarding all Diagnostic and Statistical Manual of
Mental Disorders (Fourth Edition [DSM-IV]; American Psychiatric Association,
1994) BPD-criteria, borderline-typical and general psychopathological symp-
toms, and quality of life. ST was superior to TFP in all measures. Moreover ST
led to fewer and later dropouts (over 3 years, 27% in ST vs. 50% in TFP),
higher remission rates (46% in ST vs. 24% in TFP), and higher rates of reliable
change (66% in ST vs. 43% in TFP; Giesen-Bloo et al., 2006). In addition, ST
was more cost-effective (van Asselt et al., 2008). A pre-post comparison
 528  Fassbinder and Arntz

demonstrated successful implementation of individual ST for patients with BPD

in general clinical practice and showed comparably good effects (pre-post effect
size of reduction of borderline typical symptoms = 1.55, recovery rate after 1.5
years = 42%) with a reduced frequency and duration of therapy (first year, two
sessions per week; in the second year, frequency of sessions was gradually
decreased; Nadort et al., 2009).
Aiming at a more efficient use of resources, a group format (group schema
therapy [GST]) was developed by Farrell and Shaw (2012) and tested in an
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RCT in the United States. In this study, 32 women with BPD either received
treatment as usual (TAU) alone or underwent a GST treatment involving 30 ST
group sessions added to TAU. The GST group showed no dropout (0% vs .25%
in the TAU alone), high remission rates of BPD (94% vs. 15% in TAU only),
and significant reductions in BPD-typical and general psychiatric symptoms as
well as improvements in psychosocial functioning with large effect sizes after
only 8 months (Farrell et al., 2009). Two outpatient pilot studies on GST in the
Netherlands (Dickhaut & Arntz, 2013) and in Germany (Fassbinder, Schuetze,
et al., 2016) using GST combined with individual ST also found large improve-
ments in BPD symptoms (pre-post effect sizes of 2.7 in the Dutch study and 1.8
in the German study), general psychopathology, schema and mode measures,
quality of life, and happiness. An inpatient GST treatment model was developed
and tested in three pilot studies, as well (Reiss et al., 2014). These studies suggest
that specific group factors may catalyze effects of ST, as effects were large and
attained in a comparably short time (8–16 months). Thus, group ST may be
particularly effective and lead to savings in treatment costs.
To systematically investigate the clinical effectiveness and cost-effectiveness
of GST for BPD and to test different formats of GST (GST only vs. a combination
of GST with individual ST), a large international multicenter RCT on GST for
BPD was commenced and is underway now (Wetzelaer et al., 2014). A meta-
analysis from 2013 (including all published outpatient studies at the time,
which are all above mentioned except Fassbinder, Schuetze, et al., 2016, and
Reiss et al., 2014) revealed an overall effect size of 2.38 of pre-post changes and
an overall dropout rate of 10% for ST in BPD patients in the first year (Jacob &
Arntz, 2013). This is a very low dropout rate compared with the average drop-
out rate of 25% for BPD patients for interventions of at least 12 months’ dura-
tion (Barnicot et al., 2011; Reiss et al., 2014).
A Dutch multicenter RCT examined the clinical effectiveness of ST also for
patients with other PDs than BPD (Cluster C, paranoid, and narcissistic) with
a majority of Cluster C PD patients. Patients (N= 323) were randomly assigned
to ST, clarification-oriented psychotherapy (COP; which is a contemporary
form of client-centered therapy adjusted for PD patients) or TAU. Both ST and
COP were delivered weekly according to a standardized protocol. ST patients
received 40 sessions in the first year and 10 booster sessions in the second
year, whereas COP was open-ended. TAU did not follow a standardized pro-
tocol; patients received the optimal treatment that was available at the treat-
ment center. Therapists in this condition were expected to follow the clinical
 Schema Therapy  529

guidelines for the treatment of PD in the Netherlands. ST was superior to both

conditions in recovery from PD (ST, 81% vs. COP, 60% vs. TAU, 52%) and
depression. Also ST patients showed less dropout (ST, 15% vs. COP, 21% vs.
TAU, 41%) and higher general and social functioning at follow-up (Bamelis
et al., 2014). In addition, ST was more cost-effective than the other treat-
ments (Bamelis et al., 2015). A qualitative study on patients’ and therapists’
perspectives on ST revealed that both value highly the therapeutic relation-
ship, the transparent and clear theoretical model, and the specific ST tech-
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niques, imagery in particular. However, unhelpful aspects of the ST protocol

were also found, as several patients and some therapists perceived length of
treatment with 50 sessions as too short, some patients lacked clear advance
information about the possibility that strong emotions might occur while
working with ST, and some patients wished for clear practical targets in the
final phase of treatment. These unhelpful aspects must be taken into account
in the further development of ST (de Klerk et al., 2017). Lastly, a RCT com-
pared ST to usual psychotherapy (both part of a treatment package) in a
high-security hospital sample of forensic patients with PDs (half of them
meeting criteria for psychopathy) and found modest positive effects of ST on
most outcomes and treatment retention (Bernstein, 2016) Three reviews
summarize the data on ST for BPD, PD, and ST in general (Jacob & Arntz,
2013; Masley et al., 2012; Sempertegui et al., 2013).
In the case of depression, an RCT with 100 depressed patients comparing
CBT and ST found both treatments to be of comparable efficacy on all key out-
comes. In a Greek single-baseline case series, 12 female patients with chronic
depression received 60 sessions of individual ST. The mean score of the Hamil-
ton Rating Scale for Depression (HRSD) dropped from 21 at baseline to 10 at
the end of treatment, 42% of the patients fully remitted (remission was defined
as a score of lower on the HRSD), and another 17% responded satisfactorily
(response was defined as a 50% drop in the HRSD). Gains of treatment were
maintained over a follow-up period of 6 months (Malogiannis et al., 2014). In
a Dutch multiple-baseline case series study, 25 patients with chronic depression
first received a 6- to 24-week baseline phase as a no-treatment control condi-
tion, then a 12-week exploration phase functioning as an attention control
condition, and then finally received up to 65 sessions of individual ST. ST had a
significant, large effect on depressive symptoms when compared with the base-
line control (effect size of 1.3). Forty percent of the patients showed good
response to treatment (defined as a 50% drop in the Beck Depression Inven-
tory), 35% reached remission (defined as a score of lower than 6 on the Quick
Inventory of Depressive Symptomatology), and 6% recovered (recovery was
defined as the absence of a DSM-IV depression diagnosis assessed with the
Structured Clinical Interview for DSM-IV Axis I Disorders at posttreatment;
Renner et al., 2016). These three studies support the use of ST as an effective
treatment for (chronic) depression.
Pilot studies also report promising results for other types of mental health
disorders. For example, an Australian study investigated a group program that
 530  Fassbinder and Arntz

included ST for veterans with PTSD and found that posttraumatic stress symp-
toms, anxiety, depression, and the strength of maladaptive schemas decreased
significantly after treatment (Cockram et al., 2010). In a case series of eight
patients with eating disorders, a group ST program led to reductions in eating
disorder severity, global schema severity, shame, and anxiety levels (Simpson et
al., 2010). For patients with obsessive-compulsive disorder who did not respond
to CBT, a 12-month inpatient treatment augmenting exposure techniques with
ST was developed and piloted with 10 patients. Results showed significant
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reductions of obsessive-compulsive symptoms and depression, with large

pre-post effect sizes ranging from 1.48 to 2.25 (Thiel et al., 2016).

MECHANISM OF CHANGE DATA

Research on mechanisms of change is in its infancy in ST. The importance of

limited reparenting is underpinned by an examination of the therapeutic alli-
ance in the first RCT on BPD. Compared with TFP, scores of the therapeutic
alliance both of patients and therapists were higher in ST. Low ratings at early
treatment predicted dropout, whereas positive ratings of patients predicted
clinical improvement (Spinhoven et al., 2007). Thus, the therapeutic alliance in
ST may serve to facilitate change processes underlying clinical improvement in
patients with BPD. Other indications of mechanisms of change come from the
non-BPD trial (Bamelis et al., 2014): Therapists in this trial were trained differ-
ently, the first cohort of therapists being trained by mainly lecture and watch-
ing video tapes and the second cohort of therapists being trained mainly by
practicing in role plays. Therapists of the second cohort stated afterward that
they felt better equipped for the treatment (de Klerk et al., 2017). These thera-
pists had significantly less dropout and better treatment effects than the first
cohort of therapists. Because independent raters, blind for condition and
cohort, detected a higher use of ST techniques in recordings of sessions of the
second cohort of therapists than in the first cohort, the better treatment effects
of the second cohort were most likely achieved by their more intensive use of
ST techniques. Moreover, a mediation analysis found that a reduction of the
vulnerable child mode especially and an increase in the healthy adult mode
preceded reductions in PD severity and improvement in general and social/
societal functioning, whereas there was no reversed time effect on these two
modes. This indicates that changes in these two modes are essential for treat-
ment success and that therapists should always focus on these modes (Yakin et
al., 2020).
With regard to imagery rescripting, there are several studies demonstrating
its effectiveness as a stand-alone technique in a broad range of psychiatric dis-
orders, including posttraumatic stress disorder (Arntz et al., 2007; Grunert et
al., 2007; Raabe et al., 2015), social phobia (Brewin et al., 2009; Frets et al.,
2014; Nilsson et al., 2012; Wild & Clark, 2011; Wild et al., 2008), and depres-
sion (Brewin et al., 2009; Wheatley et al., 2007; review in Arntz, 2012). A
 Schema Therapy  531

recent meta-analysis showed large effect sizes in reducing psychological com-

plaints due to aversive memories in diverse psychiatric disorders in a small
number of sessions (Morina et al., 2017). This meta-analysis supports the use
of imagery rescripting as a transdiagnostic tool in the treatment of aversive
memories. Therapeutic techniques using imagery instead of verbalization prob-
ably have greater impact on emotions (Holmes et al., 2009). Imagery rescript-
ing can, therefore, be considered as an empirically supported technique that
contributes to the effectiveness of ST. This is supported by qualitative studies
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into views of patients and therapists that received ST in two different RCTs, as
both stakeholders reported finding experiential techniques, especially imagery
rescripting, to be powerful and leading to important changes (de Klerk et al.,
2017; Tan et al., 2017). Other techniques used in ST, such as chair dialogues or
historical role play, call for further investigation, although one study compared
the (short-term) effects of experiential techniques focusing on the past to the
more traditional present-focused CBT techniques and detected no significant
differences in the treatment of nonborderline PDs (Weertman & Arntz, 2007).
An RCT demonstrating strong effects of art therapy provided in an ST frame-
work is important to mention, as the treatment heavily relied on experiential
methods and led to strong improvements compared with a wait-list control
group (Haeyen et al., 2018).
Lastly, it should be noted that because of its integrative nature, ST incorpo-
rates many CBT techniques whose mechanisms of change are discussed else-
where. Component analysis in which the respective techniques and elements
of ST are tested could shed further light on the mechanism of change (e.g., ST
with experiential techniques vs. ST without experiential techniques; ST with
only chair dialogues vs. ST with only imagery rescripting vs. normal ST includ-
ing all techniques). Another helpful approach would be to test the effects of a
single technique in experimental designs, such as testing the (short-term) effec-
tiveness of the empty chair technique to fight the punitive parent mode by
comparing this technique to exploring the mode (attention control) or to using
a traditional cognitive technique.

DISSEMINATION

In the last decade, ST has been disseminated throughout the world after publi-
cation of the first RCT on BPD (Giesen-Bloo et al., 2006). The International
Society for Schema Therapy (ISST; https://www.schematherapysociety.org) is
growing quickly and has members all over the world. Moreover, ST has been
accepted by most CBT organizations as an advanced development for chronic
complex problems, which facilitates dissemination. Dissemination has been
supported by the availability of theory and protocol books (e.g., Arntz & van
Genderen, 2009; Arntz & Jacob, 2012; Young et al., 2003), many of which have
been translated into various languages. DVDs with examples of techniques
have been produced that help therapist understand the specific techniques
 532  Fassbinder and Arntz

(e.g., Jacob & Seebauer, 2013; van der Wijngaart & Bernstein, 2010; van der
Wijngaart & Sijbers, 2016).
ST was originally developed for an individual setting; however, as develop-
ment continues, it has been adapted successfully to the group setting (Farrell &
Shaw, 2012; Farrell et al., 2014), with very promising results in the treatment
of BPD (Dickhaut & Arntz, 2013; Farrell et al., 2009; Fassbinder, Schuetze, et
al., 2016; Reiss et al., 2014). ST is used also in couples therapy and self-therapy
for therapists. Originally developed as outpatient treatment programs, ST is
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now offered as day treatment or inpatient treatment, for various patient groups,
including forensic patients. Moreover, online treatment programs that combine
face-to-face ST with an online tool have been developed (Fassbinder et al.,
2015). A detailed overview on the wide range of patient populations and set-
tings in which ST is applied can be gained through the handbook by van
Vreeswijk et al. (2012).

APPLICATION TO DIVERSE POPULATIONS

There is a dearth of research in the application of ST to different races/ethnici-

ties, sexual orientations, ages, and other diverse populations. We shortly sum-
marize the information we have thus far. Heilemann et al. (2011) tested an
adapted version of ST in low-income, second-generation Latinas living in the
United States and suffering from depression, with good results. Videler et al.
(2018) piloted ST as treatment for Cluster C PDs in a multiple-baseline case
series design in a sample of older patients (mean age 69 years old), with good
results (i.e., large effect sizes). Lastly, applications of ST for youths with PDs in
development or with a criminal development have been designed and will
probably be tested in the near future. Two preparatory small-scale case series
studies reported promising results (Roelofs et al., 2016; van Wijk-Herbrink et
al., 2017). As can be seen, future research on ST needs to address how it can be
applied with these populations.

CONCLUSION AND FUTURE DIRECTIONS

ST is one of the major recent psychotherapeutic developments in the treatment

for patients with PD and chronic psychopathological problems, especially in the
treatment of BPD and Cluster C PDs. Besides large effect sizes in symptom
reduction and increases in quality of life, ST is characterized by high acceptance
from patients and therefore low dropout rates. ST was also demonstrated to be
a cost-effective treatment. In principle, ST is a transdiagnostic model, but it also
encompasses disorder-specific models for most PDs. The mode model provides
a clear structure for case conceptualization and guides the treatment, as there
are specific tasks for each mode, and the therapy techniques are chosen based
on the active mode in the therapy situation. Besides cognitive and behavior-
 Schema Therapy  533

oriented techniques, there is a special emphasis on experiential techniques and

the therapeutic relationship. Psychotherapy research has focused so far mainly
on BPD and Cluster C PDs.
Future research should, of course, address other disorders like antisocial,
narcissistic, and histrionic PDs and/or chronic Axis I disorders such as eating
disorders, substance use disorders, or PTSD, but it should also deepen the evi-
dence base for BPD and Cluster C PDs. More information is needed especially
on treatment duration, frequency of sessions, group/individual or combined
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treatment, and the optimal setting and application. ST has been directly com-
pared with TFP in patients with BPD; however, studies comparing ST with
other major evidence-based treatments like dialectical behavior therapy and
mentalization-based therapy are still warranted. STs for adolescents and cou-
ples, which are already often applied, need to be explored by systematic studies.
Moreover, ST uses a variety of techniques and features. Currently it is impos-
sible to say which are the most relevant for treatment success. Dismantling
studies are necessary to reveal the most important features.

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