SAFE-PLACE IMAGE PRACTICE

Result of using
Day Situation Mode the Safe-Place Image

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
 MY YSQ (SELECTED ITEMS)

UNTRUE OF ME TRUE OF ME
Completely Mostly Slightly Slightly Mostly Completely
1 2 3 4 5 6

P1 = Personal Life; P2 = Professional Life P1 P2

ABANDONMENT/INSTABILITY
When I feel someone I care for pulling away from me, I get desperate.
Sometimes I am so worried about people leaving me that I drive them away.
EMOTIONAL DEPRIVATION
For the most part, I have not had someone who really listens to me,
understands me, or is tuned into my true needs and feelings.
Most of the time, I haven’t had someone to nurture me, share him/herself with
me, or care deeply about everything that happens to me.
DEFECTIVENESS/SHAME
I am too unacceptable in very basic ways to reveal myself to other people.
I’m unworthy of the love, attention, and respect of others.
SOCIAL ISOLATION/ALIENATION
I’m fundamentally different from other people.
I always feel on the outside of groups.
FAILURE
I’m not as talented as most people are at their work.
I don’t feel confident about my ability to solve everyday problems that come up.
ENTITLEMENT
I feel that what I have to offer is of greater value than the contributions of
others.
I hate to be constrained or kept from doing what I want.
SELF-SACRIFICE
I’m the one who usually ends up taking care of the people I’m close to.
Other people see me as doing too much for others and not enough for myself.

From Young Schema Questionnaire by Jeffrey E. Young. Copyright © 2017 Jeffrey E. Young. Adapted by permission of the
author in Experiencing Schema Therapy from the Inside Out: A Self- Practice/Self- Reflection Workbook for Therapists by
Joan M. Farrell and Ida A. Shaw. Published 2018 by The Guilford Press. This material is for personal use only, and the
reader may distribute up to 20 printed copies to clients or students. The full version of the YSQ can be ordered online at
www.schematherapy.org.
APPROVAL/RECOGNITION SEEKING
Unless I get a lot of attention from others, I feel less important.
It is important to me to be liked by almost everyone I know.
EMOTIONAL INHIBITION
I am too self-conscious to show positive feelings to others (e.g., affection,
showing I care).
I find it hard to be warm and spontaneous
UNRELENTING STANDARDS
I try to do my best; I can’t settle for “good enough.”
I can’t let myself off the hook easily or make excuses for my mistakes.
 MY SMI (SELECTED ITEMS)

FREQUENCY: In general
1 = Never or Almost Never 4 = Frequently
2 = Rarely 5 = Most of the time
3 = Occasionally 6 = All of the time

P1 = Personal Life; P2 = Professional Life P1 P2

VULNERABLE CHILD MODE
I feel fundamentally inadequate, flawed, or defective.
I feel lonely.
ANGRY CHILD MODE
I have a lot of anger built up inside of me that I need to let out.
It makes me angry when someone tells me how I should feel or behave.
IMPULSIVE CHILD MODE
I say what I feel, or do things impulsively, without thinking of the
consequences.
I have trouble controlling my impulses.
UNDISCIPLINED CHILD MODE
I don’t discipline myself to complete routine or boring tasks.
I get bored easily and lose interest in things.
COMPLIANT SURRENDERER
I try very hard to please other people in order to avoid conflict, confrontation, or
rejection.
I let other people get their own way instead of expressing my own needs.
DETACHED PROTECTOR
I feel indifferent about most things.
I feel detached (no contact with myself, my emotions, or other people).
DETACHED SELF-SOOTHER
I like doing something exciting or soothing to avoid my feelings (e.g., working,
gambling, eating, shopping, sexual activities, watching TV).
In order to be bothered less by my annoying thoughts or feelings, I make sure
that I’m always busy.

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
SELF-AGGRANDIZER
I’m demanding of other people.
I have to be the best in whatever I do.
BULLY–ATTACK
I demand respect by not letting other people push me around.
I belittle others.
DEMANDING CRITIC (PARENT)
I don’t let myself relax or have fun until I’ve finished everything I’m supposed to
do.
My life right now revolves around getting things done and doing them “right.”
PUNITIVE CRITIC (PARENT)
I deny myself pleasure because I don’t deserve it.
I can’t forgive myself.
HAPPY CHILD MODE
I feel loved and accepted.
I feel spontaneous and playful.
HEALTHY ADULT
I can solve problems rationally without letting my emotions overwhelm me.
I have a good sense of who I am and what I need to make myself happy.
Interpretation Grid: Divide the score for each mode by 2 and enter it in the column “Your
Score.” Next circle the number in each row that your score is equal to or less than.
Mode Name Your Score Very Low Average Moderate High Very High Severe
The Innate Child Modes
Vulnerable Child 1 1.47 1.98 3.36 4.47 6

Angry Child 1 1.81 2.29 3.09 4.03 6

Impulsive Child 1 2.15 2.68 3.05 4.12 6

Undisciplined Child 1 2.27 2.87 3.47 3.89 6

(2.95)
Maladaptive Coping Modes
Compliant Surrenderer 1 2.51 3.07 3.63 4.27 6
(3.32)
Detached Protector 1 1.59 2.11 2.95 3.89 6

Detached Self-Soother 1 1.93 2.58 3.32 4.30 6

Self-Aggrandizer 1 2.31 2.90 3.49 4.08 6

(2.63)
Bully–Attack 1 1.72 2.23 2.74 3.25 6
(2.21)
Dysfunctional Critic Modes
Demanding Critic 1 3.06 3.66 4.26 4.86 6
(3.71)
Punitive Critic 1 1.47 1.86 2.75 3.72 6

Healthy Modes (high scores are positive)

Your Score Very Low Low Average High

Healthy Adult 2.77 3.60 4.60 5.16

Happy Child 2.11 2.88 4.52 5.06

 MY ST SELF-CONCEPTUALIZATION
Date:
1. My identified problem:

2. My related life pattern:

3. Developmental origins of EMS

Core childhood need How was it met, absent, or excessive in your early environment?
Secure attachment, which
includes safety, stability,
nurturance, and love
Autonomy, competence,
sense of identity

Freedom to express valid

needs and emotions

Acceptance and praise

Realistic limits and self-

control

4. Family members: Significant events and personality style or temperament of core figures
relevant to quality of attachment
Mother

Father

Siblings

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
Other significant figures
(teacher, family member,
peers, etc.)
5. Relevant temperamental/biological factors:

6. Most relevant EMS linked with developmental origins

Schema Developmental origin

7. Core childhood memories or images: List some specific memories or images likely to be
relevant for EMS formation or attachment history.
8. Current EMS triggers: What situations or feelings trigger schema-related reactions in you?

9. My schema modes and behaviors

For the listed modes, if you have not named them, do so now, as in Julia’s example.
Avoidant mode and behaviors

Mode involved: My name for it:

Surrender mode and behaviors

Mode involved: My name for it:

Overcompensating mode and behaviors

Mode involved: My name for it:

Child modes
Vulnerable Child mode experience: My feelings, thoughts, behaviors
 My name for it:
Angry or Impulsive/Undisciplined Child mode experience: My feelings, thoughts, behaviors

My name for it:

Dysfunctional Critic Mode experience: My feelings, thoughts, behaviors

My name for it:

My Healthy Adult mode’s strengths and abilities
•

My Happy Child mode behaviors

•

•
 MY MODE MAP

FUNCTIONAL MODES

MALADAPTIVE COPING MODES

DYSFUNCTIONAL
CRITIC MODES

INNATE CHILD
MODES

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
 MY SELF-MONITORING CIRCLE

SITUATION–SCHEMA

SCHEMA MODE PHYSICAL AWARENESS

UNDERLYING NEED

WANTS CHOICES TO MEET NEED THOUGHTS

ACTION TAKEN

FACTS FEELINGS

RESULT: Was your need met?

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan M.
Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).
 MY MODE–SCHEMA CHART #1
Date:

Divide the circle with lines based on your experience of the modes over the last 2 weeks.

Mode labels key: VCM, Vulnerable Child; ACM, Angry Child; I/UCM, Impulsive/Undisciplined Child; DCM, Demanding
Critic; PCM, Punitive Critic; AVM, Avoidant Coping Modes; DPM, Detached Protector; DSS, Detached Self-Soother; OCM,
Overcompensating Coping Modes; POC, Perfectionistic Overcontroller; BAM, Bully–Attack; SAM, Self-Aggrandizer; AAP,
Attention/Approval Seeking; CSM, Compliant Surrender Modes; PCM, Punitive Critic; DECM, Demanding Critic; HAM, Healthy
Adult; HCM, Happy Child.

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan M.
Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).
 MY PROBLEM ANALYSIS

1. My Identified
PROBLEM

2. SCHEMA(S)
involved

3. Activating
Situations

4. What is my
underlying NEED?

5. How is the
VULNERABLE
CHILD MODE
involved?

6. Is another CHILD
MODE involved?
How?

7. Is a CRITIC MODE
involved? How?

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
 8. Is a MALADAPTIVE
COPING MODE
involved? How?

9. What do you usually

do and what is the
RESULT?

10. Is your underlying

NEED MET?
 MY GOALS BY MODE

Vulnerable Child

Angry/Impulsive
Child

Dysfunctional Critic
Mode

Maladaptive Coping
Mode

CHANGE PLAN: First Steps

Healthy Adult Mode

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
 MY MODE AWARENESS SUMMARY FORM

Awareness summary for my mode

Situations

Early warning signs that

this mode is triggered

Physical sensations

Feelings

Thoughts

Related memory

Schema activated

Survival function of the

mode
What need is present?

Usual action taken

Does my action get the

need met?

Do I flip into another

mode?

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
 MY PROS AND CONS LIST

Pros and Cons for keeping the mode at its current intensity
From past PROS: Reasons not to change CONS: Reasons to change
situations in
which I used the
old Coping mode
behavior

From situations
in the last 3
months in which
I used old Coping
mode behavior

What need of the Vulnerable Child mode

underlies the Maladaptive Coping mode?

Does the old Coping mode behavior

meet the need?

Are there results from the Coping mode

that I don’t like?
Does it damage my relationships?
Should I change my old Coping mode
behavior?

Does my usual action get my need

met?

What is my decision regarding change?

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
 MY MODE MANAGEMENT PLAN, STEP 1

Need Validation
What else could I do
to try to meet this
need?

What are the pros

and cons of the new
alternative?

Results of trying the Healthy Adult behavior

Try the new behavior
and record the result
here.

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
 MY MALADAPTIVE COPING MODE MANAGEMENT PLAN

My Mode Management Plan for (fill in the Maladaptive Coping mode)

Which EMS triggers this
mode?
What need is involved?

How could I get the need

met in a healthy way?

What mode flip might

interfere with healthy
action?

Reality check: What are

the objective facts of this
situation?

How can I use my

awareness of the
Maladaptive Coping mode
to stop and make a choice?

How could my Healthy

Adult mode challenge the
Critic’s message?

What was the result and

was my need met?

What new message can

I use as an “antidote”
against the Critic mode?

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
 MY SUMMARY OF MY MODE MANAGEMENT PLAN RESULTS

Actions taken

Results

Was my NEED met?

Healthy Adult message

to take from this

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
 MY DYSFUNCTIONAL CRITIC MODE AWARENESS SUMMARY

Situations

Early warning signs that

this mode is triggered

Physical sensations

Feelings

Thoughts (my critic’s

message)
Related memory

Schema(s) activated

Survival function of the

mode
What need is present?

Usual action taken

Does my action get the

need met?

Do I flip into another

mode?

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
 MY DYSFUNCTIONAL CRITIC MODE MANAGEMENT PLAN

Activating situation

Schemas activated

Mode triggered

Emotions

What do you need?

Old coping mode action

Need met?

How could I fight my Critic and meet my needs?

Cognitive Antidote

Behavioral Antidote

Experiential Antidote [Added in Module 18]

Result

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
 MY ST FLASHCARD

Right now I feel because my mode

was triggered when

However, I know that this is probably my schema being activated,

Which I learned through

This schema(s) leads me to distort the degree to which

So, even though I believe that

The reality is that

Evidence supporting my Healthy Adult view includes:

So, even though I feel like

I choose to do this instead:

Short Form
My Flashcard for (schema)
Even though I feel

Mode Awareness: I know my reaction is based on my childhood experience of

and that my schema has been activated.

Mode Management: Although tempted to use my old coping mode, I will connect with my
Healthy Adult mode and as that will get my need met.

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
 MY MODE–SCHEMA CHART #2
Date:

Divide the circle with lines based on your experience of the modes over the last 2 weeks.

Mode labels key: VCM, Vulnerable Child; ACM, Angry Child; I/UCM, Angry/Undisciplined Child; DCM, Demanding Critic; PCM,
Punitive Critic; AVM, Avoidant Coping; DPM, Detached Protector; DSS, Detached Self-Soother; OCM, Overcompensating; POC,
Perfectionistic Overcontroller; BAM, Bully–Attack; SAM, Self-Aggrandizer; AAP, Attention/Approval Seeking; CSM, Compliant
Surrenderer; PCM, Punitive Critic; DECM, Demanding Critic; HAM, Healthy Adult; HCM, Happy Child.

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan M.
Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchasers of this
book for personal use only (see copyright page for details).
 MY SELF-PRACTICE REVIEW

Schemas

Maladaptive Coping mode

What has changed?

What work is still left to

do?

Dysfunctional Critic mode

What has changed?

What work is still left to

do?

Vulnerable Child mode

What has changed?

What work is still left to

do?

Other Child mode

(specify type)
What has changed?

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
What work is still left to
do?

Happy Child mode

What has changed?

What work is still left to

do?

Healthy Adult mode

What has changed?

What work is still left to

do?
 PROS AND CONS LIST FOR CONTINUING SP/SR WORK

Reasons to continue SP/SR work Reasons to stop SP/SR work

What is your decision?

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
 MY ANGRY OR IMPULSIVE/UNDISCIPLINED CHILD MODE
MANAGEMENT PLAN

What situations does this

mode get triggered in?
Which EMS triggers this
mode?
What need is involved?

How can I use my

awareness of the this mode
to stop and make a choice?

How could I vent the

surplus anger safely, if
needed? Try it.

How could I get the need

met in a healthy way? Try it.

What was the result and

was my need met?

What message from my

Healthy Adult can I use as
an “antidote” for this mode?

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
 MY VULNERABLE CHILD MODE MANAGEMENT PLAN

What need am I aware

of in the Vulnerable
Child mode?

How do I usually try to

get my need met?

Result

What schemas and

modes interfere with
taking a healthy action?

Healthy Adult reality check:

What are the objective
facts of this situation?

“Good Parent” action

to get the need met in
a healthy way

Result

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
 MY HEALTHY ADULT MODE MAINTENANCE PLAN

MODE Vulnerable Child mode Maladaptive Coping Dysfunctional Critic

AWARENESS mode mode
Feeling

Thought

Trigger

Need

Healthy Adult
Plans

Results

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).
 MY MODE–SCHEMA CHART #3
Date:

Divide the circle with lines based on your experience of the modes over the last 2 weeks.

Mode labels key: VCM, Vulnerable Child; ACM, Angry Child; I/UCM, Angry/Undisciplined Child; DCM, Demanding
Critic; PCM, Punitive Critic; AVM, Avoidant Coping; DPM, Detached Protector; DSS, Detached Self-Soother; OCM,
Overcompensating; POC, Perfectionistic Overcontroller; BAM, Bully–Attack; SAM, Self-Aggrandizer; AAP, Attention/
Approval Seeking; CSM, Compliant Surrenderer; PCM, Punitive Critic; DECM, Demanding Critic; HAM, Healthy Adult;
HCM, Happy Child.

From Experiencing Schema Therapy from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists by Joan
M. Farrell and Ida A. Shaw. Copyright © 2018 The Guilford Press. Permission to photocopy this form is granted to purchas-
ers of this book for personal use only (see copyright page for details).