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The self has garnered a great deal of interest since receiving its first prominent treatment in the writings of William James (1890). James distinguished between the “me” – the known, or experienced, object self, and the “I” – the experiencing, knowing subject self. Both were seen as playing central roles in thought, affect, and behavior. Modern treatments of the self, particularly social cognitive and neuroscience ones (e.g., Linville & Carlson, 1994; Zaki & Ochsner, 2011), have equated the “me” with the declarative knowledge we have about ourselves, and the “I” with the procedural knowledge that directs our actions, thoughts, and feelings.
For decades, the self (particularly the “me”) was seen as unitary (Allport, 1955; Rogers, 1977; Wylie, 1974, 1979); for example, the vast literature on self-esteem was predicated on the idea that people have a unitary self and that a single dimension of esteem can apply to it. However, pioneering psychologists (James, 1890; Kelly, 1955) and sociologists (Mead, 1934) offered a multifaceted view of the self as something composed of various aspects, roles, and perspectives. Each of the multiple “me”s contains the information we have about ourselves as objects of knowledge – i.e., as we are in that particular aspect of ourselves (cf. Rafaeli & Hiller, 2010). Similarly, each of the multiple “I”s holds our subjective experience in one particular facet, part, or mode of our being.
Schema therapy (ST), the integrative model of psychotherapy described in this chapter, adopts this multifaceted view of the self as both a clinical challenge and a clinical opportunity in the understanding and treatment of psychopathology and distress. In the following sections, we review the development of the ST model, placing particular emphasis on the way ST has come to view and work with the multiplicity of selves – that is, on the ST mode model. After reviewing the evidence base for the concepts and efficacy of ST, we devote the latter half of the chapter to the application of ST.
Schema therapy and the emergence of the mode model
ST was first proposed by Jeffrey Young (1990) as an expansion of cognitive behavioral therapy (and particularly of Beck’s cognitive therapy) aimed at addressing a wide spectrum of long-standing emotional/relational difficulties. Such difficulties often fit the definition of one or more personality disorders, but may also be present in disorders marked by chronic mood problems, anxiety or obsessions, traumatic responses, or dissociation, formerly labeled “Axis-I” disorders.
As Young (1990) explains, a major impetus for the development of the ST model (originally titled a “schema-focused approach to cognitive therapy”) was the realization that a sizable group of clients were not responding fully to traditional cognitive therapy. Quite consistently, these non-responders, as well as clients experiencing relapse following improvement, are those whose problems are more characterological. Young reasoned that effective work with such clients would require a shift in focus from surface-level cognitions or beliefs to deeper constructs – i.e., to the schemas (which gave this therapy its name).
Schemas (Greek for template, shape, or form) are enduring foundational mental structures which help us represent a complex world in ways that allow efficient, sometimes even automatic, action. The use of this term in psychology (in reference to basic cognitive processes) dates back to Bartlett (1932), but has its roots even earlier, in Kant’s Critique of Pure Reason (1781). As a term tied to psychopathology, it first appeared in Beck’s seminal work (e.g., 1976) on cognitive therapy for emotional disorders. Beck posited that symptoms ensue from the activation of one particular set of (negative) schemas – those related to the self, others, world, and future.
In ST, the notion of schemas goes beyond addressing cognitive features of the mind; schemas are thought to encompass emotions, bodily sensations, images, and memories: “hot,” and not just “cold” cognition. Over the years, Young (1990) and his colleagues (Young, Klosko, & Weishaar, 2003) have worked on refining a taxonomy of early maladaptive schemas, which are thought to emerge when core emotional needs go unmet or are met inappropriately, usually by a child’s caregivers.1 These needs (e.g., for safety, security, validation, autonomy, spontaneity, and realistic limits) are seen as universal. In infancy and childhood, meeting these needs falls to the child’s caregivers, and is considered necessary for a child to develop into psychological health as an adult. Young posited that enduring client problems often stem from present-day activation of the early maladaptive schemas. At times, problems directly involve the distress felt when the schemas are activated. Quite often, however, they result from the characteristic behaviors enacted as a response to the schema – which Young first referred to as “coping styles.”
Starting in the mid 1990s, Young (e.g., McGinn & Young, 1996) began recognizing the necessity of revising ST to move beyond its predominant focus on universal needs, pervasive schemas, and characteristic coping styles. Needs, schemas, and coping styles are all trait-like, and therefore leave unexplained much of the phenomenology and symptomatology of the clients for whom ST was developed in the first place – individuals with borderline or narcissistic personality characteristics, who manifest quick and often intense fluctuation among various self-states or moods. This led to the development of the mode concept.
A mode refers to the predominant schemas, coping reactions, and emotional states that are active for an individual at a particular time. By definition, modes are transient states, and at any given moment, a person is thought to be predominantly in one mode. Most individuals inhabit various modes over time; the manner in which they shift from one mode to another – that is, the degree of separation or dissociation between the modes – differs and lies on a continuum. On the milder end, modes could be like moods (e.g., one may feel a bit listless in the morning, but gradually feel more animated and upbeat by the evening) – i.e., a sense of consistent selfhood, an overarching “I,” is maintained. At the most extreme end, total separation and dissociation between modes takes the form of dissociative identity disorder, in which each mode may present as a different personality – i.e., distinct and seemingly unrelated “I”s.
The manner in which modes shift reflects the structure of the self, yet individuals may also vary in the content of the self – i.e., the specific identity of the modes they tend to inhabit. For example, persons suffering from borderline personality disorder (BPD) tend to experience abrupt transitions and a strong dissociation among a specific set of characteristic modes (e.g., detached protector, angry child, abandoned/abused child, punitive parent; Lobbestael, van Vreeswijk, and Arntz, 2008; Shafran et al., 2015). People characterized by narcissism have a different set of characteristic modes (e.g., self-aggrandizer, detached self-soother, lonely/inferior child). Moreover, a key principle of ST is to remain very “experience-near” (Greenberg & Rice, 1996); thus, in describing a particular client’s “mode-map” in exact terms, schema therapists would pay special attention to idiosyncratic deviations (of this particular person) from the prototypical set of modes (characteristic of others who may suffer from the same symptoms).
Modes as self-states
ST theorists (Rafaeli, Bernstein, & Young, 2011; Young et al., 2003) have paid considerable attention to the developmental origins of schemas, and have argued that they come about when core emotional needs go unmet. Less attention has been given to the origins of modes, but given the centrality of the mode concept to the way ST is practiced today, such attention is very much needed. Luckily, developmental accounts of self-development can help here. Such accounts (e.g., Putnam, 1989; Siegel, 1999) tell a story that is about non-integration, rather than about fragmentation.
According to Putnam, Siegel, and other developmental theorists (e.g., Chefetz, 2015; van der Hart, Nijenhuis, & Steele, 2006), human infants come equipped with a basic set of loosely interconnected “behavioral states”: psychological and physiological patterns that co-occur and that repeat themselves, often in highly predictable sequences, in a relatively stable and enduring manner. These states (or “states-of-mind”; Siegel, 1999) can be defined as the total pattern of activation – affect, arousal, motor activity, cognitive processing, access to knowledge and memory, and self-of-self – that occurs in the brain at a particular moment in time.
States-of-mind begin as ad hoc combinations of mental faculties organized in response to discrete challenges or situations in the infant’s life. Yet situations tend to repeat themselves – and thus, to repeatedly activate the same states. Over time and repeated activation, basic states-of-mind cluster together into self sub-systems – ingrained and separate “self-states” (Siegel, 1999). These serve as the early prototypes of what ST refers to as modes.
Below, we review the four major mode, or self-state, categories discussed by ST: (a) child modes, (b) coping modes, (c) internalized parental modes, and (d) the healthy adult mode. We also note our current thinking regarding these modes’ etiology and briefly explain how ST works with each category of modes.
A taxonomy of modes and their etiology
Child modes
When a child’s needs are, on balance, appropriately met, the ensuing self-states tend to be flexible and adaptive. Through repeated experience of situations in which emotional needs are met (emotions are regulated, distress is soothed), the child (and later, the adult he or she will become) develops what in ST terms is referred to as a Happy Child mode. In this mode, the person experiences closeness, trust, and contentment, and becomes free to access inner sources of vitality, spontaneity, and positive motivation. These innate feelings of playfulness and freedom may not be very accessible to many adult (or even adolescent) clients whose childhood was not marked by the safety and encouragement which foster such curiosity and joy. Even (or rather, particularly) when that is the case, ST seeks to reconnect clients with their Happy Child mode by removing obstacles or creating opportunities to develop such feelings, even if no such opportunity existed in childhood.
When a child’s experience is marked by repeated instances of unmet (or inadequately met) needs, a self-state referred to as the Vulnerable Child (VC) mode coalesces. The VC mode is present for everyone to some degree, but its specific nature differs from person to person, depending primarily on the unique profile of met and unmet needs. For example, when childhood needs for safety and security were repeatedly met with frightening parental behaviors (e.g., anger or violence), fear and anxiety typically prevail in the VC mode. When needs for empathy and validation were left unmet, the VC mode typically involves a chronic sense of loneliness, of being unseen or easily misunderstood by others. When needs for praise and encouragement were met with frequent blame and criticism, the VC mode typically contains feelings of shame, a lack of self-worth, and an expectation of further blame and criticism.
Although the VC mode is rooted in childhood experiences, it can often be triggered in an adult’s life by situations that bear even small degrees of similarity to the originating experience (e.g., anger, invalidation, or criticism – see Porges, 2011, for a detailed description of how such triggering may occur neurologically). When these occur, individuals essentially re-experience an earlier relational trauma (Howell, 2013), which activates concomitant distress (e.g., fear, loneliness, or shame, respectively). Typically, they are not aware that the distress is linked to earlier experiences; instead, when the VC mode becomes activated, people simply think and feel as they did as vulnerable or mistreated children, and expect others to treat them as they had been treated at that early age. In a sense, the activated VC mode bears the brunt of most maladaptive schemas (e.g., mistrust/abuse, emotion deprivation, or defectiveness/shame).2
A primary goal of ST is to heal the relational trauma of unmet needs. To do so, the VC mode needs to be activated and accessible so that it may receive the care it needs. At first, much of this care is offered by the therapists. Over time, as clients’ healthy adult modes gain strength, they internalize this care and learn how to administer it to themselves or obtain it from others outside of therapy. This process by which therapists identify and partially gratify the unmet needs of the VC is the central therapeutic stance within ST and is referred to as limited re-parenting.
In addition to the Happy and Vulnerable child modes discussed above, early life experiences often give rise to two additional child modes. The first is the Impulsive/Undisciplined Child (IUC) mode, which often results from improper limit setting on the parents’ part. It embodies those schemas characterized by externalizing behavior (e.g., entitlement and insufficient self-control schemas). The second is the Angry Child (AC) mode, which emerges in spontaneous angry, or even rageful, reactions to unmet needs. The function of the AC mode is a protective one, and it can be thought of as a nascent manifestation of a coping reaction. However, just like other coping reactions (and coping styles), it often fails to achieve its intended goal. When either the AC or the IUC modes is present, ST calls for empathic yet firm limit-setting. It also calls for empathic exploration so as to discover the unmet needs (which typically underlie the AC mode) or to distinguish whims and wishes from needs (if the IUC mode is present).
Coping modes
Like the Child Modes described above, Maladaptive Coping Modes also represent behavioral states that coalesce into modes due to repeated activation. However, whereas Child Modes (particularly the VC) represent the organic emotional reactions of the child, Coping Modes emerge from a child’s rudimentary survival and adaptation psychological strategies, strategies enacted to withstand the (inevitably depriving) environment encountered by the child. In some cases, especially in environments that were extremely emotionally negligent or otherwise noxious, the strategies were put to use again and again, consolidating into an easily triggered coping mode. In other cases, the coping modes may have been less of a response to a depriving or abusive environment, and more of an internalization of it.
Maladaptive Coping Modes correspond to three coping styles (avoidance, overcompensation, or surrender), which parallel the basic general adaptation responses to threat: flight, fight, or freeze (Young et al., 2003). For different people (and sometimes, even for the same person), these modes may take on varied forms: avoidance may involve dissociation, emotional detachment, behavioral inhibition, or withdrawal; overcompensation may involve grandiose self-aggrandisement or perfectionistic over-control; and surrender may involve compliance, victimhood, and/or dependence.
For ST to achieve its main goal (of healing the relational trauma and allowing the client to develop healthy ways of having needs met), it must contend with the coping modes – negotiate with them, bypass them, or weaken their hold, so that the VC mode becomes accessible. It may be easiest to understand this process by thinking of one particular (and prominent) coping mode – the avoidant mode referred to as the Detached Protector. In this mode, clients are disconnected from emotions – painful ones, but also adaptive ones such as sadness over a loss, assertive anger over a violation, intimate warmth towards close others, or a sense of vitality and motivation. The detachment, distraction, and avoidance in this mode are maintained in various ways (e.g., self-isolation, emotional eating, excessive drinking or drug use). To achieve its goals of re-parenting the VC and healing the relational trauma, ST must bypass the Detached Protector – i.e., find a way to break through the protective shield of numbness, dissociation, and disconnection.
The Detached Protector is often the most prominent mode seen in individuals prone to dissociation and avoidance (e.g., ones with BPD). Other clinical groups are characterized by other coping modes. For example, the Self-Aggrandizer, a mode very prominent among those characterized by narcissistic personality disorder, is an overcompensating Coping Mode that attempts to shore up the fragile self-esteem, loneliness, and inferiority that make up the Vulnerable Child for such people. The Bully/Attack Mode is often seen in individuals with antisocial traits, and is a more extreme adult version of the Angry Child mode. The Compliant Surrenderer, a typical mode among individuals with dependent personality traits, is an example of a surrender Coping Mode.
Once coping modes coalesce, they tend to be deployed almost automatically whenever schemas are triggered, as a way of coping with the ensuing distress. Paradoxically, though, they actually lead to schema maintenance by blocking the opportunity for new corrective emotional learning. For this reason, coping modes are considered maladaptive by definition. Indeed, they are typically seen as a cause of many, if not most, present-day problems.
As noted earlier, ST seeks to weaken the hold of coping modes. At the same time, it must acknowledge that these modes involve behaviors that were, at some point, adaptive responses to harsh interpersonal environments. Thus, ST sees the reasons for the coping modes’ historical emergence as valid; it also calls for empathy towards the way in which particular triggering situations activate the mode. Together, the ST approach to these modes balances validation and empathy (to the “why”) with directive intervention (towards the “how”). This approach, termed empathic confrontation, empathizes with the reasons for the coping mode(s)’ emergence, yet helps clients recognize the costs involved in the inflexible use of such modes, ultimately reducing their reliance on these modes.
Parental modes
A third, more pernicious class of modes, are the Internalized Dysfunctional Parental Modes. By internalization, a process which incorporates principles of implicit learning through modeling (e.g., Bandura, 2006), children learn to treat themselves the way early influential others had treated them – ways that are often quite dysfunctional. Notably, despite the term chosen to label these modes, the maltreatment may not necessarily be that of actual parental figures, but rather of harmful non-parental figures or of the broader social milieu. Still, good-enough parental support under adverse circumstances tends to mitigate their long-term negative impact dramatically, resulting in much weaker internal influence of malevolent self-states; at times, it is the absence of such support that is internalized.
Internalized Parental Modes represent distinct ways in which individuals may be their own worst enemies – a phenomenon recognized by many clinicians, with terms such as punitive super-egos (Freud, 1940), internalized bad objects (Klein, 1946), malevolent introjects (Chessick, 1996), perpetrator parts (van der Hart et al., 2006), or internal critics (Greenberg & Watson, 2006). Young et al. (2003) recognize two prototypical forms of Internalized Parental Modes: a Punitive Parent (PP) and a Demanding Parent (DP). In a PP mode, the client becomes aggressive, intolerant, impatient, and unforgiving towards himself (or others), usually due to the perceived inability to meet the mode’s standards. When in a DP mode, he might feel as if he must fulfill rigid rules, norms, and values and must be extremely efficient in meeting all these. In either mode, he might become very critical of the self or of others, and, as a result of the VC mode’s co-activation, may also feel guilty and ashamed of his shortcomings or mistakes, believing he should be severely punished for them (Arntz & Jacob, 2012). The goal in ST is to help the client recognize these modes, assertively stand up to their punitiveness or criticism, and learn to protect and shield the VC mode from their destructive effects.
Healthy Adult mode
Alongside painful child modes, maladaptive coping modes, and dysfunctional parental modes, most people also have self-states that are healthy and positive. One (the Happy Child mode) was discussed earlier. The other, referred to as the Healthy Adult (HA) mode, is the part of the self that is compassionate, capable, and well-functioning. When parents meet their child’s basic needs in an attentive and suitable way, they serve as a model for healthy (rather than punitive, demanding, or neglectful) adults. Indeed, for many clients, the HA mode is modeled after these positive aspects of their caregivers. For others, who lacked such models, the task of constructing such a mode is more challenging, yet not impossible. In fact, a major aim of ST is to have the therapist’s behaviors, and particularly their limited re-parenting efforts, serve as a model for the development or reinforcement of this mode. The HA mode, like an internalized therapist, has to respond flexibly to the various other modes. With time, it begins to nurture, protect, and validate the VC mode, set limits on the impulsivity of the IUC mode, validate the AC mode while containing its angry outbursts, negotiate with maladaptive coping modes so as to limit their presence, and mitigate the effects of dysfunctional parent modes.
Empirical evidence
ST, as an intervention model, has undergone a variety of empirical testing for several disorders, particularly personality disorders. In the first major test of ST, Giesen-Bloo et al. (2006) conducted a multicenter randomized controlled trial (RCT) of ST vs. transference-focused therapy (TFP), a psychodynamic therapy, in the treatment of 86 BPD patients, treated twice-weekly for three years. A significantly greater proportion of patients recovered or reliably improved in BPD symptoms at the end of treatment in the ST arm (45.5% recovered and 65.9% improved) than in the TFP arm (23.8% recovered and 42.9% improved). Given that patient retention is notoriously difficult in the treatment of personality disorders, it is important to note that dropout rates were considerably lower in ST (25%) than in TFP (50%). Among those who dropped out, ST patients had a median of 98 sessions (close to 1 year) while TFP patients had a median of 34 sessions (roughly 4 months).
Extending the generalizability of these findings, Nadort et al. (2009) conducted a feasibility study with 62 BPD patients in which the patients were randomly assigned to two conditions, with or without between-session phone contact with the therapist. There was no difference in outcome, indicating that it was the within-session work that contributed to outcome. Overall, the treatment was found to be feasible and effective when delivered in the community, with 42% of patients reaching recovery from BPD after 1.5 years of treatment.
In another multicenter RCT, Bamelis, Evers, Spinhoven, and Arntz (2014) extended the mode model to patients with various personality disorders (but not BPD). A total of 300 patients were randomized to either ST, psychodynamically oriented treatment-as-usual (TAU) in the community, or clarification-oriented psychotherapy (COP). At the end of two years of treatment, ST had significantly better outcomes than TAU and COP, with personality disorder recovery rates of 81.4%, 51.8%%, and 60.0%, respectively. Interestingly, a moderator effect showed that the second of two cohorts of schema therapists drove the positive findings. This second cohort was trained more extensively in implementation of ST techniques. Initial process ratings validate that these therapists did use more of the ST techniques than the earlier cohort. This provides initial evidence that it is methods of actively evoking modes (which facilitate working with different self-states within the therapy session) that serve as key active ingredients. Additionally, very promising results emerged for the use of ST in a group format with BPD patients (Farrell, Shaw, & Webber, 2009). A single-case series (N = 12) examining ST for chronic depression found that by the end of 60 sessions of treatment, 60% of patients responded well or remitted (Malogiannis et al., 2014). Finally, some additional effectiveness studies have also yielded positive results (see Bamelis et al., 2012, and Sempértegui, Karreman, Arntz, & Bekker, 2014, for reviews of evidence for efficacy of ST for BPD and other conditions). Overall, the evidence for the efficacy of ST can be considered promising but preliminary, as there have not yet been any direct replications of the RCTs reviewed above.
Although tests of ST as a complete intervention package provide indirect support for the utility of the theoretical model, more research is needed to further validate it as a model of pathology. Some research into the reliability and validity of modes has been conducted (see Lobbestael, 2012, and Sempértegui et al., 2014, for reviews), mainly centering on the development of the Schema Mode Inventory (Lobbestael, van Vreeswijk, Spinhoven, Schouten, & Arntz, 2010), a measure of 14 clinically relevant schema modes. This measure taps into the main modes discussed in the present chapter, but also offers further differentiation of some modes (e.g., differentiating the Angry Child and the Enraged Child). Using this measure, modes have largely been found to relate to personality disorders in theoretically coherent ways (Lobbestael, 2012). For example, patients with BPD have been found to be higher in the frequency of the Abandoned/Abused Child, the Punitive Parent, the Detached Protector, and the Angry Child than both healthy controls and Cluster C personality disorder patients. Experimental studies involving watching a traumatic film clip (Arntz, Klokman, & Sieswerda, 2005) as well as anger induction experiments (Lobbestael, Arntz, Cima, & Chakhssi, 2009) have begun to validate the theory that modes are state-like experiences that occur in response to triggers in the environment, and much more so for personality disorder patients. More work is needed to show that in addition to activated emotion, modes also involve characteristic ways of thinking and behaving. Finally, a priority for research into the mode model lies in the area of process-outcome research within intervention studies, to demonstrate that in-session mode states can be reliably recognized, and further, that working actively with modes transforms underlying schemas and leads to lasting mental health.
Related posts:
The self in bipolar disorder
The self in posttraumatic stress disorder
Self processes in obsessive–compulsive disorder
Painful incoherence: the self in borderline personality disorder
Basic self disturbance in the schizophrenia spectrum: a review and future directions
Future directions in examining the self in psychological disorders
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