Schema Therapy for
Cluster-C
Personality Disorders
Hannie van Genderen
Remco van der wijngaart
Community Mental Health Centre Maastricht
Overview
Dag 1
Casusconceptualisatie en diagnostiek bij cluster C
Behandeling:
Afhankelijke persoonlijkheidsstoornis
- Willoos Inschikkelijke
Obsessief-compulsieve persoonlijkheidsstoornis
- Overcontroleerder
Dag 2
Afhankelijke persoonlijkheidsstoornis
- Schuldinducerende oudermodus
Ontwijkende persoonlijkheidsstoornis
- Ontwijkende en onthechte beschermer
- Straffende oudermodus
Overview
Dag 3
Obsessief-compulsieve persoonlijkheidsstoornis
- Veeleisende oudermodus
Versterken gezonde volwassene en blije kind
Afhankelijke persoonlijkheidsstoornis
Uiten van kwaadheid en woede
Dag 4
Praktijktoets
Imaginairerescripting
Autonoom gedrag
DAG 1
Kennismaken
Ervaring met ST
Supervisie/ intervisie ST
Welke knelpunten bij het maken van de
casusconceptualisatie
(formulier en model)
© H. van Genderen
9
Relatieproblemen
In gezelschap angstig
en conflicten vermijden
Werkproblemen!
Ik moet voor de
ander zorgen want
die is zwakker dan ik
(zelfopoffering)
Ik ben niet belangrijk
(emotionle
verwaarlozing)
Ik ben heel anders
dan anderen (sociaal
Isolement)
Alles heel goed
willen doen
(meedeogenloze
normen)
Overgave
Altijd eerst aan
anderen denken
Vermijding
Contact met anderen
uit de weg gaan
Overgave
Altijd hard werken
en studeren
Gevoelig en
intelligent kind
Vader vaak
overspannen
Moeder zorgt
Voor vader
en broertje
Vader
veeleisend
Gezinsregel: over
gevoelens en problemen
wordt niet gepraatl
Moeder
teruggetrokken
en stil
General Conditions for
Therapy
Check motivation for therapy, so sometimes
motivational interviewing first
Reason for treatment can be chronic depression,
anxiety or burnout
Explain therapy model:
- talking about the past is necessary
- changing means stop avoiding
Pay attention to autistiform disorders
Addiction that needs detox first
General Conditions for
Therapy
If patiënt is not motivated to work on
PD: repeat therapy for axis I
Explain that not working on a deeper
level can lead to chronic complaints
Research
Effect Schema Therapy compared with
treatment as usual:
Less drop out
More recovery
Better social functioning (>GAF)
Less depression
Bamelis, L.L. M., Evers, M.A.A., Spinhoven, P. & Arntz, A. (2014). Results of a
multicentered randomized controlled trial on the clinical effectiveness of schema
therapy for personality disorders. American Journal of Psychiatry,
© H. van Genderen
13
“difficult”
parents
“difficult”
temperament
Traumas
Dysfunctional
Schemas
Dysfunctional
Coping stratgies
Complaints
Basic core needs
Secure attachments to others (safety,
stability, nurturance and acceptance)
Autonomy, competence and sense of
identity
Freedom to express needs and emotions
Spontaneity and play
Realistic limits and self-control
Concept of a Schema Mode:
Schema modes are moment-to-
moment emotional-cognitive states with
specific coping responses
Similar, but more extreme to what we
all experience
Schema modes are triggered by life
situations that we are sensitive to
An individual may shift from one
schema mode into another (flipping)
Schema Modes
Child modes
Dysfunctional Coping modes
(Surrender, avoid, overcompensate)
Dysfunctional Parent modes
Healthy Adult mode
Unravelling the connection between
schemas, coping styles, and
modes:
empirical findings
Marleen Rijkeboer
&
Jill Lobbestael
Why did Jill and Marleen start
this project?
Schism in schema therapy:
the schema model vs. the mode model
Jill Lobbestael performed research into
modes. Marleen into schemas
Both interested in:
To what extent are these two models
related?
What are the connections between the
constructs in both models?
Connecting the constructs
Adaptation of the Schema Polarity Model
by Elliott & Lassen (1997)
schema
surrender
overcompensation
avoidance
Connecting the constructs
Defectiveness/Shame
vulnerable child:
“I am unloveable”
self-aggrandizer:
“I am very special”
detached
protector
Healthy Adult “I am OK”
Connecting the constructs
Emotional Deprivation
vulnerable child:
“No-one will meet my
needs”
angry child:
“I want my needs to be
met right now”
detached
protector
healthy adult “I am respected”
The integrated model
A mediation model in which coping styles
mediate the relationship between
schemas and modes
coping style
schema schema mode
The integrated model:
another way of categorizing
modes
Trying to connect the schema model and mode model
into a more parsimonious model
Basically the function of moment-to-
moment states is assessed by taking
into account:
What are the origins: the underlying theme/schema?
What is the dominant coping style?
We were a bit confused by the term ‘coping mode’. Isn’t
this a pleonasm? Don’t modes always involve coping?
Results
surrender
schema vulnerable child
Schemas: emotional deprivation, abandonment, mistrust,
social isolation, defectiveness, failure, vulnerability,
negativity/pessimism, functional dependence, & approval
seeking
All indirect effects were significant
Results
avoidance
schemas detached protector
Schemas: emotional deprivation, abandonment, mistrust,
social isolation, defectiveness, failure, vulnerability,
negativity/pessimism, functional dependence, emotional
inhibition & approval seeking
All indirect effects were significant
Results
overcompensation / surrender
schema angry child
Schemas: emotional deprivation, abandonment, mistrust,
social isolation, defectiveness, failure, vulnerability,
negativity/pessimism, functional dependence, emotional
inhibition & approval seeking (overcompensation)
Schemas: insufficient self-control & entitlement (surrender)
All indirect effects were significant
Results
surrender
schema punitive parent
Schemas: defectiveness, failure, punitiveness, & unrelenting
standards
All indirect effects were significant
Results
surrender/avoidance
schema compliant surrender
Schemas: approval seeking, self-sacrifice & enmeshment
(surrender)
Schemas: abandonment (avoidance)
All indirect effects were significant
Results
overcompensation / surrender
schema self-aggrandizer
Schemas: defectiveness, failure, & social isolation
(overcompensation)
Schema: entitlement (surrender)
All indirect effects were significant
Results
overcompensation
schema bully & attack
Schema: mistrust/abuse
the indirect effect was significant
Conclusion & Discussion
Straight forward and clear relationships
between schemas, coping styles, and schema
modi were found
Findings were cross-validated, hence results
are robust
The schema model and the schema mode
model are closely related
Schism of both models seems unwarranted
Emotion theory Lang
Three basic levels on which emotional
experiences are represented in memory:
Sensory stimuli
Meaning
Bodily response
Therefore its important to use diverse
diagnostic methods!
Schema Therapy
Integrative Therapy based on the
Schema Model
Three ways of changing schemas:
Doing - Behavioural Techniques
Feeling - Experiential Techniques
Thinking - Cognitive Techniques
Four foci:
Therapeutic Relationship
Experiences outside therapy
Memories from childhood
Future
© H. van Genderen
34
Difference between
cluster C and B
Cluster C
Too much protection
Emotional abuse
Too many rules
Deficits in parents more
subtle
Punitive parent more
restrictive and guilt
inducing
More loyalty towards
parents
Patient quiet & obedient
Parentification
Not enough anger
Cluster B
Insufficient protection
Sexual or violent abuse
Lack of rules
Deficits in parents
more obvious
Punitive parent more
abusive
Loyalty towards
parents sometimes
easier to break through
P. is not so cooperative
Takes no responsibility
Too much anger
Roleplay
Roleplay
about common problems
during case
conceptualisation
Protocol cluster C
40 sessions in year 1
Sessions 1-6: introduction, case
conceptualization
Sessions 7-25: focus on childhood
Sessions 26-40: focus on present &
behavioural change
10 booster sessions in year 2
(+ monthly)
Protocol Session1-6
First phase of treatment
If PD treatment is indicated and patient
agrees with Schema Therapy:
Intake Schema Therapy, assessment of:
Schemas, coping styles, and modes
(Discuss SMI & YSQ & Scid's)
Origins in childhood (Life history & YPI)
Unmet basis emotional needs
Imagery with father (alone)
Imagery with mother (alone)
Current problems
First phase of treatment
Link between origins, schemas, coping and
modes, and current problems
Together with the patient: formulation of the
case conceptualization
Explain aim and methods of the treatment
(also reading books)
Mutual agreement and clarity on
appointments and rules
Building a safe therapy relationship
Mode models Cluster C
Avoidant PD
Dependent PD
Obsessive-Compulsive PD
AVOIDANT
& DETACHED
PROTECTOR
(& COMPLIANT
SURRENDER)
LONELY/INFERIOR
CHILD
&
ABANDONED/ABUSED
CHILD
PUNITIVE
PARENT
HEALTHY
ADULT
Avoidant PD
HAPPY
CHILD
Avoidant PD
P. worries that he is socially inept and inferior: low
self-esteem
P. fears that he has not the capacity to deal with
challenging situations
Fear of novelty and emotions
Avoids:
Feelings (negative AND positive, especially anger)
Experiencing bodily sensations (f.e. sexual arousal, eating
strong flavored and spicy food)
Engaging in potentially risky activities
Social contacts and roles
Intimacy
Making choices
Having opinions and expressing them
Emotionally abused or abandoned in childhood
Avoidant PD
Inept and inferior: low self-esteem
Emotionally abused or abandoned in childhood
NEEDS:
- nurturance and acceptance
- Freedom to express needs and emotions
COMPLIANT
SURRENDER
DEPENDENT
CHILD
&
ABANDONED/ABUSED
CHILD
PUNITIVE
PARENT
(punishes
Autonomy,
Guilt inducing)
HEALTHY
ADULT
Dependent PD
HAPPY
CHILD
Dependent PD
FUNCTIONAL DEPENDENCY
EMOTIONAL DEPENDENCY
FUNCTIONAL DEPENDENCY
Patient worries about his capacity to lead an adult life
Cannot make minor and major decisions in a practical
sense
Believes he has to rely on a strong person to help him
Lack of self-confidence
Lack of autonomy
Authoritarian parenting
Dependent PD
EMOTIONAL DEPENDENCY
Desperately needs somebody for emotional support
When alone patient feels lonely and empty
Clings to family members and friends
Constant fear of abandonment
Threat of abandonment in youth or parent was
dependent on the child
Dependent PD
Believes he has to rely on a strong person to help him
Lack of self-confidence
Lack of autonomy
Authoritarian parenting
Constant fear of abandonment
NEEDS:
Secure attachments to others (safety, stability,
nurturance and acceptance)
Autonomy, competence and sense of identity
Freedom to express needs and emotions
PERFECTIONISTIC
OVERCONTROLER
(denied/
not accessible)
VULNERABLE
CHILD
DEMANDING
PARENT
HEALTHY
ADULT
SELF-
AGGRANDIZER
Obs-Comp PD
HAPPY
CHILD
Obsessive-Compulsive PD
Patient has an excessive and compulsive
devotion to productivity at the expense of
other areas of life
Standards are usually extremely high
Emotions are not seen as valuable
Views himself as superior to others in terms
of conscientiousness, responsibility and moral
norms
Emotional abuse in childhood
Cold and strict parenting
Obsessive-Compulsive PD
Standards are usually extremely high
Emotions are not seen as valuable
Emotional abuse in childhood
Cold and strict parenting
NEEDS:
Secure attachments to others ( nurturance and
acceptance)
Freedom to express needs and emotions
Spontaneity and play
Idiosyncratic schema-mode
model
Develop together with patient idiosyncratic
mode model
Patient may read Young & Kloskos self-
help book
Adapt names of the modes
E.g., the wall, your punishing side
Draw on white board
Relate to historical roots
Must explain present problems
Example: Dependent & OC PD
patient
Compliant Surrender
Dependent Child
PUNITIVE & DEMANDING
PARENT MODE
Perfectionistic
Overcontroller
Healthy
Adult
Happy
Child
Recognizing Schema Modes
Feeling tone – each mode has its own
characteristic affect
Life history
Therapeutic relationship
Imagery
Questionnaires: Schema Mode Inventory
Collecting information
Interview (life history and current
complaints)
Questionnaires
Imagery
Downward-arrow
Avoidance & modes
Detached protector
Avoids feeling & connection (passive) incl. somatization
Avoidant protector
Situational avoidance
Compliant surrender
Avoids autonomy
Detached self soother
Active substance abuse & activities to avoid (active,
sensation seeking)
Recognizing different modes
at cluster C Personality
Disorder
Protocol Sessions 7-25
Second phase of treatment
Start with asking about: Audiotape and last
week
Identification of schemas and coping styles in
the here and now, by recognizing modes
which are present during the sessions
Changing schemas and coping styles by
working with the modes through experiential,
cognitive, and behavioural techniques
Processing of traumas
Protocol Sessions 7-25
Focus on vulnerable child mode
- Sometimes directly
- Sometimes you need to address
coping mode or punitive parent
mode first
Fight Punitive/Demanding Parent Mode
Bypass the protector: Repeat explanation
why it will not help now
At least once every 2 sessions
imagery rescripting
Treatment:
Content of a session
Ask how last week went
Examine which mode is present (don’ task)
Choose a technique to change this mode
Connect to the vulnerable child
Support, and comfort the child
Educate about needs
Conclusions aimed at changing the schemas
and modes
Enhance the Healthy Adult
© H. van Genderen
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© H. van Genderen
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Planning session in the first phase of therapy
Ask how last week went
(Don’t go into too much detail)
5
Which mode is present?
(don’t ask but name it.)
3
C
B
T
I
m
R
e
S
t
o
e
l
e
n
20-
30
Vulnerable Child
Conclusions aimed at changing the schemas
and modes. Psycho education
± 15
COMPLIANT
SURRENDER
DEPENDENT
CHILD
&
ABANDONED/ABUSED
CHILD
PUNITIVE
PARENT
(punishes
Autonomy,
Guilt inducing)
HEALTHY
ADULT
Dependent PD
HAPPY
CHILD
Treatment of Dependent PD
Correct authoritarian parenting
Don t allow P to submit to you and make you
an authority (mind your own schema s)
Push to express own opinions and emotions
Push autonomy
Stimulate selfconfidence
Teach how to have disagreements
Note: this reparenting is a bit different than
with many other PDs (don t promote
dependence, but independence)
Dependent PD
Recognizing modes
Make contact with the vulnerable child
VULNERABLE CHILD
Empathize with and protect the
Vulnerable Child
Process loneliness, abuse and
abandonment
Offer safe attachment in treatment
Help Vulnerable Child to receive love
and care
DEPENDENT CHILD
Note: this reparenting is a bit different
than with many other PDs
Push to express own opinions and
emotions
Push autonomy
Stimulate almost any initiative to do new
things
Set limits to not coming to therapy or
not trying to do new things
MAKING CONTACT WITH
VULNERABLE/DEPENDENT CHILD
Ask direct contact with the VC/DC
Two chair technique
Imagery
Empathic confrontation
BYPASSING
THE COPING MODE
Label the Coping Mode
(protector or overcompensator)
Explain development in childhood &
empathize with its adaptive value
Link to trigger events
Bypassing the Coping Mode
Review pros and cons in the present
(= cognitive technique)
Empathic confrontation
Motivate & push for behavioral change
Two-or-more-chair technique
Historical role play
Imagery rescripting
BYPASSING THE COMPLIANT
SURRENDER
(willoos inschikkelijke)
Exercise
Review pros and cons of compliant
surrender in the present
Motivate patient to reduce this
protection
Short term versus long term
(relationship, job, family, children)
PERFECTIONISTIC
OVERCONTROLER
(denied/
not accessible)
VULNERABLE
CHILD
DEMANDING
PARENT
HEALTHY
ADULT
SELF-
AGGRANDIZER
Obs-Comp PD
HAPPY
CHILD
Obsessive-Compulsive PD
Get rid of demanding parent mode
Ask P to reduce Perfectionistic
Overcontroller or Self Aggrandizer:
review pros and cons
Empathic confrontation
Explain & push for importance of
emotions, intimacy and social contacts
Let P experiment with imperfection
BYPASSING
THE COPING MODE
Review pros and cons of perfectionistic
overcontroller present & motivate patient to
reduce this protection
Empathic confrontation
Expressing understanding about the
patients schemas and schema-driven
behaviour while simultaneously confronting
the need for change
Confront in a friendly, not punitive, way
Confront in a personal way
Make connections between behaviour,
schemas and modes and childhood
experiences
Pay attention to the emotions that might be
triggered
Empathic confrontation: example
overcontroller
This happens quite often that you interrupt me, to tell me
that I dont exactly understand you.
I really understand that you feel that it is necessary that
every fact and every detail is exactly right, and that you
want to be absolutely sure that everything I say is
correct. I understand that your controlling side then gets
active, and wants to take control over our conversation.
Remember, you developed this side because your father
was extremely critical to you when you made a mistake
or forgot to report every detail.
Although I understand that this side is afraid that if it
does not control whether what I am thinking and saying
is correct, I really want to ask you to reduce this side and
let me speak, even when not every detail is correct.
The first reason for this is that I find these
interruptions, to be honost, quite annoying. Your
perfectionistic overcontroller distracts me from what I
am trying to say.
The second reason is that I feel that letting the
overcontroller control you and me so much is that it
prevents us to have real contact. I feel that it is much
more important to attend to the emotional sides of
your problems, and not to whether every factual detail
is 100% correct. By letting the overcontroller rule our
sessions, I cannot contact little John and address his
needs. And when I cannot do that, the loneliness and
the emotional needs of this side of you cannot be
addressed, and if they cannot be addressed you will
not recover from your problems.
So that is why I want you to try to stop letting the
overcontroller rule your behaviour, and give both
room to me and to the mode of little John, because
little John and I also have the right to take part in the
conversation.
Obsessive-Compulsive PD
Excersize:
Empathic confrontation of the
overcontroller
DAG 2
Punitive parent:
Guilt inducing parent
Parent(s) are excessively dependent on
the child
Separation means danger
Parent(s) punish autonomy
FUNCTIONAL DEPENDENCY
EMOTIONAL DEPENDENCY
COMPLIANT
SURRENDER
DEPENDENT
CHILD
&
ABANDONED/ABUSED
CHILD
PUNITIVE
PARENT
(punishes
Autonomy,
Guilt inducing)
HEALTHY
ADULT
Dependent PD
HAPPY
CHILD
FIGHTING THE GUILT INDUCING
PARENT (PUNITIVE OR DEMANDING)
Fight the GP, PP or DP:
Ttwo chair technique therapist combats GP, PP
or DP or dialogue between HA and GP,
Educate about universal needs and feelings
Imagery exercise
Use CBT to develop alternative perspectives on
needs, feelings and normal life problems, like
making a mistake
Replacement of strict rigid rules by more
adaptive moral standards
Experiential Techniques
Imagery Rescripting
Two-or-more-chair Technique
Role Play
Imagery Rescripting: rationale
Change the meaning of the original
experiences that contributed to the
development of schemas and modes
Imagery has stronger emotional and
memory effects than verbal processing
Pathways to childhood
memory
Safe
Place
Present
Problem
Childhood
memory
Instruction Instruction
Instruction
Spontaneous Spontaneous
Imagery Rescripting: rationale
Identify those schemas that are relevant
for the mode of your patient
Experience schemas on affective level
Help patients link on an emotional level
the origins of their schemas in childhood
and adolescence with problems in their
current lives
Important
Imagery is not the same as exposure
Stop the image at the right moment
Imagery and rescripting for traumatic
experiences: not in the beginning of the
therapy
Dependent PD
Excersize:
Imagery rescripting
Guilt inducing parent
Optimale verwerking van correctieve emotionele ervaringen
Window of Tolerance
(Siegel, 1999; Ogden, 2006)
Too much emotion
(hyperarousal)
Overcompensation
Emotionally flooded,
fearfull , angry,
flashbacks, nightmares,
High risk behaviour
Efforts to reduce : abuse of
alcohol and drugs,
automutilation, suïcide attempt
Surrender= freeze
Terrified, frozen, mute
dissociatie.
High arousal coupled
with physical immobility
Optimal arousal Encompassing both high emotion and states of
calm and relaxation in which emotions can be
tolrated and information can be integrated
Little emotion
(hypoarousal)
Flat affect, numb, empty, collapsed
Cognitively dissociated , inabbility to think
Helpless and hopeless
Efforts to reduce : abuse of alcohol and drugs, automutilation,
suïcide attempt
Window of Tolerance
Influenced by intelligence, working memory capacity,
temperament, stressors, etc.
Patients can only integrate corrective emotional
experiences when they are within their Window of
Tolerance
Dysfunctional behaviours are (dysfunctional) attempts
to regulate distress by a person striving to be within
the Window of Tolerance
Need for process assessment
Need for a more functional affect regulation
Implications for ST
Constant assessment of modes
Constant assessment of needs
Be aware of re-traumatization: don’t let
patients relive traumatic moments
Phase experiential exercises
Work with soothing / bonding / transitional
objects
Be validating
Teach patients functional ways of coping
Have fun
How?
Through the therapeutic
relationship
Activation of schemas of the
therapist
(Counter transference)
© H. van Genderen
93
Schema activation
1. Avoidant behaviour (missing sessions/
arriving too late, doesnt do homework)
2. Crisis (relapse in depression/ somatic
complaints)
3. Dependent behaviour towards therapist
4. Compliant surrender towards therapist
© H. van Genderen
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© H. van Genderen
95
DIFFICULT
COMBINATIONS OF
SCHEMAS OR MODES!
© H. van Genderen
96
!
!
COMPLEMENTARITY
Stagnation
Alienation
Abuse
!
!
© H. van Genderen
97
!
SIMILARITY OF SCHEMAS
Stagnation through
identification
Alienation
Conflict
How to deal with schema
activation?
Take care:
Is it caused by the behaviour of the
Patient?
Or is it activation of your own schema?
In case of problems with own schemas:
Seek help (supervision)
© H. van Genderen
98
AVOIDANT
& DETACHED
PROTECTOR
(& COMPLIANT
SURRENDER)
LONELY/INFERIOR
CHILD
&
ABANDONED/ABUSED
CHILD
PUNITIVE
PARENT
HEALTHY
ADULT
Avoidant PD
HAPPY
CHILD
Avoidant PD
Inept and inferior: low self-esteem
Emotionally abused or abandoned in
childhood
NEEDS:
- Nurturance and acceptance
- Freedom to express needs and
emotions
Avoidant PD
Recognize the modes of the
Avoidant PD
Empathic confrontation
Expressing understanding about the
patients schemas and schema-driven
behaviour while simultaneously
confronting the need for change
Confront in a friendly, not punitive, way
Confront in a personal way
Make connections between behaviour,
schemas and modes and childhood
experiences
Pay attention to the emotions that might be
triggered
Empathic confrontation:
example Avoidance
So you have reported ill again when your boss provoked you.
I really understand that you feel badly treated and that you are
angry at your boss, but that your detached protector side thinks
that it is not wise to express your anger because this was severely
punished when you was a child.
Although I understand that you are afraid that your boss will
punish you, when you are assertive, just like your father did, I still
want you to discuss the whole thing with your boss and to express
your opinion.
Because I think this is a healthier way of dealing with these
problems than reporting ill.
And because I think that you have the fundamental right, just like
everybody else, to express your opinion; it is not okay what you
have been taught when you were a child.
(You may refer to the fundamental human rights (UN))
Avoidant PD
AVOIDANT & DETACHED PROTECTOR:
Push to less avoidance of
Feeling
Social contacts and roles
Intimacy
Making choices
Having opinions and expressing them
What are the needs of the child?
Two chair technique
Two-chair technique
with the avoidant protector
State that the avoidant mode is active
Put this mode in a separate chair and
let this mode express its opinion
Ask the patient to go back to original
chair
The Healthy Adult (or the Therapist)
addresses the Dysfunctional Mode
Express needs of the patient
105
Multiple-chair Technique
When the Dysfunctional Coping Mode and
the Punitive Parent alternate quickly
Give each Mode a chair
Discuss with or fight against each mode
Focus on the reaction of the Child Mode
Help Child or Healthy Adult to express
needs!
106
Avoidant PD
Excersize:
Two chair technique
AVOIDANT & DETACHED
PROTECTOR:
Pathways to childhood
memory
Safe
Place
Present
Problem
Childhood
memory
Instruction Instruction
Instruction
Spontaneous Spontaneous
Avoidant PD
Excersize:
Imagery rescripting
PUNITIVE PARENT MODE
DAG 3
PERFECTIONISTIC
OVERCONTROLER
(denied/
not accessible)
VULNERABLE
CHILD
DEMANDING
PARENT
HEALTHY
ADULT
SELF-
AGGRANDIZER
Obs-Comp PD
HAPPY
CHILD
Obsessive-compulsive PD
Exercise:
Imagery rescripting
Demanding parent
TREATMENT OBJECTIVES:
healthy adult mode
Help patient to strengthen the
Healthy Adult Mode
Therapist / therapeutic
relationship is model
Healthy Choices
Aim = to improve mental health
Motivation: explain that choices so far
were based on dysfunctional modes
(name them)
Help patient to reflect on what (s)he really
wants
Support with making healthy choices and
the fears that they raise
Ask next session how it went!
Strenghtening The Healthy Adult
Behavioural techniques
Two chair technique
Imagery rescripting
Teach healthy attitudes
Push towards healthy choices:
Education / work
Hobbies
Friends
Partner:
Breaking through dysfunctional partner choices;
Learning to make a healthy partner choice
Empathic confrontation to
push for behavioural change
Aim = motivate & push for behavioural
change
Step 1: Empathise with the function of the
original dysfunctional behaviour & link with
schema mode
Step 2: Nevertheless, ask for behavioural
change
Step 3: Motivate this
Happy Child
Happy, Spontaneous Joyful
Make fun during sessions
Stimulate play outside sessions
Happy Child
Demonstration:
Pushing for spontaneity
COMPLIANT
SURRENDER
DEPENDENT
CHILD
&
ABANDONED/ABUSED
CHILD
PUNITIVE
PARENT
(punishes
Autonomy,
Guilt inducing)
HEALTHY
ADULT
Dependent PD
HAPPY
CHILD
Experiential Techniques
Two-or-more-chair Technique
Historical role Play
Imagery Rescripting
Historical Role Play
Find relevant events in the past
P. gets more insight in her own part in
the interaction
P. gets more insight in the motivation her
parents could have had
Changing interpretation of the situation
Therapist can give feedback after
playing the child role
Try out new behaviour from a healthy
perspective
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Aim is NOT
That patient feels guilty of having done it wrong
- But patient gets new insight (in own part, in possible
perspective of the parents)
- and change of the interpretation of the original situation
Another perspective, does not excuse the parents
for not meeting the needs of the child
Behavioral rehearsal
- But changes in emotions and cognitions
Immediate change in present behavior
- Don’t expect that!
In sum: aim is change on schema level
Historical Role Play: Preparation
Discuss a behavioral pattern that gets
stuck every time
P. thinks of a relevant event in the past
which is similar to patterns in the present
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© H. van Genderen
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Historical role play
1.
P. = Child
T. = the other person
Original situation
Conclusion about myself:
Assumed perspective of the other person:
2.
P.= the other person
T.= Child
Original situation: role switching
P. Experiences the perspective of the other
Alternative conclusion about myself:
Alternative assumed perspective of the other person:
3.
P. = Child
T. = the other person
P. Now tries out a new behavior
Alternative conclusion about myself:
Alternative assumed perspective of the other person:
Original conclusion about myself:
Implications for the future:
Avoidant PD
Exercise:
Historical role play
Punitive parent and autonomy
Protocol sessions 26-40
Start asking about:
Audiotape & last week; focus more on
behavioural change
Detect which mode is (was) active
Focus more on present life
How to address current problems
Push towards behavioural change
Support this with schema-mode
techniques and flashcards
Protocol sessions 26-40
Also focus on therapeutic relationship
Discuss dysfunctional schema mode
in the relationship
Help to achieve healthy view
Push healthy behaviour in the
therapeutic relationship
Protocol sessions 41-50
(booster sessions)
Focus on last month
Especially behavioural changes
Detect what modes are / were active
Praise healthy attitudes and behaviours
View problems as challenges
Dont criticize or catastrophize relapse
Formulate problems as choices
Educate:
old modes dont disappear completely, but will
have less influence if you practice healthy ways
Motivate to healthy choices and autonomy
Empathic confrontation to
push for behavioural change
Aim = motivate & push for behavioural
change
Step 1: empathise with the function of the
original dysfunctional behaviour & link
with schema mode
Step 2: nevertheless, ask for behavioural
change
Step 3: motivate this
Behavioural change
Aim = behavioural change
Motivation: explain that new behaviour is
necessary to come to a final change
Rehearse in role plays or using imagery;
give (informal) model and ask patient to try
out
Ask next session how it went!
Learning to express anger
Being afraid of feeling and expressing
irritation and anger is important in
Cluster-C
Patients need to learn that it is normal
and healthy to express anger and be
assertive
Learning to express anger
Practice by:
Role plays
Imagery exercises
Writing assignments (e.g. write letter
expressing anger; don t send)
Expressing anger towards T.
Drama Therapy
Playful exercizes like tug-of-war
Cluster C PD
Exercise:
Expressing Anger
DAG 4
Imagery Rescripting: rationale
Identify those schemas that are relevant
for the mode of your patient
Experience schemas on affective level
Help patients link on an emotional level
the origins of their schemas in childhood
and adolescence with problems in their
current lives
Imagery Rescripting:
Patient rescripts
1. Original situation (P. is Child)
2. P. is Healthy Adult who helps the Child
3. P. is Child again: Now he experiences
the support of his own Healthy Adult
T. Paraphrases what H. A. of P. does.
Cluster C PD
Exercise:
Imagery rescripting
Patient rescripts
Autonomy
Being afraid of feeling and expressing
irritation and anger is important in
Cluster-C
Patients need to learn that it is normal
and healthy to express anger and be
assertive
Avoidant PD
Exercise:
Pushing for more autonomy
Extra Slides
Coping vragenlijst
Overcompensa,e-
Ik kan erg kritisch zijn over wat anderen
doen of laten.
Ik fantaseer over beroemd, rijk, belangrijk of
succesvol te zijn.
Wanneer ik kritiek krijg, schiet ik meteen in
de verdediging..
Ik heb de neiging anderen te overheersen en
te controleren.
Coping vragenlijst
Overgave--
Bij problemen of moeilijkheden denk ik: “Zie je
wel, dit overkomt mij weer”.
Als er moeilijkheden zijn, ben ik geneigd om bij
de pakken neer te gaan zitten.
Als anderen mij slecht behandelen, laat ik dat
gebeuren.
Ik laat mijn leven door anderen bepalen.
Coping vragenlijst
Vermijding-
-
Ik ga liever geen intieme vriendschappen of
relaties aan.
Ik ga confrontaties liefst uit de weg.
Het is beter om je gevoel zoveel mogelijk uit te
schakelen
Ik houd het graag oppervlakkig.