List of Schemas Emotional Deprivation: The belief and expectation that your primary needs will never be met. The sense that no one will nurture, care for, guide, protect or empathise with you. Abandonment: The belief and expectation that others will leave, that others are unreliable, that relationships are fragile, that loss is inevitable and that you will ultimately end up alone.
Defectiveness: The belief that you are flawed, damaged or unlovable and you will therefore be rejected. Social Isolation: The pervasive sense of aloneness, coupled with a feeling of alienation.
Vulnerability: The sense that the world is a dangerous place, that disaster can happen at any time and that you will be overwhelmed by the challenges that lie ahead. Failure: The expectation that you will fail or the belief that you cannot perform well enough. Subjugation: The belief that you must submit to the control of others or else punishment or rejection will be forthcoming.
Self-Sacrifice: The belief that you should voluntarily give up your own needs for the sake of others, usually to a point which is excessive. Emotional Inhibition: The belief that you must control your self-expression or others will reject or criticise you. Unrelenting Standards: The belief that you need to be the best, always striving for perfection or that you must avoid mistakes. Punitiveness: The belief that people should be harshly punished for their mistakes or shortcomings.
Also can manifest in an exaggerated focus on superiority for the purpose of having power or control. Also, that you cannot resist acting upon impulses that lead to detrimental results.
List of Modes Child Modes Vulnerable Child: feels lonely, isolated, sad, misunderstood, unsupported, defective, deprived, overwhelmed, incompetent, doubts self, needy, helpless, hopeless, frightened, anxious, worried, victimised, worthless, unloved, unlovable, lost, directionless, fragile, weak, defeated, oppressed, powerless, left out, excluded, pessimistic. Angry Child: feels intensely angry, enraged, infuriated, frustrated, impatient because the core emotional or physical needs of the vulnerable child are not being met.
Detached Protector: cuts off needs and feelings; detaches emotionally from people and rejects their help; feels withdrawn, spacey, distracted, disconnected, depersonalised, empty or bored; pursues distracting, self-soothing or self-stimulating activities in a compulsive way or to excess; may adopt a cynical, aloof or pessimistic stance to avoid investing in people or activities.
Over compensator: feels and behaves in an inordinately grandiose, aggressive, dominant, competitive, arrogant, haughty, condescending, devaluing, over-controlled, controlling, rebellious, manipulative, exploitative, attention-seeking or status-seeking way. Within interpersonal effectiveness patients learn how to reach their goal in a specific situation without hurting others or damaging their own self-respect.
Psychopathology in this area arises if the control of attention is inflexible and not directed to the situational context. Some patients avoid the perception of the situational context by distraction or dissociation because of fears of interpersonal rejection. Others focus their attention inwards on physical symptoms of anxiety or on internal cognitive processes like worry or rumination or try to suppress unwanted thoughts or emotions. Mindfulness exercises in DBT help to keep the focus of attention in the presence and to avoid inflexible attachment to internal events like thoughts and emotions.
Problems in this category are consequences of dysfunctional information processing. DBT assumes that patients have insufficient skills in dialectic thinking, that they do not consider sufficiently the opposing forces that make up inner and outer realities. Patients fluctuate between invalidation of their internal experience on the one side and states of cognitive fusion, when they treat interpretations, assumptions and thoughts and emotions as facts in the outer world on the other side e.
One core technique to teach dialectic thinking is validation. Using validation strategies, the therapist communicates to the patient that her behavior makes sense and has a connection to her present context and past learning history. The repeated use of validation strategies by the therapist will finally result in patients using validation as a skill.
It is intended to help patients to view thoughts as thoughts and emotions as emotions and to disentangle thoughts and emotions from actual facts. With this skill patients learn to consider actual facts for their decisions. DBT uses mindfulness skills with their focus on the present context as an antidote to worry, rumination and threat monitoring. DBT conceptualizes problems in the appraisal category as caused by dialectical dilemmas: Patients often show patterns of dichotomous thinking are stuck in polarities, unable to move to a synthesis and are unable to anticipate or accept change.
Further psychopathology in this category arises from meta-beliefs patients have on emotions e. DBT explains problems in this area with high emotional reactivity and sensitivity as well as skills deficits in emotion regulation, interpersonal effectiveness, distress tolerance and mindfulness. This skill is indicated when the emotion driven behavior is not in accordance with the facts or the values of the patient. Moreover, managing emotional after effects and vulnerability factors are important subcategories in DBT.
For BPD patients emotions often come with a high intensity of aversive physical sensations causing a high distress and a strong action urge, DBT provides a set of distress tolerance skills. These skills aim to calm down the high physiological arousal and to block acting on maladaptive urges. For the down-regulation of distress there are many other strategies in the DBT manual including self-soothing with the five senses, distracting e.
Half smiling was developed in line with research showing that facial expression influence emotions Ekman, Ice cold water, 2. Bite into chili pepper.
It is very important to acknowledge the dialectic that DBT aims at mindfully accepting arousal and emotions without judgment while at the same time acting to reduce arousal. These skills serve as crisis strategies in high distress situations to block dysfunctional action urges like self-injury, rage attacks, or alcohol consumption, which lead to a further complication of the situation.
Every emotion comes with an action urge. Many times acting on the urge is effective. If the behavior does not fit the facts or the values of the patient, there is the possibility to modify the behavioral response. This skill of course includes exposure to unpleasant emotions and follows similar principles as exposure-based treatments for anxiety disorders e. These principles are transferred to other emotions such as shame, disgust, anger, guilt, or sadness.
Changing action tendencies includes changing the overt action e. To address all these components patients are also trained in interpersonal effectiveness. It is important to distinguish opposite action from thought or emotion suppression or submissive interpersonal behavior: Opposite action does not intend to suppress an emotion, but to be mindfully aware and accepting of an emotion and its action urge, but to be able to decide to act differently.
Emotions do not only influence concurrent behavior, cognition and emotion but also future behaviors, cognitions and emotions. Therefore, emotional after-effects of events are an important topic for emotion regulation. After effects may give rise to specific changes in attention, physiology, behavior, and appraisal. Humans avoid or perform specific behaviors because they anticipate specific emotional states. Much of emotional distress is caused by secondary emotions due to judgments about the primary emotion e.
Mindful awareness of these emotion cycles helps to interrupt them and to apply change strategies if necessary. In the first step DBT provides psychoeducation on emotions in general and on specific emotions such as anger, disgust, guilt, joy, love, shame, fear, envy, jealousy, or sadness.
A very important aspect is mindfulness and acceptance in exposure to emotional experience , especially to the primary emotions. DBT aims at fostering resilience by addressing emotional vulnerability factors.
Although, emotion-oriented interventions and systematic emotional work are central to ST, it is important to keep in mind that in ST regulation of emotions is not in the foreground of ST theory. ST intends to change dysfunctional schemas on the self, on relationships to others and on the world as a whole as well as on the meaning of emotions , which underlie today's problems.
These dysfunctional schemas were developed early in childhood through adverse experiences and gave rise to coping strategies such as avoidance, surrender or overcompensation to deal with expected threat or gratification. These coping strategies have often become very rigid and block access to the underlying schemas. Thus, the schemas cannot be changed and the disorder is maintained. ST of course aims to break through these rigid coping mechanisms to reach the dysfunctional schemas, however the ultimate aim is to change the underlying schemas.
Painful emotions and difficulties in regulating them are seen as a consequence of these underlying dysfunctional schemas. If corrective experiences in treatment lead to a change of the schema representation of other people, then the problem is resolved. If the representation of emotion entails that emotions constitute a threat, the patient will feel unsafe with emotion, and use avoidance or overcompensation to prevent that emotions are triggered. The aim of ST then is to help the patient feel safer with emotions.
Thus, the way patients view, experience and regulate emotions changes substantially through the course of treatment without emotion regulation being directly addressed. To give a better overview on how emotions are worked with in ST we decided to present ST techniques with special regard to emotions first in line with the basic ST literature Young et al.
Afterwards we explain how these concepts and techniques can be mapped to the process model of emotion regulation see also Table 1. The therapy relationship is an important vehicle for corrective emotional and interpersonal experiences.
He helps the patient to become aware of his emotions and needs, gives support in expressing emotions and needs, validates them and—within certain boundaries—fulfills the needs.
Especially important is the fulfillment of needs that were frustrated in childhood. The therapist directly models and shapes the emotional response of the patient providing external emotion regulation like parents do for their children e. Moreover, the therapist models healthy ways of intrinsic emotion regulation by showing how he deals with his own emotions and needs.
Thus, the therapist sets up emotional work in small steps and actively guides through the process. He emphasizes the adaptive value of the coping mode, and at the same time makes clear that the coping mode blocks access and fulfillment of the patient's needs leading to enduring aversive emotions.
Also he promotes functional emotional reactions. ST assumes that by using these strategies the patient's fear of emotions reduces, while willingness to overcome the coping modes increases and by this the pathway to heal dysfunctional schemas opens. In a way, ST-therapy relationship-strategies resemble the way how emotion regulation develops in children. In childhood extrinsic emotion regulation by caregivers is initially dominant Gross, ; e. By experiencing adaptive extrinsic emotion regulation by caregivers and getting models for intrinsic and extrinsic emotion regulation, children can learn intrinsic emotion regulation e.
Cognitive techniques compromise a range of techniques similar to the techniques also used in CBT. In regard to emotion regulation strategies patients receive intensive psychoeducation on schemas, schema coping, modes, needs, emotions as well as on normal development of children.
Within the mode model the therapist illustrates, why and how coping modes developed and validates their function, which is mainly to shelter the child modes from more emotional pain.
He explains what children need to develop a healthy way to deal with emotions and points out the differences to the patient's history e. Every child would feel guilty then. The parent needs to talk to the child, to find out why it is angry and help the child to calm down. The therapist fosters mode awareness , in which emotions play an important role e. He explains the mode-specific goals of ST e.
He helps with the identification and re-appraisal of schemas and mode-related cognitive distortions e. Other important cognitive techniques compromise reviewing pros and cons e. Experiential techniques including emotional processing of aversive childhood memories are extensively used and are central to ST, which is a main difference to standard CBT. The main focus of ST is on changing dysfunctional schemas and the meaning of emotions and needs through emotional restructuring.
As such ST does not place a strong emphasis on typical CBT exposure techniques aiming at habituation and extinction. An emotion is processed until the respective emotion i. In chair dialogs different chairs are used for different perspectives or emotions. In ST, most often different modes are placed on different chairs and dialogs between them are performed. The patient changes the seats and expresses on every chair the perspective and emotions of the related mode.
When another mode pops up, the therapist usually asks the patient to change the seat to the chair that symbolizes the popped-up mode e. I think this is connected to your vulnerable child mode. Would you please take a seat on the vulnerable-child-chair and tell me how little Tanja feels?
The therapist helps the patient to express his feelings and needs and to detect and experience different mode perspectives. The therapist might also model to express those perspectives, emotions and needs the patient finds hard to express. These exercises clarify ambivalent emotions and inner conflicts, which is an important diagnostic step to the solution of an emotional problem. Moreover, chair dialogs can be used to restructure modes and emotions leading to new emotional experiences and changes in the dysfunctional schemas, meaning of needs, and emotions.
To achieve this, the therapist or the healthy adult mode addresses every mode by adapting his tone of voice, the content of what he says to the mode and his actions following the mode-specific goals of ST e. Thus, the patient experiences in a highly emotional way, that his needs and emotions are important and that self-devaluation can be reduced.
Imagery exercises can also be used for diagnostic reasons to clarify the biographical origin of dysfunctional schemas and emotional problems as well as related behavior patterns diagnostic imagery.
Most often diagnostic imagery exercises start from a current situation associated with strong emotions. The patient is asked to image that situation with eyes closed, the therapist focusses especially on the emotions and where in the body the patient can feel the emotion.
When the emotion is clear enough, the therapist asks the patient to wipe away the image of the current situation and just stay with the emotion affect bridge and go back to his childhood and see if an image that is associated to that emotion pops up. The childhood image is then again explored with emphasis on emotions and needs. Imagery Rescripting Arntz and Weertman, is considered to be the most powerful technique to change schemas and the meaning of adverse childhood events and emotions.
The patient is asked to image a stressful childhood memory related to his maladaptive schemas e. Such a situation can be found through affective bridges as explained above or can be directly taken from the reports of the patient. This helping figure can be the patient himself in his healthy adult mode, if he is already strong enough. For patients with PD this is often not the case in the beginning of therapy.
Thus, the therapist or another helpful person even a fantasy figure can be introduced as helping figure. Aversive emotions such as anxiety, shame or guilt are reduced, while experiencing safety, secure attachment, warmth, love, joy, and other pleasant emotions are promoted.
By this, the original meaning of the trauma is changed. For some patients rescripting works better in the form of a role play, for instance if imagery constitutes a problem. Note that from an ST-perspective it is not necessary that the patient relieves the whole trauma, since habituation is not the primary goal. Historical role-play Arntz and Weertman, is a form of drama therapy, where therapist and patient play a traumatic biographical memory together as a role play. The patient switches roles by playing his own role most often as a child in the first round and the role of the perpetrator most often a parent in the second.
This helps the patient to see another perspective on the events and to change the meaning of the situation. If a patient e. By this he can understand that it is not him being unlovable, but the circumstances of the situation that made his father act like that. Behavioral techniques mainly aim at breaking through rigid behavior patterns connected with the coping modes.
After many years of dysfunctional coping this behavior has often become habitual and patients lack other skills to deal with emotions and needs. Thus, they need support to learn new strategies. ST compromise a range of techniques similar to the techniques also used in CBT such as behavioral experiments, role play, homework, planning of activities, problem solving , or skill training.
If pathological choices e. Often it is very hard or even impossible for patients to change their behavior in the beginning of therapy due to maladaptive schemas, thus these strategies have a stronger emphasis later in the course of therapy, and are often prepared by experiential techniques. In the following we map the ST concepts and techniques on the James Gross' process model of emotion regulation by going through each category of emotion regulation strategies see also Table 1.
Schema therapy explains why patients avoid situations that might be useful for them and do not leave situations that are harmful using the concepts of schema avoidance, schema surrender, and schema overcompensation. It is assumed that dysfunctional child, parent and coping modes are responsible for problematic avoidance behavior or inaction.
ST uses psychoeducation about the mode model to help to understand and overcome problematic schematic coping and experiential avoidance. Empathetic confrontation is used to confront patients with dysfunctional situation selection that repeats history and by this maintains schemas e.
Behavioral techniques like role plays of the present situation and actively changing what situations to select may be used to foster transfer of behavior from the therapy session into the life of the patient. Similarly, ST assumes that problem solving skills that are necessary to improve situations may be blocked by schema avoidance, schema surrender or schema overcompensation. ST supports the patient to develop awareness of their modes and individual needs and helps patients to modify situations so that needs are better fulfilled.
Behavioral techniques help with testing and transfer of problem solving skills. Cognitive techniques help to identify problematic situations, situational triggers and alternative ways to get needs met. Imagery rescripting and historical role play may in particular modify the internal context in problematic situations.
Dysfunctional schemas and modes are maintained, since attention is focused on information that confirms the dysfunctional schema or mode. This problem of attention that is inflexible and not directed to the situational context is addressed by ST using the attention shift that is associated with mode work through cognitive and experiential techniques.
Chair dialogs for example require the patient to shift their attention to varying aspects of internal and interpersonal situations and facilitate the experience of the emotional changes associated with shifting attentional deployment.
One core assumption of ST is that information processing and decision making is influenced by early maladaptive schemas and that psychopathology is related to a dominance of dysfunctional modes to the detriment of the healthy adult mode. Consequently, when dealing with emotion regulation, appraisal is a core area for ST. Identification and re-appraisal of schemas through cognitive and experiential techniques are central for ST.
ST assumes that mode awareness and cognitive flexibility that is developed during therapy allows the patient to switch from dysfunctional modes to the healthy adult mode and by this eliminate problematic appraisal processes. All experiential techniques promote change of appraisal especially through changing the meaning of emotions and early experiences that underlie schema. ST assumes that psychopathology in this category is related to dysfunctional modes in particular dysfunctional child and parent modes and coping modes.
The therapy relationship techniques, especially limited reparenting, aim to model and shape emotional responses in direct contact with the patient. Empathic confrontation is used to block problematic emotional reactions and promote healthy emotional reactions. Emotional exposure in experiential techniques is set up in small steps with shelter by the therapist and plays an important role of response modulation. In imagery rescripting traumatic experiences are processed and through the new script where the patient's needs get fulfilled the emotional response is directly altered.
Behavioral techniques support the transfer of new responses into the everyday life of the patient. Both treatments share a CBT background and help patients to deal with emotional dysregulation. Both explain development of emotional dysregulation with invalidating aversive experiences in childhood in interplay with biological factors even if later in the therapy process the biographical aspects play a more distinct role in ST.
In both methods the therapeutic relationship is marked by validation, acceptance and warmth for patients and both treatments address experiential avoidance. However, there are major differences in the terminology, explanatory models and techniques used in both methods. Table 2 summarizes the main features, similarities and differences. In this passage we will describe a case example of a woman with BPD and present the main strategies regulating emotions first from a DBT and then from a ST perspective.
I do not even understand myself. I guess, that is why I just cannot have a normal relationship. With my last boyfriend I had so many fights. I always thought he would leave me for another woman. I just could not trust him. I had so many rage attacks and threw things at him. And then he really left me. He said, he just could not stand it anymore….
Well, and since then, I just do not want anyone close to me anymore, besides my little sister. It just does not work with me.
If I was dead, this all would stop and I would have peace and silence. I would not feel guilty and ashamed anymore. Nobody would miss me. I tried it four times with pills, but it did not work. I really do nothing. She also suffers from disturbing intrusive memories and nightmares, where she relieves physical and emotional abuse from her father and stepmother, but also from the death of her older sister.
The sister died year-old of a heroin overdose, when Mona was 15 years. Mona feels guilty that she did not help her. He was very impulsive, violent-tempered, often shouted at us and beat us. We all had panic, when he came home. My real mother was caring and warm-hearted, but she was also afraid of him and could not protect us. She died from cancer, when I was seven. My stepmother was also addicted to alcohol. She was very moody, sometimes she was nice, but then, and you could never tell when and why, she got angry, insulted and beat us.
My elder sister was the only one, who was there for me. But when she began to take drugs, she became very unreliable and I was totally lost. She is still living with my parents. I cannot forgive myself that I left her there.
After a thorough assessment of Mona's presenting problems and her biography, the therapist educates Mona about BPD as a disorder of the emotion regulation system by using the biopsychosocial model: The precipitation factors were a history of invalidation, physical and emotional abuse by her parents in combination with a high emotional sensitivity. Mona has skills deficits in emotion regulation, in particular in dealing with grief and sadness death of mother and sister, breaking up of partner , mistrust expectations to be betrayed , anger rage attacks , guilt own behavior toward elder sister before her death, insufficient present support for her younger sister , and shame own body, being mentally ill, abusing substances, disturbed eating behavior, inactivity.
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