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Case Presentation 3 | DAY 2: 10.45 AM - 12.15 PM

Topics Include: Schema Therapy with an Enmeshed Family; Challenges of Overcoming Patterns

by Samantha Flores and Lydia Tineo

Segment 1

Title: Schema mode therapy with an enmeshed family: twins with the same underlying need showing dicothomic maladaptive coping styles

Presenter: Samantha Flores Reynoso


Mexican family, moderate level of functioning Mother: 45-year-old, accountant, now a houswife. Father: 47-year-old, accountant now a salesman. Twin 1: 24-year old, Industrial Engineer working as a Manager. Single Twin 2: 24-year old, Biology Engineer studying a Master´s degree. Single. 


Father: depresive disorder Mother: generalized anxiety disorder and panic disorder Twin 1: Panic disorder. Narcisistic personality disorder, histrinic and antisocial traits. Twin 2: Panic disorder. Dependent and Avoidant personality disorders. 

Current mayor problems 

Father Problem: doesn´t make decisions, his wife´s father does Life pattern: Doesn´t feel important to others, has no voice at home nor work. Doesn´t engage in therapy. 

Mother Problem 1: Difficulty with individuation Life pattern: Depends on her father for living, doesn´t allow daughters to make their own decisions or develop their own identities, overprotects them and decides for them in most issues. Problem 2: Anxiety Life pattern: Feels anxious about issues related to the idea of her daughters making decisions that could cause them to underdevelop or be unhappy. Worried about safety and wellbeing. 

Twin 1

Problem 1: Aggressive behavior towards family members Life pattern: When forced to do as the mother wants, she overcompensates with verbal and physical abuse. 

Problem 2: Distress in social situations Life pattern: Anxiety when feeling not sufficient in social interactions, needs to be seen, to be the most beutiful and successful. Behaves condescending and belittles others. 

Problem 3: Excessive enphasis on physical beauty Life pattern: spends a lot of money on aesthetic treatments. Panic attaks related to beauty issues. 

Twin 2 

Problem 1: Panic attaks Whenever the mother gets mad or stops talking to her. When she thinks her friends or romantic partner is getting away. 

Problem 2: Anxiety in social interactions Difficulty relating to others, meeting new people, spending time with aquitances, fear of making a mistake or being different and being rejected. 

Problem 3: Dependent and enmeshment with the mother Asks for the mother´s consent over almost everything, feels anxious and fears the mother will get angry and will abandon her. Dresses as the mother and worries when the mother worries. Thinks she should think and behave as the mother does. 

Developmental origins 

Mother enmeshed with her own father Husband (twins´father) is emotionally absent and oppressed by the wife´s father Mother enmeshes the family When born, as twins, the mother thought one ot them would be “the evil twin”, decided to raise them not allowing much time together (going to a different school and not allowing to share friends) but trying to raise them excactly as twins (same clothes, same toys, same room decoration, etc), and forcing them to love each other and show caring when spending time together. Forced them “to be both good”. 

Core childhood memories and images 

Mother: being happy as an only child, being like her mother and spending a lot of time time with her father. Father made decisions for her (carreer and husband). 

Twin 1: Mother rejected her as being “the evil twin”, forced her to love her “good” sister. Wanted her to do as she said. Forced her to dress like the sister and to have the same belongings but did not allow them to share. 

Twin 2: Not allowed her to spend time with her sister, she felt she hated her. Mother decided everything for her: what friends to have, what to do, what to wear, etc. Felt rejected by her peers at school. The mother stopped talking to her whenever she tried to do something she had not consent for. Felt lonely. 

Unmet core needs 

Mother and both twins: sense of identity, autonomy and competence 

Twin 1: Secure attachment, Realistic limits and self control 

Twin 2: Secure attachment, freedom to express valid needs and emotions Most relevant schemas related to origins and copying styles Mother: Enmeshment, vulnerability to harm and illness, dependence linked to being an only child, overprotected by the mother and enmeshed while forced to think, feel, behave and desire as her parents. Surrenders 

Twin 1: Enmeshement related to the mothers need to control, mother hindered her separated development (overcomepensates) Defectiveness as being identified as “the evil twin” not allowed to share with the sister (overcomepensates and surrenders). Emotional deprivation absence of companonship and empathy (overcomepensates). Entitlement, as a sobrecompensation for emotional deprivation Insufficient sel-control, as a sobrecompensation for enmeshment Unrelenting standars, related to beauty and social desiredness as a sobrecompensation for defectiveness and emotional deprivation,. 

Twin 2: Enmeshment related to the mothers need to control, mother hindered her separated development. Not keeping anything for her (surrenders). Dependence related to the mother making all decisions for her, overprotecting her from her “evil twin” (surrenders). Abandonment related to the mother emotionally abandoning her when she behaves in a way different to the mother´s demands. Abandoned by school peers in elementary school (surrenders). Defectiveness related to feeling there is something inherently bad in her so that not even her sister loves her nor anyone at school wants to be friends with her (surrenders and overcomepensates). Social isolation: spent elementary school and junior high school with no friends, did not spend time with the sister who was the popular in the family bacause the mother did not allow them to be togheter. Spent most of her time with the mother (surrenders) Subyugation as a surrendering coping style to avoid being abandoned and to keep the connection with the mother. Unrelenting standards related to school performance as an overcocompensation for defectiveness. 

Current schema triggers 

Mother: When any of the twins wants to do something different to what she expected. 

Twin 1: When the mother wants her to do something or not to do something she wants. When compared to others as being better than she is (a good person, more beautiful, more intelligent, etc) . 

Twin 2: When she wants something different from her mothers desires and wants. When the mother stops talking to her or when her boyfriend spends time without her. In social interactions and when doing bad at aschool. 

Relevant schema modes (besides healthy adult and happy child) 

Mother Abandoned child Demanding parent Puitive parent Manipulative Overcontroller 

Twin 1 Defective, unloved child Enraged & impulsive child Demanding & punitive parent Self agrandizer Attetion seeker Perfectionistic overcontroller Bully and attack 

Twin 2 Vulnerable child: abandoned, defective Dependent Demanding & punitive parent Compliant surrender Perfectionistic overcontroller 

Possible temperamental/biological factors 

Mother, both twins: labile, anxious, obsessive 

Twin 1: aggresive, sociable 

Twin 2: passive, shy Therapy relationship Good, at the beginning a Little difficult because twin 1 didn´t want to share therapist Treatment focuses on mode work.

Segment 2

Title: Challenges of Overcoming Patterns

Presenter: Lydia Tineo 

History and Ethiology: Marta, a 26-year-old woman, comes to the consultation for meeting the insistence of an aunt to try this new therapy. He has had depressive episodes, associated with frustrations in interpersonal relationships since adolescence, characterized by ideas of emotional deprivation (no one be there for her or care about), abandonment, emotional inhibition, self-sacrifice and high demands for achievement. These ideas convinced her that life is so hard and frustrating that it is not worth living, so she tried to commit suicide with pills three times (at 18, at 22 and at 24). At the time of the consultation is determined to do it again better than previous. Is the eldest daughter of a socially successful marriage with two daughters. Parents entrusted her with responsibility for the care and control home and her 5 years younger sister from his early childhood supplying absences for work and intense social life of them 

Diagnosis: Mixed Personality Disorder: a) Borderline: 1) frantic effort to avoid abandonment; 2) pattern of unstable and intense interpersonal relationship alternating intense idealization and devaluation; 3) unstable self-image or sense of self; emotional over impulsively spending extreme amounts of time working, neglecting her basic needs (eat, rest, sleep); 6) affective instability due to marked reactivity of mood, irritability, anxiety; 7) inappropriate, intense anger and difficulty to control it, frequent rants of temper; 7) chronic feeling of emptiness; 8) stress related paranoid ideas about “the others”. B) Avoidant PD Specific objectives of treatment: Priority Axis 1: Suicide Ideas, showing the relationship between their ideas of underlying interpersonal frustrations as drivers of previous attempts and future expectations, linked to EDT and Modes. 


Marta to discover the relationship between frustrating interpersonal conflicts and EMS and reactions of Modes at the same time that we work on suicidal ideas- Treatment plan: Agree on a No Suicide pact until finding the schemes and ways of dealing with them that hide alternative solutions to the conflict Evaluation in schema terms inside conflictive interpersonal situations using cognitive, emotional and Imaging techniques, Schema and modes identification, working on early memories to turn in new understanding and change the basis and patterns of her interpersonal relationship inside and outside family patterns Treatment progress: Neutralized ideas of suicide resulting from the dynamics of schemes and modes promote a new understanding of interpersonal conflicts. The new information about found to analyse and change her Mode reactions and schemas, starting with a crucial limited reparenting experience on emotional deprivation schema and detached protector mode, increasing more distant relationships first and gradually moving towards the most intimate ones.

  • Is it appropriate to work simultaneously with Axis I and Axis II?
  • Other options for Resolution ?
  • Limits and Scope of Limited Parentalization
  • How far have we managed to modify the Personality Structure?
  • What explanatory hypotheses about the change of structure of Personality through Scheme Therapy offers Neuropsychology today?

Why Schema Therapy?

Schema therapy has been extensively researched to effectively treat a wide variety of typically treatment resistant conditions, including Borderline Personality Disorder and Narcissistic Personality Disorder. Read our summary of the latest research comparing the dramatic results of schema therapy compared to other standard models of psychotherapy.

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