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The Schema Therapy Bulletin

The Official Publication of the 

International Society of Schema Therapy

WORKING ON THE HEALTHY MODES AND CLUSTER-C PERSONALITY DISORDER (PD) 

By Guido Sijbers Clinical Psychologist  (Netherlands) 

In this workshop Remco van der Wijngaart and Guido Sijbers presented how to work on the healthy modes in general, using a cluster C patient as example. John, a patient with an Obsessive compulsive personality  disorder (OCPD) to illustrate how to work on the healthy adult (HA) mode.

The occurrence of Cluster C PD’s is characterized by excessive anxiety, control or inhibition. They probably cohere with a combination of a genetic predisposition and environmental factors (for instance problematic parenting styles, emotional abuse in childhood and repeated negative experiences in social contacts).

Although the associated behavior with Cluster C PD is more predictable and clinicians experience less crisis driven situations, the treatment does go with specific challenges. Particularly the rigid nature of this type of Personality Disorder  can make such treatments  more frustrating endeavour for therapists than anticipated on at the at the start of treatment.

OCPD’s are characterized by an inability to accomplish a healthy balance between play and spontaneity and achievement, coming from an upbringing witch an overemphasis on control and performance. These patient can be extremely rigid and so John was a nice example to show how to use a phased approach to help a patient to work on and strengthening the healthy modes. 

We decided to show how a few steps of how to implement working specifically on healthy modes in the course of therapy

Make dysfunctional modes egodystonic

John comes into therapy with a strong identification with, what in schema therapy is called, his dysfunctional coping modes. Until he came in therapy the maladaptive coping seemed the wisest, safest and most sensible thing to do in moments of (anticipating on) stress.

The therapist, on the other hand, using the mode model, needs him to understand that there are more modes defining John. Moreover he wants John to understand that these coping modes are one of the main sources of the problems he seeks help for. One of the first goals will be to make this egosyntonic coping mode more egodystonic.

Apart from investigating and understanding the short and long term consequences of this dysfunctional coping, a lot of experiential work has to be done to also experience that his coping need to change. And typically, even if Cluster C patients even then, there often is quite some resistance to change in real life. Often leaving therapist with feelings of inadequacy and frustration.

By pointing out when a particular mode is active and allocating each one a particular spot in the room, helps the patient not only to understand but also to experience the mode model. Consequently also learning which part is the health mode. 

Remco van der Wijngaart added to this how he learns his trainees to underscore this process by the using more explicit hand waves. 

Fill in the Health Adult mode

Making dysfunctional modes egodystonic does not automatically mean that healthy attitudes and thinking is being learned.As a next step we focussed on the importance of filling in the healthy adult mode, by introducing how to distinguish different aspects of this mode and learning them in several steps.

Judith Vanhommerig, a psycho-dramatherapist participating in a phase oriented group schema therapy model, developed in Maastricht, based on the Farrell and Shaw model, designed three steps to help patients work on the HA mode already early in therapy. One of the advantages is that every step can also be practiced separately.

3 steps for filling the healthy adult mode

  1. Recognition: I see that you …. I hear that you ….
  2. Invalidate (parent mode): It’s not true that …., because…
  3. Inspire with hope: I know that you can ….., because …., you are good at …


In group therapy, patients can help each other practicing this, with each playing different roles or changing positions. 

We showed how to introduce the several steps in individual therapy. In the start the therapist can model the HA, the patient being the recipient. Later roles can be reversed or more modes can participate. The therapist can then choose to participate in the chair technique or guide the patient in the playing different sides himself.

We showed a technique, used halfway through the therapy, were John is guided to play the vulnerable child mode on the one side and the three steps of the HA mode (using three separate chairs) on the other. John, having become familiar with the three steps, practices them all tree. An important focus here is to have the patient experience the familiar feeling of inadequacy on one side, opposite to experience the HA points of view on the other and the various effects.

John in the HA chair is saying (if needed the therapist completes with suggestions):

1. “I see that you are afraid. I hear that you believe there is no room for emotions and enjoying.”

2. “It is not true that you are lazy when doing pleasant things instead of something useful; it’s impossible to always be in control; because play and spontaneity is a basic need and an important ingredient to strengthen relationships and to keep a good balance in life.”

3. “I know that you can do this, because you have been changing here in therapy, you’re not always in your controller mode and you more and more connect with your emotions; you are good in persevering, you also already changed things in your life (talk to your wife about emotions and her needs, talk about you need for connection with her).”

Strengthening the HA mode

In the last part of the cluster C therapy (behavior change) there is a stronger focus on strengthening the HA.Here we showed a videoclip were we could see how John, preparing for behavior change, is practicing imagery in the future in two steps:
1. being aware of what mode is being activated (self monitoring) when trying new behavior

2. learning to switch to the HA mode (consciously use HA mode resources).

Use of humor in a therapeutic way

Finally Remco van der Wijngaart talked about how he started to use humor in a therapeutic way to strengthen healthy modes (HA and happy child mode) and to practice new behavior with John.

Especially John needs to learn to appreciate play and spontaneity for finding a healthier life balance. Moreover does his wife need him to be more open for positive sharing.

Examples of using humor in therapy are:

- sharing funny youtube clips

- exchanging jokes

- brainstorming about what nice things he could plan with his wife

- having the patient try this outside therapy

We can imagine that for John it isn’t easy to appreciate more play and spontaneity at once. The therapist needs to explain how the patient can benefit from this and to persevere.

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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