Change Processes in Schema Therapy Treatment for Clients Diagnosed with Avoidant Personality Disorder Ofer Peled (Feldmann) Department of Psychology Ph.D. Thesis Submitted to the Senate of Bar-Ilan University Ramat-Gan, Israel April 2016 This work was carried out under the supervision of Prof. Eshkol Rafaeli Department of Psychology and Gonda Multidisciplinary Brain Research Center, Bar-Ilan University. Table of Contents Abstract___________________________________________________________ i Introduction________________________________________________________ 1 Avoidant Personality Disorder_____________________________________ 2 An Introduction to Schema Therapy_________________________________ 4 Core emotional needs________________________________________ 4 Early maladaptive schemas (EMS)_____________________________ 5 Maladaptive coping styles____________________________________ 5 Modes____________________________________________________ 6 Schema Therapy Intervention Strategies________________________________ 7 Research on Schema Therapy________________________________________ 9 Mode Models for Personality Disorders and Empirical Supportive Data_______ 10 Schema Therapy for Avoidant Personality Disorder_______________________ 11 Overall Project Design and Method____________________________________ 11 Study 1. Stability or Instability in Avoidant Personality disorder: Mode Fluctuations within Schema Therapy Sessions________________________________________ 13 Material and Method ______________________________________________ 17 Participants____________________________________________________ 17 Therapy training and procedure____________________________________ 18 Materials______________________________________________________ 18 Psychiatric diagnoses________________________________________ 18 Client's Modes Rating Scale (CMRS)___________________________ 18 Rating procedure_______________________________________________ 19 Data analysis__________________________________________________ 19 Results__________________________________________________________ 20 Mode frequency and intensity____________________________________ 20 Mode fluctuation______________________________________________ 22 Discussion_______________________________________________________ 22 Stability and instability in APD____________________________________ 23 A mode-based description of APD clients in therapy___________________ 24 The utility of the schema therapy mode concept as a lexicon for capturing personality states and their instability_______________________________ 26 The use of in-session segment-by-segment ratings to assess client change__ 27 Limitations and Summary___________________________________________ 28 Study 2. Therapist Interventions and Mode Changes within Schema Therapy Sessions for Avoidant Personality Disorder_______________________________ 29 ST for APD___________________________________________________ 30 Techniques within the ST model___________________________________ 31 Micro-analysis of therapist-client therapy processes____________________ 32 Hypotheses____________________________________________________ 33 Method_________________________________________________________ 34 Overview_____________________________________________________ 34 Participants____________________________________________________ 34 Therapy training and procedure____________________________________ 36 Materials______________________________________________________ 36 Psychiatric diagnoses_______________________________________ 36 Client's modes rating scale (CMRS)____________________________ 36 Schema therapist's interventions rating scale (STIRS)______________ 37 Rating procedure_______________________________________________ 38 Data analysis___________________________________________________ 38 Results__________________________________________________________ 41 Discussion_______________________________________________________ 43 The therapeutic stance___________________________________________ 43 Emotion-focused interventions____________________________________ 45 Relational interventions__________________________________________ 46 Cognitive interventions__________________________________________ 47 Behavioral pattern breaking interventions______________________________ 48 Schema exploration and assessment________________________________ 49 Clinical implications____________________________________________ 49 Limitations and Future Directions____________________________________ 50 Summary_______________________________________________________ 51 Study 3. Temporal Associations among Modes in Schema Therapy: A Time-Series Panel Analysis______________________________________________________ 52 The notions of self-states_________________________________________ 53 Avoidant personality disorder_____________________________________ 55 TSPA studies and idiographic analyses________________________________ 56 Method_________________________________________________________ 59 Participants____________________________________________________ 59 Therapist training and procedure___________________________________ 60 Materials______________________________________________________ 60 Psychiatric diagnoses________________________________________ 60 Client's modes rating scale (CMRS)____________________________ 61 Rating procedure________________________________________________ 61 Data analysis___________________________________________________ 62 Results and Discussion_____________________________________________ 63 Client A_______________________________________________________ 63 Client B_______________________________________________________ 67 Client C_______________________________________________________ 70 Summary and Conclusions___________________________________________ 72 General Discussion___________________________________________________ 76 Contribution to Schema Therapy Research and Practice____________________ 76 Contribution to Avoidant Personality Disorder Research and Practice_________ 81 The Promise of the Statistical Methods Used Here for Psychotherapy Research_ 82 The Mode Concept and its Utility for Psychopathology and Psychotherapy Research_________________________________________________________ 85 Limitation and Future Directions______________________________________ 86 References__________________________________________________________ 89 Appendix Client Modes Rating Scale (CMRS)___________________________________ 102 Schema Therapist Interventions Rating Scale (STIRS)____________________ 110 Hebrew Abstract____________________________________________________ ‫א‬ Tables and Figures Study 1 Table 1. Intra-Correlation for Client Modes Rating Scale (CMRS)______________ 20 Table 2. Descriptive Statistics of Clients' Modes____________________________ 21 Study 2 Table 1. Descriptive Statistics of Clients' Demographic and Diagnostic Data______ 35 Table 2. Raters' Inter Class Coefficient (ICC) for Client Modes Rating Scale (CMRS) and for Schema Therapist Interventions Rating Scale (STIRS)__________ 38 Table 3. Prevalence of Client Modes and Therapist Interventions_______________ 39 Table 4. Multilevel Regression between Therapists' Intervention and Clients' Mode 42 Study 3 Table 1. Raters' Inter Class Coefficient (ICC) for Client Modes Rating Scale (CMRS)____________________________________________________________ 62 Figure 1. Idiographic TSPA Model_______________________________________ 63 Table 2. Client A: Idiographic TSPA – Linear Trends, Auto Regressions, Cross Regressions_________________________________________________________ 64 Table 3. Client A: Idiographic TSPA – Synchronous Associations and Mode Descriptive Statistics__________________________________________________ 64 Figure 2. Client A: Idiographic TSPA Model_______________________________ 65 Table 4. Client B: Idiographic TSPA - Linear Trends, Auto Regressions, Cross Regressions_________________________________________________________ 67 Table 5. Client B: Idiographic TSPA – Synchronous Associations and Mode descriptive Statistics__________________________________________________ 68 Figure 3. Client B: Idiographic TSPA Model______________________________ 68 Table 6. Client C: Idiographic TSPA – Linear Trends, Auto Regressions, Cross Regressions________________________________________________________ 70 Table 7. Client C: Idiographic TSPA – Synchronous Associations and Mode Descriptive Statistics________________________________________________ 70 Figure 4. Client C: Idiographic TSPA Model_____________________________ 71 List of Abbreviations and Acronyms AD – Avoidant Detached Mode APD – Avoidant Personality Disorder BPD – Borderline Personality Disorder CMRS – Client Mode Rating Scale CS – Compliant Surrenderer Mode DSM - Diagnostic and Statistical Manual of Mental Disorders HA – Healthy Adult Mode MSSD – Mean Square Successive difference NPD – Narcissistic Personality Disorder OVC – Over Compensator Mode PAR – Dysfunctional Parent Mode PD – Personality Disorder RCT – Randomized Controlled Trail SCID – The Structured Clinical Interview for DSM SIDP – Structured Interview for DSM SMI – Schema Mode Inventory ST – Schema Therapy STIRS – Schema Therapist Interventions Rating Scale TAU – Treatment as Usual TSPA – Time Series Panel Analysis VC – Vulnerable Child Mode Abstract Most psychotherapy research has focused on treatment efficacy, using the common "gold standard" of randomized controlled trials (RCT) to examine pre-topost treatment changes. Despite the great advantages of this methodology, it has shortcomings in describing change mechanisms within psychotherapy. The current dissertation joins a growing number of studies focused on change processes that occur within therapy. It is the first to study in-session change processes among clients diagnosed with avoidant personality disorder (APD), and also the first to do so within the context of schema therapy (ST) treatment. Sixty sessions were randomly selected from the treatments of 15 APD clients, each treated by a different schema therapist. These sessions were divided into 5-minute segments (n=645), which were coded by independent raters on two rating scales. These scales – one assessing therapist interventions and the other assessing client modes achieved adequate-to-high interrater reliability. The rating scale data were then used in three studies, each implementing a statistical method which is relatively novel within psychotherapy research. Study 1 made use of within-session mean-square-successive-difference (MSSD) scores to assess mode (self-state) fluctuations among APD clients. It found APD clients to be characterized by relative instability. The frequency, intensity, and rate of fluctuation of each mode are described in detail and their implications for therapy are elaborated. Study 2 made use of multilevel-regression models to reveal associations among therapist interventions and client mode changes within sessions. It found that a good implementation of the therapist stance was followed by a decrease in the avoidant/detached mode and by an increase in the healthy adult mode; a good implementation of emotion-focused and relational interventions was followed by a decrease in the over-compensating mode; a good implementation of cognitive interventions was followed by an increase in the vulnerable child and the dysfunctional parent modes; and a good implementation of behavioral interventions was followed by a decrease in the dysfunctional parent modes. These findings' implications for the therapy process are described in detail. i Study 3 made use of time-series-panel-analyses (TSPA) to reveal three idiographic models of change among specific APD clients. These three distinct mode change models were chosen to demonstrate variants of APD clients that fell into (a) rigid, (b) confused, and (c) the receptive patterns. Each of these idiographic mode change models is described in detail and conclusions for specific tailored therapeutic focus are drawn. This dissertation is novel in several respects. Its focus on a micro-analytic inquiry of segment-by-segment therapy processes stands to contribute to ST research and practice in particular, and to research and practice with APD more broadly. It demonstrates the added value of the statistical methods used to psychotherapy research. And it illustrates the trans-diagnostic and trans-theoretical possibilities embedded in the mode concept to capture and measure the dynamic facets of personality, and to help guide both generic and individualized treatment strategies. ii Introduction Most psychotherapy research has focused on treatment efficacy, examining preto-post treatment changes using methods such as the randomized controlled trial (for review, see Kazdin & Blase, 2011; Stiles, Hill, & Elliott, 2015). Seligman (1995) claimed that these efficacy studies, which compare among groups under well controlled conditions (such as single diagnosis, randomization, manualized treatments, fixed number of sessions, double-blind method, etc.) are not the best way of finding out what treatments actually work because they omit too many crucial elements of what is done in the field. Indeed, as many other authors have noted, there is much less knowledge of what really works in therapy. This lacuna has led to a growing interest in studying the change processes that occur within therapy sessions (Greenberg, 2007; Gumz, Geyer, & Brähler, 2014; Kazdin & Nock, 2003; Kazdin, 2009; Pascual-Leone, Greenberg, & Pascual-Leone, 2009). This dissertation is the first to study in-session change processes among clients diagnosed with avoidant personality disorder (APD), and also the first to do so within the context of schema therapy (ST) treatment in particular. Based on segment-bysegment empirical analyses, the three studies that compose this dissertation explore APD characteristics across ST sessions (Study 1), associations between ST interventions and APD clients change (Study 2), and characteristics of three idiographic change process models based on particular APD clients (Study 3). In each of the three studies, this dissertation demonstrates the implementation of relatively novel statistical analyses within psychotherapy research: the use of meansquare-successive-differences (MSSD) to assess mode (self-state) fluctuations among APD clients (Study 1); the use of multilevel-regression models to reveal associations among therapist interventions and clients' mode changes within sessions (Study 2); and finally, the combination of descriptive statistics and time-series-panel-analyses (TSPA) to reveal idiographic models of change processes among specific APD clients (Study 3). This general introduction will begin with a review of APD, and will be followed by a broad introduction to ST. In particular, it will emphasize the possible utility of the ST mode concept for capturing and assessing dynamic facets of personality. I will then provide an overview of the three studies which comprise this dissertation, and 1 which aim to explore different aspects of both the disorder and the therapy processes that occur over the course of ST conducted with APD clients. Following the three studies, the General Discussion will focus on the contribution of these studies to ST research and practice and to the understanding of APD, and on the way they demonstrate techniques which may prove valuable in micro-analytic research on change processes in psychotherapy. Avoidant Personality Disorder APD is among the most prevalent personality disorder (PD), affecting about 1020% of patients in psychiatric clinics and 1-2% of the general population (Sanislow, Bartolini, & Zoloth, 2012; Zimmerman, Rothschild, & Chelminski, 2005). Nonetheless, this disorder has received relatively little empirical attention (Alden, Laposa, Taylor, & Ryder, 2002; Sanislow et al., 2012), possibly due to the ongoing debate about its overlap with other disorders, particularly social anxiety (see Chambless, Fydrich, & Rodebaugh, 2008). Co-morbidity is very common among APD clients. For instance, APD is present in up to 28% of individuals suffering from major depressive disorder (MDD) and up to 53% of individuals suffering from obsessive compulsive disorder (OCD) (Alden et al., 2002). Millon (1969) was the first to describe APD. According to Millon (1991), APD is a problem of relating to persons, and is distinguished from social phobia (which he sees as a problem of performing in particular situations). Moreover, individuals with social phobia may have satisfying social and personal relationships whereas people with APD are socially withdrawn, and have great trouble initiating and maintaining interpersonal relationships because of their low self esteem and their excessive need for reassurance and acceptance. DSM-IV and DSM-5 (American Psychiatric Association [APA], 2000, 2013) defined APD as a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: (1) avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection; (2) is unwilling to get involved with people unless certain of being liked; (3) shows restraint within intimate relationships because of the fear of being shamed or ridiculed; (4) is preoccupied with being criticized or 2 rejected in social situations; (5) is inhibited in new interpersonal situations because of feelings of inadequacy; (6) views self as socially inept, personally unappealing, or inferior to others; (7) is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing. APD is also characterized by avoidance of making decisions, experiencing negative as well as positive emotions, sharing intimate feelings, experiencing bodily sensations, engaging in potentially risky activities, etc. (Arntz, 2012). APD impedes occupational, educational, and social functioning, and hinders people from realizing their potential (APA, 2000; Skodol et al., 2002). People who suffer from APD tend to narrow their educational and occupational opportunities in order to reduce social contact. They tend to avoid team-work and refrain from asking for help. They are often avoidant of others who try to approach them because they are terrified of their flaws being exposed and of becoming others' laughing-stock. In short, they typically feel inferior and unlovable. A diagnosis of APD appears to raise several hurdles in psychotherapy. Clients with this disorder shy away from open and intimate relationships even with their relatives, let alone therapists who are first seen as strangers. These clients tend to reject help and feel skeptical regarding their therapists' authentic and sincere concern. Hence, therapists need to be especially attuned to these clients' sensitivity to criticism and rejection, as even neutral interventions can be perceived to be judgmental. Therapists' minor empathic failures may grow into major therapeutic ruptures due to these clients' avoidance of sharing their thoughts and feelings. It is a real challenge to develop a collaborative therapeutic relationship addressing the emotional triggers because of their tendency toward inhibition of both negative and positive feelings (Arntz, 2012). Several forms of psychotherapy have been proposed as treatment for APD. These include group behavioral treatments focusing on exposure, general social skill training, and intimacy skill training (Alden et al., 2002; Alden, 1989; Sanislow et al., 2012), as well as individual short term CBT or dynamic psychotherapy (Emmelkamp et al., 2006). Studies testing these approaches have indicated better outcomes compared to waiting lists, and better gains for CBT compared to dynamic psychotherapy, but overall the improvement for APD clients have been less than 3 satisfactory. Since APD clients often have great difficulty engaging in the therapy process, and establishing a secure therapeutic alliance, they may require or least benefit from an approach specifically tailored for working with personality disorders. One such approach is ST. An Introduction to Schema Therapy ST is an evidence-based integrative approach which has grown out of cognitivebehavioral therapy (Young, Rygh, Weinberger, & Beck, 2008). ST was developed by Jeffrey Young (Young, 1999; Young, Klosko, & Weishaar, 2003) as a treatment for clients with PDs and other difficult-to-treat patterns. ST has four basic concepts: core emotional needs, maladaptive schemas, coping styles, and modes. Core emotional needs are universal, healthy human development is thought to require adequate meeting of these needs. When these core emotion needs are inadequately met, early maladaptive schemas (which help construct meaning about oneself, others, and the world) may emerge. The activation of these schemas is often painful or distressing, and various (broad) coping styles and (more situationally-specific) coping behaviors are implemented to reduce pain and distress. Finally, in each particular moment, individuals are thought to inhabit different modes, which reflect clusters of schemas and/or coping behaviors. The following paragraphs provide more detailed description of these four basic concepts. Core emotional needs. Young and his colleagues (2003) defined five domains of universal core emotional needs that should be met across a human being's life span: (1) secure attachment to others; (2) autonomy, competence, and sense of identity; (3) freedom to express valid needs and emotions; (4) spontaneity and play; (5) realistic limits and self-control. These core emotional needs can lead to complex behaviors, at times even contradictory ones, as individuals try to find a relative balance between these needs. For instance, the need for secure attachment to others may lead to approach behaviors in the hope of maintaining relationship closeness, whereas the need for autonomy may lead to distancing behaviors which foster separation and individuation. Similarly, spontaneity and play needs may lead to behaviors guided by internal inclinations whereas realistic limits and self-control needs may foster greater assimilation to social norms. 4 A major developmental task, first tackled by parents or other caregivers but later handled by individuals themselves is the task of recognizing, addressing, and balancing these core emotional needs. Within the context of psychotherapy, this task dictates the therapist's stance – which also centers on recognizing, addressing, and balancing the needs, as a healthy parental figure would be expected to do so. This stance is premised on the idea that as long as needs are not adequately met, individuals will develop and stay attached to the lessons they learned about themselves and the world – that is, to their early maladaptive schemas. Early maladaptive schemas (EMS). Early maladaptive schemas, or in short schemas, are relatively constant prisms through which a person interprets internal cues as well as external events. Each schema contains memories, bodily sensations, cognitions, and affects. Schemas emerge from repetitive toxic interactions with significant others such as parents, siblings, relatives, mentor figures, and peers, as well as with the broader social and cultural environment. Young et al. (2003) grouped the 18 schemas they identified into 5 groups, each related to a different core emotional need domain. The disconnection and rejection group, tied to the domain of inadequately handled secure attachment needs, contains the abandonment/instability, mistrust/abused, emotional deprivation, defectiveness/shame, and social isolation/alienation schemas. The impaired autonomy and performance group, tied to the domain of inadequately handled autonomy, competence, and sense of identity needs, contains the dependence/incompetence, vulnerability to harm or illness, enmeshment/undeveloped self, and failure schemas. The other-directedness group, tied to the domain of inadequately handled needs for freedom to express valid needs and emotions, contains the subjugation, self-sacrifice, and approval/recognition seeking schemas. The over-vigilance and inhibition group, tied to the domain of inadequately handled spontaneity and play needs, contains the negativity/pessimism, emotional inhibition, unrelenting standards/hypercriticalness, and punitiveness schemas. And finally, the impaired limits group, tied to the domain of inadequately handled needs for realistic limits and self-control, contains the entitlement/grandiosity and the insufficient self-control/self-discipline schemas. Maladaptive coping styles. The maladaptive coping styles determine ones' behavior when schemas are triggered. According to Young, there are three 5 maladaptive coping styles (avoidance, over-compensation, and surrender) in order to reduce emotional pain and distress related to schema activation. The avoidance style involves avoidance of triggering situations; typical avoidance behaviors are disconnection, dissociation, distancing, isolation, distraction, excitement seeking, etc. The over-compensation style involves fighting with or denying the schema; typical over-compensating behaviors are self aggrandizement, attention seeking, condescension, competitiveness, bulling, perfectionism, etc.. The surrender style involves coping with the schema activation in passive compliant ways; typical surrender behaviors are subjugation, self-depreciation, obedience etc. All three maladaptive coping styles aim to reduce distress in the short term, but unfortunately, tend to perpetuate and keep people imprisoned by their schemas in the long term. This occurs because the coping styles drive people away from getting their core emotional needs met. Modes. Whereas the needs, schemas and coping styles are considered relatively stable or trait-like components of personality, Young et al. (2003) added the concept of modes to describe transient emotional states characterizing a person's personality. Indeed, several contemporary personality theories emphasize the contextual nature of personality (e.g., Dunlop, 2015; Fleeson, 2007). Fleeson (2007) has demonstrated that individuals manifest different trait contents in their behavior at different moments. Dunlop (2015) has argued that these self-state reflect self-representations operating within specific times and contexts, each with its own autobiographical memory and narrative. Similarly, different clinical theories (Bromberg, 1996; Greenberg, 2004; Stone & Stone, 2011) have developed similar contextual models that emphasize the multiplicity of self-states, and that focus their intervention on working with these states. In ST the mode concept was originally introduced (Young et al., 2003) so as to capture the emotional instability characteristic of individuals with personality disorders reflected by rapid changes in behaviors, cognitions, and feelings. Importantly, we now recognize the presence of modes in all people, not only those with personality disorders. Modes are transient; thus, at any given moment, a person is thought to be predominantly in one particular mode, which serves as the stance from which the person acts. Each mode involves some emotional state, typical 6 cognitions, and characteristic behaviors activated at a given moment. There are four mode categories in ST: (1) Child modes, which reflect a regression into intense child-like emotional states (of vulnerability, impulsivity, anger, or playful contentedness), (2) Maladaptive coping modes, which enact protective or defensive behaviors, (3) Dysfunctional parent modes, which echo negative aspects of internalized objects such as punitive and critical stance, which attack the person from within, and (4) The healthy adult mode, which reflects the positive aspects of the person's internalized objects and helps in attaining appropriate need fulfillment, and in regulating emotions and behaviors in one's relationships and life events. Modes can trigger one another and appear in varying strengths and orders. They are triggered in reaction to changes in the environment or internal cues that are linked to one's core oversensitive issues. Young et al. (2003) identified ten different modes (and subsequently, others have expanded this list to include over 20 mode; Bamelis, Renner, Heidkamp, & Arntz, 2011; Bernstein, Arntz, & Vos, 2007), but these continue to fall into the four categories described above. Schema Therapy Intervention Strategies Psychotherapy integration, as Clarkin, Cain, and Lovesley (2015) recently note, "is the unique combination of domains of dysfunction matched with modules of intervention that are applied in a particular sequence over time" (p. 4). In that sense ST is an integrative form of psychotherapy combining cognitive, behavioral, psychodynamic object relations, attachment, and gestalt approaches, with various modules of interventions addressing the clients' self-states. The goal of all ST interventions is to help clients find adaptive ways to meet their core emotional needs. The therapy course is based on three main phases. The first phase focuses on assessment processes, case conceptualization and psychoeducation regarding the clients' current problems and their links to the unmet core emotional needs, prominent schemas, coping styles and cycles of mode activations which perpetuate the clients' problems. In this phase the cognitive interventions take the lead. When implementing such interventions, the therapist identifies core emotional needs, schemas, modes, and life patterns; educates the client and conceptualizes the client's problems in schema terms; and links them to their past 7 origins. Additionally, the therapist may use other techniques drawn from cognitive therapy (e.g., reframing, listing pros and cons to refute schemas, building a strong rationale against the schemas, conducting schema vs. healthy adult dialogues, and composing flashcards or diaries). The second phase of ST focuses on processing and on change techniques that blend cognitive, experiential, behavioral, and interpersonal strategies to heal the clients. The therapeutic relationship is shaped according to the clients' modes and schemas which focus the therapist on the specific core emotional needs that are most prominently unmet at the moment, and that could be met more adequately within the therapeutic relationship. Special attention is given to emotional processing of painful memories and to creating corrective emotional experiences. In this phase, the experiential (emotion-focused) interventions take the lead. When implementing these interventions, the therapist asks the client to refer to childhood memories as if they are happening 'here-and-now' in order to activate the client's emotions and to supply corrective experiences. Emotion-focused interventions include imagery rescripting, chair work, historical role play etc. The third phase of ST focuses on strengthening adaptive coping behaviors consolidated during the second phase, generalizing them in the clients' actual relationships, addressing relapse prevention, and tapering off therapy toward termination. In this phase the behavioral interventions take the lead. When implementing such interventions, the therapist guides the client in handling daily-life triggering situations by teaching and rehearsing interpersonal skills, conducting roleplays, gradual exposures, behavioral experiments, assigning homework, and encouraging life changes. Throughout the course of therapy the therapist implements two other sets of interventions: relational interventions and therapist stance interventions. Relational interventions are implemented when schemas, coping styles, or modes are activated by the therapy relationship itself. Through cognitive restructuring, self disclosure, and behavioral rehearsal relating to enactments of "here-and-now" activations the therapist make use of the therapeutic relationship itself to promote further change. Interventions based on the therapist stance (T-stance) are implemented in order to partially meet the patient's core emotional needs. These interventions include the 8 use of limited reparenting and empathic confrontation; the therapist’s attunement; the degree to which the therapist maintained a collaborative focus in the segment and/or obtained the client’s feedback; the therapist’s balance and flexibility; and the therapist’s confidence and ease in the role. Especially limited reparenting and empathic confrontation were defined by Young et al. (2003) as the core features of the therapy relationship that is considered as the "base" through which all other change agents are delivered Research on Schema Therapy ST emerged during the 1980s. In its first two decades, most of the work within it was theoretical. In contrast, the last decade has brought growing empirical evidence for the theoretical components and the effectiveness of the therapy itself. First, several studies have documented the validity of schema inventories (and later on, mode inventories; Hawke & Provencher, 2012; Lobbestael, van Vreeswijk, Spinhoven, Schouten, & Arntz, 2010; Lobbestael, Arntz, Lobbes, & Cima, 2009; Lobbestael, van Vreeswijk, & Arntz, 2007; Schmidt, Joiner Jr, Young, & Telch, 1995; Soygut, Karaosmanoglu, & Cakir, 2009; Trip, 2006; etc.). As a group, these studies support the schema and mode models, although they failed to fully support the classification of schema domains suggested by Young (e.g., 1990). Other studies have tested the idea that certain schemas and modes would be typical of individuals with particular disorders. For example, Lobbestael et al. (2010) investigated the modes characteristic of individuals with Axis I disorders, Axis II disorders, and of nonclinical control participants. For most modes, Axis I patients had significantly higher scores than nonclinical controls but lower scores than personality disordered patients. Similarly, Hawke & Provencher (2011) reviewed studies exploring the schemas characteristic of anxiety and mood disorders. They found distinct associations between specific EMSs and mood disorders (major depressive and bipolar disorders) as well as anxiety disorders (panic, agoraphobia, social phobia, obsessive-compulsive and post-traumatic stress disorders). Pugh (2015) recently published a comprehensive review of ST in eating disorders, which documented distinct profiles of EMSs for different subtypes of eating disorders (e.g. restrictive anorexia, binge-purging anorexia, and bulimia). 9 Most importantly, recent years have brought with them several studies documenting the treatment efficacy and effectiveness of ST, for a range of clinical disorders, including anxiety, depressive, eating disorders, substance-abuse, borderline and other personality disorders (for reviews: Hawke & Provencher, 2011; Masley, Gillanders, Simpson, & Taylor, 2012). The majority of these studies examined individual treatments (Bamelis, Evers, & Arntz, 2012; Bamelis, Evers, Spinhoven, & Arntz, 2014; Bernstein et al., 2012; Giesen-Bloo et al., 2006; Nadort et al., 2009; Spinhoven, Giesen-Bloo, Van Dyck, Kooiman, & Arntz, 2007; van den Broek, Keulen-de Vos, & Bernstein, 2011), but others have found impressive results for group interventions as well (Farrell, Shaw, & Webber, 2009; Gude & Hoffart, 2008; Hoffart Lunding & Hoffart, 2014; Koepke & Denissen, 2012; Renner et al., 2013; Skewes, Samson, Simpson, & van Vreeswijk, 2014; Vreeswijk, Spinhoven, Eurelings-Bontekoe, & Broersen, 2014). Mode Models for Personality Disorders and Empirical Supportive Data In recent years, ST has progressed toward disorder-specific mode models, which have received considerable empirical support with regards to several personality disorders. Young et al. (2003) were the first to develop mode models for borderline personality disorder (BPD) and narcissistic personality disorder (NPD). Arntz, Klokman, and Sieswerda (2005) were the first to empirically support Young's mode models for BPD. Bernstein, Arntz, and Vos (2007) developed a mode model for antisocial personality disorder, and Lobbestael, Arntz, and Sieswerda (2005) tested the applicability of the mode model to BPD and to antisocial personality disorder. Lobbestael, Van Vreeswijk, and Arntz (2008) assessed the relationships between the schema modes and all 10 PDs. The results indicated unique profiles for all PDs and supported the construct validity for the mode model. Bamelis et al. (2011) formulated schema mode models for cluster C, paranoid, histrionic and narcissistic personality disorders, based on empirical data. Later on, she and her colleagues (Bamelis et al., 2014) conducted a large-scale RCT study comparing the effectiveness of ST with that of clarification-oriented psychotherapy and of TAU in addressing various PDs (other than BPD). ST was found to have greater recovery rates and lower dropout rates. Importantly, over 60% of the clients in this study were ones who had 10 APD. Schema Therapy for Avoidant Personality Disorder Arntz (2012) developed a ST protocol for Cluster C personality disorders, with particular recommendations for the treatment of APD. These included a focus on low self esteem, inferiority, and inadequacy feelings as well as on the avoidant behaviors themselves. The schema mode model underlying this protocol suggested that clients with APD will be characterized by seven modes: lonely/inferior child, abandoned/abused child, avoidant protector, detached protector, compliantsurrenderer, punitive parent, and (a relatively weak) healthy adult. In a study using the schema-mode-inventory (SMI; SMI-2), clients with APD were found to be characterized by the following modes: abandoned/abused, lonely, angry and undisciplined child modes; compliant surrenderer, detached protector, detached selfsoother, avoidant protector, and suspicious over-controlling compensator coping modes; and punitive and demanding dysfunctional parent modes (Bamelis et al., 2011; Lobbestael et al., 2008). The current dissertation uses data obtained in an open trial based on Arntz's (2012) protocol for APD, to explore psychotherapy processes. It places particular emphasis on the assessment of modes within therapy sessions, and uses these assessments to explore the following three topics: (1) the frequency, intensity, and stability of modes among clients with APD; (2) the associations between therapist interventions and client mode changes; and (3) the existence of idiographic dynamic models of change among different clients. These topics form the three studies which appear below. Before turning to these studies, I devote the following section to describing the design and method of the overall project on which these studies are based. Overall Project Design and Method Overview. The data reported in the three studies which compose this dissertation come from an open-trial study of ST for APD. Fifteen clients were treated (each by a different therapist). On average, clients received 41.3 sessions (ranging from 4-97). Four clients (26.6%) dropped out (after 4, 20, 28, and 30 sessions, respectively). All sessions (N=439) were audio-recorded. Of these, 20 sessions were 11 randomly sampled from each of 3 stages in the therapy: Stage 1 (beginning, sessions 1-10), stage 2 (middle, sessions 11-30), and stage 3 (ending, sessions 31-end). The resulting 60 recordings were subsequently coded on a segment-by-segment basis, using 5-min segments (N=645). The selected sessions were coded twice – first for the clients’ modes, then for the therapists’ interventions. The coding was made on two rating scales developed in our lab by Mittelman-Kirshenfeld (2012): the client's modes rating scale (CMRS) and the schema therapist's interventions rating scale (STIRS), which are described in the Studies' method sections. In Study 1 ('Stability or Instability in Avoidant Personality Disorder: Mode fluctuations within schema therapy sessions') the CMRS was used to obtain segmentby-segment ratings of the presence and intensity of each mode. In Study 2 ('Therapist interventions and mode changes within schema therapy sessions for avoidant personality disorder'), both the CMRS and the STIRS were used to examine the associations between therapists' interventions and clients' mode changes. In Study 3 ('Temporal associations among modes in schema therapy: A time-series panel analysis'), the CMRS data was analyzed using time-series-panel-analyses (TSPA) to construct three distinctive idiographic models of mode change for APD clients. 12 Study 1 Stability or Instability in Avoidant Personality Disorder: Mode Fluctuations within Schema Therapy Sessions Instability is one of the common facets of personality disorders (PDs) (APA, 2013). It encompasses fluctuations in affect, behavior, cognition, and interpersonal relations (Dimaggio, Nicolò, Semerari, & Carcione, 2013). The most common form of instability recognized and studied to date is emotional lability, which is defined as instability of intense emotional experiences or moods which are easily aroused. Emotional lability is often attributed to difficulties in emotional regulation, and these are a common target of most evidence-based models for the treatment of PDs such as mentalization based treatment (Bateman & Fonagy, 2006), dialectical behavioral therapy (Linehan, 1987), transference focused psychotherapy (Levy et al., 2006) and schema therapy (Young et al., 2003). In addition, emotional lability is a possible predictor of therapy outcome (Dimaggio et al., 2013; Newton-Howes, Clark, & Chanen 2015). Importantly, as these authors and others have noted, the role of emotional lability or other forms of instability in personality disorders has been studied extensively only with regards to borderline personality disorder (BPD); research regarding its role in other PDs remains quite sparse (Dimaggio et al., 2013; Newton-Howes et al., 2015). One disorder within which the concept of instability merits further attention is avoidant personality disorder (APD; see Snir, Bar-Kalifa, Berenson, Downey, & Rafaeli, 2015). APD is among the most prevalent personality disorders, affecting about 10-20% of patients in psychiatric clinics and 1-2% of the general population (Sanislow et al., 2012; Zimmerman et al., 2005). Nonetheless, it has received relatively little empirical attention (Alden et al., 2002; Sanislow et al., 2012), possibly due to the ongoing debate about its overlap with other disorders, particularly social anxiety (see Chambless, Fydrich, & Rodebaugh, 2008). People with APD are socially withdrawn, and have great trouble initiating and maintaining interpersonal relationships because of low self-esteem and an excessive need for assurance or acceptance. They often avoid making decisions, refrain from sharing intimate feelings, and go to great lengths to avoid experiencing intense bodily sensations as well as positive or negative emotions (Arntz, 2012). APD impedes occupational, 13 educational, and social functioning, and hinders people from realizing their potential. APD is associated with severe dysfunction and subjective distress, at a level comparable to that of BPD (Wilberg, Karterud, Pedersen, & Urnes, 2009). Though individuals with APD often display negative affectivity – particularly intense feelings of anxiety, nervousness, and panic (APA, 2013), only a handful of studies have examined instability – affective or otherwise - in APD. It appears that this client population is often assumed to be an exaggeration of normal personality (Alden et al., 2002), quite stable, and restricted behaviorally, to the strategy of avoidance. Studies that have considered instability in APD have typically compared it to that found in individuals with BPD or in healthy controls. Herpertz et al. (2000) found few differences between individuals with APD, BPD, or healthy controls in either self-reported or psychophysiological reactivity to emotional pictures. In contrast, results from an fMRI study (Koenigsberg et al. 2014) indicated that whereas healthy participants habituated to negative emotional pictures, neither BPD nor APD participants did; additionally, the failure to increase neural activity in certain brain structures was associated with greater affective instability among both BPD and APD participants. Recently, a daily diary study (Snir et al., 2015) found APD participants to show greater temporal instability in negative affect compared to the healthy controls, though less temporal instability compared to BPD participants. As noted earlier, a common focus of the studies addressing instability in APD, and most of the studies addressing it in BPD and other disorders (e.g. Henry et al., 2001; Hollander, Pallanti, Allen, Sood, & Rossi, 2005; Koenigsberg et al., 2002; Miller & Pilkonis, 2006) has been that of emotional lability. Yet instability can manifest itself in other phenomenological aspects. Indeed, as recent advances in personality psychology (Dunlop, 2015; Fleeson, 2007; Mischel & Shoda, 2010) have illustrated, personality itself – including traits, goals, and even life-narratives, is often contextual. These contextualized "selves" or parts of an individual's personality are, by definition, state-like. The identity of these states, and the shifts between them, may be just as important as the fluctuations in emotions or core affect. To be able to discuss fluctuations among self-states as a clinical phenomenon, we must adopt a clinical view of the self as multi-faceted. Several clinical theories adopt such a view (e.g., Bromberg, 1996; Greenberg, 2004; Stone & Stone, 2011). 14 One theory that offers a promising approach for mapping the multi-faceted terrain of the self is schema therapy (ST; Edwards & Arntz, 2012; Young et al., 2003), and particularly, the way in which ST has come to view and work with the multiplicity of selves through the concept of modes. The mode concept was developed by Young et al. (2003) in order to capture the instability reflected by rapid changes in behaviors, cognitions, and feelings of clients with personality disorders. A mode is said to reflect the individual's cognitive, emotional, and behavioral state at a given moment. Each mode has its own typical thoughts, emotions, and behaviors - in other words, its unique combination of schemas and coping strategies. We can anticipate the way an individual will think, feel, and act when a specific mode becomes active in a given moment, and we can often predict the interpersonal responses that this mode will elicit in others. For instance, when an APD client who is painfully eager for an emotional connection reverts into an avoidant mode (e.g., by declining a social invitation and instead opting for an evening of internet gambling) they may temporarily feel emotional relief and have some reprieve from the onslaught of self-critical automatic thoughts; interpersonally, the repeated activation of this mode is likely to turn others (e.g., the friend who extended the invitation) away in the long run. According to ST (Young et al., 2003), all individuals inhabit several modes over time. They differ, however, both in the identity of these modes, and in the manner in which they shift from one mode to another – that is, in the degree of integration or dissociation between the modes. In terms of their identity, modes fall into four categories. Some modes reflect a sort of regression into intense child-like emotional states (child modes; e.g., the lonely/inferior child); others have a self-protective function (maladaptive coping modes; e.g., the avoidant protector mode); still others reflect negative aspects of internalized object relations (dysfunctional parent modes; e.g., the critical parent mode); and one reflects the positive aspects of the internalized object relations (the healthy adult mode). These four categories can be (and have been) further divided, with more and more specific modes identified as ST is applied to various patient populations (Bernstein et al., 2007; Gross, Stelzer, & Jacob, 2012; Lobbestael et al., 2008; Lobbestael et al., 2007) 15 In terms of the fluctuation between modes, individuals can be thought of as falling on a continuum. For those on one end, modes could be like transient moods (e.g., one may feel a bit anxious early in the day, but gradually feel more content and energetic as the day progresses) which fluctuate in a relatively healthy way, maintaining a sense of consistent selfhood, an overarching "I". For those at the other end, extreme separation and dissociation among modes can lead to very fragmented senses of self, with each mode presenting as a different personality – i.e., distinct and seemingly unrelated "I"s – which may characterize various forms of severe psychopathology (Rafaeli, Maurer, Lazarus, & Thoma, 2016). Theoretically, some disorders (e.g., BPD) are characterized by sudden and abrupt shifts between modes whereas others (e.g., obsessive compulsive personality disorder) are characterized by greater rigidity (Lobbestael et al., 2007). To date, however, few studies have investigated mode shifts or fluctuations. Most studies on modes, their shifts, or their fluctuations have relied on clients' self report inventories, such as the Schema Mode Inventory (SMI; Arntz et al., 2005; Bamelis et al., 2011; Lobbestael et al., 2008). Arntz et al. (2005) and Lobbestael et al. (2008) were the first to provide evidence for the construct validity of the mode model as well as for unique mode profiles of specific PDs. Similar contributions were made by (Bamelis et al., 2011). Several studies have gone beyond self-report measures of modes. In an experimental test of the mode concept, Arntz et al., (2005) demonstrated that a stressinducing situation (viewing an emotionally distressing film clip) led to greater increases in the detached protector mode among BPD patients compared to healthy control participants or to patients with other PDs. In an experience-sampling study conducted in our lab, Shafran et al. (2016) examined mode fluctuations in the daily lives of participants from 3 different groups: individuals with APD, BPD, and healthy controls. Participants completed electronic diaries up to 5 times a day for three weeks. No significant differences were found in the identity or intensity of the modes typical for BPD and APD, except for the dominance of the angry child mode in the BPD group. Additionally, although the BPD group showed the greatest amount of mode fluctuation, the APD group also showed a moderate amount of mode fluctuation, and both clinical groups showed more fluctuation than the healthy control one. The minimal differences between the BPD and APD groups highlight the possible 16 similarity in the two disorders' intrapsychic dynamic, even when their behavioral manifestations (e.g., the greater instability and greater anger in BPD) set them apart. To date, only one study has used psychotherapy data to operationalize and examine modes. van den Broek, Keulen-de Vos, & Bernstein (2011) used videotaped sessions of psychotherapy conducted with forensic clients who were randomly assigned to ST or TAU. Independent raters reviewed entire sessions and used the Mode Observation Scale (MOS) to rate the degree to which each mode was present in the session. ST was found to evoke more child modes than TAU as well as a greater frequency of healthier emotional states, especially when art therapy techniques were used alongside verbal techniques. The current study examines the frequency, intensity, and fluctuation patterns of modes over the course of ST sessions among APD clients who took part in an opentrial treatment study (which followed a protocol developed by Arntz, 2012). It is the first to use segment-by-segment in-session data to examine modes. Sixty sessions, randomly sampled out of 439 audiotapes obtained from the psychotherapy of 15 clients, were each coded by two raters. These sessions yielded 645 five-minute segments. We analyzed mode fluctuations by using mean-squared-successivedifferences (MSSD; von Neumann, Kent, Bellinson, & Hart, 1941), an index which takes into account both variability and temporal instability. This method has been the recommended method for exploring fluctuations in psychopathology (Ebner-Priemer, Eid, Kleindienst, Stabenow, & Trull, 2009) and psychotherapy (Tryon, 1982). Material and Method Participants. Clients who met criteria for APD were recruited from two sites: a university-based community mental health center and a student counseling center. Both clinics offer low-cost psychological treatment carried out by postgraduate interns (who take part in a joint clinical psychology internship program). After a screening intake by the clinics’ staff, clients with avoidant features were given the option to take part in the open-trial study of ST, which required a more detailed intake process. Of the 23 clients who consented to participate, 15 (CMHC: N=9; SCC: N=6) were found to meet the criteria for APD (using the Structured Interview for the DSMIV; Pfohl, Blum, & Zimmerman, 1997) and were included in the treatment trial. Exclusion criteria were: 1. Borderline personality disorder (BPD) 2. Cluster A 17 personality disorder 3. Psychotic disorder 4. Substance-related addictive disorder 5. Asperger’s syndrome. 6. Severity of symptoms that required in-patient treatment. Of the 8 clients excluded from the study, 2 did not met APD criteria, 2 met BPD criteria, 1 met asperger’s syndrome criteria, and 3 chose to withdraw for unknown reasons. Therapy training and procedure. The therapists were trained in ST by two senior clinical psychologists certified as trainers and supervisors in ST. All therapists were clinical psychology interns. The therapists participated in a 2-day ST workshop which combined didactic as well as dyadic role-play exercises on mode work. Each therapist received 45 minutes of individual ST supervision once every 2-3 weeks alongside a 90-minute group ST supervision meeting once a week. The clients received weekly (50-60 minute) individual therapy sessions; when needed, these were augmented by telephone, text, or email contact outside of session. On average, clients received 41.3 sessions (ranging from 4-97). Ten clients completed therapy (at times somewhat earlier than ideal, due to the interns’ training schedule: range 23-97 sessions); one was still in therapy; four (26.6%) dropped out (after 4, 20, 28, and 30 sessions, respectively). Materials. Psychiatric diagnoses. The Structured Clinical Interview for DSM–IV Axis I Disorders (SCID-I; First, Gibbon, Spitzer, & Williams, 1996) and the Structured Interview for DSM–IV Personality (SIDP-IV; Pfohl, Blum, & Zimmerman, 1997) were used to establish diagnoses and ensure the meeting of inclusion criteria. Both are widely used interviews; the reported reliability for SCID-I is kappa >0.6 (Williams et al., 1992). The reported reliability for any PD on SIDP-IV is good (kappa = 0.77) and for Cluster C even better (kappa = 0.87) (Zimmerman et al., 2005). Client’s Modes Rating Scale (CMRS). The CMRS was developed in our lab (Mittelman-Kirshenfeld, 2012) to observe and rate the presence and intensity of clients’ modes and schemas within therapy sessions. This rating instrument was modeled on Callaghan, Follette, Ruckstuhl, and Linnerooth's (2008) coding system for functional analytic psychotherapy (FAPRS), a system which allows coding both therapist and client behaviors during the therapy session. In the current study we used data obtained from the first section of the CMRS in which raters are asked to note the presence and intensity of client modes on a 4 point Likert scale (0-not present, 1-moderately present, 2-present, 3-clearly present). These ratings are provided for every 5-minute segment of the session; thus, a 50-minute 18 session will have 10 segments. Ratings were obtained for 16 modes thought to be prevalent in APD (Lobbestael et al., 2008). These included 7 Child Modes (Angry, Impulsive/Undisciplined, Happy, Abandoned/Abused, Dependent, Lonely/Inferior, and an additional category of Vulnerable Child Not Otherwise Specified [NOS]), 6 Maladaptive Coping Modes (Compliant-Surrenderer, Detached Protector, Avoidant Protector, Perfectionist/Over-controller, Self-Aggrandizer, and an additional category of Over-compensator NOS), 2 Dysfunctional Parent Modes (Punitive-Critical and Demanding Parent) and a Healthy Adult mode. Rating procedure. Eight raters were trained by 2 clinical psychologists who are certified trainers and supervisors in ST (OP and ER). All raters were graduate students in clinical psychology. They received 6 hours of training on the CMRS. The raters worked in pairs. Each pair of coders used the CMRS to code an entire session (segment-by-segment). During the coding, each successive 5-minute segment was played, and each rater provided their independent scores. In case of rater discrepancies, the raters listened to the segment once again and reached a consensus rating. The initial ratings (prior to reaching consensus) were used to compute inter-rater agreement (using Intra-Class Correlation, or ICC), across the 645 5-min segments obtained from 60 randomly sampled sessions out of 439 audiotaped sessions of 15 clients. The ICC estimates ranged from good to excellent across the different modes (Table 1). Data analysis. The clients’ mode ratings from the CMRS were reduced from 14 separate mode scores into 6 mode variables. When multiple mode ratings were combined into a single score, the MAX function was used. The variables retained were (1) Dysfunctional Parent (PAR; composed of the Punitive/Critical and Demanding Parent scores). (2) Over-Compensator (OVC); composed of the Perfectionist/Over-controller, Self-Aggrandizer, and Over-Compensator NOS scores). (3) Avoidant/Detached Protector (AD; composed of the Detached Protector and Avoidant Protector scores). (4) Compliant-Surrenderer (CS). (5) Vulnerable Child (VC; composed of the Abandoned/Abused, Dependent, Lonely/Inferior, and Vulnerable Child Not Otherwise Specific [NOS] scores). (6) Healthy Adult (HA). Because the Happy, Angry, and Impulsive/Undisciplined Child modes were quite rare in the coded sessions, we excluded them from analyses. 19 Table 1 Intra-Class Correlation for Client Modes Rating Scale (CMRS) CMRS – Client modes rating scale Agreement ICC (n=60) MODE ICC MODE ICC Abandoned/abused child (AAC) .74 Detached protector (DP) .94 Dependent child (DC) .78 Avoidant protector (AP) .82 Lonely/inferior child (LIC) .83 Perfectionist/over-controller (PO) .80 Vulnerable child NOS (VCN) .71 Self–aggrandizer (SA) .74 Angry child (AC) .84 Over-compensator NOS (OCN) .68 Impulsive/undisciplined child (IUC) .74 Punitive/critical parent (PCP) .79 Happy child (HC) .75 Demanding Parent (DEP) .69 Compliant-surrenderer (CS) .77 Healthy adult (HA) .79 Results Mode frequency and intensity. We assessed the frequency and the mean intensity of each measured mode across all segments. These are presented in Table 2. A series of one-sample t-tests indicated that each of the modes was present at a level significantly different from zero. A series of paired t-tests was used to examine differences in intensity levels between each pair of modes. The avoidant/detached mode was the most frequent (and most intense), and differed significantly from all other modes: the vulnerable child mode (t[14]= 2.59, p<0.05), the dysfunctional parent mode (t[14]= 4.91, p<0.001), the compliant-surrenderer mode (t[14]= 7.09, p<0.001), the over-compensator mode (t[14]= 4.75, p<0.001), and the healthy adult mode (t[14]= 6.55, p<0.001). The avoidant/detached mode was present in 74% of the therapy segments; moreover, in 52% of the segments it was at least of medium 20 intensity (≥2 on a 0-3 scale). The vulnerable child mode was the second most frequent (or intense) mode, and its intensity also differed significantly from all other modes: the dysfunctional parent mode (t[14]= 3.46, p<0.01), the over-compensator mode (t[14]= 3.00, p<0.01), the compliant-surrenderer mode (t[14]= 4.61, p<0.001), and the healthy adult mode (t[14]= 4.18, p<0.001). The vulnerable child mode was present in 58% of the therapy segments (with 29% of the segments of at least medium intensity). Table 2 Descriptive Statistics of Clients' Modes Mode Frequency Mode (% ) M SD One level≥2 t-test Mean MSSD SD (MSSD) Significance of MSSD a (%) 1.PAR 40.16 18.76 0.60 0.31 7.52*** 0.95 0.59 6.25*** 2.OVC 33.02 13.18 0.57 0.45 4.91*** 0.74 0.50 5.65*** 3.AD 73.64 51.94 1.41 0.41 13.46*** 1.14 0.34 13.12*** 4.CS 33.64 15.50 0.44 0.29 5.84*** 0.70 0.41 6.58*** 5.VC 58.29 28.68 0.91 0.44 8.02*** 0.99 0.43 8.90*** 6.HA 34.11 8.53 0.38 0.26 5.79*** 0.48 0.30 6.12*** Note. Client modes: PAR = dysfunctional parent; OVC = over compensator; AD = avoidant detached; CS = compliant surrenderer; VC = vulnerable child; HA = healthy adult; Frequency of mode = % of segments; Mode level ≥2= % of the segments; M = mean of mode intensity (0-not present, 1-moderately present, 2-present, 3-clearly present); SD= standard deviation of M; †=<.10; a Significance of MSSD is based on one sample t-test (df=14); * = p<.05; ** = p<.01; *** = p<.001 The third most frequent mode, the dysfunctional parent mode, differed in its intensity significantly from the healthy adult mode (t[14]= 3.02, p<0.01). The dysfunctional parent mode was present in 40% of the therapy segments (with 19% of the segments of at least medium intensity). The healthy adult, compliant-surrenderer, and the over-compensator modes were the least present modes with no significant differences of intensity among them. The healthy adult mode was present in 34% of the therapy segments (with 9% of the 21 segments of at least medium intensity). The compliant-surrenderer mode was present in 34% of the therapy segments (with 16% of the segments of at least medium intensity). The over-compensator mode was present in 33% of the therapy segments (with 13% of the segments of at least medium intensity). Mode fluctuation. To test the extent to which each of the six modes fluctuated from segment to segment within the session, we calculated the mean squared successive difference (MSSD) for each mode. The averages and standard deviations of these MSSD scores across the 15 clients are presented in Table 2. A series of onesample t-tests indicated that each of the modes fluctuated to a significant degree. A series of paired t-tests was used to examine differences in fluctuation levels between each pair of modes. The avoidant/detached mode showed the greatest amount of fluctuation, and differed significantly from the over-compensator mode (t[14]= 2.32, p<0.05), the compliant-surrenderer mode (t[14]= 3.18, p<0.01) and the healthy adult mode (t[14]= 6.33, p<0.001). The healthy adult mode showed the least amount of fluctuation, and differed significantly from the over-compensator mode (t[14]= 2.21, p<0.05), the dysfunctional-parent mode (t[14]= 3.03, p<0.01), and the vulnerablechild mode (t[14]= 4.25, p<0.001), as well as the compliant surrenderer mode, at a trend level (t[14]= 1.94, p<0.10). Finally, the vulnerable-child mode fluctuated more than the compliant-surrenderer mode, at a trend level (t[14]= 1.91, p<0.10). Discussion The current study aimed to characterize the instability of APD clients by measuring the frequency, intensity, and fluctuation patterns of the typical modes (selfstates) thought to characterize this population. Six modes (the dysfunctional parent, the over-compensator, the avoidant/detached protector, the compliant-surrenderer, the vulnerable child, and the healthy adult) were rated, by two independent raters, over 645 segments drawn from 60 schema therapy sessions. The results indicated that the avoidant/detached mode was the most frequent and intense mode, and showed the greatest amount of fluctuation; the vulnerable child mode was the second most frequent and intense mode, and fluctuated more than the healthy adult and the compliant-surrenderer modes; the dysfunctional parent mode was the third most frequent and intense mode, and fluctuated more than the healthy adult mode; and finally, the healthy adult mode, though not less frequent than the over-compensator or 22 the compliant-surrenderer, did show the least amount of fluctuation. This study offers several innovations, which should be of interest to those interested in schema therapy and/or avoidant personality disorder in particular, but may also be of interest to the broader psychotherapy research community. First, as noted above, it documents the considerable instability characteristic of APD clients. Second, it offers rich data regarding the mode-based description of APD, and notes the possible implications of this mode-based model for intervention. More broadly, it demonstrates the utility of the schema therapy mode concept (Young et al., 2003) as a lexicon for capturing personality states and their instability. Finally, it illustrates the use of in-session segment-by-segment ratings to assess client change within psychotherapy. Stability and instability in APD. One prominent finding of the current study is the considerable instability found to characterize all of the modes typically found among individuals with APD. Three modes in particular - the avoidant/detached mode, vulnerable child mode, and the dysfunctional parent mode – had markedly more elevated fluctuation levels than the other modes. Thus, this study joins several recent studies (e.g, Koenigsberg et al., 2014; Shafran et al., 2016; Snir et al., 2015) highlighting the notion that APD clients are characterized by considerably more instability than is suggested by the formal criteria (e.g., in DSM-V; APA, 2013). Each of the four studies (the current study, as well as the three earlier ones) arrived at the unanimous conclusion – i.e., that APD is characterized by considerable instability – using unique research methods and focusing on somewhat different aspects of the phenomenology of APD patients (emotional habituation assessed using fMRI [Koenigsberg et al., 2014]; fluctuations in negative affect using electronic diaries in daily life [Snir et al., 2015]; and mode instability in daily life [Shafran et al., 2016]). Unlike the current study, the three earlier studies compared APD clients to healthy controls (who were significantly more stable) but also to BPD clients (who were significantly less stable). Importantly, unlike the current study, none of these studies focused on instability within psychotherapy, instead examining it in the lab (Koenigsberg et al.,) or in daily life (Snir et al., and Shafran et al.). Given the shared focus on schema modes, it is particularly important to compare our results to those of Shafran et al., (2016), the one extant study documenting mode 23 fluctuation patterns among individuals with APD. Shafran and her colleagues found great similarity between APD and BPD participants in the intensity of all of their modes, with both groups showing higher levels of all negative modes (and lower levels of the healthy adult mode) than the healthy control participants. The two PD groups did differ, however, in the degree of mode fluctuation for most modes, with APD participants showing less fluctuation than BPD participants in six out of eight negative modes; additionally, APD participants did not differ from the healthy control participants in the fluctuation level of the healthy adult mode, with both groups showing considerably less variability than the BPD group. Like us, Shafran et al. conclude that for individuals with APD, the healthy adult mode is the steadiest; indeed, this steadiness may serve, to some extent, as a stabilizing factor which helps distinguish individuals with APD from those with BPD, despite the similarities between the two groups. Shafran and her colleagues' data were based on self-reports (rather than observer ratings) obtained over the course of three weeks in the daily life of their respondents (rather than in 5-min segments of psychotherapy sessions). Importantly, the participants in the present study were all treatment-seeking, whereas those in Shafran et al.'s study were mostly not treatment-seeking. Though both studies show considerable fluctuation among individuals with APD, the methodological and sample differences may help explain why the results differ somewhat. For instance, Shafran et al. report higher levels of the healthy adult mode, and considerably lower levels of avoidance. These differing results may reflect fundamental differences between the samples in their distress levels. Alternatively, they may have to do more with the unique context created by therapy sessions, which may pull for a different admixture of modes than the contexts encountered in daily life (for review, see Dunlop, 2015; Fleeson, 2007). If that is the case, it serves as a reminder that our clients may not always behave or feel outside the therapy room in the same ways that they feel within it – in other words, that the therapy setting is not necessarily a one-to-one microcosm of daily life. A mode-based description of APD clients in therapy. Our results add considerable details to the mode-based model of avoidant personality disorder (Arntz, 2012; Bamelis et al., 2011; J. Lobbestael et al., 2008), informing us about the frequency, intensity, and rate of fluctuation of the modes seen among APD clients in 24 therapy. Below, we note these details, focusing in turn on each of the modes hypothesized to play a role in this disorder and on their possible implications for therapy. Finding the avoidant/detached mode to be the most frequent and most intense in our sample of individuals suffering from APD is certainly not surprising. The APD clients in our study were in the avoidant/detached mode a majority of the time; in fact, in over half the segments, this mode was of at least medium intensity. Importantly, this mode also showed the greatest amount of fluctuation. Such frequency and intensity of avoidance and detachment pose a formidable challenge for therapists, as these coping mechanisms often impede progress in therapy. On the other hand, the considerable level of fluctuations found in this mode may be seen as a positive sign: it suggests that even among strongly avoidant or detached clients, repeated moments of lower avoidance and detachment occur, and these offer opportunities for intervention and for greater access to other modes, particularly the vulnerable child mode. This vulnerable child mode was the second most frequent and intense mode, appearing in over half the segments. We see this finding as very encouraging. Specifically, the vulnerable child mode offers direct access to the clients' core emotional needs and hence opens up the opportunity for therapeutic corrective experience to occur (Arntz & Jacob, 2013; Arntz & Van Genderen, 2009; Rafaeli, Bernstein, & Young, 2010; Young et al., 2003). Indeed, increasing access to this vulnerability is a key objective within schema therapy. Nevertheless, the fact that this mode fluctuates strongly might impede the therapeutic process, as the vulnerable child often becomes inaccessible quite rapidly, thus turning less (or not at all) amenable to corrective therapeutic experience. The dysfunctional parent mode was the third most frequent and intense mode, appearing significantly more frequently than the healthy adult mode. The relatively high frequency of this mode in our sample is not encouraging: after all, this mode reflects clients' self-punitiveness, criticism, or harshness. We see this frequency as an indication of the severity of psychopathology in the sample; a main target of therapy is to reduce this mode's influence and to supplant it with a more empowered and selfcompassionate healthy adult mode. Still, despite the relatively high frequency, the fact that the dysfunctional parent mode was not present at all in more than half of the 25 segments, and that it fluctuated significantly more than the healthy adult mode, are reasons for some cautious optimism. Specifically, whereas the dysfunctional parent mode fluctuated quite widely, the healthy adult appeared to be steadier (in those times that it was present). The healthy adult mode was present in approximately a third of the segments, but was lower in its intensity. Nevertheless, as noted above, it fluctuated significantly less than all other modes. This relative stability may serve as a valuable resource for APD clients; afterall, the healthy adult mode carries out fundamental emotional functions including self-compassion, adaptation to reality, and self regulation. Two additional coping modes (the over-compensator and the compliantsurrenderer) were also present in a substantial portion of segments, though significantly less than the avoidant/detached mode or the vulnerable child mode. The fact that these coping modes were less prominent than avoidance or detachment speaks to the characteristic behaviors of this clinical population, and is therefore entirely not surprising. Clinically, this finding validates the importance of keeping our focus on strategies for overcoming detachment and avoidance, but also remaining alert to moments of dependence and over-compliance on the one hand, or of entitlement, perfectionist over-control, or self-aggrandizement on the other hand. The utility of the schema therapy mode concept as a lexicon for capturing personality states and their instability. The mode concept, first introduced by Young et al. (2003), offers a solution to a problem that has received growing attention from both basic research on personality and applied clinical theories. Specifically, the realization that the self is multi-faceted (e.g., Bromberg, 1996; Greenberg, 2004; Stone & Stone, 2011), which dovetails with recent advances in personality psychology (Dunlop, 2015; Fleeson, 2007; Mischel & Shoda, 2010) creates a need for a language of self- (or personality-) states. This study joins several earlier ones (e.g Arntz et al., 2005; Lobbestael et al., 2008; Lobbestael & Arntz, 2010; Shafran et al., 2016) in widening the evidence base for the schema therapy mode concept as such a language. Much of the research on instability, especially within psychopathology, has focused on affective fluctuations (e.g., Houben, Van Den Noortgate, & Kuppens, 2015; Trull, Lane, Koval, & Ebner-Priemer, 2015). Yet affect is just one part of the 26 phenomenology of fluctuating self-states (Dunlop, 2015; Fleeson, 2007). The mode concept offers a taxonomy of states, each involving emotional, but also cognitive, behavioral, and motivational aspects. For instance, the APD clients in the current study appeared to shift among a relatively defined set of modes. Most commonly, in moments identified as reflecting avoidant/detached mode, they seemed to experience emotional restraint or numbness, voiced statements such as "I don't care" or "nothing matters", and exhibited behavioral disengagement. In other moments, reflecting the vulnerable child mode, they seemed to experience emotional distress, voiced statements such as "I wish I had a partner" or "I need someone to care for me", and exhibited behavioral approach (e.g., actively seeking comfort or help). In yet other moments, reflecting the dysfunctional parent mode, they seemed to be experiencing self-loathing or recrimination, voiced statements such as "I'm not good, I always ruin everything", and exhibited self-punitive or self-critical behaviors. Specific individuals differ in the frequency, intensity, and fluctuation pattern of these modes, as well as in the identity of additional modes they may inhabit. Nonetheless, our ability to anticipate a particular set of self-states for individuals from a certain clinical group is aided by having the schema therapy language of modes, as well as the recognition that specific mode maps are characteristic of different groups (Lobbestael et al., 2008) . The mode concept further helps in providing a way of thinking about instability and change – namely, by recognizing the manner in which dynamic mode shifts occur. The use of in-session segment-by-segment ratings to assess client change. The schema mode language offers a way of speaking about moment-to-moment changes, and the segment-by-segment analytic approach used in the current study complements this language with a methodology that allows tracking these changes. Indeed, by utilizing independent raters' evaluations of segment-to-segment mode changes, the current study demonstrates as an innovative approach to the assessment of change within psychotherapy sessions. It complements existing methods (e.g., ratings made of entire sessions [van den Broek et al., 2011]; mode profiles obtained using self-reports [Lobbestael et al., 2008]) and opens up the possibility of modeling within-session change processes in theoretically meaningful constructs. 27 For instance, obtaining independent coders' ratings for every 5-minute segment of the sampled therapy sessions allows us to examine idiographic patterns of interplay among the modes displayed by different APD clients (Peled, Bar Kalifa, & Rafaeli, 2016). It also allows us to study the associations among the therapist interventions (within those same segments) and the clients' mode changes over the course of the session (Peled, Mittelman-Kirshenfeld, Bar Kalifa, & Rafaeli, 2016). In the current study, obtaining these ratings allowed us to paint a richer picture regarding each mode's temporal change characteristics. As we posited earlier, these characteristics offer an innovative approach to understanding the complexity of personality, and in particular, the fluctuating nature of personality states. Limitations and Summary The current study suffers from some limitations. Although it is based on 645 therapy segments, these were drawn from only 15 clients. Further replication studies on larger samples are needed. In addition, the homogenous sample of APD clients did not allow us to compare the obtained patterns to those which may emerge in nonclinical samples, or to ones with other clinical conditions. Finally, though the language of schema modes can be a general one, the current study examined it only among clients receiving schema therapy; similar analyses of sessions from other forms of psychotherapy are certainly worthwhile. In short, additional studies on within-session changes in clients' modes or self-states and on broader changes which may occur as therapy progresses are strongly needed. In summary, our study used segment-by-segment codings of sessions from a sample of clients with APD who received schema therapy. It documents the considerable instability characteristic of APD clients, offered rich data regarding the mode-based description of APD, demonstrated the utility of the schema therapy mode concept as a lexicon for capturing personality states and their instability, and illustrated the use of in-session segment-by-segment ratings to assess client change within psychotherapy. 28 Study 2 Therapist Interventions and Mode Changes within Schema Therapy Sessions for Avoidant Personality Disorder Avoidant Personality Disorder (APD) is the most prevalent PD, affecting about 10-20% of patients in psychiatric clinics and 1-2% of the general population (Sanislow et al., 2012; Zimmerman et al., 2005). Nonetheless, it has received relatively little empirical attention (Alden et al., 2002; Sanislow et al., 2012), possibly due to the ongoing debate about its overlap with other disorders, particularly social anxiety (see Chambless et al., 2008). According to Millon (1991) APD is a problem of relating to people, whereas social phobia is a problem of performing in situations. Moreover, social phobic individuals may have satisfying social and personal relationships whereas people with APD are socially withdrawn and have great trouble initiating and maintaining interpersonal relationships because of their low self-esteem and their excessive need for reassurance and acceptance. APD is also characterized by widespread avoidance (e.g., of decision making, experiences of negative as well as positive emotions, sharing of intimate feelings, experiences of bodily sensations; Arntz, 2012). APD impedes occupational, educational, and social functioning, and hinders people from realizing their potential. Most forms of psychotherapy, including CBT, show limited effectiveness with APD (Alden et al., 2002; Alden, 1989; Sanislow et al., 2012), as APD clients often have great difficulty engaging in the therapy process, and establishing a secure therapeutic alliance. Schema therapy (ST) might be an effective treatment for APD due to its emphasis on meeting the client need for secure attachment in the therapy relationship as well as focusing on changing processes of coping styles, such as avoidance. Spinhoven et al. (2007) showed in their study that the therapeutic alliance in ST was higher than in psychodynamic therapy (Kerenberg's transference focus psychotherapy – TFP see in Yeomans, Clarkin, & Kernberg, 2002) and was associated with lower dropout and better therapy outcome with Borderline Personality patients (BPD). ST demonstrated significantly better therapy outcomes compared to therapy as usual or clarification-oriented psychotherapy with patients diagnosed with various personality disorders including APD (Bamelis et al., 2014). 29 The present study goes beyond outcome research to look at the processes within ST for APD by using in-session micro-analysis. The next section describes the ST approach for treating APD. Then the micro-analysis method will be discussed. ST for APD. Schema Therapy (ST) is an integrative form of psychotherapy combining cognitive, behavioral, psychodynamic object relations, attachment, and gestalt approaches, which was developed by Jeffrey Young (Young, 1999; Young et al., 2003) as a treatment for clients with personality disorders (PDs) and other difficult to treat patterns. Integration as Clarkin et al. (2015) described it, "is the unique combination of domains of dysfunction matched with modules of intervention that are applied in a particular sequence over time" (p. 4). Young and his followers described several integrative ST protocols for most of the PDs (Arntz, 2012; Arntz, & Van Genderen, 2009; Bernstein et al., 2007; Young et al., 2003). ST has proven to be highly efficacious as a treatment for borderline personality disorder (BPD) (Farrell et al., 2009; Giesen-Bloo et al., 2006; cf., Sempértegui, Karreman, Arntz, & Bekker, 2013), a mixed sample of Axis I and Axis II clients (Vreeswijk et al., 2014), and some other Cluster B and Cluster C personality disorders (Bamelis et al., 2014). Contemporary schema therapy focuses its attention on identifying and working with modes, which are defined (Young et al. 2003) as the predominant schemas or coping reactions active for an individual at a particular moment in time. Modes are transient; thus, at any given moment, a person is thought to be predominantly in one particular mode, which serves as the stance from which the person acts. Each mode involves some emotional state, typical cognitions, and characteristic behaviors activated at a given moment. Young et al. (2003) identified 10 different modes (and subsequently, others have expanded this list to include over 20 modes; Bamelis et al., 2011; Bernstein et al., 2007). Importantly, these myriad modes compose 4 broad categories: child modes, maladaptive coping modes, dysfunctional parent modes, and a Healthy Adult mode. In ST terms, each PD has its own profile of modes. Arntz (2012) developed a ST protocol for Cluster C personality disorders, with particular recommendations for the treatment of APD. These included a focus on feelings of low self-esteem, inferiority, and inadequacy, as well as on the avoidant behaviors themselves. Using the contemporary focus of ST on the mode concept, Arntz argued that APD is characterized by two child modes (lonely/inferior child, and abandoned child); three coping modes (avoidant protector, detached protector, and 30 compliant surrender); and a punitive parent mode. Techniques within the ST model. The ST mode model (cf., Arntz & Jacob, 2013; Arntz, & Van Genderen, 2009; Rafaeli et al., 2010; van Vreeswijk, Broersen, & Nadort, 2012; Young et al., 2003) proposes interventions that can be drawn from four toolboxes: cognitive, emotion-focused, behavioral, and relational. Cognitive interventions include schema or mode exploration, assessment, education, and linking. When implementing such interventions, the therapist identifies core emotional needs, schemas, modes, and life patterns; educates the client and conceptualizes the client's problem in schema terms and links them to their past origins. Additionally, the therapist may use other techniques drawn from cognitive therapy (e.g., reframing, listing pro and cons to refute schemas, building a strong rationale against the schemas, conducting schema vs. Healthy Adult dialogues, and composing flashcards or diaries). Emotion-focused interventions include imagery rescripting, chair work, historical role play, and other techniques aimed at activating emotions. Behavioral interventions include teaching and rehearsing interpersonal skills, conducting gradual exposures, assigning homework, and encouraging life changes. Finally, relational interventions are ones which promote change through particular use of the therapeutic relationship itself. The therapist relates to enactments of "here-and-now" schema, coping style, or mode activation in the therapy relationship by using cognitive restructuring, self disclosure, and behavioral rehearsal. Although relational interventions can be seen as one of the four tool boxes, they can also be thought of as part of the broad therapeutic stance adopted within ST. Young et al. (2003) defined limited reparenting and empathic confrontation as the core features of the therapy relationship that is considered as the "base" through which all other change agents are delivered. Throughout the course of the therapy, the therapist partially meets the patient’s core emotional needs through limited reparenting and paves the way for change by empathically addressing his adverse past origins and, at the same time, confronting his maladaptive behaviors. Theoretically, an important determinant of the effectiveness of ST is the appropriate matching of specific interventions to the client's predominant and specific mode present at a given moment. For instance, psychoeducation, a cognitive intervention, is not recommended when the client is in an avoidant protector mode (one of the maladaptive coping modes), because the client is not really engaged at that 31 moment. Instead, some form of empathic confrontation that validates the client's need to feel protected, while suggesting better ways to feel protected and engaged might prove more effective. To date, however, no empirical examination has explored such moment-to-moment client-therapist processes in ST. Thus, the aim of the present study is to test whether theoretically-motivated therapist interventions produce their intended immediate effects on the clients’ modes in the course of ST sessions. Micro-analysis of therapist-client therapy processes. Randomized controlled trials (RCT) have been considered the gold-standard method for establishing treatment efficacy (for review, see Kazdin & Blase, 2011; Stiles, Hill, & Elliott, 2015) but such studies offer little clarity about what actually transpires within the psychotherapy process. Recently, there has been a growing interest in studying the change processes that occur in the therapy sessions (Greenberg, 2007; Gumz et al., 2014; Kazdin & Nock, 2003; Kazdin, 2009; Pascual-Leone et al., 2009). Hoffart and his colleagues (Hoffart & Sexton, 2002; Hoffart, Versland, & Sexton, 2002) were the first to use session-by-session analyses of schema-focused-therapy. In order to explore treatment processes of clients diagnosed with panic disorder and/or agoraphobia and cluster C personality traits, they used self-report questionnaires completed by clients and therapist before and after each session. They found that greater client-rated self-understanding during the first session was related to greater decreases in schema belief and emotional distress throughout therapy; greater therapist-rated empathic experience during the first session was related to greater decreases in clients-distress throughout therapy; greater in-session reduction of schema belief predicted lower level of next pre-session distress and vice versa. They also found positive feedback between decreased client-schema-belief and increased optimism in session-by-session analyses and across therapy. They especially recommended therapists to address the emotional inhibition schema early in treatment as this initial schema severity in particular predicted these clients' therapy outcome (Hoffart Lunding & Hoffart, 2014). In a recent study on Beck's cognitive therapy for personality disorders (CT-PD) (Beck, Freeman, & Davis, 2004), Hayes and Yasinski (2015) examined in-session processes as predictors of treatment outcomes in APD and OCPD clients. They reported that more destabilization of maladaptive personality patterns and emotional processing in the schema-focused phase predicted more improvement in personality 32 disorder symptoms and positive pattern change at the end of treatment. In this study, we used a micro-analytic sequential process design (Elliott, 2010) to examine sequences of client and therapist in-session behaviors. This design facilitates testing the impact of in-session therapeutic interventions on therapeutic change processes (Greenberg, 1986). Hypotheses. Based on the general ST model (Young et al., 2003) as well as on the specific ST protocol for the treatment of APD (Arntz, 2012), we formulated several hypotheses regarding the expected associations between good implementation of particular therapist interventions in one 5-minute segment, and clients' mode changes in the following segment. (1) We expect a good implementation of the therapist stance (T-Stance) to precede greater visibility of the healthy adult mode (because an adequate T-Stance serves as a model for this mode) and of the vulnerable child modes (because an adequate T-Stance addresses emotional needs directly). We also expect good T-Stance to precede decreased visibility of maladaptive coping modes (because an adequate T-Stance involves effective empathic confrontation). (2) We expect schema exploration, assessment, and education (SEA) as well as implementation of other cognitive interventions (COG) to precede increased visibility of the healthy adult mode (as these interventions aim to strengthen the client's ability to adopt a rationally observant stance of their own). (3) We expect emotion-focused interventions (EMO) to precede increased visibility of the vulnerable child modes and by decreased visibility of the dysfunctional parent modes, given the emphasis on protecting the child and confronting the parent modes in these interventions. We also expect a decreased visibility of maladaptive coping modes, as emotion-focused interventions model alternative ways of addressing emotional needs while maintaining direct contact with them. (4) We expect relational interventions (REL) to precede decreased visibility of maladaptive coping modes (especially the overcompensating modes), as they model healthy resolution of interpersonal conflicts in the here-and-now of the therapy relationship. Finally, (5) we expect behavioral pattern breaking interventions (BEH) to precede decreased visibility of maladaptive coping modes and dysfunctional parent modes (which are the root cause of the maladaptive patterns), and by increased visibility of the healthy adult mode (which is the mode that breaks the patterns and enacts healthier behaviors). 33 Method Overview. The data reported here comes from an open-trial study of ST for APD. Six hundred forty five segments of 5 minute therapy interaction were analyzed from 60 sessions randomly sampled out of 439 audiotaped sessions conducted with 15 clients. The therapy course was divided into 3 stages: Stage 1 (beginning, sessions 110), stage 2 (middle, sessions 11-30), and stage 3 (ending, sessions 31-end). For each stage, 20 audiotapes were randomly sampled. The selected sessions were coded twice – first for the clients’ modes, then for the therapists’ interventions. The coding process is described in greater detail below. Participants. Clients who met criteria for APD were recruited from two sites: a university-based community mental health center (CMHC) and a student counseling center (SCC). Both clinics offer low-cost psychological treatment carried out by postgraduate interns (who take part in a joint clinical psychology internship program). After a screening intake by the clinics’ staff, clients with avoidant features were given the option to take part in the open-trial study of ST, which required a more detailed intake process. Of the 23 clients who consented to participate, 15 (CMHC: N=9; SCC: N=6) were found to meet the criteria for APD (using the Structured Interview for the DSM-IV; Pfohl, Blum, & Zimmerman, 1997) and were included in the current study. Exclusion criteria were: 1. Borderline personality disorder (BPD) 2. Cluster A personality disorder 3. Psychotic disorder 4. Substance-related addictive disorder 5. Asperger’s syndrome. 6. Severity of Symptoms that required in-patient treatment. Of the 8 clients excluded from the study, 2 did not met APD criteria, 2 met BPD criteria, 1 met Asperger’s syndrome criteria, and 3 chose to withdraw for unknown reasons. Descriptive statistics of clients' demographic and diagnostic data are presented in Table 1 for the total sample, as well as for each site separately. All clients were single. The two sites did not differ in any demographic characteristic (including education, sex, habitation, and vocational status) with the exception of age (SCC were younger), or in any comorbid diagnosis, with the exception of social anxiety disorder (CMHC: N=9[100%], SCC: N=3[50%]). 34 Table 1 Descriptive Statistics of Clients' Demographic and Diagnostic Data CMHC N = 9 (60%) SCC N = 6 (40%) Sites Differences Total Sample Age M= 32.56(2.70) M= 25.17(1.33) t(13)= 6.17*** M= 29.6(4.34) Years of Education M= 14.33(2.00) M= 12.83(0.75) t(13)= 1.74 M=13.73(1.75) Female N=4 (44.4%) N=3 (50.0%) χ2(1)=0.05 N=7(46.7%) Habitation with parents N=2(22.2%) N=4(66.7%) χ2(1)=2.96 N=6(40.0%) Employed N=5(55.6%) N=4(66.7%) χ2(1)=0.18 N=9(60.0%) Receiving pharmacotherapy N=4(44.4%) N=4(66.7%) χ2(1)=0.71 N=8(53.3%) Social Phobia N=9(100%) N=3(50.0%) χ2(1)=5.62* N=12(80%) GAD N=3(33.3%) N=0(0%) χ2(1)=2.50 N=3(20.0%) Simple Phobia N=1(11.1%) N=2(33.3%) χ2(1)=1.11 N=3(20.0%) Panic disorder N=2(22.2%) N=1(16.7%) χ2(1)=0.07 N=3(20.0%) OCD N=1(11.1%) N=0(0%) χ2(1)=0.71 N=1(6.7%) PTSD N=1(11.1%) N=0(0%) χ2(1)=0.71 N=1(6.7%) MDD N=1(11.1%) N=3(50.0%) χ2(1)=2.78 N=4(26.7%) Dysthymia N=1(11.1%) N=1(%16.7) χ2(1)=0.10 N=2(13.3%) No Axis 1 disorder N=0(0%) N=2(33.3%) χ2(1)=3.46 N=2(13.3%) OCPD N=2(22.2%) N=2(33.3%) χ2(1)=0.23 N=4(26.7%) Narcissistic N=1(11.1%) N=1(16.7%) χ2(1)=0.10 N=2(13.3%) Dependent N=0(0%) N=1(16.7%) χ2(1)=1.61 N=1(6.7%) No other PDs N=6(66.7%) N=3(50.0%) χ2(1)=0.42 N=9(60.0%) Axis I: Axis II: Note. CMHC = community mental health clinic; SCC = student counseling center; GAD = generalized anxiety disorder; OCD = obsessive compulsive disorder; PTSD = posttraumatic stress disorder; MDD = major depressive disorder; OCPD = obsessive compulsive personality disorder. 35 Therapy training and procedure. Fifteen therapists (9 female) were trained in ST by two senior clinical psychologists certified as trainers and supervisors in ST. All were clinical psychology interns. The therapists participated in a 2-day ST workshop which combined didactic as well as dyadic role-play exercises on mode work. Each therapist received 45 minutes individual ST supervision once every 2-3 weeks and a 90-minute group ST supervision once a week. The clients received weekly (50-60 minute) individual therapy sessions; when needed, these were augmented by telephone, text, or email contact outside of the sessions. On average, clients received 41.3 sessions (ranging from 4-97). Ten clients completed therapy (at times somewhat earlier than ideal, due to the interns’ training schedule: range 23-97 sessions); one was still in therapy; four (26.6%) dropped out (after 4, 20, 28, and 30 sessions, respectively). Materials. Psychiatric diagnoses. The Structured Clinical Interview for DSM–IV Axis I Disorders (SCID-I; First, Gibbon, Spitzer, & Williams, 1996) and the Structured Interview for DSM–IV Personality (SIDP-IV; Pfohl, et al., 1997) were used to establish diagnoses and ensure the meeting of inclusion criteria. Both are widely used interviews; the reported reliability for SCID-I is kappa >0.6 (Williams et al., 1992). The reported reliability for any PD on SIDP-IV is good (kappa = 0.77) and for Cluster C even better (kappa = 0.87) (Zimmerman et al., 2005). Client’s modes rating scale (CMRS). The CMRS was developed in our lab (Mittelman-Kirshenfeld, 2012) to observe and rate the presence and intensity of clients’ modes and schemas within therapy sessions. This rating instrument was modeled on Callaghan et al., (2008) coding system for functional analytic psychotherapy (FAPRS), a system which allows coding both therapist and client behaviors during the therapy session. The CMRS consists of 2 sections. In the first section, raters are asked to note the presence and intensity of client modes on a 4-point Likert scale (0-not present, 1moderately present, 2-present, 3-clearly present). These ratings are provided for every 5-minute segment of the session; thus, a 50-minute session will have 10 segments. Ratings are obtained for 16 modes thought to be prevalent in APD (Lobbestael et al., 36 2008). These included: 7 Child Modes (Angry, Impulsive/Undisciplined, Happy, Abandoned/Abused, Dependent, Lonely/Inferior, and Vulnerable Child Not Otherwise Specified [NOS]), 6 Maladaptive Coping Modes (Compliant-Surrender, Detached Protector, Avoidant Protector, Perfectionist/Over-controller, SelfAggrandizer, and Over-Compensator NOS), 2 Dysfunctional Parent Modes (PunitiveCritical and Demanding Parent) and a Healthy Adult mode. In the second section of the CMRS, raters are asked to reflect on the session as a whole and note the presence and intensity of the client's schemas on the same 4-point Likert scale. They are asked to answer several open-ended questions regarding the client's behavior (e.g., how did the client switch from one mode to the other; was the client aware of his/her modes; which moods were most present during the session). Schema therapist’s interventions rating scale (STIRS). The STIRS was developed in our lab (Mittelman-Kirshenfeld, 2012) to observe and rate the presence and quality of specific ST interventions within therapy sessions. This rating instrument was adapted from the Schema Therapy Rating Scale for Individual Therapy Sessions (Young & Fosse, 2005), originally developed to rate therapist competency and adherence to ST in outcome studies. The STIRS consists of 2 sections. The first section includes 10 items, divided into three parts. In the first part, raters are asked to judge the quality of the therapist’s stance using 5 items (limited reparenting; understanding and attunement to the client's "inner reality"; collaboration, feedback, and session focus; therapist balance and flexibility; and therapist confidence and ease). In the second part, raters are asked to judge the therapist’s use of schema exploration using a single item (which addresses schema exploration, assessment, and education, as well as linking schemas to situations). In the third part, raters are asked to judge the therapist’s application of particular change techniques using 4 items (cognitive change techniques; emotion-focused change techniques; behavioral pattern-breaking; and use of the therapy relationship for change). The ratings of the 10 items which compose Section 1 of the STIRS are provided for every 5-minute segment of the session (as were the ratings of Section 1 of the CMRS). These ratings are provided on a 6-point Likert scale (1-very poor, 2–poor, 3– unsatisfactory, 4–adequate, 5–good, 6–very good or excellent). For the schema exploration item and the 4 change technique items, the option of coding the 37 intervention as “not-relevant” was also possible. On the second section of the STIRS, raters are asked to reflect on the session as a whole and note (a) their general impression of the therapist’s competence as a schema therapist and (b) the client’s difficulty level. Both items were rated on a scale of 0 (very poor) to 6 (excellent). Additionally, the raters were asked to note whether self-help techniques were assigned to be used outside the session. Rating procedure. Eight raters were trained by 2 clinical psychologists who are certified trainers and supervisors in ST (OP and ER). All raters were graduate students in clinical psychology. They received 6 hours of training on the CMRS and on the STIRS. The raters worked in pairs. Each pair of coders used the CMRS to code an entire session (segment-by-segment), and then used the STIRS to code the same session (again, segment-by-segment). During the coding, each successive 5-minute segment was played, and each rater provided their independent scores. These were used to compute interrater agreement. The average ICC for the mode ratings on the CMRS ranged from .68 (good) to .94 (excellent). The average ICC for the intervention ratings on the STIRS ranged from .67 (good) to .89 (excellent; see more details in Table 2). In case of rater discrepancies, the raters listened to the segment once again and reached a consensus rating. Data analysis. The data reported here comes exclusively from the first sections of both the CMRS and the STIRS (i.e., the segment-by-segment sections). The clients’ mode ratings from the CMRS were reduced from 14 scores into 6 variables. When multiple mode ratings were combined into a single score, the MAX function was used. The variables retained were (1) VC (Vulnerable Child; composed of the Abandoned/Abused, Dependent, Lonely/Inferior, and Vulnerable Child NOS scores). (2) AD (Avoidant/Detached Protector; composted of the Detached Protector and Avoidant Protector scores). (3) HA (Healthy Adult). (4) PAR (Dysfunctional Parent; composed of the Punitive/Critical and Demanding Parent scores). (5) CS (CompliantSurrender). 6. OVC (Over-Compensator; composed of the Perfectionist/Overcontroller, Self-Aggrandizer, and Over-Compensator NOS scores). Because the Happy, Angry, and Impulsive/Undisciplined Child modes were quite rare in the coded sessions, we excluded them from analyses. The prevalence of each mode in the segments is presented in Table 3. 38 Table 2 Raters' Inter Class Coefficient (ICC) for Client Modes Rating Scale (CMRS; ;left side) and for Schema Therapist Interventions Rating Scale (STIRS; right side) CMRS ICC STIRS ICC Abandoned/abused child (AAC) .74 Limited reparenting (LR) .89 Dependent child (DC) .78 Understanding & attunement (UA) .89 Lonely/inferior child (LIC) .83 Collaboration feedback focus (CFF) .83 Vulnerable child NOS (VCN) .71 Therapist balance & flexibility (TBF) .86 Angry child (AC) .84 Therapist confidence &ease (TCE) .88 Impulsive/undisciplined child (IUC) .74 Schema exploration (SEA) .87 Happy child (HC) .75 Cognitive techniques (COG) .69 Compliant-surrender (CS) .77 Emotion-focus techniques (EMO) .87 Detached protector (DP) .94 Behavioral techniques (BEH) .85 Avoidant protector (AP) .82 Relational techniques (REL) .67 Perfectionist/over-controller (PO) .80 Self–aggrandizer (SA) .74 Over-compensator NOS (OCN) .68 Punitive/critical parent (PCP) .79 Demanding Parent (DEP) .69 Healthy adult (HA) .79 Note. ICC=inter-class coefficient 39 Table 3 Prevalence of Client Modes (Left Side) and Therapist Interventions (Right Side) MODE PREVALENCE (%) INTERVENTION PREVALENCE (%) Vulnerable child (VC) 58.29 Therapist stance (Tstance) 87.75 Compliant surrender (CS) 33.64 Schema exploration & assessment (SEA) 42.64 Avoidant/Detached (AD) 73.64 Cognitive (COG) 4.34 Over compensator (OVC) 33.02 Emotion-focused (EMO) 5.27 Dysfunctional parent (PAR) 40.16 Relational (REL) 4.34 Healthy adult (HA) 34.11 Behavioral (BEH) 5.43 The therapists’ interventions ratings from the STIRS were reduced from 10 scores into 6 variables. The variables retained were (1) T-Stance (the average of the 5 items addressing the quality of the therapist’s stance, which were highly correlated r= .54 to .73, Cronbach alpha=.90); (2) SEA (Schema exploration); (3) COG (Cognitive Techniques); (4) EMO (Emotion-Focused Techniques); (5) BEH (Behavioral PatternBreaking Techniques); and (6) REL (Therapy Relationship for Change). Given our interest in studying the impact of high quality application of specific interventions, we dichotomized the T-Stance, SEA, COG, EMO, BEH, and REL scores so that values less than 4 were recoded as 0, and values greater than 4 were recoded as 1. The prevalence of each therapist's intervention is presented in Table 3. 40 Results Because our data has a multilevel structure (segments nested within sessions nested within clients), we used multilevel regression models (SAS PROC MIXED). Such models have three levels (the segment level - a within-session level; the session level; and the person level - a between-individual level) and can accommodate nonbalanced data (see Laurenceau & Bolger, 2013). We sought to predict the client’s mode in a particular segment of a particular session from the therapist’s interventions used in the previous segment. In addition, we adjusted for the intensity of the same mode in the previous segment; this allowed us to reduce the possibility of reverse causation (i.e., that changes in the client's mode precede – and possibly cause - the therapist's intervention). Consequently, we can interpret the outcomes as segment-to-segment change scores. The generic within-client (Level 1: segment level) equation was: Modeist = β0is + β1is*T-Stanceis(t-1) + β2is*SEAis(t-1)+ β3is*COGis(t-1)+ β4is*EMOis(t-1)+ β5is*BEHis(t-1)+ β6is*RELis(t-1) + β7is*Modeis(t-1) + eist Where Modeist is the predicted mode (e.g., VC mode) for subject i in session s at segment t, β0is is the regression intercept for this client in this session; β1is to β6is are the interventions’ regression slopes, reflecting the extent to which the therapist's interventions in the previous segment predict the client's mode in the current segment in this session; β7is is the regression slope for the previous segment’s mode; and eist is a residual component for this client on this particular session and segment. Intercepts were treated as random at both level-2 and level-3, to capture between-client and between-session variation in the mean level of the modes. First-order autoregressive structure was imposed on the covariance matrix for the within-person residuals, to account for autocorrelation between the outcome's residuals. This generic multilevel model was implemented for each of the six modes that were examined; the results are presented in Table 4. As can be seen in Table 4, segments characterized by good T-Stance preceded decreases in the AD mode and increases in the HA mode. Segments characterized by good EMO interventions preceded decreases in the OVC mode (which also showed a trend-level decrease following good REL interventions). Finally, segments characterized by good COG interventions preceded increases in the VC mode and in the PAR mode. In contrast, segments characterized by good BEH interventions preceded a (trend-level) decrease in the PAR mode. 41 Table 4 Multilevel Regression between Therapists' Intervention (t-1) and Clients' Mode (t) Outcomes VC AD HA PAR CS OVC Fixed effects b(SE) b(SE) b(SE) b(SE) b(SE) b(SE) Intercept 0.75(0.15)*** 1.70(0.15)*** 0.25(0.10)* 0.57(0.13)*** 0.61(0.12)*** 0.56(0.14)*** T-Stance 0.14(0.12) -0.39(0.13)** 0.17(0.07)* 0.05(0.11) -0.16(0.10) 0.00(0.09) SEA 0.02(0.08) 0.09(0.08) -0.00(0.05) -0.05(0.07) 0.01(0.07) 0.01(0.06) COG 0.34(0.16)* 0.04(0.18) -0.13(0.11) 0.31(0.16)* 0.05(0.15) -0.02(0.13) EMO 0.12(0.15) 0.21(0.16) -0.10(0.09) 0.17(0.14) 0.15(0.13) -0.29(0.12)* BEH 0.14(18) 0.28(0.18) -0.03(0.10) -0.27(0.15)† -0.16(0.15) 0.04(0.12) REL 0.04(0.17) -0.05(0.19) -0.08(0.11) 0.19(0.16) 0.08(0.15) -0.25(0.13)† Lagged outcome -0.08(0.04)† 0.33(0.04)*** 0.45(0.04)*** 0.26(0.04)*** 0.33(0.04)*** 0.45(0.04)*** Random effects Estimate(SE) Estimate(SE) Estimate(SE) Estimate(SE) Estimate(SE) Estimate(SE) 0.14(0.07)* 0.12(0.05)* 0.08(0.03)** 0.08(0.04)** 0.08(0.04)* 0.18(0.07)** AR(1) 0.37(0.09)*** -0.05(0.09) -0.28(0.05)*** -0.23(0.06)** -0.03(0.10) -0.28(0.06*** Residual 0.72(0.07)*** 0.76(0.05)*** 0.31(0.02)*** 0.60(0.04)*** 0.50(0.03)*** 0.44(0.03)*** Between-person: Intercept Within-person: Note. Client modes: VC = vulnerable child; AD = avoidant detached; HA = healthy adult; PAR = dysfunctional parent; CS = compliant surrender; OVC = over compensator; Therapist Interventions: T-Stance = therapist stance; SEA = schema exploration; COG = cognitive techniques; EMO = emotion-focused techniques; BEH = behavioral pattern-breaking techniques; REL = therapy relationship for change; † = p<.10; * = p<.05; ** = p<.01; *** = p<.001 42 Discussion Leading voices within the field of psychotherapy research have been advocating for a shift towards micro-analytic studies examining change processes within sessions (Greenberg, 2007; Gumz et al., 2014; Kazdin & Nock, 2003; Kazdin, 2009; PascualLeone et al., 2009). Our study is the first micro-analytic examination of such withinsession change processes in schema therapy in general and in the treatment of APD in particular. We analyzed six hundred and forty five segments of therapy, each comprising 5 minutes, which came from 60 sessions sampled from the treatment of 15 APD clients. We coded these using two reliable coding instruments: one focused on therapists’ interventions, the other on clients’ modes. We then used multi-level modeling (segments nested within sessions nested within persons) with segment-tosegment time lags (of 5 min) to examine the association between the therapists’ interventions in one segment and the clients’ changes in the modes evident in the subsequent segment. Several notable findings consistent with the premises of ST emerge from this study; alongside these, other associations that would be expected based on ST premises did not emerge. A good therapist-stance increases the healthy adult mode and decreases the avoidant/detached modes. Good emotion-focused or relational interventions decrease over-compensation modes. Good cognitive interventions increase the vulnerable child modes as well as the dysfunctional parent modes. Finally, good behavioral pattern-breaking interventions decrease the dysfunctional parent modes. Below we address each of the interventions, and discuss their obtained (as well as un-obtained) associations with client mode changes. We then broaden the scope on clinical implications, limitations, and future directions. The therapeutic stance. The therapeutic stance variable, as we defined it, summarizes five fundamental ingredients of the desired therapeutic stance in ST (Arntz & Jacob, 2013; Rafaeli et al., 2010; Young et al., 2003): the use of limited reparenting and empathic confrontation; the therapist’s attunement; the degree to which the therapist maintained a collaborative focus in the segment and/or obtained the client’s feedback; the therapist’s balance and flexibility; and the therapist’s confidence and ease in the role. We expected the segments preceded by a “good enough” therapeutic stance – that is, a stance marked by high averaged scores on these five ingredients - to be 43 marked by greater visibility of the healthy adult mode, and by decreased visibility of maladaptive coping modes. To a large extent, this was indeed the case. We also expected greater visibility of the vulnerable child modes and reduced visibility of dysfunctional parent modes, but found no evidence for these. One major premise of ST supported by our findings is that an adequate therapist stance (and particularly, the therapist’s use of limited reparenting and empathic confrontation) serves as a model for the client's healthy adult mode. ST assumes that most clients have (at least the potential for) a healthy mode – a part of the self that is self-compassionate, that takes responsibility, that pursues pleasurable activities, and that commits to both people and actions in ways that leads to a fulfilling life. This mode, like the good parents or therapists that serve as its model, is able to integrate the other modes by responding flexibly and appropriately to them. When therapists enact their stance well, they exemplify for their clients how a “good enough” parent reacts and handles intrapersonal, as well as, interpersonal difficulties. The ingredients comprising a good therapeutic stance in ST are quite similar to the ones identified across other therapeutic models (e.g., Fonagy & Bateman, 2006; Linehan, 1993a; Linehan, 1993b; Newman, 2007). The therapeutic stance promotes the therapy alliance which was found as significantly related to therapy outcome across variety of psychotherapy approaches (Horvath, Del Re, Fluckiger, & Symonds, 2011). Indeed, a recent review (McMain, Boritz, & Leybman, 2015) posits that the construct of therapist responsiveness (which, just like our therapist stance, includes a strong emphasis on empathic validation, flexibility, and collaboration), helps clients become self-aware and accepting of their emotions, facilitates the regulation of emotions and the modulation of behaviors. These are exactly the functions ascribed to the healthy adult mode in ST. Another premise supported by our findings is that an adequate therapist stance will be tied to reductions in the most prominent coping modes seen in our APD clients: the avoidant/detached modes (Arntz, 2012; Bamelis et al., 2011). Reducing avoidance and detachment is of course a major goal of therapy with this population – as it is with other clinical groups. Our findings suggest that the therapy relationship is a key for achieving this goal. Other authors have reached a similar conclusion. For example, Cloitre, Stovall-McClough, Miranda, & Chemtob (2004) found that for adult clients abused in childhood, a strong therapeutic alliance predicted better use of emotional regulation skills during the exposure phase; additionally, alliance and 44 emotion regulation combined to ameliorate PTSD symptoms, particularly the avoidance typical of this disorder. Such findings suggest that the therapeutic stance and, in all likelihood, the alliance it fosters - are "active" ingredients in therapy and reduce avoidance coping strategies (Castonguay, Constantino, & Holtforth, 2006), and pave the way for other change-promoting interventions. Alongside the encouraging results of increased healthy and decreased avoidant/detached modes, we did not find support for other associations expected of a good therapeutic stance (namely, increased vulnerable child modes, or decreased compliant-surrender coping). With regards to the vulnerable child mode, the findings may reflect the fact that APD clients have great difficulty accessing vulnerability. Although a good therapist stance may be required to allow such access, it may not be sufficient. The absence of any association between the therapist stance and the overcompensator coping modes may have to do with the way in which we constructed our coding system. Specifically, our system did not include a distinct code for a key intervention in ST - namely, the use of empathic confrontation. This unfortunate omission on our part has meant that we were unable to distinguish a key intervention used to address over-compensation from other (often less relevant) therapeutic-stance interventions. In future use of our coding system, we plan to include a separate code for empathic confrontation, and expect it to be specifically tied to decreases in overcompensation. Finally, the therapist stance variable was not tied to change in the compliant surrender mode; in fact, no therapist intervention was associated with change of this mode. The impregnability of this mode, though dismaying, is not entirely surprising. As a recent review (Disney, 2013) notes, dependence and compliance are poorly understood clinically, and have received very little focused theoretical or empirical attention. Though some ST theorists (e.g. Arntz, 2012) have made some progress in conceptualizing this personality trait, the road to a fuller understanding of how it should be addressed clinically is still quite long. Emotion-focused interventions. Emotion-focused interventions, as we defined them, refer to several techniques (e.g., imagery with rescripting, chair-work, or historical role play; Arntz, 2012; Kellogg, 2004) aimed to emotionally activate schemas and allow them to undergo deep transformation. We expected the segments 45 preceded by good implementation of emotion-focused interventions to be marked by decreased visibility of maladaptive coping modes; to a certain extent, this was indeed the case. We also expected greater visibility of the vulnerable child mode and reduced visibility of dysfunctional parent modes, but found no evidence of those. One finding supportive of ST premises was that the adequate use of emotionfocused interventions preceded a decrease in over-compensation modes (e.g., perfectionistic/over-controlling or self-aggrandizing behaviors), modes in which clients escape vulnerability by adopting the opposite stance of interpersonal superiority, power or control. When therapists implement emotion-focused interventions in the face of over-compensating modes, they shift the focus from the interpersonal back to the intrapersonal, thus guiding clients towards a more adaptive approach to their own vulnerability. There is accumulating evidence that interventions promoting emotional processing are related to better therapy outcomes (Whelton, 2004; for review, see Greenberg, 2012). For instance, Shahar and his colleague (2012) found that the emotion-focused two-chairs-dialogue intervention was associated with increases in self-compassion and self-reassuring and with reduction in depressive and anxiety symptoms and self-criticism. Our results would have provided even stronger support for ST premises had we found the expected associations between emotion-focused interventions and increases in vulnerability or decreases in other coping modes (e.g., avoidance) and parental modes. What should we learn from the absence of these associations? We tend to believe that increasing vulnerability and decreasing avoidance/detachment requires gradual trust building (as discussed earlier with regards to the therapist stance findings) rather than the use of these more emotionally intense techniques. Alternatively, these expected effects of emotion-focused interventions may be slower to emerge, and thus would not be evident from one (5-min) segment to the next. As for the amelioration of dysfunctional parent modes, we speculate that other forms of intervention (particularly, direct behavioral practice, discussed later) may be more effective than emotion-focused ones. Relational interventions. Relational interventions are ones in which the therapist uses the here-and-now interaction as a vehicle to promote change by focusing on the therapy relationship. We expected the segments preceded by good implementation of relational interventions to be marked by decreased visibility of 46 maladaptive coping modes – in particular, over-compensating ones. That was indeed the case. Relational interventions offer the opportunity to model healthy resolution processes when interpersonal issues are triggered in the here-and-now. When done well, they involve validating and addressing emotional needs as they arise, and striving to resolve tensions with mutuality and reality testing. This idea echoes one voiced by several authors (e.g., Dalenberg, 2004; Hill et al., 2003, 2014) who have shown that therapists who use genuine self-disclosure of feelings (a central relational intervention) tend to diffuse their clients' expressed hostility. Relational interventions involve validation of the clients' needs, acknowledgment of the therapist’s own contribution to whatever is occurring in the room, appropriate self-disclosure, and generalization of these interpersonal dynamics to the clients' relationships outside therapy. These are akin to interventions that are central to many integrative models of therapy (particularly ones developed for the treatment of personality disorders; e.g., Clarkin et al., 2015). These interventions, focused as they are on here-and-now processes in the therapy room, provide clients with an opportunity to learn about their impact on others (McMain et al., 2015). Hill et al., (2014) uses the term 'therapist immediacy' to stress the effectiveness of catching the moment for processing therapist-client here-and-now activations. These interventions are particularly potent when they involve exploration, and repair, of alliance ruptures (Safran & Muran, 2000, 2006; Safran, Muran, & Eubanks-Carter, 2011). Cognitive interventions. Cognitive interventions focus on the logical, empirical, and rational analysis of the clients' beliefs. We expected the segments preceded by good implementation of cognitive interventions to be marked by increased visibility of the healthy adult mode but found no evidence for that. Instead, we found that these interventions preceded increases in both the dysfunctional parent modes and the vulnerable child modes. Cognitive interventions intend to help clients externalize maladaptive schemas, coping strategies, and modes and examine their accuracy and effectiveness. As such, these interventions are essentially argumentative and often polarize two points-ofview. One point of view supports the maladaptive schema side, which holds negative views of the self, of others, and of the world. This is the dysfunctional parent’s point 47 of view, which attacks the self from within. Our results suggest that inevitably, this attack brings with it the activation of the vulnerable child. We failed to find support for the prediction that well-implemented cognitive interventions would precede increased visibility of the opposite point-of-view – that of the healthy adult mode, a prediction based on the reasoning presented by Young and his colleagues (2003). It may be that, for the particular population studied here, and possibly for those with other PDs, cognitive interventions are not powerful enough to serve as an immediate model for the healthy adult mode. Indeed, it seems that the functions of this mode – including self-compassion, assertiveness, flexibility, and resilience – go far beyond what rationality can offer. Behavioral pattern breaking interventions. Behavioral interventions offer clients the chance to rehearse and then enact healthier ways of handling real-life situations. We expected the segments preceded by good implementation of behavioral interventions to be marked by decreased visibility of dysfunctional parent modes; this was indeed the case. We also expected them to be marked by increased visibility of the healthy adult mode and by decreased visibility of maladaptive coping modes, but found no evidence for that. Interestingly, our study found relatively few instances of behavioral patternbreaking (see Table 3). One reason for this may be that behavioral pattern-breaking is typically used later in the therapy, and therefore was less relevant in many of the sessions included here. Still, when behavioral interventions were present, their immediate effect seemed limited to a decrease in the dysfunctional parent modes. It is possible that this decrease is a preliminary stage, and that it appears before the other (expected) effects of pattern-breaking – namely, reduced coping behaviors and increased healthy adult functioning – can appear. After all, behavioral interventions aim to replace existing schema-driven patterns of actions with healthier and adaptive behaviors. They model the antithesis of the maladaptive coping behaviors that emerge when individuals’ schemas are triggered. Not surprisingly, behavioral work focused on the triggered schemas and on the distress they entail encounters the dysfunctional parent modes very rapidly. After all, schema activation inevitably includes the activation of these parent modes (which convey the frightening, belittling, critical, or punitive messages which underlie the schema). Prior to any actual behavioral change (which would result in stronger 48 healthy modes and weaker coping modes), behavioral interventions seem to help clients overcome the feeling that they are helpless victims of their internal dynamics (Dimaggio, Salvatore, Lysaker, Ottavi, & Popolo, 2015); this may pave the way for healthier behaviors to take place. Schema exploration and assessment. Schema exploration and assessment is a psycho-educational process through which present-day problems are linked to their past origins. This process is part of the ongoing effort to conceptualize the client’s problems and goals in schema terms. We expected the segments preceded by good schema exploration and assessment interventions to be marked by increased visibility of the healthy adult mode, but found no evidence for that. The process of exploration and assessment in schema therapy stems from one of the most important ingredients in cognitive behavioral therapy – namely, the conceptualization process (e.g., Kuyken et al., 2015). It may be that this process, which fosters intellectual understanding and helps clients integrate information, is important for setting the stage for mode work but does not exert immediate effects on the modes inhabited by the client. Future work should explore the possibility that exploration and assessment, coupled with experiential techniques, (e.g., imagery for assessment; see Arntz, 2015; Rafaeli et al., 2015) would be tied more strongly to mode changes on the emotional level. Clinical implications. Our findings provide some initial evidence for the differential effects of distinct therapeutic interventions on the clients’ present emotional, cognitive, and behavioral states – i.e., on their modes. This evidence may be useful in helping therapists choose the most fruitful intervention to match the current or the desired mode. For example, by using a therapeutic stance which is compassionate, warm, genuine, and caring, and which balances flexibility with sturdiness, therapists may help clients become less detached and avoidant. This therapeutic stance appears to foster clients' self-compassion and increase the likelihood of clients' mature and balanced behaviors. Alternative interventions may prove more useful in other moments. For example, when clients become angry, hostile, controlling, or demeaning towards others, therapists' implementation of experiential techniques may help the clients connect to their emotional needs and diminish their aggressive tension. Similarly, when clients respond aggressively to here-and-now ruptures in the therapeutic 49 alliance, relational interventions based on mutuality may prove most useful to resolve the conflict. Finally, when clients are self-critical or lack self-compassion, behavioral pattern-breaking interventions may be particularly useful in paving the way towards greater self-compassion and healthier coping with triggering situations. Limitations and Future Directions We rated 645 segments from 60 randomly sampled therapy sessions, giving us a large sample of observations on which to base our conclusions. On the other hand, given the small number of participants (N=15) in this study, its results should be seen as tentative until further replication. Though ST is a versatile approach, aimed to address various personality disorders and interpersonal problems, the data presented here was collected from clients who were all diagnosed with APD (though often suffering from additional comorbid disorders). The ability to generalize these results beyond this patient group will require replications of this study with diverse samples. The therapists in this study were psychology interns with limited therapy experience. This relative inexperience may explain the relative prevalence of various interventions within our data. Specifically, the most prevalent technique used in the coded sessions was schema exploration and assessment; contrast this with the expectation (e.g., Arntz, 2012; Arntz & Van Genderen, 2009) that experienced schema therapists would perform emotion-focused interventions roughly every other session (i.e., half the time). It is quite likely that data obtained from trials using more experienced schema therapists would show somewhat different patterns. We used two newly developed instruments, the CMRS to assess schema modes, and the STIRS to assess therapist interventions. Although the reliabilities obtained with these two instruments were good, these instruments require further validation and possibly further specification. For example, the STIRS code for emotion-focused interventions reflected an array of complex interventions (e.g., validation, protection, encouragement, re-scripting, confrontation etc.) and modalities (e.g., imagery, chair work, historical role-play, writing letters). Further micro-analytic studies may wish to explore the unique association of each of these with mode changes and treatment outcomes. Similarly, we created the therapist stance variable as an amalgam of several therapeutic ingredients (limited reparenting; understanding and attunement to the 50 client's "inner reality"; collaboration, feedback, and session focus; therapist balance and flexibility; and therapist confidence and ease). Future studies should illuminate which of these ingredients are the most potent. In particular, we hope such studies will examine the specific effects of limited reparenting and of empathic confrontation. Future work should also explore the association between therapist stance (and its various components) and the more widely studied concept of therapeutic alliance. Castonguay et al. (2006) noted that therapeutic alliance may develop over the course of therapy in various patterns (e.g., linear, quadratic, V- shape deflections). Furthermore, Strauss et al. (2006) described the association between patterns of alliance and CBT treatment outcomes with APD and OCPD clients. Examining such patterns, while also exploring in-session transactions as we have done here, could help elucidate the role of the therapeutic relationship as a mechanism of change affecting therapy outcomes. Summary There is a growing interest in psychotherapy process studies that help clarify what works within therapy sessions. Our study is the first to use in-session segmentby-segment micro-analysis of the therapy process in schema therapy in particular and with APD clients in general. This study presents two innovations. First, it presents two new rating scales developed to identify and measure the client's modes (CMRS) and the therapist's interventions (STIRS) within segments of therapy sessions. Second, it uses these instruments to code therapy sessions and reveal therapist-client in-session interactions, and uses multilevel regression models to shed lights on the links between specific schema therapy interventions and subsequent the mode changes among clients with APD. We found that good implementation of the recommended therapist stance in schema therapy precedes increases in the healthy adult mode and decreases in the avoidant and detached modes. We also found that emotion-focused and relational interventions precede decreases in clients' over-compensating modes; cognitive interventions precede increases in the vulnerable child and the dysfunctional parent modes; and behavioral interventions precede decreases in the dysfunctional parent modes. These results illustrate the way in which micro-analytic studies of therapy processes can guide therapists in choosing effective interventions when facing distinct moments in their interaction with their clients. 51 Study 3 Temporal Associations among Modes in Schema Therapy: A Time-Series Panel Analysis Most psychotherapy research has focused on treatment efficacy, examining preto-post treatment changes using methods such as the randomized controlled trial (for review, see Kazdin & Blase, 2011; Stiles et al., 2015). Studies using these methods have in common a nomothetic approach: they aggregate results across individuals and provide group averages (Rosmalen, Wenting, Roest, de Jonge, & Bos, 2012). In doing so, they run the risk of overlooking two factors. First, the process of psychotherapy may not be a simple linear one (Fisher, Newman, & Molenaar, 2011). Second, idiographic changes for specific individuals may not be well represented by a group average (Molenaar, 2004). In recognition of the first limitation, the last decades have brought with them a growing interest in studying the change processes that occur over the course of psychotherapy in order to ascertain how and why psychotherapy works (Greenberg, 2007; Hayes & Yasinski, 2015; Kazdin & Nock, 2003; Pascual-Leone et al., 2009). A more recent interest, in exploring individual differences in treatment process, has begun to address the second limitation, helping answer the more idiographic question of how and why psychotherapy works for specific individuals. Appropriate modeling of therapy processes, and particularly ideographic modeling of these processes, requires the development of methods that explore both within-session and between-session processes (Elliott, 2010). To permit idiographic analyses, these methods need to take into account variability that exists both between individuals and within individuals. Methods that do that enable a tailored analysis of each client's therapy process (Rosmalen et al., 2012). One method that has recently been implemented in psychotherapy research is the time-series-panel-analysis (TSPA) approach. It offers a statistical approach to the modeling of sequentially dependent observations (Ramseyer, Kupper, Caspar, Znoj, & Tschacher, 2014; Tschacher, Zorn, & Ramseyer, 2012; Tschacher & Ramseyer, 2009) which can be used both within- and between-sessions, and which takes into account variability between individuals. This method can address both immediate and lagged associations between multiple psychotherapeutic variables. As such, it provides data which can be interpreted in a quasi-causal way, in what is referred to as 52 Granger causality – i.e., causality derived from systematic time-lagged associations between several variables (Granger, 1969). Granger causality is a test for the directionality of the influence between two time series. The essential idea behind it is that a cause cannot come after an effect; the temporal ordering of events can thus be used to empirically distinguish between leading and lagging variables. To date, only a handful of studies have used TSPA to explore trajectories in psychotherapy mechanisms of change. The current project aims to use TSPA in a novel way. Specifically, it will explore the idiographic associations among clients' modes (self-states) as they become evident over the course of psychotherapy sessions. Below, we discuss the notion of self-states, with a focus on the terminology of modes developed within schema therapy. Schema therapists have put forward several disorder-specific models of modes, and we zero in on one such model – the one developed for the understanding and treatment of clients with avoidant personality disorder (APD). Using TSPA, we address a question that has yet to be examined – namely, how do the modes of individuals (in this case, ones suffering from APD) change over the course of therapy sessions, and what is the interplay among these modes. The notion of self-states. Several contemporary theories emphasize the contextual nature of personality (e.g., Dunlop, 2015; Fleeson, 2007). Fleeson (2007), for example, has demonstrated that individuals manifest different trait contents in their behavior at different moments. Dunlop (2015) has argued that these self-states reflect self-representations operating within specific times and contexts, each with its own autobiographical memory and narrative. Interestingly, many clinical theories (Bromberg, 1996; Greenberg, 2004; Stone & Stone, 2011) have developed similar contextual models that emphasize the multiplicity of self-states, and that focus their intervention on working with these states. All these theories posit that it is important to explore changes in these self-states. These changes, which occur both within and between psychotherapy sessions, may prove to be key mechanisms of change in psychotherapy. One clinical approach in which the concept of self-states is very central is the schema therapy (ST) approach, and particularly the schema mode concept developed by Young et al. (2003). The mode concept was put forward to capture the emotional 53 instability reflected by rapid changes in behaviors, cognitions, and feelings among clients (originally, ones with personality disorders, though in recent years the model has been applied to a variety of client populations). Like other approaches that recognize a multiplicity of self-states, the schema mode model argues that each person manifests several modes, which can be seen as different aspects of the person's personality. A unique feature of ST is its attempt to create a taxonomy of such modes that characterize many individuals. The modes that have been identified to date (Lobbestael et al., 2007; Rafaeli et al., 2010; Young et al., 2003) may reflect both healthy and pathological aspects of an individual's self. The schema model speaks of four mode categories: (1) Child modes, which reflect a regression into intense child-like emotional states (of vulnerability, impulsivity, anger, or playful contentedness), (2) Maladaptive coping modes, which enact protective or defensive behaviors, (3) Dysfunctional parent modes, which echo negative aspects of internalized objects, and (4) The Healthy adult mode, which reflects the positive aspects of the internalized objects. Modes can trigger one another and appear in varying strengths and orders. They are triggered in reaction to changes in the environment or internal cues that are linked to one's core oversensitive issues. In recent years, ST progressed toward disorder-specific mode models, which have received considerable empirical support with regards to several personality disorders (Bamelis et al., 2011; Lobbestael et al., 2008). Young et al. (2003) were the first to develop mode models for borderline personality disorder (BPD) and narcissistic personality disorder (NPD). A protocol for individual ST for BPD was developed by Arntz & van Ganderen (2009) and a protocol for group ST for BPD was developed by Farrell et al., (2009). Both protocols have shown promising efficacy even when compared with established evidence-based approaches (for a comprehensive review see: Sempértegui et al., 2013). ST mode models and protocols have also been developed for anti-social personality disorder (Bernstein et al., 2007) and for cluster C personality disorders (Arntz, 2012). Bamelis and her colleagues (Bamelis et al., 2014) conducted a large-scale RCT study comparing the effectiveness of ST with that of clarification-oriented psychotherapy and of treatment-as-usual in addressing various PDs (other than BPD). ST was found to have greater recovery rates and lower dropout rates. Importantly, over 60% of the clients in the Bamelis et al. study were ones who had avoidant personality disorder. This is also the client 54 group studied in the current project. Avoidant personality disorder. Avoidant personality disorder (APD), one of the most prevalent personality disorders (Sanislow et al., 2012; Zimmerman et al., 2005) has received relatively little empirical attention (Alden et al., 2002; Sanislow et al., 2012). Much of this attention has been in the form of various intervention studies (e.g., testing group behavioral treatments [Alden et al., 2002; Alden, 1989; Sanislow et al., 2012], individual short term CBT or dynamic psychotherapy [Emmelkamp et al., 2006]). These studies provide evidence for the efficacy of these treatments (compared to wait lists), and suggest stronger gains for CBT compared to dynamic psychotherapy. Still, the overall improvement of clients with APD is less than satisfactory. These clients prove to be difficult to treat, and their excessive fear of humiliation, attack, and rejection, as well as their profound deprivation of the emotional need for acceptance (Benjamin, 1996) pose significant hurdles or challenges to therapeutic progress. Yet, as Bamelis and her colleagues (2014) have shown, ST appears to be a promising approach for the treatment of clients with this disorder. To facilitate the treatment of APD using ST, Arntz (2012) developed a specific mode model for the disorder. This model reasoned that clients with APD will be characterized by 7 modes: a lonely/inferior child, an abandonment/abused child, an avoidant protector, a detached protector, a compliant/surrender protector, a punitive parent, and a healthy adult. Two studies using the self-report Schema Mode Inventory (Young et al., 2007), indeed found clients with APD to be characterized by these modes, but also by angry and undisciplined child modes, detached self-soother and suspicious/over-controlling compensator coping modes, and a demanding parent mode (Bamelis et al., 2011; Lobbestael et al., 2008). Like these two studies, most of the research on modes has relied on clients' self reports (Arntz, Klokman, & Sieswerda, 2005; Bamelis et al., 2014, 2011; Lobbestael et al., 2009; Lobbestael et al., 2008). Only two studies have obtained independent raters' assessment of modes. In the first study, raters watched videotapes of whole therapy sessions conducted with forensic patients and used the Mode Observation Scale (MOS) to note the presence of modes. These were used to determine changes in these modes in response to the interventions (van den Broek et al., 2011). In the 55 second study (which used data drawn from the same sample as the present study), raters listened to audiotapes of ST sessions conducted with clients suffering from APD. The raters used the Client Mode Rating Scale (CMRS) to note the presence of modes on a segment-by-segment basis, with 5-min segments. These (alongside segment-by-segment ratings of therapist interventions) were used to examine the differential response of modes to interventions (Peled, Mittelman-Kirshenfeld, Bar Kalifa, & Rafaeli, 2016). Importantly, no study to date has explored the manner in which modes change or interplay within therapy sessions. This is the aim of the present study, which utilizes recently developed time-series-panel-analyses (TSPA) for this purpose. TSPA studies and idiographic analyses. TSPA is a statistical methodology which has been used to quantify temporal (usually session-to-session) aspects of change in psychotherapy (for a comprehensive review, see Ramseyer et al., 2014). TSPA is based on vector auto-regression (VAR), an extension of univariate autoregression models to multivariate time-series data. TSPA models are constructed in two steps. In step 1, individual time-series analyses are performed to compute idiographic models based on individuals' data. In step 2, a panel analysis is conducted to aggregate the level 1 models into a prototypical nomothetic model (Ramseyer et al., 2014). This methodology permits a focus on temporal aspects of associations among multiple psychotherapy variables, a focus which can help identify potential causal associations between these variables. Several studies have applied TSPA for the study of psychotherapy processes. We briefly review these below. Tschacher, Baur, & Grawe (2000) used pre-to-posttherapy and session-by-session self reports as a data base for linear time series models to explore the prototypical dynamics among clients' and therapists' variables and the linkage between these dynamics and therapy outcomes. They found that the clients' sense of self-efficacy preceded next session increases of all four variables measured in this study: clients' view of the therapeutic bond, clients' sense of self-efficacy, therapists' view of their own effectiveness, and therapists' view of clients' engagement. In addition, clients' sense of self-efficacy appeared to be the pivotal change mechanism related to better therapy outcome. Tschacher and Jacobshagen (2002) used pre-to-post-therapy questionnaires and self-report diaries completed by clients hospitalized in a crisis intervention unit as 56 a data base for linear time series models to explore the process of crisis intervention. Clients rated their mood, tension, and cognitive orientation three times a day. Linear trends were found pointing to an improvement of mood, a decrease of tension, and an increase of outward cognitive orientation. Additionally, on average, outward cognitive orientation preceded improved mood. Finally, these process variables, and especially outward cognitive orientation, were associated with better therapy outcome. In another study, Tschacher and Ramseyer (2009) examined the reciprocal associations between patients' well-being and their motivation for therapy. Motivation for therapy appeared to improve well-being; conversely, elevated well-being diminished motivation for therapy. Wild et al. (2010) used linear time series models to analyze electronic diary data of obese patients with and without binge eating disorder (BED). Participants in both groups completed daily electronic assessments of eating behavior and level of depression, anxiety, and control over their eating behaviors. The results indicated that in both groups: (1) High depression scores were related to high level of eating on the same day. (2) Low control over eating behaviors was associated with high level of eating on the same day. On the other hand, the groups did differ when lagged associations were examined. Specifically, for obese patients with BED, high levels of eating became more probable following days of high depression. In contrast, for obese patients without BED, the opposite pattern emerged, with depression becoming more probably following days of high levels of eating. Tschacher et al. (2012) used TSPA to model change mechanisms in schemacentered group psychotherapy, a specific group treatment based on some of the basic schema therapy components. Clients diagnosed with narcissistic (NPD), borderline (BPD), avoidant (APD), or dependent (DPD) personality disorders completed selfreports after each group session. These assessed four factors: clarification (patients' experience of insight into their maladaptive schemas), bond (a positive therapeutic relationship), rejection (feelings of being socially rejected and/or neglected by the therapist as well as the group), and emotional activation (a sense of emotional arousal due to group processes touching on the patient's core problems). Time-lagged associations revealed that clarification preceded reductions in rejection and in emotional activation, and may have served as regulators for the patients' emotions; additionally, rejection preceded reductions in bond. The further application of TSPA to diagnostic subgroups, although limited by the small sample sizes, highlighted some 57 additional associations. Among clients with APD, rejection preceded an increase in clarification, whereas among clients with NPD, rejection preceded emotional activation. Clients with DPD showed fluctuating, unstable emotionality, though emotional activation abated following rises in perceived therapeutic alliance. Finally, clients with BPD had no significant lagged parameters but showed reductions in rejection over the course of treatment. Ramseyer et al. (2014) used TSPA to analyze data from outpatient psychotherapy to examine associations among 5 factors: (1) patients' alliance experiences, (2) patients' self-efficacy, (3) therapists' alliance experiences, (4) therapists' clarification interventions, (5) and therapists' mastery interventions as they were tied to therapy outcome. All five factors showed temporal stability. Alliance and self-efficacy were connected in a positive feedback loop, enhancing each other from one session to the next. All of the TSPA studies noted above have relied on data collected from selfreported questionnaires or diaries obtained daily or on a session-by-session basis. As such, the time lags explored in them are those that transpire between successive sessions (Ramseyer et al., 2014; Tschacher et al., 2012; Tschacher et al., 2000; Tschacher & Ramseyer, 2009) or daily reports (Tschacher & Jacobshagen, 2002; Wild et al., 2010). Our study is the first to use TSPA to examine segment-by-segment in-session change processes, and the first to do so with data obtained from independent ratings. Additionally, our study focuses on an idiographic, rather than nomothetic models, and was inspired by recent calls for more nuanced examination of intraindividual change processes in psychotherapy (e.g., Barlow, Nock, & Hersen, 2009). As these authors and others have argued, idiographic and single case analyses have the potential of identifying temporal causal patterns and functional relationships, and may help unravel etiological heterogeneity by studying complex temporal dynamics. Ultimately, such analyses may underlie person-tailored treatment specification. Several recent studies demonstrate the fruitfulness of this approach. For example, Boswell and his colleagues (Boswell, Anderson, & Barlow, 2014) used a time-series analysis with one client suffering from major depression disorder (MDD) as a primary diagnosis and from generalized anxiety disorder (GAD) as a secondary 58 diagnosis. The client was treated using the unified transdiagnostic protocol. Idiographic analyses suggested that one of the protocol's modules (focused on present-focused and nonjudgmental emotion awareness) was most effective in increasing mindfulness skills, whereas another module (focused on emotion monitoring and functional analysis) was most effective in increasing reappraisal skills. Moreover, mindfulness preceded decreases in depression and anxiety, and reappraisal preceded decreases in depression. As the authors noted, this single-case study does not establish generalizability, but does begin to elucidate processes of change. Yet idiographic analyses sometimes attest to heterogeneity in such processes. For example, Rosmalen et al. (2012) used idiographic analyses to document three distinctive paths of association between physical activity and depressive symptoms following myocardial infarction. Daily self-reports completed over 2-3 months by 4 participants and analyzed with time-series analyses revealed heterogeneity in the cross-sectional association between these two variables (with 2 participants showing increases in depression preceding decreases in physical activity, 1 participant showing the reverse pattern, and 1 participant showing no association at all). Like Rosmalen et al. (2012), the data explored in the present study aims to examine heterogeneity in change processes – and in particular, in within-session changes in the clients' self-states. Our data come from an open-trial study of ST for APD which followed Arntz's (2012) protocol. It illustrates the use of TSPA with within-session data using three single case models. For each case, a minimum of five sessions were sampled from various stages in the therapy process. Each session was coded by two raters to obtain scores for each mode in every 5-minute segment of the session. Idiographic TSPA methods were then used to estimate segment-by-segment associations between modes. Method Participants. Clients who met criteria for APD were recruited from two sites: a university-based community mental health center (CMHC) and a student counseling center (SCC). Both clinics offer low-cost psychological treatment carried out by postgraduate interns (who take part in a joint clinical psychology internship program). After a screening intake by the clinics’ staff, clients with avoidant features were given the option to take part in the open-trial study of ST, which required a more detailed 59 intake process. Of the 23 clients who consented to participate, 15 (CMHC: N=9; SCC: N=6) were found to meet the criteria for APD (using the Structured Interview for the DSM-IV; Pfohl et al., 1997) and were included in the treatment trial. Exclusion criteria were: 1. Borderline personality disorder (BPD) 2. Cluster A personality disorder 3. Psychotic disorder 4. Substance-related addictive disorder 5. Asperger’s syndrome. 6. Severity of Symptoms that required in-patient treatment. Of the 8 clients excluded from the study, 2 did not met APD criteria, 2 met BPD criteria, 1 met asperger’s syndrome criteria, and 3 chose to withdraw for unknown reasons. Of the 15 clients in the trial, 7 had a sufficient number of sessions. In the current study we present 3 single case models of APD clients' mode associations from one segment to the next by using TSPA. These particular 3 single case models differ significantly from each other in their complexity and distinctively display the importance of idiographic analysis over the nomothetic model of the "average client". Therapist training and procedure. The therapists were trained in ST by two senior clinical psychologists certified as trainers and supervisors in ST. All therapists were clinical psychology interns. The therapists participated in a 2-day ST workshop which combined didactic as well as dyadic role-play exercises on mode work. Each therapist received 45 minutes of individual ST supervision once every 2-3 weeks alongside a 90-minute group ST supervision meeting once a week. The clients received weekly (50-60 minute) individual therapy sessions; when needed, these were augmented by telephone, text, or email contact outside of session. On average, the 3 clients in this study received 54 sessions (ranging from 35-76). Materials. Psychiatric diagnoses. The Structured Clinical Interview for DSM–IV Axis I Disorders (SCID-I; First et al., 1996) and the Structured Interview for DSM–IV Personality (SIDP-IV; Pfohl et al., 1997) were used to establish diagnoses and ensure the meeting of inclusion criteria. Both are widely used interviews; the reported reliability for SCID-I is kappa >0.6 (Williams et al., 1992). the reported reliability for any PD on SIDP-IV is good (kappa = 0.77) and for Cluster C even better (kappa = 0.87) (Zimmerman et al., 2005). 60 Client’s modes rating scale (CMRS). The CMRS was developed in our lab (Mittelman-Kirshenfeld, 2012) to observe and rate the presence and intensity of clients’ modes and schemas within therapy sessions. This rating instrument was modeled on Callaghan's et al., (2008) coding system for functional analytic psychotherapy (FAPRS), a system which allows coding both therapist and the client behaviors during the therapy session. In the current study we used data obtained from the first section of the CMRS in which raters were asked to note the presence and intensity of client modes on a 4 point Likert scale (0-not present, 1-moderately present, 2-present, 3-clearly present). These ratings are provided for every 5-minute segment of the session; thus, a 50minute session will have 10 segments. Ratings were obtained for 16 modes thought to be prevalent in APD (Lobbestael et al., 2008). These included 7 Child Modes (Angry, Impulsive/Undisciplined, Happy, Abandoned/Abused, Dependent, Lonely/Inferior, and an additional category of Vulnerable Child Not Otherwise Specified [NOS]), 6 Maladaptive Coping Modes (Compliant-Surrender, Detached Protector, Avoidant Protector, Perfectionist/Over-controller, Self-Aggrandizer, and an additional category of Over-Compensator NOS), 2 Dysfunctional Parent Modes (Punitive-Critical and Demanding Parent) and a Healthy Adult mode. Rating procedure. Eight raters were trained by 2 clinical psychologists who are certified trainers and supervisors in ST (OP and ER). All raters were graduate students in clinical psychology. They received 6 hours of training on the CMRS. The raters worked in pairs. Each pair of coders used the CMRS to code an entire session (segment-by-segment). During the coding, each successive 5-minute segment was played, and each rater provided their independent scores. In case of rater discrepancies, the raters listened to the segment once again and reached a consensus rating. The initial ratings (prior to reaching consensus) were used to compute inter-rater agreement (using Intra-Class Correlation, or ICC), across the 645 5-min segments obtained from 60 randomly sampled sessions out of 439 audiotaped sessions of 15 clients. The ICC estimates ranged from good to excellent across the different modes (Table 1). 61 Table 1 Raters' Inter Class Coefficient (ICC) for Client Modes Rating Scale (CMRS) CMRS – Client modes rating scale Agreement ICC (n=60) MODE ICC MODE ICC Abandoned/abused child (AAC) .74 Detached protector (DP) .94 Dependent child (DC) .78 Avoidant protector (AP) .82 Lonely/inferior child (LIC) .83 Perfectionist/over-controller (PO) .80 Vulnerable child NOS (VCN) .71 Self–aggrandizer (SA) .74 Angry child (AC) .84 Over-compensator NOS (OCN) .68 Impulsive/undisciplined child (IUC) .74 Punitive/critical parent (PCP) .79 Happy child (HC) .75 Demanding Parent (DEP) .69 Compliant-surrender (CS) .77 Healthy adult (HA) .79 Data Analysis. The clients’ mode ratings from the CMRS were reduced from 14 separate mode scores into 6 mode variables. When multiple mode ratings were combined into a single score, the MAX function was used. The variables retained were (1) Dysfunctional Parent (PAR; composed of the Punitive/Critical and Demanding Parent scores). (2) Over-Compensator (OVC); composed of the Perfectionist/Over-controller, Self-Aggrandizer, and Over-Compensator NOS scores). (3) Avoidant/Detached Protector (AD; composted of the Detached Protector and Avoidant Protector scores). (4) Compliant-Surrender (CS). (5) Vulnerable Child (VC; composed of the Abandoned/Abused, Dependent, Lonely/Inferior, and Vulnerable Child Not Otherwise Specific [NOS] scores). (6) Healthy Adult (HA). Because the Happy, Angry, and Impulsive/Undisciplined Child modes were quite rare in the coded sessions, we excluded them from analyses. Idiographic TSPA allowed us to estimate for each client the following parameters (see Figure 1): 1. Linear trends (i.e., the linear change in each mode across segments and sessions) 62 2. Auto-regressions (i.e., the associations of each mode at time t-1 with the same mode at time t). 3. Cross-regressions (i.e., the association between each mode at time t-1 and another mode at time t). 4. Synchronous associations (i.e., the association between each mode at time t and another mode at time t)1. 5. Causal inference (i.e. a variable on time t-1 causally influences the succeeding value of the other variable on time t). single case model t-1 PAR t 2,5 TR(+) 1 OVC AD 4 3,5 CS VC HA Figure 1. Idiographic TSPA model: 1= linear trend; 2= auto-regression; 3= crossregression; 4= synchronous associations; 5= causal inferences; → positive association; ---› negative association. Results and Discussion Client A (male, 29 year old). Seven sessions (4, 6, 7, 20, 35, 60, 63) taken from this client's therapy process were coded. As Table 2 and Figure 2 show, this client evidenced a positive linear trend across all sessions in both the PAR mode and VC mode. There was positive auto-regression in the PAR, OVC, and HA modes. There were cross-regression associations between the PAR mode (at time t-1) and 1 In effect, this component reflects the correlations between the variables residuals controlling for all other components of the TSPA. 63 greater OVC as well as AD modes (at time t); between the CS mode (at t-1) and a lower AD mode (at time t); and between the HA mode (at time t-1) and greater OVC, lower AD, and lower VC modes (at time t). Finally as Table 3 and Figure 2 show, there were positive synchronous associations between the PAR mode on the one hand, and the OVC and CS modes on the other. Table 2 Client A: Idiographic TSPA – Linear Trends, Auto Regressions, Cross Regressions Mode t Mode Linear Trend 1 2 3 4 5 6 1. PAR 0.01(0.00)+ 0.25(0.14)+ 0.37(0.13)** 0.37(0.18)* 0.09(0.11) 0.10(0.13) -0.01(0.14) 2. OVC 0.00(0.00) 0.11(0.11) 0.36(0.10)*** -0.21(0.14) 0.01(0.09) 0.13(0.10) -0.05(0.11) 3. AD 0.00(0.01) 0.01(0.09) 0.04(0.08) 0.14(0.11) -0.02(0.07) -0.06(0.08) 0.00(0.09) 4. CS 0.00(0.00) -0.27(0.16) 0.05(0.16) -0.84(0.22)** -0.00(0.14) -0.24(0.16) 0.21(0.17) 5. VC 0.01(0.004)** -0.04(0.14) -0.08(0.13) 0.17(0.17) -0.07(0.11) -0.12(0.13) 0.06(0.13) 6. HA 0.01(0.00) -0.05(0.13) 0.44(0.12)*** -0.30(0.17)+ -0.14(0.10) -0.31(0.12)* 0.44(0.13)** (t-1) Note. Client modes: PAR = dysfunctional parent; OVC = over compensator; AD = avoidant detached; CS = compliant surrenderer; VC = vulnerable child; HA = healthy adult; †=<.10; * = p<.05; ** = p<.01; *** = p<.001. Table 3 Client A: Idiographic TSPA – Synchronous Associations and Mode Descriptive Statistics Mode t Mode t 2 3 4 5 6 Frequency % Intensity MIN-MAX M(SD) 1. PAR 2. OVC 3. AD 4. CS 0.32** -0.19 0.21+ 0.04 -0.03 26.47 0.35(0.64) 0.00-2.00 0.00 -0.13 -0.22 0.18 33.82 0.51(0.81) 0.00-3.00 -0.10 -0.08 -0.13 91.18 2.06(0.87) 0.00-3.00 0.09 -0.11 8.82 0.13(0.45) 0.00-2.00 0.01 32.35 0.39(0.63) 0.00-2.00 19.12 0.28(0.64) 0.00-3.00 5. VC 6. HA Note. Client modes: PAR = dysfunctional parent; OVC = over compensator; AD = avoidant detached; CS = compliant surrenderer; VC = vulnerable child; HA = healthy adult; Frequency of mode = % of segments; M = mean of mode intensity (0-not present, 1-moderately present, 2-present, 3-clearly present); SD= standard deviation; †=<.10; * = p<.05; ** = p<.01; *** = p<.001 64 Client A t-1 t PAR TR(+) OVC AD CS VC TR(+) HA Figure 2. Client A: Idiographic TSPA Model To interpret this idiographic pattern of results, we begin by focusing on the linear trends found in two of the client's modes: the dysfunctional parent and the vulnerable child modes. These trends indicate that both modes grew stronger as the therapy progressed. We can also see that these two modes were fairly similar in their frequency (PAR 26.5%; VC 32.4%) and intensity (PAR: M=0.35, SD=0.64; VC: M=0.39, SD=0.63). It may be that this client's vulnerability and distress activated the critical or punitive parent mode, or vice versa. However, these two modes did not evidence synchronous (time t to time t) or cross-regression (time t-1 to time t) associations. Our interpretation must therefore contend with the evidence for the gradual growth in both distress and harshness, but also with the fact that these two qualities do not seem to occur in temporal proximity to each other. One way of understanding this pattern of results is by noting the frequency and intensity of the coping modes as well as the associations between the parent mode and all three of the coping modes. For this client, the avoidant/detached mode was most strongly present (91.2%; M=2.06, SD=0.87), followed by the over-compensating mode (33.82%; M=0.51, SD=0.81) and the compliant surrender mode (8.82%; 65 M=0.13, SD=0.45) at a great distance. Moreover, the parent mode was tied to compliance/surrender (concurrently), to avoidance/detachment (prospectively), and to overcompensation (both concurrently and prospectively). Such rampant activation of coping modes may be the reason why vulnerability itself does not seem prominent in the same segments in which the internalized parent voice is heard: when the harsh parental mode was present, the client seemed to gravitate towards various forms of self-protection, thus evading his own vulnerability. For this client, the healthy adult mode, though present (in 19.1% of the segments with a mean intensity of 0.28, SD=0.64) did not strengthen over the course of therapy. Additionally, it was not recruited in temporal proximity to the parent mode, neither co-occurring with it nor following it prospectively. In short, the healthy adult mode seemed to have little ability to counteract the effects of the dysfunctional parent mode. True, it was tied to some reduction in vulnerability and in avoidance, but was actually tied to an increase in the overcompensation mode, which may suggest that the client has difficulty distinguishing healthy assertiveness from overcompensation. An interesting prospective association found within the coping modes indicated that avoidance/detachment seemed to decrease following segments of compliance/surrender. One possibility is that for this client, the experience of surrender is antithetical to that of detachment. Auto-regression which implies stability from one segment to the other was seen in three of the modes: dysfunctional parent, over-compensation, and healthy adult. Two of these modes, the parent and the over-compensator, are dysfunctional, but (given their relatively high frequency and intensity) quite persistent. On the other hand, finding stability in the healthy adult mode would have been a more encouraging finding, were it not for its low frequency and intensity implying that there is still much to do in empowering this client's healthy adult mode. In summary, for client A, the dysfunctional parent mode seemed to play a central role, and was tied to increased use of all three maladaptive coping modes. The avoidant/detached mode was present almost constantly. In contrast, this client's healthy adult mode, although relatively weak, did have some immediate impact on vulnerable and coping modes (though not on the dysfunctional parent mode) from one 66 segment to the next. These findings led us to characterize client A as fitting into a "rigid" pattern; indeed, our clinical impression was that this client would have benefitted from continued therapy, particularly focused on interventions promoting flexibility and strengthening the healthy adult mode as an alternative for the dysfunctional parent and maladaptive coping modes. Client B (male, 26 year old). Five sessions (9, 27, 32, 34, 39) taken from this client's therapy process were coded. As Table 4 and Figure 3 show, this client evidenced a positive auto-regression in OVC, AD, CS, and VC modes. There were cross-regression associations between the PAR mode (at time t-1) and greater HA as well as CS modes (at time t); between the OVC mode (at time t-1) and greater CS mode (at time t); between the AD, VC, and HA modes (at time t-1) and greater PAR mode (at time t); between the CS mode (at time t-1) and a lower PAR mode (at time t1); and between the HA mode (at time t-1) and a lower CS mode (at time t). Finally, as Table 5 and Figure 3 show, the VC mode showed positive synchronous associations with the PAR, CS, and HA modes; the PAR mode showed a negative synchronous association with the AD mode. Table 4 Client B: Idiographic TSPA – Linear trends, Auto Regressions, Cross Regressions Mode t Mode Linear Trend 1 2 3 4 5 6 1. PAR -0.00(0.00) -0.09(0.13) -0.21(0.31) 0.46(0.42) 0.53(0.28)+ -0.24(0.25) 0.39(0.16)* 2. OVC 0.00(0.01) 0.00(0.06) 0.47(0.14)** 0.05(0.18) 0.30(0.12)* 0.10(0.11) -0.06(0.07) 3. AD 0.01(0.01) 0.10(0.05)* -0.08(0.11) 0.34(0.14)* 0.16(0.01) 0.05(0.09) -0.03(0.06) 4. CS -0.01(0.01) -0.10(0.05)* 0.02(0.12) -0.10(0.16) 0.63(0.11)*** 0.12(0.09) 0.01(0.06) 5. VC -0.01(0.01) 0.24(0.10)* 0.06(0.22) -0.07(0.30) 0.08(0.20) 0.35(0.18)* 0.18(0.12) 6. HA -0.00(0.00) 0.33(0.12)** 0.12(0.26) 0.03(0.36) -0.51(0.24)* 0.17(0.21) 0.19(0.14) (t-1) Note. Client modes: PAR = dysfunctional parent; OVC = over compensator; AD = avoidant detached; CS = compliant surrenderer; VC = vulnerable child; HA = healthy adult; †=<.10; * = p<.05; ** = p<.01; *** = p<.001 67 Table 5 Client B: Idiographic TSPA – Synchronous Associations and Mode Descriptive Statistics Mode t Mode t 2 3 4 5 6 Frequency % Intensity MIN-MAX M(SD) 1. PAR 2. OVC -0.15 -0.26+ 0.02 0.33* 0.20 7.41 0.09(0.35) 0.00-2.00 0.10 -0.03 0.01 -0.13 31.48 0.44(0.72) 0.00-2.00 0.07 -0.22 -0.11 85.19 1.72(0.94) 0.00-3.00 0.25+ 0.12 31.48 0.54(0.88) 0.00-3.00 0.49*** 18.52 0.26(0.59) 0.00-2.00 14.81 0.17(0.42) 0.00-2.00 3. AD 4. CS 5. VC 6. HA Note. Client modes: PAR = dysfunctional parent; OVC = over compensator; AD = avoidant detached; CS = compliant surrenderer; VC = vulnerable child; HA = healthy adult; Frequency of mode = % of segments; M = mean of mode intensity (0-not present, 1-moderately present, 2-present, 3-clearly present); SD= standard deviation of M; †=<.10; * = p<.05; ** = p<.01; *** = p<.001 Client B t-1 t PAR OVC AD CS VC HA Figure 3. Client B: Idiographic TSPA Model It is important to note that no linear trend was found for this client – i.e., no mode grew stronger as the therapy progressed. Instead, many concurrent (same segment) and lagged (next segment) associations were found among the modes, creating a pattern we see as confused. 68 Both the vulnerable child mode and the dysfunctional parent mode were relatively rare (18.5%; M=0.26, SD=0.59, and 7.4%; M=0.09, SD=0.35, respectively), but were tied to each other both concurrently and prospectively (with the former preceding the latter). The vulnerable child mode was stable. Interestingly, it also tended to be accompanied by the healthy adult and compliant surrender modes (14.8%; M=0.17, SD=0.42; 31.5%, M=0.54, SD=0.88, respectively), and these two were themselves tied to each other prospectively; specifically, though the former was less prevalent, it tended to precede decreases in the latter. The healthy adult and dysfunctional parent modes showed a bi-directional prospective association, with each being tied to subsequent increases in the other. This zig-zagging pattern may indicate that this client failed to hold a clear stance, and instead exhibited shifts between critical harshness and a healthier and compassionate attitude. It is interesting to examine the way the coping modes operated for this client. The compliant surrender mode (noted above), as well as the over compensator (31.5%, M=0.44, SD=0.72) and avoidant/detached (85.2%, M=1.72, SD=0.94) modes were stable from one segment to the other. Unfortunately, only the compliant mode led to decreases in the dysfunctional parent mode; indeed, the avoidant/detached mode (which was almost always active) led to increases in the parental mode from one segment to the next (though it was negatively tied to it within the same segment). Finally, the over-compensator mode was tied to greater compliance in subsequent segments. In summary, for client B, several – though somewhat confusing - patterns emerged. First, alternating bi-directional associations between the dysfunctional parent mode and the healthy adult mode suggested considerable instability. Second, the avoidant/detached mode was used extensively but appeared to have little efficacy. Third, the compliant surrender mode was less likely to appear after segments in which the healthy adult mode was present, but did tend to follow the occurrence of overcompensator or parental modes, and to precede decreases in the parental mode. These findings led us to characterize client B as fitting into a "confused" pattern. A central therapeutic goal for this patient seems to be the establishment of greater stability in ways other than his characteristic avoidance. 69 Client C (male, 36 years old). Five sessions (9, 12, 15, 40, 46) taken from this client's therapy process were coded. As Table 6 and Figure 4 show, this client evidenced only two major types of associations. First, there were positive autoregressions in the PAR, OVC, and HA modes. Second, as Table 7 and Figure 4 show, there were positive synchronous associations between the AD mode on the one hand, and the CS and VC modes on the other; and a negative synchronous association between the OVC and HA modes. Table 6 Client C: Idiographic TSPA – Linear trends, Auto Regressions, Cross Regressions Mode t Mode (t-1) Linear Trend 1 2 3 4 5 6 1. PAR 0.01(0.01) 0.29(0.13)* -0.04(0.08) -0.16(0.12) 0.01(0.10) -0.14(0.11) -0.11(0.10) 2. OVC 0.00(0.00) 0.21(0.21) 0.34(0.13)** -0.05(0.21) -0.19(0.17) -0.09(0.18) 0.03(0.17) 3. AD -0.01(0.01) 0.11(0.15) -0.03(0.09) 0.21(0.14) -0.06(0.12) 0.05(0.13) 0.03(0.12) 4. CS -0.00(0.01) -0.19(0.17) -0.03(0.10) 0.07(0.17) 0.19(0.14) 0.11(0.15) -0.01(0.14) 5. VC -0.00(0.01) -0.17(0.16) 0.11(0.10) 0.19(0.16) 0.01(0.13) 0.21(0.14) 0.17(0.13) 6. HA 0.00(0.01) 0.08(0.17) -0.07(0.10) 0.18(0.16) 0.07(0.13) 0.22(0.14) 0.23(0.13)+ Note. Client modes: PAR = dysfunctional parent; OVC = over compensator; AD = avoidant detached; CS = compliant surrenderer; VC = vulnerable child; HA = healthy adult; †=<.10; * = p<.05; ** = p<.01; *** = p<.001 Table 7 Client C: Idiographic TSPA – Synchronous Associations and Mode Descriptive Statistics Mode t Mode t 2 3 4 5 6 Frequency % Intensity M(SD) MIN-MAX 1. PAR -0.08 -0.09 -0.02 -0.09 -0.08 52.94 0.90(0.98) 0.00-3.00 -0.03 -0.04 -0.17 -0.21+ 13.24 0.21(0.56) 0.00-2.00 0.29* 0.32** 0.15 60.29 1.09(0.99) 0.00-3.00 -0.13 -0.09 30.88 0.44(0.72) 0.00-2.00 0.10 52.94 0.78(0.84) 0.00-3.00 67.65 0.90(0.76) 0.00-3.00 2. OVC 3. AD 4. CS 5. VC 6. HA Note. Client modes: PAR = dysfunctional parent; OVC = over compensator; AD = avoidant detached; CS = compliant surrenderer; VC = vulnerable child; HA = healthy adult; Frequency of mode = % of segments; M = mean of mode intensity (0-not present, 1-moderately present, 2-present, 3-clearly present); SD= standard deviation of M; †=<.10; * = p<.05; ** = p<.01; *** = p<.001 70 Client C t-1 t PAR OVC AD CS VC HA Figure 4. Client C: Idiographic TSPA Model To interpret this idiographic pattern of results, it is important to note that no linear trends were found for this client; in other words, his modes did not change in a systematic way over the course of therapy. There were also no cross-regression associations; in other words, modes did not precede or follow each other in a systematic manner. The positive auto-regressions in the PAR, OVC, and HA modes indicate that these mode were stable from one segment to the other. Two of the modes – the internalized parent and the healthy adult - both appeared frequently and were strong in their average intensity (PAR: 52.9%, M=0.90, SD=0.98; HA: 67.7%, M=0.90, SD=0.76). The over-compensator mode, which appeared somewhat less frequently (OVC: 13.2%, M=0.21, SD=0.56) evidenced a negative association with the healthy adult mode. Finally, the vulnerable child mode, which appeared quite frequently (VC=52.9%, M=0.78, SD=0.84) tended to co-occur with the most prominent of the coping modes: avoidant/detached protector (AD: 60.3%, M=1.09, SD=0.99). Additionally, avoidance/detachment tended to co-occur with the compliant surrender mode (CS: 30.9%, M=0.44, SD=0.72). 71 In summary, client C was characterized by an impoverished mode model. The high frequency of the healthy adult mode was present throughout, and was tied to less over-compensation. The vulnerable child, internalized parent, and avoidant/detached modes also appeared frequently, and the latter tended to co-occur with both vulnerability and compliance/surrender. Clinically speaking, the high frequency with which the healthy adult mode appeared is encouraging, as is the client's willingness to access his own vulnerable child mode. Additionally, the coping modes were considerably less dominant than for the other clients. These findings led us to characterize client C as fitting into a "receptive" pattern. At the same time, we would have hoped to see clearer patterns of mode change over time, as well as of mutual associations between the healthier modes and the less healthy ones. Summary and Conclusions In this summary we will relate to 4 aspects: (1) this study's results of idiographic models that led us to describe 3 variants of APD clients; (2) the advantage of mode (self-states) models as a taxonomy that enables measuring and describing dynamic interactions of the personality's distinct psychic parts, reaching trans-diagnostic mode models, and matching evidence based interventions; (3) the advantage of combining descriptive statistics and TSPA models for the multidimensional description of psychotherapy process; (4) the contribution of bottom-up models as a complimentary research to the more prevalent top-down psychotherapy research. This study aimed to explore idiographic models from our APD clients in order to reveal nets of association among modes (self-states) as they emerged during schema therapy treatment. We focused on 3 distinct models in attempt to decipher the meanings of each variant and draw clinical implications on the individual client level. Only after drawing conclusions from the empirical data we went back to the clinical notes of each clients' achievements in the course of therapy, which supplied some clinical support to the empirical phase. This added clinical information is discussed at the end of the following paragraphs on each variant: 72 (1) The rigid pattern. Based on the statistical analyses, client A was characterized by a strong self-harsh attitude which grew stronger as therapy progressed and by vulnerability which also grew stronger with time. The self-harsh attitude was tied to massive use of avoidance and detachment as coping strategies. This client also had a relatively weak self-compassionate reasonable attitude which did not have sufficient strength to overcome the dysfunctional harsh self attitude. Based on these analyses we concluded that this client would have benefitted from interventions promoting flexibility. Some findings from our other empirical study, on the associations among therapist interventions and clients' mode changes, may indicate flexibility in promoting interventions. In that study we found that a good therapist stance significantly decreases clients' avoidance / detachment and increases clients' self-compassionate reasonable attitude; we also found that good behavioral pattern breaking interventions decreases clients' self critical punitive attitude (for a comprehnsive discussion, see Peled, Mittelman-Kirshenfeld, Bar Kalifa, & Rafaeli, 2016). When we reviewed our clinical notes we found that this rigid client's actual progress in therapy was limited except for his academic career achievements. (2) The confused pattern. Based on the statistical analyses, client B was characterized with marked alternation between a self-harsh attitude and a self-compassionate reasonable attitude which contributed to his instability. This client was also characterized by a very complex mode association model and by entangled use of various maladaptive coping strategies which led to further confusion. Above all he was highly avoidant and detached which made him less receptive to therapy. Based on these analyses we concluded that this client would have benefitted from interventions promoting stability. Therapists may induce stability by implementing mindfulness and distress tolerance training (for further details see Young et al. [2003] p. 327) as well as implementing a good therapist stance which calms the client (Peled, Mittelman-Kirshenfeld, Bar Kalifa, & Rafaeli, 2016). When we reviewed our clinical notes we found that this confused client was inhibited throughout the therapy and made less progress compared to the two others described here. 73 (3) The receptive pattern. Based on the statistical analyses, client C was characterized by a fairly prominent self-harsh attitude, a strong selfcompassionate reasonable attitude, prominent vulnerability and frequent (but not extreme) use of avoidance and detachment. His mode association model was meager and simple. Based on these analyses we concluded that this client was the least challenging compared to the 2 others described here, and that he could benefit the most from the rich interventions that schema therapy provides. He would have benefitted from further work on reducing his self-harsh attitude. As we found in the other study, good behaviorpattern-breaking interventions are associated with decrease in self-harsh attitude (Peled, Mittelman-Kirshenfeld, Bar Kalifa, & Rafaeli, 2016). When we went back to our clinical notes we found that this receptive client made considerable progress and by the end of therapy started pursuing professional training, was able to maintain stable employment, and became engaged to be married. This is the first study to explore the in-session mutual influences of modes in schema therapy in particular and in APD in general. This taxonomy of modes and their inter-relation nets can serve as a language to describe, empirically, clients' emotional states and processes. On the individual level these case studies of the mode nets elucidated distinctive variants of APD clients. We expect that further analysis of idiographic clients' models may reveal additional variants of APD clients. Our study made the first step of exploring idiographic paths but did not proceed to the next nomothetic level due to the limited number of clients. Future studies are recommended to aggregate these additional idiographic analyses to nomothetic analyses that may reveal distinct APD subtypes. Moreover, further studies on mixed psychopathology samples may reveal trans-diagnostic mode models and may help match evidence-based interventions for each model. Tschacher & Ramseyer (2009) suggested implementing time-series-panelanalysis for empirical exploration of the idiographic paths associations among psychotherapeutic variables and aggregate the different idiographic clients' models to a nomothetic psychotherapy model (Ramseyer et al., 2014). Our study is the first to combine descriptive statistics and time-series-panel-analysis for characterizing individual clients. The descriptive statistics contributed overall information about the 74 frequency and intensity of the various modes (self-states) of each client throughout therapy. The idiographic TSPA models added complex dynamic information about insession mode associations (both concurrent and lagged) and across therapy processes. We believe this combination of descriptive statistics and time-series-panel-analysis models enriches the multidimensional description of what happens in the therapy process by widening our knowledge about microanalytic links among therapeutic variables on the segment level and across therapy as well. There is a growing interest in matching the specific interventions to the individual client. In general medicine, considerable efforts and funds are invested in promoting personalized medicine, which optimizes treatment by prescribing the right drug at the right dose at the right time to the particular client (Hamburg & Collins, 2010). A similar trend is evident in the psychotherapy field, aiming to tailor psychotherapeutic interventions to the individual client's characteristics (Rosmalen et al., 2012). TSPA is an example of bottom-up exploration. By bottom-up explorations we may gain additional insight on the individual client as well as on the distinct group and discover in-therapy processes. This bottom-up approach can serve as a complementary research to more top-down approaches which explore pre-to-post therapy changes and interventions' effectiveness. Both approaches may help us discover what happens in the therapeutic process and which therapy offers the best fit for whom. 75 General Discussion This dissertation aimed to study distinct facets of psychotherapy processes in ST for APD. Fifteen APD clients were recruited and treated with ST by 15 clinical psychology interns who were trained and supervised by 2 ST supervisors (Rafaeli & Peled). Sixty sessions were randomly sampled, and every 5-minute segment of these sessions was coded by 2 independent raters. Two novel rating scales were used: The client mode rating scale (CMRS) and the schema therapist intervention rating scales (STIRS). In total, six hundred and forty five segments were coded. Using these ratings, three studies were conducted. The first study inquired whether APD is characterized by stability or instability. In particular, it sought to explore the frequency, intensity, and fluctuation patterns characteristic of the modes displayed by clients with APD during the therapy process. The second study aimed to micro-analyze the segment-by-segment associations between the therapists' interventions and the clients' mode changes. In particular, it sought to examine empirically some of the theoretical premises put forward by ST regarding the matching of specific interventions to changes in specific modes. The third study set out to examine short-term associations (concurrent as well as segment-to-segment) and long-term changes (across the therapy process) in and among clients' modes. In particular, this study focused on three distinct clients and analyzed their unique idiographic change models which hinted at the considerable heterogeneity in client profiles within the APD population. The following sections will describe the contributions of these 3 studies to ST research and practice in particular, and to research and practice with APD more broadly. The discussion will then turn to the added value of the statistical methods used in these studies to psychotherapy research. Finally, the discussion will elaborate on the possibilities embedded in the mode concept to capture and measure the dynamic facets of personality, and to help guide both generic and individualized treatment strategies. Contribution to Schema Therapy Research and Practice Most empirical studies on ST have explored one or more of the following three areas: (a) validation of inventories measuring ST components; (b) exploration of 76 schemas or modes typical of various disorders; and (c) efficacy of ST in the treatment of a variety of mental disorders. The current dissertation is therefore one of the first to shed light on in-therapy processes that may occur in ST. By dividing each sampled session into 5-minute segments, and by coding each segment with the CMRS and the STIRS, exploring various processes occurring during the ST treatment was possible. Across its three studies, the dissertation proceeded from a more general level (which attempted to characterize the entire patient group in terms of the frequency, intensity, and stability of their modes [Study 1] as well as in terms of the expected association between interventions and mode changes [Study 2]) to a very idiographic description (in which the unique profiles of specific exemplars were explored in depth [Study 3]). On each of these levels, therapeutic implications which inform the practice of ST were drawn. Study 1 explored the characteristics of the modes displayed by APD clients within therapy sessions. The most frequent and intense mode, which also showed the greatest degree of fluctuation, was the avoidant/detached mode, followed by the vulnerable child and the dysfunctional parent modes, respectively. The least frequent and intense modes, which also showed a lower degree of fluctuation, were the overcompensator and the compliant-surrenderer coping modes. The healthy adult mode was as infrequent and low in intensity as these latter two coping modes, but was significantly most steady compared to all other modes. Study 1's findings help explain why it is that APD clients are so difficult to treat. The relatively high frequency and intensity of the dysfunctional parent mode reflects the severity of these clients' psychopathology, and particularly their selfpunitiveness, criticism, and harshness. In addition, the frequent and intense presence of the avoidant/detached mode blocks access to the clients' emotions and their core emotional needs. Moreover, the considerable instability of vulnerable child mode makes it quite evasive and poses an additional hurdle for the corrective therapeutic experience to occur; afterall, it is this mode alone which is truly connected to the clients' core emotional needs. On the other hand, Study 1 also provided some positive signals for the conduct of ST with APD clients. Despite its instability, the sheer intensity and frequency of the vulnerable child mode does suggest that there are ample opportunities to make 77 direct contact with the client's core emotional needs. Additionally, the instability of the avoidant/detached mode (which was greater than that found in any other mode) suggests that at least intermittently, this mode abates somewhat and leaves cracks through which corrective therapeutic experience may occur. Moreover, though the dysfunctional parent mode was quite frequent, approximately 40% of segments did not manifest this mode; furthermore, the healthy adult mode (though present in only a third of segments) was the steadiest, and suggests that the clients might be able to get some traction when practicing self-compassion, adaptation to reality, and selfregulation. Study 2 explored the associations among the therapists' interventions in one segment and the clients' mode changes in the next 5-minute segment. The findings indicated that good implementation of the recommended therapist stance in ST precedes increases in the healthy adult mode and decreases in the avoidant/detached mode. Hence, by using the schema therapeutic stance (which is compassionate, warm, genuine, and caring, and which balances flexibility with sturdiness), therapists may help clients become less detached and avoidant. This therapeutic stance appears also to foster clients' self-compassion and increase the likelihood of clients' mature and balanced behaviors. Good implementation of emotion-focused and relational interventions was found to precede decreases in the clients' over-compensating mode. When clients become angry, hostile, controlling, or demeaning towards others, therapists' implementation of experiential techniques may help the clients connect to their emotional needs and diminish their aggressive tension. Similarly, when clients respond aggressively to here-and-now ruptures in the therapeutic alliance, relational interventions based on mutuality may prove most useful to resolve the conflict. A good implementation of cognitive interventions was found to precede increases in the vulnerable child and the dysfunctional parent modes. Therapists need to be aware of the paradoxical impact of cognitive interventions. On the one hand, cognitive interventions seem to enable greater access to the clients' core emotional needs but on the other hand they increase the clients' tendency for self-punitiveness, criticism, and harshness. 78 Finally, a good implementation of behavioral interventions was found to precede decreases in the dysfunctional parent modes. Hence, when clients are selfcritical or lack self-compassion, behavioral pattern-breaking interventions may be particularly useful in paving the way towards greater self-compassion and healthier coping with triggering situations. Study 3 used time-series-panel-analyses to explore idiographic models of change in three APD clients. After revealing idiographic nets of associations among modes over the course of ST treatment, the next step was to demonstrate how each variant can be understood as reflective of a unique profile of change requiring a tailored therapeutic response. The first pattern, which was referred as the rigid client, was characterized by a strong attitude of self-harshness which grew stronger as therapy progressed, and by a vulnerability which also grew stronger with time. The self-harshness was tied to massive use of avoidance and detachment as a coping strategy. This client also had a relatively weak self-compassionate reasonable attitude (i.e., healthy adult mode), which was not strong enough to over-rule the self-harshness. Clinically, I reasoned that this client would have benefitted from interventions promoting flexibility. Based on the Study 2, which explored the associations between therapist interventions and clients' mode changes, I reasoned that a good therapeutic stance, which tends to decrease avoidance/detachment and to increase selfcompassion, would have been advisable for this client. Additionally, good behavioral pattern-breaking interventions, which were found to decrease clients' self-criticism and punitiveness, would have been recommended to overcome this client's dysfunctional parent mode. The second pattern, which was referred as the confused client, was characterized by marked alternation between self-harshness and self-compassion, which resulted in considerable instability. This client was also characterized by a very complex mode association model, marked by an entangled use of various maladaptive coping strategies which overloaded him with further confusion. Above all, he was highly avoidant and detached which made him less receptive to therapy. 79 Clinically, I reasoned that this client would have benefitted from interventions promoting stability. The therapist could have tried to induce stability by implementing mindfulness and distress tolerance training (for further details see Young et al. [2003] p. 327) as well as implementing a good therapeutic stance, which (again, based on Study 2) would be expected to reduce the client's avoidance. The third pattern, which was referred as the receptive client, was characterized by fairly prominent self-harshness, alongside a strong reasonable and selfcompassionate attitude, as well as by prominent vulnerability and frequent (but not extreme) use of avoidance and detachment. The net of associations seen for this client was considerably simpler than for the other two. Clinically, I reasoned that this client would be the least challenging to work with, and could benefit the most from the variety of interventions that ST offers. Still, he would have probably benefitted from further behavioral pattern-breaking work focused on reducing self-harshness. Study 3 demonstrates the utility of exploring idiographic (i.e., single client) mode change models. By revealing the unique nets of associations among the modes characterizing each individual client, it was possible also to reason about the most appropriate interventions which may help each particular client. In summary, the three studies which compose this dissertation are innovative with regards to ST. They are the first to explore within-session processes in such a manner, and each of them leads to some novel realization about this treatment approach. Study 1 revealed the unique characteristics of APD clients' modes during ST sessions, and discussed their possible treatment strategy implications. Study 2 revealed the associations between the therapists' interventions and the clients' mode changes from one segment to the next. For the first time, the data gathered permitted the examination of the immediate effects of specific interventions within ST. Finally, Study 3 demonstrated the utility of developing idiographic mode change models for individual clients as a way of reasoning about the tailored interventions recommended for each client. 80 Contribution to Avoidant Personality Disorder Research and Practice APD is one of the most prevalent personality disorders (Sanislow et al., 2012; Zimmerman et al., 2005), but it has received relatively little empirical attention. This dissertation focused on APD clients and thus yielded some novel information on this particular disorder. Study 1 explored whether APD clients are characterized by stability or instability. Traditionally, APD has been thought to be characterized by stability on par with normal personality (Alden et al., 2002). DSM-5 (APA, 2013) and its earlier editions have not listed instability as a criterion for this PD. Only recently have studies addressing instability in APD (e.g, Koenigsberg et al., 2014; Shafran et al., 2016; Snir et al., 2015) begun to appear. These studies have begun to document the degree to which APD patients are characterized by significantly more instability than healthy control individuals, though with less instability than BPD patients (who are often included in the same studies). The results of Study 1 support the notion of instability as a characteristic of APD, and indicate that the 3 most prominent modes for APD clients (the avoidant/detached, vulnerable child, and dysfunctional parent modes) were indeed characterized by considerable instability. Study 1 provides additional information regarding the phenomenology of APD clients in therapy, which is mostly in agreement with the DSM-5 (APA, 2013) criteria for this diagnosis. The clients in this study were found to be in an avoidant/detached mode in approximately 3/4 of the time segments, as might be expected given their diagnosis. Moreover, their vulnerable child mode was present in over half of the segments, which is in line with the DSM's description of "hypersensitivity to negative evaluation that begins by early adulthood and is present in a variety of contexts (p.673) […] often starts in infancy or childhood with shyness (p.674)". The third dominant mode - the dysfunctional parent - was present in over 1/3 of the segments, and is in line with the tendency of APD clients to view themselves as socially inept, personally unappealing, or inferior to others (criterion 6 in the DSM-5; p. 673). Study 2 was focused on the link between interventions and mode change, and helps point out which therapeutic interventions may be most effective in helping APD clients. As was described in the previous section (which focused on the contribution of these studies to ST research and practice), we found that the implementation of a 81 particular therapeutic stance which is compassionate, warm, genuine, and caring, and which balances flexibility with sturdiness, helped reduce clients' behaviors of avoidance and detachment and foster clients' more self-compassionate, mature, and balanced behaviors. When APD clients become angry, hostile, controlling, or demeaning towards others, therapists' implementation of experiential techniques appeared to help clients connect to their emotional needs and diminish their aggression. Similarly, when clients responded aggressively to ruptures in the here-and-now therapeutic alliance, relational interventions based on mutuality appeared to help resolve the conflict. Finally, when clients were self-critical or lacked self-compassion, behavioral patternbreaking interventions appeared to help in paving the way towards greater selfcompassion and healthier coping with triggering situations. Study 3 focused on idiographic models of specific APD clients, and demonstrated the heterogeneity which characterizes this disorder – in this case, in change patterns over the course of psychotherapy. In this study, three variant patterns were presented, and named according to their unique characteristics: the rigid client, the confused client, and the receptive client. This heterogeneity poses a therapeutic challenge which needs to be considered in tailoring interventions to any particular client diagnosed with APD. This idea of tailored interventions goes in line with the personalized medicine movement, which recommends optimizing treatment by steering clients to the right drug or intervention at the right dose at the right time (Hamburg & Collins, 2010; Rosmalen et al., 2012). The Promise of the Statistical Methods Used Here for Psychotherapy Research Randomized controlled trials (RCT) have been considered the gold-standard method for establishing treatment efficacy (for review, see Kazdin & Blase, 2011; Stiles et al., 2015) but such studies offer little clarity about what actually transpires within the psychotherapy process. Recently, there has been a growing interest in studying what change processes occur in the therapy sessions (Greenberg, 2007; Gumz et al., 2014; Kazdin & Nock, 2003; Kazdin, 2009; Pascual-Leone et al., 2009) and what really works for the individual client (e.g. Barlow & Nock, 2009; Boswell et al., 2014; Rosmalen et al., 2012). 82 This dissertation was designed to explore change processes occurring in ST for APD clients. Our coding of therapy sessions on a 5-minute segment-by-segment basis permitted several different types of analysis. Study 1 focused on stability and instability characteristics of our client group, Study 2 focused on the associations between the therapists' interventions in one segment and the clients' changes in the next segment, and Study 3 focused on the unique characteristic of individual APD clients. Study 1 made use of mean-square-successive-differences (MSSD) indices to assess stability and instability among APD clients. MSSD is a recommended statistic for indexing fluctuations in psychopathology (Ebner-Priemer et al., 2009). Indeed, several studies have used MSSD to explore fluctuation patterns in various forms of psychopathology including social phobia (e.g. Farmer & Kashdan, 2014), depression (e.g. Bowen, Wang, Balbuena, Houmphan, & Baetz, 2013), bipolar disorder (e.g. Gershon & Eidelman, 2015), psychosis (e.g. Palmier-Claus, Shryane, Taylor, Lewis, & Drake, 2013), ADHD (e.g. Factor, Reyes, & Rosen, 2014), and BPD (e.g. EbnerPriemer et al., 2007). However, although MSSD has been recommended as an index for instability within psychotherapy as well (e.g., Tryon, 1982), Study 1 appears to be the first to use this method to examine fluctuation within psychotherapy sessions, and is certainly the first to do so with APD clients. Study 2 made use of multilevel-regression models (MLM) to explore associations among therapists' interventions and APD clients' mode changes within ST sessions. Kahn & Schneider (2013) stated that MLM is the recommended method to assess patterns of change in studies of psychotherapy outcome. Indeed, various studies have made use of MLM to explore change processes in specific psychotherapies for specific forms of psychopathology including acceptance-based behavior therapy for generalized anxiety disorder (e.g. Roemer, Orsillo, & SaltersPedneault, 2008), cognitive-processing-therapy for PTSD (e.g. Resick, Suvak, Johnides, Mitchell, & Iverson, 2012), prolonged exposure for PTSD (e.g. Aderka, Foa, Applebaum, Shafran, & Gilboa-Schechtman, 2011), group CBT for social phobia (e.g. Taube-Schiff, Suvak, Antony, Bieling, & McCabe, 2007), and dialectical behavioral therapy for BPD (e.g. Stepp, Epler, Jahng, & Trull, 2008). 83 Study 2 joins this growing research. However, it uses MLM to carry out a micro-analytic analysis which explores the associations between ST interventions in one segment and the change occurring in the clients' states in the next therapy segment. To our knowledge, this is an entirely innovative research focus in ST as well as in APD, and has yet to be used extensively in other areas of psychotherapy research. Study 3 made use of time-series-panel-analyses (TSPA) to explore idiographic models of change for particular APD clients. These idiographic models revealed how the modes of each individual client changed over the course of the therapy sessions, as well as what the interplay among these modes for that particular client was. TSPA offers a statistical approach to the modeling of sequentially dependent observations (Ramseyer et al., 2014; Tschacher et al., 2012; Tschacher & Ramseyer, 2009) which can be used both within- and between-sessions, and which takes into account variability between individuals. This method can address both immediate and lagged associations between multiple psychotherapeutic variables. Interestingly, only a handful of studies have used TSPA to date, in exploring trajectories in psychotherapy mechanisms of change. For example, Tschacher and Jacobshagen (2002) explored the process of crisis intervention. Tschacher and Ramseyer (2009) examined the reciprocal associations between patients' well-being and their motivation for therapy. Wild et al. (2010) explored characteristics of obese patients with and without binge-eating disorder. Tschacher et al. (2012) were the first to used TSPA to model change mechanisms in schema-centered group psychotherapy for mixed clients diagnosed with several personality disorders. To date, TSPA studies have relied on data collected from self-reported questionnaires or diaries obtained daily or on a session-by-session basis. As such, the time lags explored in them are those that transpire between successive sessions (Ramseyer et al., 2014; Tschacher et al., 2012; Tschacher et al., 2000; Tschacher & Ramseyer, 2009) or days (Tschacher & Jacobshagen, 2002; Wild et al., 2010). Study 3 is the first to use TSPA to examine segment-by-segment in-session change processes, and the first to do so with data obtained from independent raters. This novel use of TSPA was inspired by recent calls for more nuanced examination of 84 intra-individual change processes in psychotherapy (e.g., Barlow, Nock, & Hersen, 2009). Such a nuanced examination led to the study's recognition of 3 distinct idiographic mode models among our APD clients. As such, this study joins the emerging movement towards recognizing idiographic patterns which may underlie psychotherapeutic interventions which could be tailored to the individual client's characteristics (Rosmalen et al., 2012). In summary, this dissertation joins the frontier line of studies exploring microanalytic change processes in psychotherapy by implementing innovative research methods (namely, coding segments of therapy sessions by independent raters) and statistic analyses (MLM, MSSD, TSPA) for various purposes. The Mode Concept and its Utility for Psychopathology and Psychotherapy Research The mode concept, first introduced by Young et al. (2003), offers a solution to a problem that has received growing attention in both basic research on personality and applied clinical theories: specifically, the realization that the self is multi-faceted (e.g., Bromberg, 1996; Greenberg, 2004; Stone & Stone, 2011). This dissertation joins several earlier studies (e.g Arntz et al., 2005; Lobbestael et al., 2008; Lobbestael & Arntz, 2010; Shafran et al., 2016) in widening the evidence base for the ST mode concept as a language. I see the mode concept as offering a lexicon of self-states, each involving emotional, cognitive, behavioral, and motivational aspects. Recent advances in personality psychology (Dunlop, 2015; Fleeson, 2007; Mischel & Shoda, 2010) have illustrated that personality itself – including traits, goals, and even life-narratives – is often contextual. These contextualized "selves" or parts of an individual's personality are, by definition, state-like. The mode concept provides a suitable taxonomy for describing these state-like selves and for empirically measuring their characteristics. For example, Study 1 demonstrated a way of measuring the frequency, intensity, and instability of each mode thought to be characteristic of avoidant personality; Study 2 demonstrated a way of measuring mode changes associated with particular therapeutic interventions among avoidant clients; Study 3 demonstrated a way of measuring the unique mode interplay of the individual 85 client and the option to describe the variance among individuals' personality characteristics. The mode concept can be used trans-diagnostically, and need not be tied to one specific theory (such as schema therapy). Instead, it enables the description of the personality of any individual and/or the characteristics of any mental disorder. It offers a way to compare between individuals or between groups, and to explore the dynamic nature of interpersonal relationships (in which one person's self-states trigger another's). In short, the mode concept brings with it a variety of possibilities which can enrich the field of personality, close relationships, psychopathology, and psychotherapy research. Limitation and Future Directions Though ST is a versatile approach, aimed at addressing various personality disorders and interpersonal problems, the data presented here were collected from clients who were all diagnosed with APD (though often suffering from additional comorbid disorders). The focus on APD did not allow comparing the obtained patterns to those which may have emerged in non-clinical samples, or to ones with which may have emerged with other clinical conditions. The ability to generalize these results (e.g., Study 2's findings regarding the immediate effects of ST interventions) beyond this client group will require replications of the studies presented in this dissertation with diverse samples. This dissertation comprised three studies utilizing objective rating data from 645 segments of 60 randomly sampled therapy sessions. As such, the studies' conclusions were based on a large sample of data points. On the other hand, given the small number of participants (N=15), its results should be seen as tentative until further replication with larger samples. The small N also precludes any analyses of moderators within our sample. Another limitation of the current dissertation concerns the participating therapists, who were psychology interns with limited therapy experience. It is quite likely that data obtained from trials using more experienced schema therapists would show somewhat different patterns. At the same time, much of psychotherapy research is conducted in training clinics with relatively inexperienced therapists. 86 Two newly-developed instruments were used in this dissertation: the CMRS to assess schema modes, and the STIRS to assess therapist interventions. Although the reliabilities obtained with these two instruments were good, both require further validation and possibly further specification. For example, the STIRS code for emotion-focused interventions reflected an array of complex modalities (e.g., imagery, chair work, historical role-play, writing letters). Further micro-analytic studies may wish to explore the unique association of each of these with mode changes and treatment outcomes. Similarly, the therapist stance variable (used extensively in Study 2) was created as an amalgam of several therapeutic ingredients (limited reparenting; understanding and attunement to the client's "inner reality"; collaboration, feedback, and session focus; therapist balance and flexibility; and therapist confidence and ease). Future studies should illuminate which of these ingredients are the most potent. In particular, studies which will examine the specific effects of limited reparenting and of empathic confrontation are recommended. Future work should also explore the association between the therapist's stance (and its various components) and the more widely studied concept of therapeutic alliance. Castonguay et al. (2006) noted that therapeutic alliance may develop over the course of therapy in various patterns (e.g., linear, quadratic, V- shape deflections). Examining such patterns, while also exploring in-session transactions as was done here, could help elucidate the role of the therapeutic relationship as a mechanism of change affecting therapy outcomes. Additionally, this dissertation made a first step towards exploring idiographic paths of APD clients; due to the limited number of clients in the study, it did not proceed to the next nomothetic level which would describe the group as a whole. Larger future studies may aggregate these idiographic analyses and reach the nomothetic level; in doing so, they may reveal distinct APD subtypes. Finally, this dissertation explored change processes occurring in ST for APD clients. Though the language of schema modes can be a general one, similar analyses of sessions from other forms of psychotherapy are certainly worthwhile in order to generalize on change processes occurring in psychotherapy beyond a specific 87 treatment approach or client population. 88 References Aderka, I. M., Foa, E. B., Applebaum, E., Shafran, N., & Gilboa-Schechtman, E. (2011). Direction of influence between posttraumatic and depressive symptoms during prolonged exposure therapy among children and adolescents. Jounal of Consulting and Clinical Psychology, 79, 421–425. doi:10.1037/a0023318 Alden, L. (1989). Short-term structured treatment for avoidant personality disorder. Journal of Consulting and Clinical Psychology, 57, 756–764. doi:10.1037/0022006X.57.6.756 Alden, L. E., Laposa, J. M., Taylor, C. T., & Ryder, A. G. (2002). Avoidant personality disorder: Current status and future directions. Journal of Personality Disorders, 16, 1–29. doi:10.1521/pedi.16.1.1.22558 American Psychiatric Association [APA]. (2000). Diagnostic and statistical manualtext revision (DSM-IV-TRim, 2000)‫‏‬. Washington, DC: Amerian Psychiatirc Association. American Psychiatric Association [APA]. (2013). Diagnostic and statistical manual of mental disorders (DSM-5) (Fifth edit.). Arlington, VA: American Psychiatric Association. American Psychiatric Association [APA]. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: American Psychiatric Association. Arntz, A. (2012). Schema therapy for cluster C personality disorders‫‏‬. In M. van Vreeswijk, J. Broersen, & M. Nadort (Eds.), The Wiley-Blackwell handbook of schema therapy: Theory, research, and practice (pp. 397–414). Chichester, UK: John Wiley & Sons, Ltd. doi:10.1002/9781119962830 Arntz, A., & Jacob, G. (2013). Schema therapy in practice: An introductory guide to the schema mode approach‫‏‬. West Sussex: Wiley-Blackwell Publication. Arntz, A., Klokman, J., & Sieswerda, S. (2005). An experimental test of the schema mode model of borderline personality disorder. Journal of Behavior Therapy and Experimental Psychiatry, 36, 226–239. doi:10.1016/j.jbtep.2005.05.005 Arntz, A., & Van Genderen, H. (2009). Schema therapy for borderline personality disorder. West Sussex: Wiley-Blackwell Publication. Bamelis, L. L., Evers, S. M., & Arntz, A. (2012). Design of a multicentered randomized controlled trial on the clinical and cost effectiveness of schema therapy for personality disorders‫‏‬. BMC Public Health, 12, 75. doi:10.1186/14712458-12-75 Bamelis, L. L. M., Evers, S. M. A. A., Spinhoven, P., & Arntz, A. (2014). Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. The American Journal of Psychiatry, 171, 305– 22. doi:10.1176/appi.ajp.2013.12040518 Bamelis, L. L. M., Renner, F., Heidkamp, D., & Arntz, A. (2011). Extended schema mode conceptualizations for specific personality disorders: An empirical study. 89 Journal of Personality Disorders, 25, 41–58. doi:10.1521/pedi.2011.25.1.41 Barlow, D. H., & Nock, M. K. (2009). Why can’t we be more idiographic in our research? Perspectives on Psychological Science, 4, 19–21. doi:10.1111/j.17456924.2009.01088.x Barlow, D. H., Nock, M. K., & Hersen, M. (2009). Single case experimental designs: Strategies for studying behavior change (3rd ed.). Boston, MA: Allyn & Bacon. Bateman, A., & Fonagy, P. (2006). Mentalizationbased treatment for borderline personality disorder: A practical guide. New York, NY: Oxford University Pres. Beck, A. T., Freeman, A., & Davis, D. D. (2004). Cognitive therapy of personality disorders. New York: Guilford Press. Benjamin, L. S. (1996). Interpersonal Diagnosis and Treatment of Personality Disorders (2nd ed.). New York: Guilford Press. Bernstein, D. P., Arntz, A., & Vos, M. (2007). Schema focused therapy in forensic settings: Theoretical model and recommendations for best clinical practice. International Journal of Forensic Mental Health, 6, 169–183. doi:10.1080/14999013.2007.10471261 Bernstein, D. P., Nijman, H. L., Karos, K., Keulen-de Vos, M., de Vogel, V., & Lucker, T. P. (2012). Schema therapy for forensic patients with personality disorders: design and preliminary findings of a multicenter randomized clinical trial in the Netherlands‫‏‬. International Journal of Forensic Mental Health, 11, 312–324. doi:10.1080/14999013.2012.746757 Boswell, J. F., Anderson, L. M., & Barlow, D. H. (2014). An idiographic analysis of change processes in the unified transdiagnostic treatment of depression. Journal of Consulting and Clinical Psychology, 82, 1060–1071. doi:http://dx.doi.org/10.1037/a0037403 Bowen, R. C., Wang, Y., Balbuena, L., Houmphan, A., & Baetz, M. (2013). The relationship between mood instability and depression: implications for studying and treating depression. Medical Hypotheses, 81, 459–462. doi:10.1016/j.mehy.2013.06.010 Bromberg, P. M. (1996). Standing in the spaces: The multiplicity of self and the psychoanalytic relationship‫‏‬. Contemporary Psychoanalysis, 32, 509–535. doi:10.1080/00107530.1996.10746334 Callaghan, G. M., Follette, W. C., Ruckstuhl, L. E., & Linnerooth, P. J. N. (2008). The functional analytic psychotherapy rating scale (FAPRS): A behavioral psychotherapy coding system. The Behavior Analyst Today, 9, 98–116. doi:10.1037/h0100648 Castonguay, L. G., Constantino, M. J., & Holtforth, M. G. (2006). The working alliance: Where are we and where should we go? Psychotherapy: Theory, Research, Practice, Training‫‏‬, 43, 271–279. doi:10.1037/0033-3204.43.3.271 90 Chambless, D. L., Fydrich, T., & Rodebaugh, T. L. (2008). Generalized social phobia and avoidant personality disorder: Meaningful distinction or useless duplication? Depression and Anxiety, 25, 8–19. doi:10.1002/da.20266 Clarkin, J. F., Cain, N., & Livesley, W. J. (2015). An integrated approach to treatment of patients with personality disorders. Journal of Psychotherapy Integration, 25, 3–12. doi:10.1037/a0038766 Cloitre, M., Stovall-McClough, K., Miranda, R., & Chemtob, C. M. (2004). Therapeutic alliance, negative mood regulation, and treatment outcome in child abuse-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 72, 411–416. doi:10.1037/0022-006X.72.3.411 Dalenberg, C. J. (2004). Maintainig the safe and effective therapeutic relationship in the context of distrust and anger: Countertransference and complex trauma. Psychotherapy: Theory, Research, Practice, Training, 41, 438–447. doi:10.1037/0033-3204.41.4.438 Dimaggio, G., Nicolò, G., Semerari, A., & Carcione, A. (2013). Investigating the personality disorder psychotherapy process: The roles of symptoms, quality of affects, emotional dysregulation, interpersonal processes, and mentalizing. Psychotherapy Research, 23, 624–632. doi:10.1080/10503307.2013.845921 Dimaggio, G., Salvatore, G., Lysaker, P., Ottavi, P., & Popolo, R. (2015). Behavioral activation revisited as a key principle of change in personality disorders psychotherapy. Journal of Psychotherapy Integration, 25, 30–38. doi:10.1037/a0038769 Disney, K. L. (2013). Dependent personality disorder: A critical review. Clinical Psychology Review, 33, 1184–1196. doi:10.1016/j.cpr.2013.10.001 Dunlop, W. L. (2015). Contextualized personality, beyond traits‫‏‬. European Journal of Personality, 29, 310–325. doi:10.1002/per.1995 Ebner-Priemer, U. W., Eid, M., Kleindienst, N., Stabenow, S., & Trull, T. J. (2009). Analytic strategies for understanding affective (in)stability and other dynamic processes in psychopathology. Journal of Abnormal Psychology, 118, 195–202. doi:10.1037/a0014868 Ebner-Priemer, U. W., Kuo, J., Kleindienst, N., Welch, S. S., Reisch, T., Reinhard, I., … Bohus, M. (2007). State affective instability in borderline personality disorder assessed by ambulatory monitoring. Psychological Medicine, 37, 961–70. doi:10.1017/S0033291706009706 Edwards, D., & Arntz, A. (2012). Schema therapy in historical perspective. In M. van Vreeswijk, J. Broersen, & M. Nadort (Eds.), The Wiley-Blackwell handbook of schema therapy: Theory, research, and practice. Chichester, UK: John Wiley & Sons, Ltd. Elliott, R. (2010). Psychotherapy change process research: Realizing the promise. Psychotherapy Research, 20, 123–135. doi:10.1080/10503300903470743 91 Emmelkamp, P. M., Benner, A., Kuipers, A., Feiertag, G. A., Koster, H. C., & van Apeldoorn, F. J. (2006). Comparison of brief dynamic and cognitive-behavioural therapies in avoidant personality disorder‫‏‬. The British Journal of Psychiatry, 189, 60–64. doi: 10.1192/bjp.bp.105.0121510.1192/bjp.bp.105.012153 Factor, P. I., Reyes, R. A., & Rosen, P. J. (2014). Emotional impulsivity in children with ADHD associated with comorbid—Not ADHD—symptomatology. Journal of Psychopathology and Behavioral Assessment, 36, 530–541. doi:10.1007/s10862-014-9428-z Farmer, A. S., & Kashdan, T. B. (2014). Affective and self-esteem instability in the daily lives of people with generalized social anxiety disorder. Clinical Psychological Science : A Journal of the Association for Psychological Science, 2, 187–201. doi:10.1177/2167702613495200 Farrell, J. M., Shaw, I. A., & Webber, M. A. (2009). A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder: A randomized controlled trial. Journal of Behavior Therapy and Experimental Psychiatry, 40, 317–28. doi:10.1016/j.jbtep.2009.01.002 First, M. B., Gibbon, M., Spitzer, R. L., & Williams, J. B. W. (1996). User’s guide for the structured interview for DSM-IV axis I disorders—research version (SCID-I, version 2.0, February 1996 final version)‫‏‬. New York: Biometrics Research. Fisher, A. J., Newman, M. G., & Molenaar, P. (2011). A quantitative method for the analysis of nomothetic relationships between idiographic structures: Dynamic patterns create attractor states for sustained posttreatment change. Journal of Consulting and Clinical Psychology, 79, 552–563. doi:10.1037/a0024069 Fleeson, W. (2007). Situation-based contingencies underlying trait-content manifestation in behavior. Journal of Personality, 75, 825–862. doi:10.1111/j.1467-6494.2007.00458.x Fonagy, P., & Bateman, A. W. (2006). Mechanisms of change in mentalization-based treatment of BPD. Journal of Clinical Psychology, 62, 411–430. doi:http://dx.doi.org/10.1002/jclp.20241 Gershon, A., & Eidelman, P. (2015). Inter-episode affective intensity and instability: Predictors of depression and functional impairment in bipolar disorder. Journal of Behavior Therapy and Experimental Psychiatry, 46, 14–8. doi:10.1016/j.jbtep.2014.07.005 Giesen-Bloo, J., van Dyck, R., Spinhoven, P., van Tilburg, W., Dirksen, C., van Asselt, T., … Arntz, A. (2006). Outpatient psychotherapy for borderline personality disorder: Randomized trial of schema-focused therapy vs transference-focused psychotherapy. Archives of General Psychiatry, 63, 649– 58. doi:10.1001/archpsyc.63.6.649 Granger, C. W. (1969). Investigating causal relations by econometric models and cross-spectral methods. Econometrica: Journal of the Econometric Society, 37, 424–238. doi:10.2307/1912791 92 Greenberg, L. S. (1986). Change process research. Journal of Consulting and Clinical Psychology, 54, 4–9. doi:10.1037/0022-006X.54.1.4 Greenberg, L. S. (2004). Emotion–focused therapy‫‏‬. Clinical Psychology & Psychotherapy, 11, 3–16. doi:10.1002/cpp.388 Greenberg, L. S. (2007). A guide to conducting a task analysis of psychotherapeutic change. Psychotherapy Research, 17, 15–30. doi:10.1080/10503300600720390 Greenberg, L. S. (2012). Emotions, the great captains of our lives: Their role in the process of change in psychotherapy. American Psychologist‫‏‬, 67, 687–707. doi:10.1037/a0029858 Gross, E., Stelzer, N., & Jacob, G. (2012). Treating OCD with the schema mode model. In M. Van Vreeswijk, J. Broersen, & M. Nadort (Eds.), The WileyBlackwell handbook of schema therapy: Theory, research and practice (pp. 173– 184). Oxford: John Wiley & Sons, Ltd. Gude, T., & Hoffart, A. (2008). Change in interpersonal problems after cognitive agoraphobia and schema-focused therapy versus psychodynamic treatment as usual of inpatients with agoraphobia and cluster C personality disorders. Scandinavian Journal of Psychology, 49, 195 – 199. doi:10.1111/j.14679450.2008.00629.x Gumz, A., Geyer, M., & Brähler, E. (2014). Psychodynamic therapy from the perspective of self-organization, a concept of change and a methodological approach for empirical examination. Clinical Psychology & Psychotherapy, 21, 299–310. doi:10.1002/cpp.1840 Hamburg, M. ., & Collins, F. S. (2010). The path to personalized medicine. The New Enagland Journal of Medivine, 363, 301–304. doi:10.1056/NEJMp1006304 Hawke, L. D., & Provencher, M. D. (2011). Schema theory and schema therapy in mood and anxiety disorders: A review. Journal of Cognitive Psychotherapy: An International Quarterly, 25, 257–275. doi:10.1891/0889-8391.25.4.257 Hawke, L. D., & Provencher, M. D. (2012). The Canadian French Young Schema Questionnaire: confirmatory factor analysis and validation in clinical and nonclinical samples. Canadian Journal of Behavioural Science, 44, 40–49. http://dx.doi.org/10.1037/a0026197 Hayes, A. M., & Yasinski, C. (2015). Pattern destabilization and emotional processing in cognitive therapy for personality disorders. Frontiers in Psychology, 6, 107. doi:10.3389/fpsyg.2015.00107 Henry, C., Mitropoulou, V., New, A. S., Koenigsberg, H. W., Silverman, J., & Siever, L. J. (2001). Affective instability and impulsivity in borderline personality and bipolar II disorders: Similarities and differences‫‏‬. Journal of Psychiatric Research, 35, 307–312. doi:10.1016/S0022-3956(01)00038-3 93 Herpertz, S. C., Schwenger, U. B., Kunert, H. J., Ukas, G., Gretzer, U., Utzmann, J., & Sass, H. (2000). Emotional responses in patients with borderline as compared with avoidant personality disorder‫‏‬. Journal of Personality Disorders, 14, 339– 351. doi: 10.1521/pedi.2000.14.4.339 Hill, C. E., Gelso, C. J., Chui, H., Spangler, P. T., Hummel, A., Huang, T., … Miles, J. R. (2014). To be or not to be immediate with clients: The use and perceived effects of immediacy in psychodynamic/interpersonal psychotherapy. Psychotherapy Research, 24‫‏‬, 299–315. doi:10.1080/10503307.2013.812262 Hill, C. E., Kellems, I. S., Kolchakian, M. R., Wonnell, T. L., Davis, T. L., & Nakayama, E. Y. (2003). The therapist experience of being the target of hostile versus suspected-unasserted client anger: Factors associated with resolution. Psychotherapy Research, 13, 475–491. doi:10.1093/ptr/kpg040 Hoffart, A., & Sexton, H. (2002). The role of optimism in the process of schemafocused cognitive therapy of personality problems. Behaviour Research and Therapy, 40, 611–623. doi:10.1016/S0005-7967(01)00027-4 Hoffart, A., Versland, S., & Sexton, H. (2002). Self-understanding, empathy, guided discovery, and schema belief in schema focused cognitive therapy of personality problems: A process–outcome study. Cognitive Therapy and Research, 26, 199– 219. Hoffart Lunding, S., & Hoffart, A. (2014). Perceived parental bonding, early maladaptive schemas and outcome in schema therapy of cluster C personality problems. Clinical Psychology & Psychotherapy. doi:10.1002/cpp.1938 Hollander, E., Pallanti, S., Allen, A., Sood, E., & Rossi, N. B. (2005). Does sustainedrelease lithium reduce impulsive gambling and affective instability versus placebo in pathological gamblers with bipolar spectrum disorders?‫‏‬. American Journal of Psychiatry, 162, 137–145. doi:10.1176/appi.ajp.162.1.137 Horvath, A. O., Del Re, A. C., Fluckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9–16. doi:10.1037/a0022186 Houben, M., Van Den Noortgate, W., & Kuppens, P. (2015). The relation between short-term emotion dynamics and psychological well-being: A meta-analysis. Psychological Bulletin, 141, 901–930. doi:org/10.1037/a0038822 Kahn, J. H., & Schneider, W. J. (2013). It’s the destination and it's the journey: using multilevel modeling to assess patterns of change in psychotherapy. Journal of Clinical Psychology, 69, 543–570. doi:10.1002/jclp.21964 Kazdin, A. E. (2009). Understanding how and why psychotherapy leads to change. Psychotherapy Research : Journal of the Society for Psychotherapy Research, 19, 418–28. doi:10.1080/10503300802448899 Kazdin, A. E., & Blase, S. L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness‫‏‬. Perspectives on Psychological Science, 6, 21–37. doi: 10.1177/1745691610393527 94 Kazdin, A. E., & Nock, M. K. (2003). Delineating mechanisms of change in child and adolescent therapy: Methodological issues and research recommendations. Journal of Child Psychology and Psychiatry, 44, 1116–1129. doi:10.1111/14697610.00195 Kellogg, S. (2004). Dialogical encounters: contemporary perspectives on “chairwork” in psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 41, 310–320. doi:10.1037/0033-3204.41.3.310 Koenigsberg, H. W., Denny, B. T., Fan, J., Liu, X., Guerreri, S., Mayson, S. J., … Siever, L. J. (2014). The neural correlates of anomalous habituation to negative emotional pictures in borderline and avoidant personality disorder patients. American Journal of Psychiatry, 171, 82–90. doi:10.1176/appi.ajp.2013.13070852 Koenigsberg, H. W., Harvey, P. D., Mitropoulou, V., Schmeidler, J., New, A. S., Goodman, M., … Siever, L. J. (2002). Characterizing affective instability in borderline personality disorder. American Journal of Psychiatry, 159, 784–788. doi:10.1176/appi.ajp.159.5.784 Koepke, S., & Denissen, J. J. A. (2012). Dynamics of identity development and separation–individuation in parent–child relationships during adolescence and emerging adulthood – A conceptual integration. Developmental Review, 32, 67– 88. doi:10.1016/j.dr.2012.01.001 Kuyken, W., Beshai, S., Dudley, R., Abel, A., Görg, N., Gower, P., & Padesky, C. A. (2015). Assessing competence in collaborative case conceptualization: Development and preliminary psychometric properties of the collaborative case conceptualization rating scale (CCC-RS)‫‏‬. Behavioural and Cognitive Psychotherapy, 1–14. doi:10.1017/S1352465814000691 Levy, K. N., Clarkin, J. F., Yeomans, F. E., Scott, L. N., Wasserman, R. H., & Kernberg, O. F. (2006). The mechanisms of change in the treatment of borderline personality disorder with transference focused psychotherapy‫‏‬. Journal of Clinical Psychology, 62, 481–501. doi:10.1002/jclp.20239 Linehan, M. M. (1987). Dialectical behavioral therapy: A cognitive behavioral approach to parasuicide. Journal of Personality Disorders, 1, 328–333. doi:10.1521/pedi.1987.1.4.328 Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press. Linehan, M. M. (1993b). The skills training manual for treating borderline personality disorder. New York, NY: Guilford Press. Lobbestael, J., & Arntz, A. (2010). Emotional, cognitive and physiological correlates of abuse-related stress in borderline and antisocial personality disorder. Behaviour Research and Therapy, 48, 116–24. doi:10.1016/j.brat.2009.09.015 95 Lobbestael, J., Arntz, A., Löbbes, A., & Cima, M. (2009). A comparative study of patients and therapists’ reports of schema modes. Journal of Behavior Therapy and Experimental Psychiatry, 40, 571–579. doi:10.1016/j.jbtep.2009.08.001 Lobbestael, J., Arntz, A., & Sieswerda, S. (2005). Schema modes and childhood abuse in borderline and antisocial personality disorders. Journal of Behavior Therapy and Experimental Psychiatry, 36, 240–253. doi:10.1016/j.jbtep.2005.05.006 Lobbestael, J., van Vreeswijk, M., & Arntz, A. (2007). Shedding light on schema modes: A clarification of the mode concept and its current research status. Netherlands Journal of Psychology, 63, 69–78. doi:10.1007/BF03061068 Lobbestael, J., Van Vreeswijk, M. F., & Arntz, A. (2008). An empirical test of schema mode conceptualizations in personality disorders‫‏‬. Behaviour Research and Therapy, 46, 854–860. doi:10.1016/j.brat.2008.03.006 Lobbestael, J., van Vreeswijk, M., Spinhoven, P., Schouten, E., & Arntz, A. (2010). Reliability and validity of the Short Schema Mode Inventory (SMI). Behavioural and Cognitive Psychotherapy, 38, 438–458. doi: http://dx.doi.org/10.1017/S1352465810000226 Laurenceau, J. P., & Bolger, N. (2013). Analyzing diary and intensive longitudinal data from dyads‫‏‬. In & T. S. Mehl (Ed.), Handbook of research methods for studying daily life (pp. 407–422). New York: Guilford Publications. Masley, S. A., Gillanders, D. T., Simpson, S. G., & Taylor, M. A. (2012). A systematic review of the evidence base for Schema Therapy. Cognitive Behaviour Therapy, 41, 185–202. doi:10.1080/16506073.2011.614274 McMain, S. F., Boritz, T. Z., & Leybman, M. J. (2015). Common strategies for cultivating a positive therapy relationship in the treatment of borderline personality disorder. Journal of Psychotherapy Integration, 25, 20–29. doi:http://dx.xoi.org/10/1037/a0038768 Miller, J. D., & Pilkonis, P. A. (2006). Neuroticism and affective instability: The same or different?‫‏‬. American Journal of Psychiatry, 163, 839–845. Millon, T. (1969). Modern psychopathology. Philadelpia: Saunders. Millon, T. (1991). Avoidant personality disorder: A brief review of issues and data. Journal of Personality Disorders, 5, 353–362. doi:10.1521/pedi.1991.5.4.353 Mischel, W., & Shoda, Y. (2010). The situated person. In B. Mesquita, L. Feldman Battett, & E. R. Smith (Eds.), The mind in context (pp. 149–173). New York: The Guilford Press. Mittelman-Kirshenfeld, R. (2012). Development of analytic tools for analysis of therapist and patient behavior within the therapeutic hour in schema focused therapy for avoidant personality disorder (Master’s thesis). Bar Ilan, Ramat Gan. Molenaar, P. (2004). A manifesto on psychology as idiographic science: Bringing the person back into scientific psychology, this time forever. Measurement: 96 Interdisciplinary Research and Perspectives, 2, 201–218. doi:doi:10.1207/s15366359mea0204_1 Nadort, M., Arntz, A., Smit, J. H., Giesen-Bloo, J., Eikelenboom, M., Spinhoven, P., & van Dyck, R. (2009). Implementation of outpatient schema therapy for borderline personality disorder with versus without crisis support by the therapist outside office hours: A randomized trial‫‏‬. Behaviour Research and Therapy, 47, 961–973. doi:10.1016/j.brat.2009.07.013 Newman, C. F. (2007). The therapeutic relationship in cognitive therapy with difficult-to-engage patients. In P. Gilbert & R. L. Leahy (Eds.), The therapeutic relationship in the cognitive behavioral psychotherapies (pp. 165–184). New York, NY: Routledge. Newton-Howes, G., Clark, L. A., & Chanen, A. (2015). Personality disorder across the life course‫‏‬. The Lancet, 385, 727–734. doi:10.1016/S0140-6736(14)61283-6 Palmier-Claus, J., Shryane, N., Taylor, P., Lewis, S., & Drake, R. (2013). Mood variability predicts the course of suicidal ideation in individuals with first and second episode psychosis. Psychiatry Research, 206, 240–245. doi:10.1016/j.psychres.2012.11.014 Pascual-Leone, A., Greenberg, L. S., & Pascual-Leone, J. (2009). Developments in task analysis: New methods to study change. Psychotherapy Research : Journal of the Society for Psychotherapy Research, 19, 527–42. doi:10.1080/10503300902897797 Peled, O., Bar Kalifa, E., & Rafaeli, E. (2016). Temporal associations among modes in schema therapy: a time-series panel analysis. Manuscript in preparation. Peled, O., Mittelman-Kirshenfeld, R., Bar Kalifa, E., & Rafaeli, E. (2016). Therapist interventions and mode changes within schema therapy sessions for avoidant personality disorder. Manuscript in prepearation. Pfohl, B., Blum, N., & Zimmerman, M. (1997). Structured interview for DSM-IV personality: SIDP-IV. Washington, DC: American Psychiatric Press. Pugh, M. (2015). A narrative review of schemas and schema therapy outcomes in the eating disorders. Clinical Psychology Review, 39, 30–41. doi:10.1016/j.cpr.2015.04.003 Rafaeli, E., Bernstein, D. P., & Young, J. (2010). Schema Therapy: Distinctive Features. London: Routledge. Rafaeli, E., Maurer, O., & Thoma, N.C. (2015). In N.C. Thoma‫‏‬, & D. McKay‫(‏‬Eds.), Working with emotion in cognitive-behavioral therapy: Techniques for clinical practice, (pp. 263-287). New York: The Guilford Press. Rafaeli, E., Maurer, O., Lazarus, G., & Thoma, N. C. (2016). The self in schema therapy. In M. Kyrios, R. Moulding, G. Doron, S. S. Bhar, M. Nedeljkovic, & M. Mikulincer (Eds.), The self in understanding and treating psychological disorders (pp. 59–70). Cambridge University Press. 97 Ramseyer, F., Kupper, Z., Caspar, F., Znoj, H., & Tschacher, W. (2014). Time-Series Panel Analysis (TSPA): Multivariate Modeling of Temporal Associations in Psychotherapy Process. Journal of Consulting and Clinical Psychology, 82, 828– 838. http://dx.doi.org/10.1037/a0037168 Renner, F., Van Goor, M., Huibers, M., Arntz, A., Butz, B., & Bernstein., D. (2013). Short-term group schema cognitive-behavioral therapy for young adults with personality disorders and personality disorder features: Associations with changes in symptomatic distress, schemas, schema modes and coping styles. Behaviour Research and Therapy, 51, 487 – 492. doi:10.1016/j.brat.2013.05.011 Resick, P. A., Suvak, M. K., Johnides, B. D., Mitchell, K. S., & Iverson, K. M. (2012). The impact of dissociation on PTSD treatment with cognitive processing therapy. Depression and Anxiety, 29, 718–730. doi:10.1002/da.21938 Roemer, L., Orsillo, S. M., & Salters-Pedneault, K. (2008). Efficacy of an acceptancebased behavior therapy for generalized anxiety disorder: Evaluation in a randomized controlled trial. Journal of Consulting and Clinical Psychology, 76, 1083–1089. doi:http://dx.doi.org/10.1037/a0012720 Rosmalen, J. G., Wenting, A. M., Roest, A. M., de Jonge, P., & Bos, E. H. (2012). Revealing causal heterogeneity using time series analysis of ambulatory assessments: Application to the association between depression and physical activity after myocardial infarction ‫‏‬. Psychosomatic Medicine, 74, 377–386. doi:10.1097/PSY.0b013e3182545d47 Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. New York, NY: Guilford Press. Safran, J. D., & Muran, J. C. (2006). Has the concept of the therapeutic alliance outlived its usefulness? Psychotherapy: Theory, Research, Practice, Training, 43, 286.‫‏‬, 43, 286–291. doi:10.1037/0033-3204.43.3.286 Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48, 80–87. doi:10.1037/a0022140 Sanislow, C. A., Bartolini, E., & Zoloth, E. (2012). Avoidant personality disorder. In V. S. Ramachandran (Ed.), Encyclopedia of human behavior (2nd ed., pp. 257– 266). San Diego: Academic Press. Schmidt, N. B., Joiner Jr, T. E., Young, J. E., & Telch, M. J. (1995). The schema questionnaire: Investigation of psychometric properties and the hierarchical structure of a measure of maladaptive schemas. Cognitive Therapy and Research, 19, 295–321.doi: 10.1007/BF02230402 Seligman, M. E. P. (1995). The effectiveness of psychotherapy: The Consumer Reports study. American Psychologist, 50, 965-974. doi:10.1037/0003066X.50.12.965 98 Sempértegui, G. A., Karreman, A., Arntz, A., & Bekker, M. H. J. (2013). Schema therapy for borderline personality disorder: A comprehensive review of its empirical foundations, effectiveness and implementation possibilities. Clinical Psychology Review, 33, 426–47. doi:10.1016/j.cpr.2012.11.006 Shafran, R., Rafaeli, E., Gadassi, R., Papamarkou, S., Berenson, K., Downey, G., & Arntz, A. (2016). Examining the schema-mode model in borderline and avoidant personality disorders using experience-sampling methods. Manuscript in preparation. Shahar, B., Carlin, E. R., Engle, D. E., Hegde, J., Szepsenwol, O., & Arkowitz, H. (2012). A pilot investigation of emotion-focused two-chair dialogue intervention for self-criticism. Clinical Psychology & Psychotherapy‫‏‬, 19, 496–507. doi:10.1002/cpp.762 Skewes, S. A., Samson, R. A., Simpson, S. G., & van Vreeswijk, M. (2014). Shortterm group schema therapy for mixed personality disorders: A pilot study. Frontiers in Psychology, 5, 1592. doi:10.3389/fpsyg.2014.01592 Skodol, A. E., Gunderson, J. G., McGlashan, T. H., Dyck, I. R., Stout, R. L., Bender, D. S., & Oldham, J. M. (2002). Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder. American Journal of Psychiatry, 159, 276 – 283. doi:10.1176/appi.ajp.159.2.276 Snir, A., Bar-Kalifa, E., Berenson, K., Downey, G., & Rafaeli, E. (2015). Affective instability as a clinical feature of avoidant personality disorder. In Progress. Soygut, G., Karaosmanoglu, A., & Cakir, Z. (2009). Assessment of early maladaptive schemas: A psychometric study of the Turkish Young Schema QuestionnaireShort Form-3. Turkish Journal of Psychiatry, 20, 75–84. Spinhoven, P., Giesen-Bloo, J., Van Dyck, R., Kooiman, K., & Arntz, A. (2007). The therapeutic alliance in schema-focused therapy and transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 75, 104–115. doi:10.1037/0022-006X.75.1.104 Stepp, S. D., Epler, A. J., Jahng, S., & Trull, T. J. (2008). The effect of dialectical behavior therapy skills use on borderline personality disorder features. Journal of Personality Disorders, 22, 549–563. doi:10.1521/pedi.2008.22.6.549 Stiles, W., Hill, C. E., & Elliott, R. (2015). Looking both ways. Psychotherapy Research, 25, 282–293. doi:10.1080/10503307.2014.981681 Stone, H., & Stone, S. (2011). Embracing our selves: The voice dialogue manuel‫‏‬. Novato, CA: New World Library. Strauss, J. L., Hayes, A. M., Johnson, S. L., Newman, C. F., Brown, G. K., Barber, J. P., … Beck, A. T. (2006). Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessivecompulsive personality disorders. Journal of Consulting and Clinical Psychology, 74, 337–345. doi:10.1037/0022-006X.74.2.337. 99 Taube-Schiff, M., Suvak, M. K., Antony, M. M., Bieling, P. J., & McCabe, R. E. (2007). Group cohesion in cognitive-behavioral group therapy for social phobia. Behaviour Research and Therapy, 45, 687–698. doi:10.1016/j.brat.2006.06.004 Trip, S. (2006). The Romanian version of Young schema questionnaire – short form 3 (YSQ-3). Journal of Cognitive and Behavioral Psychotherapies, 6, 173–181. Trull, T. J., Lane, S. P., Koval, P., & Ebner-Priemer, U. W. (2015). Affective dynamics in psychopathology. Emotion Review, 7, 355–361. doi:10.1177/1754073915590617 Tryon, W. W. (1982). A simplified time-series analysis for evaluating treatment interventions. Journal of Applied Behavior Analysis, 15, 423–429. doi: 10.1901/jaba.1982.15-423 Tschacher, W., Baur, N., & Grawe, K. (2000). Temporal interaction of process variables in psychotherapy. Psychotherapy Research, 10, 296–309. doi:dx.doi.org/10.1093/ptr/10.3.296 Tschacher, W., & Jacobshagen, N. (2002). Analysis of crisis intervention processes‫‏‬. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 23, 59–67. doi:10.1027//0227-5910.23.2.59 Tschacher, W., & Ramseyer, F. (2009). Modeling psychotherapy process by timeseries panel analysis (TSPA). Psychotherapy Research, 19, 469–481. doi:10.1080/10503300802654496 Tschacher, W., Zorn, P., & Ramseyer, F. (2012). Change mechanisms of schemacentered group psychotherapy with personality disorder patients. PLoS One, 7, 1–10. doi:10.1371/journal.pone.0039687 van den Broek, E., Keulen-de Vos, M., & Bernstein, D. P. (2011). Arts therapies and schema focused therapy: A pilot study. The Arts in Psychotherapy, 38, 325–332. doi:10.1016/j.aip.2011.09.005 van Vreeswijk, M., Broersen, J., & Nadort, M. (Eds. ). (2012). The Wiley-Blackwell Handbook of Schema Therapy: Theory, Research and Practice. West Sussex: John Wiley & Sons. von Neumann, J. von, Kent, R. H., Bellinson, H. R., & Hart, B. I. (1941). The mean square successive difference. The Annals of Mathematical Statistics, 12, 153– 162. doi:10.1214/aoms/1177731746 Vreeswijk, M. V., Spinhoven, P., Eurelings-Bontekoe, E. H. M., & Broersen, J. (2014). Changes in symptom severity, schemas and modes in heterogeneous psychiatric patient groups following short-term schema cognitive–behavioural group therapy: A naturalistic pre-treatment and post-treatment design in an outpatient clinic. Clinical Psychology & Psychotherapy, 21, 29–38. doi:10.1002/cpp.1813 Whelton, W. J. (2004). Emotional processes in psychotherapy: Evidence across therapeutic modalities ‫‏‬. Clinical Psychology & Psychotherapy, 11, 58–71. doi:10.1002/cpp.392 100 Wilberg, T., Karterud, S., Pedersen, G., & Urnes, Ø. (2009). The impact of avoidant personality disorder on psychosocial impairment is substantial‫‏‬. Nordic Journal of Psychiatry, 63, 390–396. doi:10.1080/08039480902831322 Wild, B., Eichler, M., Friederich, H. C., Hartmann, M., Zipfel, S., & Herzog, W. (2010). A graphical vector autoregressive modelling approach to the analysis of electronic diary data‫‏‬. BMC Medical Research Methodology, 10, 28. doi:10.1186/1471-2288-10-28 Williams, W. J. B., Gibbo, M., First, M. B., Spitzer, R. L., Davis, M., Borus, J., … Wittchen, H. U. (1992). The structured clinical interview for DSM-III-R (SCID) multisite test-retest reliability. Arch Gen Psychiatry, 49, 630–636. doi:10.1001/archpsyc.1992.01820080038006. Yeomans, F. E., Clarkin, J. F., & Kernberg, O. F. (2002). A primer for transference focused psychotherapy for the borderline patient. Northvale, NJ: Jason Aronson. Young, J. E. (1999). Cognitive Therapy for Personality Disorders: A Schema-focused Approach. Sarasota, FL: Professional Resource Press. Young, J. E., Arntz, A., Atkinson, T., Lobbestael, J., Weishaar, M. E., van Vreeswijk, M. F., & Klokman, J. (2007). The Schema Mode Inventory. New York: Schema Therapy Institute. Retrieved from http://www.schematherapy.com/id49.htm Young, J. E., & Fosse, G. (2005). Schema therapy rating scale for individual therapy sessions. New York, NY: Schema Therapy Institute. Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema Therapy: A Practitioner’s Guide. New York: The Guilford Press. Young, J. E., Rygh, J. L., Weinberger, A. D., & Beck, A. T. (2008). Cognitive therapy for depression. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders : A step-by-step treatment manual (4th ed., pp. 250–305). New York, NY: Guilford Press. Zimmerman, M., Rothschild, L., & Chelminski, I. (2005). The prevalence of DSM-IV personality disorders in psychiatric outpatients. The American Journal of Psychiatry, 162, 1911–8. doi:10.1176/appi.ajp.162.10.1911 101 ‫ כלי להערכת המודים של המטופל‬:1 ‫נספח‬ Appendix 1: Client Mode Rating Scale (CMRS) schema modes: 1-moderately present, 2- present, 3- clearly present modes Child modes Maladaptive coping modes Dysfunctional parent modes Healthy adult mode Time Vulnerable modes Overcompensator modes AAC DC LIC VCN AC IUC HC CS DP AP PO SA OCN PCP DEP HA ‫ילד‏‬ ‫שע‬/‫נטוש‬ ‫בר‏‬ ‫התעללות‬ ‫ילד‏‬ ‫תלותי‬ ‫ילד‏‬ ‫‏‬/‫בודד‬ ‫נחות‬ ‫ילד‏פגיע‏‬ ‫ילד‏‬ ‫כועס‬ ‫ילד‏‬ ‫אימפול‬ ‫‏‬/‫סיבי‏‬ ‫לא‏‬ ‫ממושמ‬ ‫ע‬ ‫ילד‏‬ ‫שמח‬ ‫נכנע‏‬ ‫מרצה‬ ‫מגן‏‬ ‫מנותק‬ ‫מגן‏‬ ‫נמנע‬ ‫פרפק‬ ‫ציוניס‬ ‫‏‬/‫ט‏‬ ‫שתלט‬ ‫ן‬ ‫מאדיר‏‬ ‫עצמו‬ ‫פיצוי‏‬ ‫יתר‬ ‫הורה‏‬ ‫‏‬/‫מעניש‏‬ ‫ביקורתי‬ ‫הורה‏‬ ‫דורשני‬ ‫מבוגר‏‬ ‫בריא‬ 0-5 5-10 10-15 15-20 20-25 25-30 30-35 35-40 40-45 45-50 Modes Index: Child modes: AAC - Abandoned/Abused Child: feels the abandonment or abuse experienced as a child again, of the fear of repetition of such experiences. DC - Dependent Child: feels, thinks and acts at a little child confronted with (practical) tasks the child does not know how to handle. LIC - Lonely/ Inferior Child: feels the loneliness and/or inferiority experienced as a little child. 102 comments VCN - Vulnerable child nos: experiences unhappy or anxious emotions, especially fear, sadness, and helplessness, when “in touch” with associated schemas. Does not meet other vulnerable child mode criteria. AC - Angry child: vents anger directly in response to perceived unmet core needs or unfair treatment related to core schemas. IUC - Impulsive/ Undisciplined child: impulsively acts according to immed-iate desires for pleasure without regard to limits or others’ needs or feelings (not linked to core needs) HC - Happy child: feels loved, connected, content, satisfied Maladaptive coping modes: CS - Compliant surrenderer: adopts a coping style of compliance and dependence. DP - Detached protector: Uses detaching from inner needs, emotions and thoughts as a survival strategy. Although there might be interpersonal contact, there is lack of connection. The person feels empty. AP - Avoidant Protector: Uses situational avoidance as survival strategy. Leads to loneliness, postponement of decisions and important tasks, and an empty and boring life. PO - Perfectionistic Overcontroller: Uses excessive control and perfectionism as strategy to avoid making mistakes and/or being guilty of things that go wrong. SA - Self-Aggrandizer: Plays superiority to compensate for inner feelings of inferiority, inadequacy, or doubts. OCN – Overcompensator nos: adopts a coping style of counterattack and control. may over-compensate through semiadaptive means, such as workaholism. Does not meet criteria‫‏‬for other overcompensator mode. Dysfunctional parent modes: PCP - Punitive/ critical parent: restricts, criticizes, or punishes the self or others. DEP - Demanding parent: sets high expectations and high level of responsibility toward others; pressures the self or others to achieve them. Healthy adult mode: HA - the healthy adult part of the self that 1.) nurtures, affirms and protects the ‘vulnerable child’. 2.) sets limits for the ‘angry child’ and the ‘impulsive/ undisciplined child’ in accord with principles of fairness and selfdiscipline. 3.) battles or moderates the ‘maladaptive coping’ and ‘dysfunctional parent modes’. 103 Overall impression of session 1. What specific modes are particularly common in the session? _____________________________________________________________________ ________________________________________ 2. When (in what situations) did the patient make transitions between modes?_______________________________________________________________ _____________________________________________________________________ _________________________________________________ 3. In what manner did the patient transition from one mode to another? (Did he/she retain a unified sense of self? Can he/she simultaneously experience blends of modes – that is, more than one mode at a time? When he/she did shift between modes, did he/she do so gradually or abruptly?)_____________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ __________________ 4. Did the patient recognize and/or acknowledge his/her modes? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ __________________ 5. What was the dominant emotion/s of the patient during the session?____________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ __________________ 6. Patient behavior during the session: _________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ __________________ 104 7. Dominant Schema: 0- not present, 1- deficient, 2- present, 3- clearly present DISCONNECTION & REJECTION 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 1. Abandonment / Instability 2. Mistrust / Abuse 3. Emotional deprivation 4. Defectiveness / Shame 5. Social isolation / Alienation IMPAIRED AUTONOMY & PERFORMANCE 6. Dependence / Incompetence 7. Vulnerability to harm or illness 8. Enmeshment / Undeveloped self 9. Failure IMPAIRED LIMITS 10. Entitlement / Grandiosity 11. Insufficient self- control / selfdiscipline OTHER-DIRECTEDNESS 12. Subjugation 13. Self- sacrifice 14. Approval – seeking / Recognition seeking OVERVIGILANCE & INHIBITION 15. Negativity / Pessimism 16. Emotional inhibition 17. Unrelenting standards / Hypercriticalness 18. Punitiveness 105 comments Schema Index: Early Maladaptive Schemas and Domains: DISCONNECTION & REJECTION 1. ABANDONMENT / INSTABILITY- This schema involves the perception that others, particularly ones from whom we expect support and connection, are unstable and/or unreliable in providing these, and will not be able to continue providing emotional support, connection, strength, or practical protection. Family environments involving frequent angry outbursts, caregivers who were only erratically present; or parental figures who left or died an untimely death are common precursors to this schema. 2. MISTRUST / ABUSE - This schema involves the expectation that others will hurt, abuse, humiliate, cheat, lie, manipulate, or take advantage of you. It usually involves the perception that the harm is intentional or the result of unjustified and extreme negligence. It may include the sense that one always ends up being cheated relative to others or "getting the short end of the stick." 3. EMOTIONAL DEPRIVATION - This schema involves the expectation that one's desire for a normal degree of emotional support will not be adequately met by others. There are three major forms of deprivation: A. Deprivation of Nurturance: Absence of attention, affection, warmth, or companionship. B. Deprivation of Empathy: Absence of understanding, listening, self-disclosure, or mutual sharing of feelings from others. C. Deprivation of Protection: Absence of strength, direction, or guidance from others. 4. DEFECTIVENESS / SHAME - This schema involves the feeling that one is fundamentally defective, bad, unwanted, inferior, or invalid in important respects, or that one would be unlovable to significant others if they could see the real self. It may involve hypersensitivity to criticism, rejection, and blame; self-consciousness, comparisons, and insecurity around others; or a sense of shame regarding one's perceived flaws. These flaws may be private (e.g., selfishness, angry impulses, unacceptable sexual desires) or public (e.g., undesirable physical appearance, social awkwardness). 5. SOCIAL ISOLATION / ALIENATION - The feeling that one is isolated from the rest of the world, especially the social world outside the family. Individuals with this schema feel different from other people, and/or not part of any group or community. Though this schema reflects the same unmet needs (for safety, stability, and acceptance) as the other four in this domain, it typically comes about as a result of social exclusion outside the home environment (though at times, this social exclusion can be traced back to parental influences: a lack of encouragement for socializing, intense shame about one’s home and background, or a sense of defectiveness and unlovability that emerges within the family of origin but is generalized to other situations. 106 IMPAIRED AUTONOMY & PERFORMANCE 6. DEPENDENCE / INCOMPETENCE - This schema involves the belief that one is unable to handle one's everyday responsibilities in a competent manner, without considerable help from others. In extreme cases, individuals might feel unable to take care of themselves, solve daily problems, exercise good judgment, tackle new tasks, or make good decisions. In other cases, this sense of helplessness may be more circumscribed and be activated in particular situations or settings (e.g., in making important professional decisions or in choosing a partner). 7. VULNERABILITY TO HARM OR ILLNESS - This schema involves an exaggerated fear that catastrophe is imminent, that it will strike at any time, and that one will be unable to prevent it. The catastrophes that are anticipated are external in nature – and may focus on one or more of the following: (A) Medical Catastrophes: e.g., heart attacks, AIDS; (B) Emotional Catastrophes: e.g., going crazy; (C): External Catastrophes: e.g., elevators collapsing, victimized by criminals, airplane crashes, earthquakes. 8. ENMESHMENT / UNDEVELOPED SELF - This schema involves excessive emotional involvement and closeness with one or more significant others (often parents), at the expense of full individuation or normal social development. It often involves the belief that at least one of the enmeshed individuals cannot survive or be happy without the constant support of the other. It may also include feelings of being smothered by, or fused with, others or of insufficient individual identity. This schema is often experienced as feelings of emptiness and floundering, having no direction, or in extreme cases questioning one's existence. 9. FAILURE - This schema involves the belief that one has failed, will inevitably fail, or is fundamentally inadequate relative to one's peers, in areas of achievement (school, career, sports, etc.). It often involves beliefs that one is stupid, inept, untalented, ignorant, lower in status, less successful than others, etc. IMPAIRED LIMITS 10. ENTITLEMENT / GRANDIOSITY - This schema involves the belief that one is superior to other people, entitled to special rights and privileges, or not bound by the rules of reciprocity that guide normal social interaction. The schema often involves insistence that one should be able to do or have whatever one wants, regardless of what is realistic, what others consider reasonable, or what costs other may bear. In some cases, the schema involves an exaggerated focus on superiority (e.g., being among the most successful, famous, wealthy) -- in order to achieve power or control (not primarily for attention or approval). At times, it includes excessive competitiveness toward, or domination of, others, in one of several ways – asserting one's power, 107 forcing one's point of view, or controlling the behavior of others in line with one's own desires – without empathy or concern for others' needs or feelings. 11. INSUFFICIENT SELF-CONTROL / SELF-DISCIPLINE - This schema involves a pervasive difficulty or refusal to exercise sufficient self-control and frustration tolerance to achieve one's personal goals, or to restrain the excessive expression of one's emotions and impulses. In its milder form, patients present with an exaggerated emphasis on avoiding discomfort: avoiding pain, conflict, confrontation, responsibility, or overexertion---at the expense of personal fulfillment, commitment, or integrity. OTHER-DIRECTEDNESS 12. SUBJUGATION- This schema involves an excessive degree of relinquishing control to others because one feels coerced to do so, so as to avoid anger, retaliation, or abandonment. The two major forms of subjugation are: A. Subjugation of Needs: Suppression of one's preferences, decisions, and desires. B. Subjugation of Emotions: Suppression of emotional expression, especially anger. The subjugation schema usually involves the perception that one's own desires, opinions, and feelings are not valid or important to others. The schema frequently presents as excessive compliance, combined with hypersensitivity to feeling trapped. It generally leads to a build up of anger, manifested in maladaptive symptoms (e.g., passive-aggressive behavior, uncontrolled outbursts of temper, psychosomatic symptoms, withdrawal of affection, "acting out", or substance abuse). 13. SELF-SACRIFICE - This schema involves an excessive focus on voluntarily meeting the needs of others, at the expense of one's own gratification. Some common motivations for behavior that is consistent with this schema are avoiding actions that may cause pain to others, avoiding guilt from feeling selfish, or maintaining a connection with others who are perceived as needy. This schema often results from an acute sensitivity to the pain of others, and at times, leads to a sense that one's own needs are not being adequately met and to resentment of those receiving one’s care. 14. APPROVAL-SEEKING / RECOGNITION-SEEKING - Excessive emphasis on gaining This schema involves an excessive emphasis on gaining approval, recognition, or attention from other people, or on fitting in, at the expense of developing a secure and true sense of self. For individuals with this schema, one's sense of esteem is dependent primarily on the reactions of others rather than on one's own natural inclinations. The schema sometimes includes an overemphasis on status, appearance, social acceptance, money, or achievement -- as means of gaining approval, admiration, or attention (but not primarily for power or control). It often results in major life decisions that are inauthentic or unsatisfying, or in hypersensitivity to rejection. 108 OVERVIGILANCE & INHIBITION 15. NEGATIVITY / PESSIMISM - This schema involves a pervasive, lifelong focus on the negative aspects of life (pain, death, loss, disappointment, conflict, guilt, resentment, unsolved problems, potential mistakes, betrayal, things that could go wrong, etc.) while minimizing or neglecting the positive or optimistic aspects. It usually includes an exaggerated expectation that things will eventually go seriously wrong in a wide range of work, financial, or interpersonal situations, or that aspects of one's life that seem to be going well will ultimately fall apart. Usually, it involves an inordinate fear of making mistakes that might lead to financial collapse, loss, humiliation, or to being trapped in a bad situation. Because potential negative outcomes are exaggerated, individuals with this schema are frequently characterized by chronic worry, vigilance, complaining, or indecision. 16. EMOTIONAL INHIBITION - This schema involves the excessive inhibition of spontaneous action, feeling, or communication -- usually to avoid disapproval by others, feelings of shame, or losing control of one's impulses. The most common areas of inhibition involve: (a) inhibition of anger & aggression; (b) inhibition of positive impulses (e.g., joy, affection, sexual excitement, play); (c) difficulty expressing vulnerability or communicating freely about one's feelings, needs, etc.; or (d) excessive emphasis on rationality while disregarding emotions. 17. UNRELENTING STANDARDS / HYPERCRITICALNESS - This schema involves the underlying belief that one must strive to meet very high internalized standards of behavior and performance, usually to avoid criticism. It typically results in feelings of pressure or difficulty slowing down, and in hyper-criticalness toward oneself and others. It invariably involves significant impairment in pleasure, relaxation, health, self-esteem, sense of accomplishment, or satisfying relationships. Unrelenting standards typically present as (a) perfectionism, inordinate attention to detail, or an underestimate of how good one's own performance is relative to the norm; (b) rigid rules and "shoulds" in many areas of life, including unrealistically high moral, ethical, cultural, or religious precepts; or (c) preoccupation with time and efficiency, so that more can be accomplished. 18. PUNITIVENESS - This schema involves the belief that people (including oneself) should be harshly punished for making mistakes. It involves the tendency to be angry, intolerant, punitive, and impatient with any person who does not meet one's expectations or standards. The schema usually includes difficulty forgiving mistakes in oneself or others, because of a reluctance to consider extenuating circumstances, allow for human imperfection, or empathize with feelings. 109 ‫ כלי להערכת התערבויות המטפל בסכמה תרפיה‬:2 ‫נספח‬ Appendix 2: Schema Therapist Interventions Rating Scale (STIRS) Part I. GENERAL THERAPEUTIC SKILLS 1. Limited reparenting Limited reparenting involves the therapist directly meeting core needs for the patient that were not fulfilled in childhood, within the appropriate boundaries of the therapeutic relationship. Limited reparenting includes warmth, acceptance, non-verbal expressions of caring, validation, promoting autonomy, setting limits, as well as other behaviors that relate to unmet childhood needs. To score 3, the therapist must reparent beyond “standard therapist” caring and warmth. 0 Not relevant 1 Acted in ways that hurt the patient (such as being critical, rejecting, or provocative); or did not engage in any healthy reparenting (i.e., there was an absence of warmth or caring); or some reparenting, but minimal. Did not hurt the patient, but had significant difficulty meeting the patient’s core emotional needs (e.g., was cold, distant, invalidating). 2 Did a good job meeting most core needs, but did not demonstrate reparenting that went beyond that of a warm, caring therapist from many other therapy approaches. 3 Excellent and appropriate reparenting. Went beyond standard warmth and caring in meeting the patient’s core needs (e.g., gave extra therapy time if needed, made phone calls, self-disclosed, gave transitional objects). Minutes 5 10 15 20 25 30 35 40 45 50 55 60 Rate Exclusions: This item does not refer to the ability of the therapist to empathize with or understand the patient, since these are covered in item 2. Also, when reparenting is done through imagery, it should be scored under emotion-focused change techniques (item 8), not rated as part of this item. 110 2. Understanding and attunement 0 Not relevant 1 Therapist repeatedly failed to understand what the patient explicitly said and thus consistently missed the point. Very poor empathic skills.Or therapist was usually able to reflect or rephrase what the patient explicitly said, but repeatedly failed to respond to more subtle communication. Limited ability to listen and empathize. 2 Good ability to listen and empathize. Therapist generally seemed to grasp the patient’s “internal reality,” as reflected by both what the patient explicitly said and what the patient communicated in more subtle ways. 3 Excellent ability to understand and empathize. Therapist seemed to understand the patient’s “internal reality” throughout and was adept at communicating this understanding through appropriate verbal and non-verbal responses to the patient (e.g., tone of the therapist’s response conveyed attunement to the patient’s emotional state). Minutes 5 10 15 20 25 30 35 40 45 50 55 60 Rate Exclusion: This item refers to the therapist’s depth of empathy and understanding, but does not include warmth, caring, or other aspects of “limited reparenting” from Item 1 above. 3. Collaboration, feedback & session focus 0 Not relevant 1 Therapist did not collaborate with the patient, establish a segment‫‏‬focus, or ask for feedback about the segment‫‏‬or the therapy relationship.Or therapist attempted to collaborate with patient, but had significant difficulty defining a problem that the patient considered important, establishing a working alliance with the patient, or asking for feedback. 2 Therapist did a good job of collaborating with the patient: focusing on a problem that both patient and therapist considered important, establishing a good working alliance, and asking for general feedback. 3 Collaboration seemed excellent. In addition to agreeing on the focus and having a very good alliance, the therapist encouraged the patient as much as possible to take an active role during the segment‫(‏‬e.g., by offering choices), so they could function as team. Therapist was adept at asking for feedback, sensing how the patient was responding to the segment, and adjusting his/her approach to further the collaboration. Minutes 5 10 15 20 25 30 Rate 111 35 40 45 50 55 60 4. Therapist balance & flexibility Therapist demonstrated a balanced and flexible approach in his/her style of therapy, appropriate to the patient’s mood and segment‫‏‬goals. For example, the therapist blended being gentle with confrontation; being directive with being less active; easygoing versus pushing; allowing freedom of expression while setting limits; and blending emotion with rationality. 0 Not relevant 1 Therapist fails to use a balanced, flexible approach in many important aspects of his/her behavior (e.g., seems rigid, overly confrontational, too passive, too domineering, too rational, or too restrictive). This lack of balance was clearly detrimental to the segment. Or therapist was balanced in some respects, but failed to be flexible in one or two important ways that affected the overall helpfulness of the segment‫‏‬negatively. 2 Therapist does a good job of balancing different elements of his/her therapeutic approach. However, the style does not seem optimal for this particular patient; the therapist lacked balance in one or more less important areas. However, these limitations did not significantly reduce the helpfulness of the segment. 3 Therapist is excellent at maintaining a balanced therapeutic style, and shows an optimal level of flexibility in adapting his/her style to the specific needs and feelings of this patient throughout the segment. Minutes 5 10 15 20 25 30 35 40 45 50 55 60 Rate 5. Therapist confidence & ease Therapist appeared to have healthy confidence about own abilities; did not seem anxious or insecure; conveyed a sense of clarity about the direction of the segment; not overconfident, trying to impress, trying too hard to please, or self-centered; seemed comfortable and at ease being him/herself, instead of playing the role of a therapist. 0 Not relevant 1 Therapist seems extremely insecure, lacking in confidence, or self-aggrandizing. Appears either much too anxious or overconfident; or does not take any control over the direction of the segment. Or therapist has significant difficulties appearing relaxed and secure, or providing direction. May come across as either too eager to please, passive, or self-centered. 2 Therapist does a good job of conveying confidence about him/herself, and providing direction to the segment. Seems generally relaxed, rather than insecure or trying to impress. 112 3 Therapist demonstrates optimal levels of self-confidence, ease, and inner security. Provides helpful direction in a comfortable manner. Therapist seems especially natural and spontaneous being him/herself, instead of seeming to follow standard “rules” about what a good therapist should be or do. Minutes 5 10 15 20 25 30 35 40 45 50 55 60 Rate Part II. CONCEPTUALIZATION AND EDUCATION 6. Schema exploration, assessment, education and linking scehmes to situations. Through a process of exploration and assessment, the therapist tries to conceptualize the patient’s problems and underlying themes and patterns in schema terms. Through the use of skillful questioning, understanding current life experiences, and the interpretation of schema inventories, the therapist identifies schemas, modes, coping styles, and life patterns.Then the therapist educates the patient in schema terms about his/her current problems, life patterns, emotional reactions, misperceptions, or maladaptive behaviors. Therapist explicitly labels schemas, core needs, modes, and/or coping styles for the patient, as they arise. Therapist effectively communicates these concepts in a manner that the patient can clearly understand. In the next step the therapist links different life situations or events – past and present -- that share the same underlying schemas, modes, emotions, behaviors, and/or coping styles. The most common links are between: current life problems, childhood or adolescent origins, earlier adult life situations, or interactions in the therapy relationship. Linking can be done through imagery, by asking the patient to identify similar situations, or by the therapist pointing out similarities between events. 0 Not relevant 1 A. The therapist failed to explore or assess themes, schemas, or patterns, although this process would have been necessary or highly desirable for this segment‫‏‬to be effective. Or made some attempt to explore or assess, but did not ask questions in a skillful way, use the inventories correctly, or integrate the information in a useful way. Thus the schema conceptualization was inaccurate, incomplete, or did not fit together in a coherent manner. B. Also Therapist did not educate the patient about his/her problems in a way that the patient could understand, and did not label schemas, core needs, modes, and/or coping styles when they came up. Or therapist attempted to educate the patient about his/her problems, but: the concepts or schema labels were explained incorrectly; the therapist failed to use schema language; or did not communicate concepts in a way that the patient seemed to understand them clearly. C. Therapist did not attempt to link life events that share common, schema-related themes. Or therapist attempted to link schema-related events, but: the links were 113 inaccurate or did not resonate for the patient; or were not communicated in a way that the patient could understand how the events were linked. 2 The therapist did a good job of conceptualizing the patient’s problems and themes in schema terms. The therapist used questioning, inventories, or the patient’s adult life experiences to develop a useful, accurate conceptualization. In addition therapist did a good job educating the patient about his/her current problems; successfully explained these problems using schema-based labels; and was effective in communicating this information in a manner that the patient could understand. Therapist could have been more skillful in explaining the patient’s problems or in using schema terminology.Therapist did a good job of linking schema-related events. However, the links could have been more central to the patient’s life problems, or could have been communicated more effectively to the patient (e.g., could have utilized imagery instead of just pointing out links verbally). 3 Excellent schema exploration and assessment. Therapist was very skillful at gathering information, asking questions, using inventories, and/or asking about life experiences. The therapist showed considerable insight, and the ability to synthesize diverse information into a unified conceptualization, custom-tailored to this patient. In addition Therapist did an excellent job educating the patient about his/her current problems; explained these problems using appropriate schema labels; and very skillfully communicated this information in a manner that the patient could easily understand and relate to. Also Therapist did an excellent job linking life events that share a common, schema-related theme. The links were central to the patient’s current issues, and were communicated to the patient using the most effective techniques and the most understandable language. Minutes 5 10 15 20 25 30 35 40 45 50 55 60 Rate Part III. SCHEMA CHANGE 7. Application of change techniques. Therapist applies cognitive techniques drawn from schema therapy in a skillful manner. Cognitive change techniques usually focus on the logical, empirical, or rational analysis of beliefs. Some of the common cognitive techniques that may be used include: a. Therapist reframes the past to fight schemas. For example, therapist reattributes parent’s negative treatment of the child to parent’s deficiencies instead of to patient’s deficiencies. b. Therapist helps patient reattribute adult life problems to schemas or schema modes instead of inherent flaws in the patient. 114 c. Therapist helps patient look at evidence to test out whether a particular schema is accurate, and points out cognitive distortions that are schema-driven. d. Therapist tests a schema by conducting a life review, gathering evidence pro and con to refute the schema. e. Therapist builds a strong rational and empirical case against a schema that the patient intellectually accepts. f. Therapist conducts a schema dialogue with the patient between the schema side and the healthy side for cognitive restructuring. g. Therapist develops a schema flashcard that summarizes the Healthy Adult viewpoint, based on the schema flashcard template. h. Therapist reviews a completed Schema Diary with the patient. Clarification: Role-playing, dialogues, and imagery are generally considered cognitive techniques only when they are intended primarily to change the patient’s distorted cognitive perspective. If the role-play, dialogue, or image is intended primarily to change emotions or for limited reparenting, then it is considered an emotion-focused technique. If the focus is on changing behavior, then it is considered behavioral pattern-breaking. 0 Not relevant 1 Therapist did not utilize any cognitive change techniques when it was needed. Or therapist did a very poor job implementing cognitive change techniques. Or there were major flaws in the way cognitive techniques were applied that significantly limited their effectiveness. 2 Therapist did a good job in applying cognitive techniques when it was needed, but could have been more skillful. 3 Therapist did an excellent job applying cognitive techniques for change. Minutes 5 10 15 20 25 30 35 40 45 50 55 60 Rate 8. Application of emotion- focused change techniques. Therapist applies emotion-focused change techniques, drawn from schema therapy, in a skillful manner. Some of the common emotion-focused techniques that may be used include: a. Reparenting the Vulnerable Child through imagery 115 b. Venting anger at significant others (usually in the Angry Child mode) c. Grieving over losses d. Imagery to bypass the Detached Protector e. Letters to parents expressing emotions and unmet needs f. Imagery dialogues to externalize and fight the Punitive Parent g. Working with traumatic memories Clarification: If the role-play, dialogue, or image is intended primarily to change emotions or for limited reparenting, then it is considered an emotion-focused technique. Role-playing, dialogues, and imagery are generally considered cognitive or behavioral techniques only when they are intended to practice an interpersonal skill or to directly change the patient’s distorted cognitive perspective. 0 Not relevant. Therapist did not utilize any emotion-focused change techniques and it was not needed. 1 Therapist did not utilize any emotion-focused change techniques even though it was needed. Or therapist did a very poor job implementing emotion-focused change techniques.Or there were major flaws in the way emotion-focused change techniques were applied that significantly limited their effectiveness. 2 Therapist did a good job in applying emotion-focused change techniques, but could have been more skillful. 3 Therapist did an excellent job applying emotion-focused techniques for change. Minutes 5 10 15 20 25 30 35 40 45 50 55 60 Rate 9. Application of behavioral pattern- breaking. Therapist applies behavioral pattern-breaking techniques, drawn from schema therapy, in a skillful manner. Behavioral techniques are focused on behavior change, including learning interpersonal skills and limit-setting. Some of the common behavioral pattern-breaking techniques that may be used include: a. Therapist uses imagery or role playing to rehearse real-life situations outside the session. b. Therapist and patient discuss new ways of handling life problems outside the session. c. Therapist discusses how to change dysfunctional patterns in intimate relationships or friendships. 116 d. Therapist discusses how to change dysfunctional patterns in work or school situations. e. Therapist pushes patient to make a life change that was discussed previously but was not followed through on, using empathic confrontation or “contingency management.” f. Therapist sets limits when patient “acts out” in a dysfunctional way (e.g., missing sessions, drinking too much, calling therapist at home too much). g. Therapist discusses making major life changes so patient can get core needs met. h. Therapist identifies schemas or modes that are blocking patient from making behavioral changes, and uses techniques to overcome obstacles to behavior change. Clarification: Role-playing, dialogues, and imagery are generally considered behavioral when they are intended to practice an interpersonal skill, directly change some other behavior, or set limits. If the role-play, dialogue, or image is intended primarily to change emotions or for limited reparenting, then it is considered an emotion-focused technique. If the focus is on changing thoughts and beliefs, then it is considered a cognitive technique. 0 Not relevant. Therapist did not utilize any behavioral pattern-breaking techniques, and it was not needed. 1 Therapist did not utilize any behavioral pattern-breaking techniques when it was needed. Or therapist did a very poor job implementing behavioral pattern-breaking techniques. Or there were major flaws in the way behavioral pattern-breaking techniques were applied that significantly limited their effectiveness. 2 Therapist did a good job in applying behavioral pattern-breaking techniques, but could have been more skillful. 3 Therapist did an excellent job applying behavioral pattern-breaking techniques. Minutes 5 10 15 20 25 30 35 40 45 50 55 60 Rate 10. Therapy relationship for change. Therapist notices when schemas, coping styles, or modes are activated by the therapy relationship itself, and then utilizes the relationship as a vehicle for bringing about schema change. Therapist focuses on interactions between the therapist and patient in the “here-and-now,” during the segment. 0 Not relevant. The patient’s relationship with the therapist did not seem to be an issue that was triggered or came up during the segment. The therapist was correct in not focusing on the therapy relationship directly. 117 1 The therapy relationship did seem to be an issue during the segment, but the therapist either failed to address it when he/she should have, or dealt with the relationship in a harmful way. Or the therapist noticed that the therapy relationship came up as an issue, and discussed it during the segment. However, the therapist either did not seem to grasp correctly what was happening in the therapy relationship; or did not attempt to change the schemas, coping styles, or modes that were activated. 2 Therapist did a good job bringing up issues that arose in the therapy relationship. Therapist seemed to have a good grasp of what was happening between them, and communicating this to the patient. Therapist was reasonably effective utilizing schema techniques to change the patient’s maladaptive reactions to the therapy relationship. 3 Therapist did an excellent job bringing up issues that arose in the therapy relationship, understood accurately what was happening between them, and helped the patient understand the schemas, modes, or coping styles that were activated. Therapist skillfully corrected the patient’s maladaptive cognitive, emotional, or behavioral reactions in order to bring about schema change in the therapy relationship, using appropriate techniques such as self-disclosure, cognitive restructuring, or behavioral rehearsal. Minutes 5 10 15 20 25 30 Rate 118 35 40 45 50 55 60 Summarizing chart 0 Not relevant. 1 Very poor, 2 poor. 3 unsatistactory. 4 Adequate 5 good 6‫ ‏‬Very good or excellent. Ti me Limited reparenting Understand ing and attunement Collaborati on, feedback & session focus Therapist balance & flexibility Therapist confidence & ease Schema exploration, assessment, education and linking scehmes to situations 5 10 15 20 25 30 35 40 45 50 55 60 119 Application of cognitive change techniques Application of emotionfocused change techniques Application of behavioral patternbreaking Therapy relationship for change comment s Part IV. OVERALL RATINGS AND COMMENTS. A. Overall session rating. How would you rate the clinician overall in this session, as a schema therapist? 0 Very Poor 1 Poor 2 Unsatisfactory 3 Adequate 4 Good 5 6 Very Good Excellent B. How difficult did you feel the patient was to work with? 0 Very easy & receptive 1 2 3 Average difficulty 4 5 6 Extremely difficult C. Self – help techniques outside session: Therapist suggests or assigns appropriate, schema-based “homework” or coping skills that the patient can try during the week outside the session, in order to consolidate or advance the therapy work that took place during the session. Therapist reviews assignments from the previous session. If patient has not completed previous assignment, therapist explores reasons and attempts to resolve obstacles. Some common self-help assignments from schema therapy include:  Flashcard  Reach out to friends  “Transitional object”  Work on intimate relationships  ”Schema Diary”  Nurture the Abandoned Child  Listen or record audiotape of healthy schema responses  List pros and cons for decision-making, or evidence to test validity of schemas  Monitor emotions, modes, or schema triggers  Call therapist when appropriate  Mode or schema dialogues  Practice healthy behavioral changes 0 Therapist did not assign self-help work, and it was appropriate not to assign any for this session. (For this item, “0” should only be used for unusual sessions. It is almost always appropriate to assign some kind of self-help work outside the session.) 1 Therapist did not assign or suggest any self-help work outside the session, even though it would have been appropriate and helpful to do so. Or therapist suggested or assigned self-help work outside the session, but the assignment was not helpful or relevant to the patient, was much too vague, or was not explained clearly enough for the patient to understand it. Therapist may also have failed to review the previous week’s self-help work adequately. 2 Therapist did a good job reviewing previous week’s self-help assignment, and working to overcome obstacles if necessary. Therapist assigned “standard” schema-based self-help work to help the patient change schemas and deal with life situations during the coming week. Selfhelp assignments could have been better-tailored to fit the unique needs of this patient, or to advance the work of this session. 3 Therapist did an excellent job reviewing previous week’s self-help assignment, and working to overcome obstacles if necessary. Therapist assigned schema-based self-help work directly relevant to this session, and custom-tailored to help the patient incorporate new perspectives. 120 ‫תקציר‬ ‫מרבית‏המחקר‏בפסיכותרפיה‏מתמקד‏בחקר‏יעילות‏של‏טיפולים‪,‬‏ועושה‏שימוש‏במתודולוגיה‏‬ ‫המקובלת‏של‏ניסוי‏אקראי‏מבוקר‏(‪,)RCT-randomized control trial‬‏אשר‏מודד‏משתנים‏לפני‏‬ ‫ואחרי‏טיפול‪.‬‏למרות‏יתרונותיה‏הרבים‏של‏מתודולוגיה‏זו‪,‬‏חסרונותיה‏מתבטאים‏בהיעדר‏מידע‏לגבי‏‬ ‫תהליכי‏שינוי‏המתרחשים‏במהלך‏הפסיכותרפיה‏עצמה‪.‬‏דיסרטציה‏זו‏מצטרפת‏לזרם‏המתרחב‏העוסק‏‬ ‫בתהליכי‏שינוי‏המתרחשים‏בתוך‏הטיפול‪,‬‏והיא‏הראשונה‏לעסוק‏בחקר‏תהליכי‏שינוי‏המתרחשים‏במהלך‏‬ ‫השעה‏הטיפולית‏בקרב‏מטופלים‏המאובחנים‏בהפרעת‏אישיות‏הימנעותית‪,‬‏והראשונה‏שחוקרת‏תהליכים‏‬ ‫אלו‏בהקשר‏של‏טיפול‏בסכמה‏תרפיה‪.‬‏‏‬ ‫הפרעת אישיות הימנעותית (‪.)APD‬‏‪APD‬‏הינה‏מהשכיחות‏ביותר‏מבין‏הפרעות‏אישיות‏(ה"א)‏‬ ‫באוכלוסיית‏המטופלים‏במרפאות‏פסיכיאטריות‏(‪)Zimmerman et al., 2005‬‏ושיעורה‏‏‪02-02%‬‏‬ ‫( ‪.)Sanislow et al., 2012‬‏באוכלוסיה‏הכללית‏שכיחותה‏של‏הפרעה‏זו‏מגיעה‏לכדי‏‪.0-0%‬‏למרות‏‬ ‫זאת‪,‬‏הפרעה‏זו‏זכתה‏לתשומת‪-‬לב‏מחקרית‏מועטה‏(‪,)Alden et al., 2002; Sanislow et al., 2012‬‏‬ ‫קרוב‏לודאי‏בשל‏הדיון‏המתמשך‏לגבי‏החפיפה‏הרבה‏עם‏הפרעות‏אחרות‪,‬‏ובעיקר‏עם‏חרדה‏חברתית‏‬ ‫(‪ )Chambless et al., 2008‬לגביה‏מדווח‏על‏חפיפה‏של‏‪95%‬‏בממוצע‪.‬‏רבים‏מהסובלים‏מ‪APD-‬‏‬ ‫סובלים‏מתחלואה‏נלווית‪.‬‏כך‏לדוגמא‪,‬‏מבין‏הסובלים‏מדיכאון‏מז'ורי‪,‬‏נמצא‏ששיעור‏ה‪APD-‬‏מגיע‏עד‏ל‪-‬‬ ‫‪;02%‬‏מבין‏הסובלים‏מהפרעה‏טורדנית‪-‬כפייתית‪,‬‏נמצא‏שיעור‏המגיע‏עד‏‪95%‬‏(‪.)Alden et al., 2002‬‏‏‬ ‫הקריטריונים‏לאבחנת‏‪APD‬‏תוארו‏לראשונה‏על‏ידי‏מילון‏(‪)Millon, 1969‬‏ונכללו‏לראשונה‏ב‪-‬‬ ‫‪,DSM-III‬‏בשנת‏‪0522‬‏(‪.)APA, 1980‬‏על‪-‬פי‏מילון‏(‪,)1991‬‏‪APD‬‏מאופיינת‏בקושי‏ביחסים‏עם‏‬ ‫אנשים‪,‬‏בעוד‏שחרדה‏חברתית‏מאופיינת‏בקושי‏לתפקד‏במצבים‏מסוימים‪.‬‏יתרה‏מכך‪,‬‏אנשים‏הסובלים‏‬ ‫מחרדה‏חברתית‏עשויים‏לקיים‏יחסים‏חברתיים‏ובינאישיים‏מספקים‏בעוד‏שאנשים‏הסובלים‏מ‪APD-‬‏‬ ‫נסוגים‏חברתית‪,‬‏ויש‏להם‏קושי‏ניכר‏ליזום‏ולקיים‏קשרים‏בינאישיים‏בשל‏הערכה‏עצמית‏נמוכה‏וצורך‏‬ ‫מוגבר‏בקבלה‏ואישור‪.‬‏‬ ‫‪DSM-IV‬‏ו‪-‬‏‪DSM-V‬‏)‪(APA, 2000, 2013‬‏הגדירו‏את‏ה‪APD-‬‏כדפוס‏נרחב‏של‏עכבה‏‬ ‫חברתית‪,‬‏תחושת‏חוסר‏תואמות‏ורגישות‏יתר‏להערכה‏שלילית‪,‬‏המופיע‏בבגרות‏המוקדמת‏והמתבטא‏‬ ‫בהקשרים‏שונים‏ולפחות‏בארבעה‏מתוך‏המאפיינים‏הללו‪:‬‏‪)0‬‏הימנעות‏מפעילות‏תעסוקתית‏הכרוכה‏‬ ‫במגעים‏בינאישיים‏משמעותיים‏בשל‏חשש‏לביקורת‪,‬‏העדר‏אישור‏או‏דחייה;‏‪)0‬‏חוסר‏נכונות‏למעורבות‏‬ ‫עם‏אנשים‏אלא‏אם‏כן‏מובטחת‏אהדה;‏‪)5‬‏שמירה‏על‏איפוק‏בקשרים‏אינטימיים‏בשל‏פחד‏מלחוש‏מבויש‏‬ ‫או‏מגוחך;‏‪)4‬‏מוטרדות‏מלהיות‏מבוקר‏או‏דחוי‏במצבים‏חברתיים;‏‪)9‬‏עכבה‏במצבים‏בינאישיים‏בשל‏‬ ‫תחושות‏של‏חוסר‏תואמות;‏‪)6‬‏תפיסת‏העצמי‏כמגושם‏חברתית‪,‬‏לא‏מושך‏באופן‏אישי‏ונחות‏מאחרים;‏‪)7‬‏‬ ‫מסויגות‏תכופה‏מלקחת‏סיכונים‏אישיים‏או‏ממעורבות‏בכל‏סוג‏של‏פעילות‏חדשה‏בשל‏חשש‏ממבוכה‏‬ ‫אפשרית‪.‬‏‏‬ ‫ל‪APD-‬‏השלכה‏מעכבת‏ניכרת‏בהקשרים‏בינאישיים‪,‬‏תעסוקתיים‏ואקדמיים‏(‪.)APA, 2000‬‏‬ ‫הלוקים‏בהפרעה‏זו‏נמנעים‏מעבודת‏צוות‏ומעדיפים‏שלא‏לפנות‏לעזרה‪.‬‏הם‏מבועתים‏מהאפשרות‏‬ ‫שאחרים‏יתקרבו‏אליהם‪,‬‏חסרונותיהם‏יתגלו‏והם‏יהיו‏ללעג‪.‬‏כמו‏כן‪,‬‏הם‏משוכנעים‏שיזכו‏רק‏לביקורת‏‬ ‫א‬ ‫ולהערכה‏שלילית‏מאחרים‏(‪.)Sanislow et al., 2012‬‏‬ ‫ישנם‏מספר‏קשיים‏להם‏ניתן‏לצפות‏בבואנו‏לטפל‏בלוקים‏ב‪.APD-‬‏ראשית‪,‬‏מעצם‏מהותה‏של‏‬ ‫הפרעה‏זו‪,‬‏מטופלים‏אלה‏נמנעים‏מיצירת‏קשר‏עמוק‏ופתוח‏אפילו‏עם‏המקורבים‏להם‪,‬‏ולא‏כל‏שכן‏עם‏‬ ‫מטפל‏שנתפס‏תחילה‏כאדם‏זר‪.‬‏בשל‏תחושת‏הנחיתות‏והאמונה‏שלא‏ניתן‏לאהוב‏אותם‪,‬‏מטופלים‏אלה‏‬ ‫מטילים‏ספק‏בכנות‏ובאותנטיות‏שבהתעניינות‏בהם‏ונוטים‏לדחות‏עזרה‪.‬‏לפיכך‪,‬‏על‏המטפל‏להיות‏ער‏‬ ‫לרגישות‏המוגברת‏לביקורת‏ודחייה‪,‬‏ולקחת‏בחשבון‏שהתערבויותיו‏יכולות‏להיחוות‏כשיפוטיות‪.‬‏יתרה‏‬ ‫מכך‪,‬‏מאחר‏ומטופלים‏אלה‏אינם‏נוהגים‏לשתף‏ברגשותיהם‏ובמחשבותיהם‪,‬‏עלולים‏כשלים‏טיפוליים‏‬ ‫מינוריים‏יחסית‏להעמיק‏ולהפוך‏לקרעים‏משמעותיים‪,‬‏בהעדר‏ההזדמנות‏לזהותם‏ולתקן‏אותם‏בעיתם‪.‬‏‬ ‫בנוסף‪,‬‏בשל‏נטייתם‏להימנע‏מלחוות‏רגשות‏עזים‏(בין‏אם‏חיוביים‏או‏שליליים;‏‪)Arntz, 2012‬‏קשה‏‬ ‫לגייס‏מטופלים‏אלה‏לשיתוף‏פעולה‏בהתערבויות‏הדורשת‏מגע‏עם‏תכנים‏מעוררי‏מצוקה‏רגשית‪.‬‏‬ ‫אכן‪,‬‏טכניקות‏לטיפול‏בחרדה‏חברתית‏(ובהן‏טיפול‏קוגניטיבי‏התנהגותי)‏הראו‏יעילות‏מסוימת‏‏‬ ‫בעבודה‏עם‏מטופלי‏‪APD‬‏(‪.)Alden, 1989; cf., Alden et al. 2002‬‏כך‏לדוגמא‪,‬‏מרבית‏המחקרים‏‬ ‫מראים‏שלמטופלי‏‪APD‬‏חומרת‏סימפטומים‏גבוהה‏יותר‏הן‏בתחילת‏הטיפול‏והן‏בסופו‪,‬‏בהשוואה‏‬ ‫למטופלים‏עם‏חרדה‏חברתית‏בלבד‪.‬‏בפרט‪,‬‏נמצא‏קושי‏בשילוב‏טכניקות‏התנהגותיות‏של‏חשיפה‏‬ ‫הדרגתית‏למצבים‏חברתיים‏מעוררי‏חרדה‏בשל‏התנגדותם‏לחוות‏באופן‏מלא‏רגשות‏שליליים‏או‏בשל‏‬ ‫נטייתם‏לניתוק‏ולהימנעות‏רגשיים‪.‬‏מחקרים‏וסקירות‏של‏אלדן‏ושל‏אחרים‏( ‪Alden, 1989; Alden et‬‬ ‫‪)al., 2002; Sanislow et al., 2012‬‏ציינו‏שלמרות‏שיפור‏בעקבות‏התערבויות‏‪CBT‬‏למיניהן‏ויעילותן‏‬ ‫על‏פני‏טיפולים‏אחרים‪,‬‏מטופלי‏‪APD‬‏אינם‏משתפרים‏מספיק‏מהתערבויות‏ממוקדות‏קצרות‪-‬מועד‪,‬‏‬ ‫ואחוזי‏הנשירה‏שלהם‏גבוהים‏למדי‪.‬‏אי‏לכך‪,‬‏נדרש‏פיתוח‏של‏דרכי‏התערבות‏ייחודיות‏שיתנו‏מענה‏‬ ‫לסוגיות‏האופייניות‏ל‪.APD-‬‏אחת‏הגישות‏המציעה‏מענה‏למטופלי‏‪APD‬‏הינה‏הסכמה‏תרפיה‪.‬‏‬ ‫סכמה תרפיה (‪.)ST‬‏‪ST‬‏היא‏אחת‏מהגישות‏האינטגרטיביות‏ונתמכות‏הראיות‏שצמחו‏מתוך‏שדה‏‬ ‫ה‪CBT-‬‏(‪.)Young et al., 2008‬‏יאנג‪,‬‏פיתח‏את‏ה‪ST-‬‏כשיטת‏טיפול‏המשלבת‏היבטים‏קוגניטיביים‪-‬‬ ‫התנהגותיים‪,‬‏המשגות‏מעמיקות‏מאסכולות‏יחסי‏האובייקט‏וההתקשרות‪,‬‏והתערבויות‏חווייתיות‏מגישת‏‬ ‫הגשטלט‪.‬‏‪ST‬‏משתמשת‏בארבעה‏מושגי‏יסוד‪:‬‏צרכי‏ליבה‏רגשיים‪,‬‏סכמות‏מוקדמות‏בלתי‪-‬מסתגלות‪,‬‏‬ ‫סגנונות‏התמודדות‪,‬‏ומודים‪.‬‏‏‬ ‫צרכי‏ליבה‏רגשיים‏הם‏אוניברסאליים‏וכוללים‏לפי‏יאנג‏(‪)Young et al., 2003‬‏צורך‏‬ ‫בהתקשרות‏בטוחה‏לאחרים;‏צורך‏באוטונומיה‪,‬‏מסוגלות‏ותחושת‏זהות;‏צורך‏בחופש‏לבטא‏צרכים‏‬ ‫ורגשות‏ברי‏תוקף;‏צורך‏בספונטניות‏ומשחק;‏וצורך‏בגבולות‏מציאותיים‏ושליטה‏עצמית‪.‬‏כאשר‏צרכי‏‬ ‫ליבה‏אלה‏אינם‏זוכים‏למענה‏הולם‏במהלך‏ההתפתחות‪,‬‏מתפתחות‏סכמות‏מוקדמות‏בלתי‪-‬מסתגלות‪.‬‏‏‬ ‫סכמות‏מוקדמות‏בלתי‪-‬מסתגלות‏הן‏פריזמות‏קבועות‏דרכן‏האדם‏מפרש‏אירועים‏סביבו‏ומעניק‏‬ ‫משמעות‏לגבי‏העצמי‪,‬‏האחר‪,‬‏והעולם‪.‬‏יאנג‏הגדיר‏‪02‬‏סכמות‏שמקורן‏באינטראקציות‏שליליות‏חוזרות‏‬ ‫ונשנות‏עם‏דמויות‏משמעותיות‏משחר‏הילדות‪.‬‏ברוב‏המקרים‏נמנים‏על‏דמויות‏אלה‏הורים‪,‬‏אחים‪,‬‏קרובי‏‬ ‫משפחה‪,‬‏דמויות‏טיפוליות‏או‏מחנכות‏וכן‏קבוצת‏השווים‪.‬‏הצתה‏של‏סכמות‏אלו‏מלווה‏בכאב‏נפשי‏‬ ‫ומצוקה‪,‬‏ועל‏כן‏נכנסים‏לפעולה‏סגנונות‏ההתמודדות‏במטרה‏להפחית‏או‏להיפטר‏מתחושות‏אלה‪.‬‏‬ ‫ב‬ ‫סגנונות‏ההתמודדות‏משפיעים‏על‏ההתנהגות‏של‏האדם‪.‬‏יאנג‏הגדיר‏שלושה‏סגנונות‏התמודדות‪:‬‏‪.0‬‏‬ ‫הימנעות‏–‏היכולה‏להתבטא‏בניתוק‏ודיסוציאציה‪,‬‏התרחקות‪,‬‏התבודדות‪,‬‏הסחת‏דעת‪,‬‏חיפוש‏אחר‏‬ ‫ריגושים‏וכד';‏‪.0‬‏פיצוי‏יתר‏–‏היכול‏להתבטא‏בהתפארות‪,‬‏משיכת‏תשומת‏לב‪,‬‏התנשאות‪,‬‏תחרותיות‪,‬‏‬ ‫בריונות‪,‬‏פרפקציוניזם‏וכד'‪.‬‏‪.5‬‏כניעה‏–‏היכולה‏להתבטא‏בכניעה‪,‬‏קבלה‏ללא‏עוררין‏של‏דעותיו‏‬ ‫ורצונותיו‏של‏האחר‪,‬‏התבטלות‏עצמית‪,‬‏התמסרות‏חסרת‏פשרות‪,‬‏פאסיביות‏בקשר‏וכד'‪.‬‏יאנג‏מתייחס‏‬ ‫לסגנונות‏התמודדות‏אלה‏כבלתי‪-‬מסתגלים‏כיוון‏שהם‏אינם‏משנים‏את‏המשמעות‏של‏הסכמות‏עצמן‪.‬‏‏‬ ‫באופן‏פרדוקסאלי‏הימנעות‪,‬‏פיצוי‏יתר‏או‏כניעה‏רק‏מחזקים‏את‏הסכמות‏ומרחיקים‏את‏האדם‏ממגע‏עם‏‬ ‫צרכיו‏הרגשיים‪.‬‏בעוד‏שהצרכים‪,‬‏הסכמות‪,‬‏וסגנונות‏ההתמודדות‏נחשבים‏למרכיבים‏יציבים‏לאורך‏זמן‏‬ ‫באישיותו‏של‏האדם‪,‬‏ההתמודדות‏עצמה‏יכולה‏להיות‏בעלת‏אופן‏מצבי‪,‬‏ולהשתנות‏מרגע‏אחד‏למשנהו‪.‬‏‬ ‫תובנה‏זו‏הובילה‏את‏יאנג‏ועמיתיו‏(‪)Young et al., 2003‬‏להוסיף‏מושג‏רביעי‪,‬‏הוא‏מושג‏המוד‪.‬‏‬ ‫מודים‏הם‏מצבים‏רגעיים‏ומתחלפים‏המאפיינים‏את‏אישיותו‏של‏האדם‪.‬‏כל‏מוד‏מאופיין‏(ומובחן‏‬ ‫ממודים‏אחרים)‏במצב‏רגשי‪,‬‏קוגניציות‏שכיחות‪,‬‏והתנהגויות‏ספציפיות‏המופעלות‏ברגע‏נתון‪.‬‏יאנג‏ושות'‏‬ ‫(‪)0225‬‏הגדירו‏‪4‬‏סוגים‏של‏מודים‪:‬‏‪.0‬‏מודים‏ילדיים‪,‬‏אשר‏משקפים‏רגרסיה‏למצב‏רגשי‏ילדי‏(של‏‬ ‫פגיעות‪,‬‏אימפולסיביות‪,‬‏כעס‪,‬‏או‏נינוחות);‏‪.0‬‏מודים‏של‏התמודדות‏בלתי‏מסתגלת‪,‬‏אשר‏מתבטאים‏‬ ‫בהתנהגויות‏הגנתיות‏(של‏הימנעות‪,‬‏פיצוי‪-‬יתר‪,‬‏כניעה‏וריצוי‏על‏נגזרותיהן‏השונות);‏‪.5‬‏מודים‏הוריים‏‬ ‫דיספונקציונלים‪,‬‏שהם‏הפנמות‏של‏היבטים‏לקויים‏של‏ההורים‏או‏של‏דמויות‏משמעותיות‏אחרות‏‬ ‫בסביבתו‏המוקדמת‏של‏האדם‪.‬‏מודים‏אלה‏תוקפים‏את‏האדם‏מבפנים‏(בד"כ‏בתובענות‪,‬‏ביקורת‪,‬‏האשמה‪,‬‏‬ ‫והענשה‏עצמית)‏ומופנים‏כנגד‏המודים‏הילדיים‏והצרכים‏שבבסיסם‪.‬‏‏‪.4‬‏מוד‏הבוגר‏הבריא‪,‬‏אשר‏משקף‏‬ ‫הפנמות‏של‏היבטים‏חיוביים‏של‏ההורים‏ודמויות‏משמעותיות‏אחרות‪.‬‏מוד‏זה‏מאפשר‏חמלה‏עצמית‏‬ ‫ומסייע‏לאדם‏לתת‏מענה‏הולם‏לצרכיו‪,‬‏לווסת‏את‏רגשותיו‏ולהתנהל‏בצורה‏שקולה‏ויעילה‏במערכות‏‬ ‫היחסים‏ואל‏מול‏מצבי‏חיים‏משתנים‪.‬‏לכל‏אדם‏יש‏מודים‏שונים‪,‬‏אולם‏הלוקים‏בה"א‏מאופיינים‏במודים‏‬ ‫מוקצנים‏יותר‏ובמעברים‏חדים‏ביניהם‏( ;‪Arntz & van Genderen, 2009; Bamelis et. al, 2011‬‬ ‫‪.)Lobbestael et al., 2007‬‏‬ ‫מטרתן‏של‏כל‏ההתערבויות‏ב‪ST-‬‏היא‏לסייע‏למטופלים‏למצוא‏דרכים‏יעילות‏ומסתגלות‏לקבל‏‬ ‫מענה‏הולם‏לצרכי‏הליבה‏הבסיסיים‪.‬‏‏‬ ‫התערבויות‏קוגניטיביות‏מופעלות‏כדי‏לבחון‏את‏הסכמות‪,‬‏דפוסי‏ההתמודדות‏והמודים‪,‬‏לקשור‏‬ ‫אותם‏לבעיות‏המרכזיות‏שאיתן‏מתמודד‏המטופל‪,‬‏ולקדם‏בחירה‏של‏דפוסי‏חשיבה‏יעילים‏יותר‪.‬‏‬ ‫התערבויות‏אלה‏כוללות‏הדרכה‏פסיכוחינוכית‪,‬‏עדויות‏תומכות‏וסותרות‏לסכמה‪,‬‏רשימת‏יתרונות‏‬ ‫וחסרונות‏של‏דפוסי‏ההתמודדות‪,‬‏ייחוס‏מחדש‪,‬‏בניית‏רציונל‏כנגד‏הסכמה‪,‬‏ניהול‏דיאלוג‏בין‏הסכמה‏לצד‏‬ ‫הבריא‪,‬‏כתיבת‏כרטיסי‏הבזק‏וכד'‪.‬‏‏‬ ‫התערבויות‏חווייתיות‏(ממוקדות‏רגש)‏מופעלות‏כדי‏ליצור‏רישום‏של‏חוויות‏רגשיות‏מתקנות‏‬ ‫לזיכרונות‏הכואבים‏שתרמו‏להתגבשות‏הסכמות‪,‬‏דפוסי‏ההתמודדות‏והמודים‏הבלתי‏מסתגלים‏המנהלים‏‬ ‫את‏המטופל‪.‬‏התערבויות‏אלה‏כוללות‏רישום‏מתקן‏בדמיון‪,‬‏עבודת‏כסאות‪,‬‏משחק‏תפקידים‏היסטורי‏וכד'‪.‬‏‏‬ ‫ג‬ ‫התערבויות‏התנהגותיות‏מופעלות‏כדי‏לתרגל‏את‏המטופל‏בניהול‏טריגרים‏של‏מצבי‏היומיום‏‬ ‫ולהיערך‏לקראת‏אינטראקציות‏נוכחיות‏ועתידיות‪.‬‏התערבויות‏אלה‏כוללות‏הקנייה‏ותרגול‏של‏מיומנויות‏‬ ‫בינאישיות‪,‬‏ביצוע‏משחקי‏תפקיד‪,‬‏חשיפה‏הדרגתית‪,‬‏ניסויים‏התנהגותיים‪,‬‏ומשימות‏בית‪.‬‏‏‬ ‫התערבויות‏התייחסותיות‏מופעלות‏במצבים‏בהם‏מתרחשת‏הצתה‏של‏סכמות‪,‬‏דפוסי‏התמדדות‏או‏‬ ‫מודים‏ברמת‏"הכאן‏ועכשיו"‏באינטראקציה‏הטיפולית‪.‬‏‏התערבויות‏אלה‏שמות‏דגש‏על‏הדדיות‪,‬‏לקיחת‏‬ ‫אחריות‪,‬‏חשיפה‏עצמית‪,‬‏הבנייה‏קוגניטיבית‏ותרגול‏התנהגותי‏באמצעותם‏המטפל‏משתמש‏בקשר‏‬ ‫הטיפולי‏עצמו‏כדי‏לקדם‏שינוי‪.‬‏‏‬ ‫התערבויות‏העושות‏שימוש‏בעמדת‏המטפל‏מלוות‏את‏הטיפול‏לכל‏אורכו‏ומהוות‏למעשה‏את‏‬ ‫המצע‏לביסוס‏הקשר‏הטיפולי‪.‬‏התערבויות‏אלה‏כוללות‏הורות‏חלקית‏מתקנת;‏עימות‏אמפאטי;‏שימוש‏‬ ‫בגישה‏קשובה‪,‬‏כנה‪,‬‏נחושה‏וגמישה;‏חתירה‏לשיתוף‏פעולה‪,‬‏מיקוד‏ומשוב‏הדדי‏בתוך‏הפגישות‪.‬‏‬ ‫מבחינה‏תיאורטית‪,‬‏מרכיב‏משמעותי‏ביעילות‏הטיפול‏קשור‏בהתאמה‏בין‏התערבויות‏טיפוליות‏‬ ‫ספציפיות‏לבין‏המוד‏הספציפי‏הפעיל‏ברגע‏נתון‏אצל‏המטופל‪,‬‏דבר‏שיש‏לבססו‏גם‏מבחינה‏מחקרית‪.‬‏‏‬ ‫מחקר בסכמה תרפיה‪ .‬בשני‏העשורים‏האחרונים‏הולכות‏ומצטברות‏עדויות‏אמפיריות‏החוקרות‏‬ ‫את‏מרכיבי‏התיאוריה‏ויעילותה‏כגישה‏טיפולית‪.‬‏מוקד‏מחקר‏ראשוני‏היה‏תיקוף‏השאלונים‏שיאנג‏‬ ‫ואחרים‏פיתחו‏לזיהוי‏ולמיפוי‏הסכמות‏והמודים‏( ‪Hawke & Provencher, 2012; Lobbestael et al.,‬‬ ‫‪2010; Lobbestael et al., 2009; Lobbestael et al., 2007; Schmidt et al., 1995; Soygut et‬‬ ‫‪.)al., 2009; Trip, 2006; etc.‬‏מחקרים‏אלה‏תמכו‏במיפוי‏מרבית‏הסכמות‏והמודים‪,‬‏ובתקפות‏‬ ‫השאלונים‏למדידתם‪.‬‏‏‬ ‫מחקרים‏אחרים‏עסקו‏בניסיון‏לזהות‏סכמות‪,‬‏דפוסי‏התמודדות‏ו‪/‬או‏מודים‏המאפיינים‏הפרעות‏‬ ‫נפשיות‏שונות‪.‬‏למשל‪,‬‏לובסטיאל‏ושותפיה‏)‪(Lobbestael et al., 2010‬‏חקרו‏את‏המודים‏האופייניים‏‬ ‫למטופלים‏המאובחנים‏בהפרעות‏ציר‏‪,I‬‏ציר‏‪,II‬‏וקבוצת‏ביקורת‏ללא‏אבחנות‪.‬‏מטופלים‏עם‏אבחנות‏ציר‏‪I‬‏‬ ‫קיבלו‏באופן‏מובהק‏ערכים‏גבוהים‏יותר‏בשאלוני‏המודים‏ביחס‏לקבוצת‏הביקורת‪,‬‏אך‏נמוכים‏יותר‏‬ ‫ממטופלים‏עם‏אבחנות‏של‏ה"א‪.‬‏באופן‏דומה ‪Hawke & Provencher‬‏(‪)0200‬‏סקרו‏מחקרים‏שחקרו‏‬ ‫את‏הסכמות‏האופייניות‏להפרעות‏חרדה‏ומצב‪-‬רוח‪.‬‏הם‏מצאו‏קשרים‏מובחנים‏בין‏סכמות‏בלתי‪-‬מסתגלות‏‬ ‫מוקדמות‏ספציפיות‏לבין‏דיכאון‏מאז'ורי‪,‬‏הפרעה‏דו‪-‬קוטבית‪,‬‏הפרעת‏אימה‪,‬‏אגורפוביה‪,‬‏חרדה‏חברתית‪,‬‏‬ ‫הפרעה‏טורדנית‪-‬כפייתית‪,‬‏והפרעת‏דחק‏פוסט‪-‬טראומטית‪Pugh .‬‏(‪)0209‬‏פרסם‏לאחרונה‏סקירה‏נרחבת‏‬ ‫על‏‪ST‬‏בהפרעות‏אכילה‪,‬‏אשר‏מתעדת‏פרופילים‏מובחנים‏של‏סכמות‏עבור‏תת‪-‬סוגים‏של‏הפרעות‏אכילה‏‬ ‫(קרי‪,‬‏אנורקסיה‏מגבילה‪,‬‏אנורקסיה‏זלילה‪-‬התרוקנות‪,‬‏ובולמיה)‪.‬‏‬ ‫מוקד‏מחקרי‏חשוב‏במיוחד‏בא‏לידי‏ביטוי‏בקבוצת‏מחקרים‏הולכת‏וגדלה‪,‬‏העוסקת‏ביעילות‏‬ ‫הטיפול‏בהפרעות‏שונות‪,‬‏כגון‏חרדה‪,‬‏דיכאון‪,‬‏התמכרויות‪,‬‏הפרעות‏אכילה‪,‬‏ה"א‏גבולית‏וה"א‏נוספות‏‬ ‫(לסקירה‏ראה‪:‬‏‪.)Hawke & Provencher, 2011; Masley et al., 2012‬‏רוב‏המחקרים‏בדקו‏‬ ‫טיפולים‏פרטניים‏( ;‪Bamelis et al., 2012; Bamelis et al., 2014; Bernstein et al., 2012‬‬ ‫‪Giesen-Bloo et al., 2006; Nadort et al., 2009; Spinhoven et al., 2007; van den Broek et‬‬ ‫‪al., 2011‬‏)‏ואחרים‏תעדו‏תוצאות‏מרשימות‏לטיפולים‏קבוצתיים‏( & ‪Farrell et al., 2009; Gude‬‬ ‫ד‬ ‫‪Hoffart, 2008; Hoffart Lunding & Hoffart, 2014; Koepke & Denissen, 2012; Renner‬‬ ‫‪ .)et al., 2013; Skewes et al., 2014; Vreeswijk et al., 2014‬‏‬ ‫חלק‏מהמחקרים‏השוו‏את‏יעילות‏הטיפול‏של‏‪ST‬‏בה"א‏לגישות‏אחרות‏לדוגמא‪,‬‏טיפול‏ממוקד‏‬ ‫העברה‏מהשדה‏הפסיכודינמי‏(‪)Giesen-Bloo et al., 2006‬‏או‏טיפול‏ממוקד‏לקוח‏מהשדה‏ההומניסטי‏‬ ‫(‪.)Bamelis et al., 2014‬‏במחקרים‏אלו‏נמצאה‏עדיפות‏ל‪ST-‬‏שהתבטאה‏בשיעורי‏החלמה‏גבוהים‏‬ ‫יותר‏ושיעורי‏נשירה‏מטיפול‏נמוכים‏יותר‪.‬‏‏‬ ‫סכמה תרפיה להפרעת אישיות הימנעותית‪.‬‏ארנץ‏(‪)0200‬‏פיתח‏פרוטוקול‏‪ST‬‏לטיפול‏בה"א‏‬ ‫מאשכול‏‪C‬‏(הימנעותית‪,‬‏תלותית‪,‬‏ואובססיבית‪-‬קומפולסיבית)‪,‬‏הכולל‏המלצות‏ייחודיות‏לטיפול‏ב‪.APD-‬‏‬ ‫לדבריו‏נדרש‏להתמקד‏בהערכה‏העצמית‏הנמוכה‪,‬‏תחושת‏הנחיתות‏וחוסר‏התואמות‏כמו‏גם‏בהתנהגויות‏‬ ‫ההימנעות‏עצמן‪.‬‏מחקרים‏שעשו‏שימוש‏בשאלון‏מודים‏(‪,)SMI; SMI-2‬‏מצאו‏שמטופלים‏עם‏‪APD‬‏‬ ‫אופיינו‏במודים‏של‪:‬‏הילד‏הנטוש‪/‬שעבר‏התעללות‪,‬‏הילד‏הבודד‪,‬‏הילד‏הכועס‪,‬‏הילד‏הבלתי‏ממושמע‪,‬‏‬ ‫המגן‏הכנוע‪-‬מרצה‪,‬‏המגן‏המנותק‪,‬‏המרגיע‏העצמי‏המנותק‪,‬‏המגן‏הנמנע‪,‬‏המגן‏המפצה‏מסוג‏חשדן‏‬ ‫והשתלטן‪,‬‏ההורה‏המעניש‏וההורה‏הדרשן‏(‪.)Bamelis et al., 2011; Lobbestael et al., 2008‬‏‏‬ ‫העבודה‏הנוכחית‏מתבססת‏על‏הפרוטוקול‏שפיתח‏ארנץ‏(‪)0200‬‏ל‪,APD-‬‏כדי‏לחקור‏תהליכי‏‬ ‫שינוי‏המתרחשים‏במהלך‏הטיפול‏ומתמקדת‏בשלושה‏תחומים‏מחקריים‪.‬‏מחקר‏‪0‬‏עסק‏בשאלה‏האם‏‬ ‫‪APD‬‏מאופיינת‏ביציבות‏או‏תנודתיות‪.‬‏לשם‏כך‪,‬‏נבדקו‏מדדים‏של‏שכיחות‪,‬‏עוצמה‏ותנודתיות‏במודים‏‬ ‫של‏המטופלים‏במהלך‏טיפול‏‪;ST‬‏מחקר‏‪0‬‏עסק‏בשאלה‏כיצד‏ההתערבויות‏של‏המטפלים‏ב‪ST-‬‏משפיעות‏‬ ‫ברמה‏המיידית‏על‏מטופלי‏‪.APD‬‏לשם‏כך‪,‬‏נבדקו‏הקשרים‏בין‏ההתערבויות‏במקטע‏אחד‏להשתנות‏‬ ‫המודים‏במקטע‏הבא;‏מחקר‏‪5‬‏עסק‏בשאלה‏של‏השונות‏בין‏מטופלי‏‪APD‬‏מבחינת‏מאפייניהם‏במהלך‏‬ ‫הטיפולים‪.‬‏לשם‏כך‪,‬‏אותרו‏ונותחו‏שלושה‏מודלים‏דינמיים‏אדיוגרפיים‏מובחנים‏של‏מטופלים‪.‬‏‬ ‫שיטה‬ ‫הנתונים‏עליהם‏מבוססים‏שלושת‏המחקרים‏המרכיבים‏את‏הדיסרטציה‏נאספו‏מ‪09-‬‏מטופלים‏‬ ‫שאובחנו‏ב‪,APD-‬‏וטופלו‏ב‪ST-‬‏על‪-‬ידי‏מטפלים‏שונים‪.‬‏בממוצע‪,‬‏המטופלים‏קיבלו‏‪40.5‬‏מפגשים‏‬ ‫טיפוליים‏(טווח‏‪.)4-57‬‏ארבעה‏(‪)06.6%‬‏מטופלים‏נשרו‏(לאחר‏פגישה‏‪,4‬‏‪,02‬‏‪,02‬‏ו‪.)52-‬‏כל‏המפגשים‏‬ ‫הוקלטו‏בקלטות‏שמע‏(‪.)N=439‬‏מתוכם‏‪62‬‏קלטות‏נדגמו‏באופן‏אקראי‪,‬‏‪02‬‏מכל‏שלב‏בטיפול‪:‬‏שלב‏‪0‬‏‬ ‫(התחלה‪,‬‏מפגשים‏‪,)0-02‬‏שלב‏‪0‬‏(אמצע‪,‬‏מפגשים‏‪,)00-52‬‏ושלב‏‪5‬‏(סיום‪,‬‏מפגשים‏‪-50‬סוף)‪.‬‏קלטות‏‬ ‫אלו‏קודדו‏מקטע‏אחר‏מקטע‪,‬‏כאשר‏כל‏מקטע‏כלל‏‪9‬‏דקות‏(‪.)N=645‬‏‬ ‫הקלטות‏קודדו‏פעמיים‏–‏ראשית‏לקידוד‏המודים‏של‏המטופל‏( ‪CMRS – Client's modes‬‬ ‫‪)rating scale‬‏‏ולאחר‏מכן‏לקידוד‏התערבויות‏המטפל‏( ‪STIRS – Schema therapist's‬‬ ‫‪.)interventions rating scale‬‏סולמות‏אלה‏פותחו‏על‪-‬ידי‏מיטלמן‪-‬קירשנפלד‏(‪)0200‬‏ונמצאו‏כבעלי‏‬ ‫מהימנות‏בין‏שופטים‏מתאימה‏עד‏טובה‪.‬‏‏‬ ‫מחקר‏‪0‬‏עשה‏שימוש‏בקידודי‏המודים‏של‏המטופלים‏כדי‏להעריך‏את‏השכיחות‏והעוצמה‏של‏‬ ‫המודים‪.‬‏כמו‪-‬כן‪,‬‏באמצעות‏ניתוחי‏‪)MSSD) Mean square successive difference‬‏הוערכה‏‬ ‫התנודתיות‏של‏המודים‏בקרב‏מטופלי‏המחקר‪.‬‏מחקר‏‪0‬‏עשה‏שימוש‏בקידודי‏המודים‏של‏המטופלים‏‬ ‫ה‬ ‫ובקידודי‏ההתערבויות‏של‏המטפלים‏ובאמצעות‏ניתוחי ‪)MLM ) Multilevel regression models‬‏‬ ‫נבחן‏הקשר‏בין‏התערבויות‏המטפלים‏במקטע‏אחד‏לשינויים‏שחלו‏במודים‏של‏המטופלים‏במקטע‏הבא‪.‬‏‬ ‫מחקר‏‪5‬‏עשה‏שוב‏שימוש‏בקידודי‏המודים‏של‏המטופל‪,‬‏ובאמצעות‏ניתוחי‏ ‪Time series panel‬‏‬ ‫‪analyses‬‏ )‪(TSPA‬‏אופיינו‏מודלים‏אדיוגרפים‏של‏מפת‏השתנות‏מודים‏עבור‏מטופלים‏נבחרים‪.‬‏‏‬ ‫תוצאות‬ ‫מחקר‏‪0‬‏מצא‏שמטופלים‏עם‏‪APD‬‏מאופיינים‏בחוסר‏יציבות‏יחסית‪.‬‏מוד‏המגן‏הנמנע‪/‬מנותק‏נכח‏‬ ‫ב‪74%-‬‏ממקטעי‏הטיפול‏ונמצא‏כבעל‏העוצמה‏והתנודתיות‏הרבות‏ביותר‪.‬‏מוד‏הילד‏הפגיע‏נכח‏ב‪92%-‬‏‬ ‫ממקטעי‏הטיפול‏ונמצא‏ברמה‏השנייה‏הגבוהה‏ביותר‏מבחינת‏עוצמה‏ותנודתיות‪.‬‏מוד‏ההורה‏‬ ‫הדיספונקציונלי‏נכח‏ב‪42%-‬‏ממקטעי‏הטיפול‏ונמצא‏ברמה‏השלישית‏הגבוהה‏ביותר‏מבחינת‏עוצמה‏‬ ‫ותנודתיות‪.‬‏מוד‏פיצוי‪-‬היתר‪,‬‏מוד‏הכנוע‏והמרצה‪,‬‏ומוד‏הבוגר‏הבריא‏נכחו‏כבשליש‏ממקטעי‏הטיפול‪,‬‏אך‏‬ ‫מוד‏הבוגר‏הבריא‏היה‏באופן‏מובהק‏עם‏רמת‏התנודתיות‏הנמוכה‏ביותר‏ביחס‏לכל‏שאר‏המודים‪,‬‏דבר‏‬ ‫שהעיד‏על‏היותו‏היציב‏מבין‏כולם‪.‬‏‏‬ ‫מחקר‏‪0‬‏מצא‏שיישום‏טוב‏של‏עמדת‏המטפל‏במקטע‏אחד‏היה‏קשור‏בירידה‏במוד‏המגן‏‬ ‫נמנע‪/‬מנותק‏ובעלייה‏במוד‏הבוגר‏הבריא‏במקטע‏הבא;‏יישום‏טוב‏של‏התערבויות‏חווייתיות‏היה‏קשור‏‬ ‫בירידה‏במוד‏פיצוי‪-‬היתר‏במקטע‏הבא;‏גם‏יישום‏טוב‏של‏התערבויות‏התייחסותיות‏היה‏קשור‏בירידה‏‬ ‫במוד‏פיצוי‪-‬היתר‏במקטע‏הבא;‏יישום‏טוב‏של‏התערבויות‏קוגניטיביות‏היה‏קשור‏בעלייה‏במוד‏הילד‏‬ ‫הפגיע‏כמו‏גם‏בעלייה‏במוד‏ההורה‏הדיספונקציונלי‏במקטע‏הבא;‏לסיום‪,‬‏יישום‏טוב‏של‏התערבויות‏‬ ‫התנהגותיות‏היה‏קשור‏בירידה‏במוד‏ההורה‏הדיספונקציונלי‏במקטע‏הבא‪.‬‏‏‬ ‫מחקר‏‪5‬‏תיאר‏שלושה‏מודלים‏אדיוגרפים‏מובחנים‏של‏רשתות‏קשרים‏והשתנות‏של‏מודים‏במהלך‏‬ ‫טיפולי‏‪.ST‬‏למודל‏הראשון‏ניתן‏השם‏המטופל‏הנוקשה‪.‬‏המטופל‏עם‏מודל‏זה‏אופיין‏בהתחזקות‏לאורך‏‬ ‫הטיפול‏של‏מוד‏ההורה‏הדיספונקציונלי‪,‬‏לצד‏התחזקות‏לאורך‏הטיפול‏של‏מוד‏הילד‏הפגיע‪.‬‏מוד‏ההורה‏‬ ‫הדיספונקציונלי‏היה‏קשור‏לשימוש‏בכל‏שלושת‏דפוסים‏ההתמודדות‏הבלתי‪-‬מסתגלים‪,‬‏אך‏בעיקר‏‬ ‫בשימוש‏מאסיבי‏בדפוס‏של‏הימנעות‏וניתוק‪.‬‏המודל‏של‏מטופל‏זה‏היה‏מאופיין‏גם‏בנוכחות‏מועטה‏באופן‏‬ ‫יחסי‏של‏הבוגר‏הבריא‪,‬‏שלא‏הצליחה‏לגבור‏על‏ההשפעה‏של‏מוד‏ההורה‏הדיספונקציונלי‪.‬‏‏‬ ‫למודל‏השני‏ניתן‏השם‏המטופל‏המבולבל‪.‬‏המטופל‏אופיין‏במעברים‏בולטים‏בין‏מוד‏ההורה‏‬ ‫הדיספונקציונלי‏לבין‏מוד‏הבוגר‏הבריא‪.‬‏מעברים‏אלה‏תרמו‏למידה‏רבה‏של‏חוסר‏יציבות‪.‬‏בנוסף‪,‬‏‏‬ ‫המטופל‏אופיין‏במודל‏של‏רשת‏קשרים‏מאד‏סבוכה‏בין‏המודים‏אשר‏חיזקו‏וסתרו‏זה‏את‏זה‪.‬‏הסבך‏בלט‏‬ ‫בקשרים‏בין‏שלושת‏דפוסי‏ההתמודדות‏לבין‏עצמם‏ובינם‏לבין‏מודים‏אחרים‪,‬‏אשר‏רק‏העצים‏את‏העומס‏‬ ‫והבלבול‏אצל‏מטופל‏זה‪.‬‏במיוחד‪,‬‏בלט‏שימוש‏במוד‏המגן‏הנמנע‪/‬מנותק‏אשר‏מנע‏ממנו‏להיפתח‏לטיפול‪.‬‏‬ ‫למודל‏השלישי‏ניתן‏השם‏המטופל‏הפתוח‪.‬‏המטופל‏אופיין‏בנוכחות‏בולטת‏ויציבה‏של‏מוד‏הבוגר‏‬ ‫הבריא‪,‬‏נוכחות‏בולטת‏למדי‏של‏מוד‏ההורה‏הדיספונקציונלי‪,‬‏כמו‏גם‏בולטות‏של‏מוד‏הילד‏הפגיע‪,‬‏‬ ‫ושימוש‏תדיר‏(אם‏כי‏לא‏מוקצן)‏במוד‏המגן‏הנמנע‪/‬מנותק‪.‬‏רשת‏הקשרים‏בין‏המודים‏אצל‏מטופל‏זה‏‬ ‫היתה‏באופן‏יחסי‏דלה‏ביחס‏לשני‏המודלים‏הקודמים‪.‬‏מוד‏הבוגר‏הבריא‏היה‏נוכח‏במרבית‏מקטעי‏‬ ‫הטיפול‏והיה‏קשור‏בירידה‏במוד‏של‏פיצוי‪-‬יתר‪,‬‏שגם‏כך‏נוכחותו‏היתה‏נמוכה‪.‬‏מכלול‏נתונים‏אלה‏‬ ‫ו‬ ‫שהעידו‏על‏נוכחות‏(אם‏כי‏לא‏מוקצנת)‏של‏פגיעות‪,‬‏ביקורתיות‏והענשה‏עצמית‪,‬‏הימנעות‏וניתוק‪,‬‏לצד‏‬ ‫נוכחות‏בולטת‏יותר‏של‏עמדה‏שקולה‏וחמלה‏עצמית‏הובילו‏לאפיון‏מודל‏זה‪,‬‏כמטופל‏הפתוח‏לטיפול‪.‬‏‬ ‫דיון‏‬ ‫התרומה למחקר והטיפול בסכמה תרפיה‪.‬‏המחקרים‏בעבודה‏זו‏עוסקים‏לראשונה‏בתהליכים‏‬ ‫המתרחשים‏במהלך‏פגישות‏טיפוליות‏של‏‪.ST‬‏המחקרים‏נעים‏מניתוח‏ברמה‏הקבוצתית‏(מחקר‏‪0‬‏ו‪)0-‬‏‬ ‫לניתוח‏ברמה‏פרטנית‏(מחקר‏‪.)5‬‏‏‬ ‫הממצאים‏במחקר‏‪0‬‏מסייעים‏בהבנה‏מדוע‏מטופלי‏‪APD‬‏הם‏קשים‏לטיפול‪.‬‏מוד‏ההורה‏‬ ‫הדיספונקצינלי‏שבאופן‏יחסי‏מאופיין‏בתדירות‏ועוצמה‏גבוהות‏משקף‏את‏חומרת‏הפסיכופתולוגיה‏של‏‬ ‫מטופלים‏אלה‪,‬‏ובעיקר‏את‏נטייתם‏לעמדה‏מחמירה‏המאופיינת‏בביקורת‏והענשה‏עצמיים‪.‬‏מוד‏המגן‏‬ ‫הנמנע‪/‬מנותק‏שמאופיין‏בתדירות‏ועוצמות‏גבוהות‏מאד‏חוסם‏את‏הגישה‏לרגשות‏ולצרכי‏הליבה‏של‏‬ ‫המטופלים‪.‬‏התנודתיות‏הרבה‏למדי‏של‏מוד‏הילד‏הפגיע‏הופכת‏מוד‏זה‏לחמקמק‪.‬‏ממצא‏זה‏תורם‏קושי‏‬ ‫נוסף‏למטפלים‏לספק‏חוויה‏מתקנת‏במהלך‏הטיפול‪,‬‏מאחר‏ורק‏במוד‏זה‏קיימת‏גישה‏ישירה‏לצרכי‏הליבה‏‬ ‫הרגשיים‏של‏המטופלים‪.‬‏מצד‏שני‪,‬‏במחקר‏‪0‬‏יש‏סימנים‏מעודדים‏לניהול‏טיפול‏‪ST‬‏עם‏מטופלי‏‪.APD‬‏‬ ‫למרות‏התנודתיות‏של‏מוד‏הילד‏הפגיע‪,‬‏התדירות‏והעוצמה‏הבולטים‏של‏מוד‏זה‏מספקים‏הזדמנויות‏למגע‏‬ ‫ישיר‏עם‏הרגשות‏וצרכי‏הליבה‏של‏המטופלים‪.‬‏כמו‏כן‪,‬‏התנודתיות‏הרבה‏מאד‏של‏מוד‏המגן‏‬ ‫הנמנע‪/‬מנותק‏מרמזת‏על‏סדקים‏במוד‏זה‏דרכם‏יכולה‏להתרחש‏חוויה‏מתקנת‏בטיפול‪.‬‏יתרה‏מזאת‪,‬‏מוד‏‬ ‫ההורה‏הדיספונקציונלי‏לא‏היה‏נוכח‏כלל‏‏בכ‪42%-‬‏ממקטעי‏הטיפול;‏ומוד‏הבוגר‏הבריא‏נמצא‏כמוד‏‬ ‫היציב‏ביותר‏(אם‏כי‏נכח‏רק‏בכשליש‏מהמקטעים)‪.‬‏נתונים‏אלה‏יחד‏מצביעים‏על‏הזדמנויות‏לא‏מבוטלות‏‬ ‫לתרגל‏עם‏מטופלים‏אלה‏חמלה‏עצמית‪,‬‏ויסות‏עצמי‏והתמודדות‏יעילה‏יותר‏עם‏המציאות‪.‬‏‏‏‬ ‫הממצאים‏במחקר‏‪0‬‏מספקים‏מידע‏על‏הקשרים‏בין‏התערבויות‏המטפלים‏במקטע‏מסוים‏‬ ‫והשינויים‏המתרחשים‏במודים‏של‏המטופלים‏במקטע‏הבא‏בתוך‏המפגש‏הטיפולי‪.‬‏הממצאים‏מצביעים‏על‏‬ ‫כך‏שעמדת‏המטפל‏המאופיינת‏בחמלה‪,‬‏חום‪,‬‏כנות‪,‬‏אכפתיות‏ואיזון‏בין‏גמישות‏לנחישות‏עשויה‏להפחית‏‬ ‫את‏ההימנעות‏והניתוק‏של‏המטופלים‪.‬‏יתרה‏מזאת‪,‬‏עמדה‏זו‏של‏המטפל‏נראה‏שהיא‏מטפחת‏את‏החמלה‏‬ ‫העצמית‏של‏המטופל‏ואת‏יכולתו‏להגיב‏לאירועים‏מעמדה‏שקולה‏ובוגרת‪.‬‏כמו‏כן‪,‬‏במצבים‏בהם‏‬ ‫המטופלים‏הופכים‏כועסים‪,‬‏עוינים‪,‬‏ושתלטניים‏שימוש‏בהתערבויות‏חווייתיות‏נמצא‏כמסייע‏למטופלים‏‬ ‫להפחית‏את‏העמדה‏האגרסיבית‏שלהם‏ולהגיע‏למגע‏עם‏צרכיהם‏הרגשיים‪.‬‏באופן‏דומה‪,‬‏כאשר‏מטופלים‏‬ ‫מגיבים‏באופן‏אגרסיבי‏בכאן‪-‬ועכשיו‏לקרעים‏בברית‏הטיפולית‪,‬‏התערבויות‏התייחסותיות‏מצד‏המטפל‏‬ ‫העושות‏שימוש‏בלקיחת‏אחריות‪,‬‏חשיפה‏עצמית‏מותאמת‏ושימת‏דגש‏על‏שמירת‏הדדיות‏בקשר‏עשויות‏‬ ‫להיות‏היעילות‏ביותר‏לפתרון‏הקונפליקט‪.‬‏בנוסף‪,‬‏על‏בסיס‏הממצאים‪,‬‏חשוב‏שהמטפלים‏יהיו‏ערים‏‬ ‫להשפעה‏הפרדוקסלית‏שיש‏להתערבויות‏קוגניטיביות‪.‬‏מצד‏אחד‪,‬‏נראה‏שהתערבויות‏אלה‏מאפשרות‏‬ ‫גישה‏רבה‏יותר‏לצרכי‏הליבה‏הרגשיים‏של‏המטופלים‏ומצד‏שני‏הן‏מגבירות‏את‏הנטייה‏של‏המטופלים‏‬ ‫להגיב‏כלפי‏עצמם‏בחומרה‪.‬‏לבסוף‪,‬‏עלה‏מהממצאים‏שהתערבויות‏התנהגותיות‏עשויות‏להיות‏יעילות‏‬ ‫בהפחתת‏הנטייה‏של‏המטופלים‏להגיב‏כלפי‏עצמם‏בחומרה‪.‬‏‏‬ ‫‏‬ ‫ז‬ ‫הממצאים‏במחקר‏‪5‬‏הצביעו‏על‏הטרוגניות‏במודלים‏האידיוגרפים‏של‏רשת‏הקשרים‏בין‏המודים‪.‬‏‬ ‫כך‏נוצר‏פרופיל‏השתנות‏ייחודי‏למטופל‪,‬‏המצריך‏בניית‏ציר‏התערבות‏מותאם‪.‬‏המודל‏הראשון‏שכונה‏‬ ‫כמטופל‏הנוקשה‏אופיין‏בנטייה‏חזקה‏ומתגברת‏להתייחס‏לעצמו‏בחומרה‪,‬‏לצד‏פגיעות‏שגם‏היא‏התחזקה‏‬ ‫לאורך‏הטפול‪.‬‏הנטייה‏להתייחסות‏עצמית‏מחמירה‪,‬‏היתה‏קשורה‏לשימוש‏מאסיבי‏בדפוס‏של‏הימנעות‏‬ ‫וניתוק‪.‬‏בנוסף‪,‬‏הנטייה‏לחמלה‏עצמית‏והתמודדות‏שקולה‏היתה‏חלשה‏למדי‏ולא‏הצליחה‏לגבור‏על‏‬ ‫ההתייחסות‏העצמית‏המחמירה‪.‬‏נראה‏היה‏שמטופל‏זה‏היה‏מרוויח‏מהתערבויות‏המקדמות‏גמישות‪.‬‏‬ ‫בהתבסס‏על‏ממצאים‏ממחקר‏‪0‬‏ניתן‏היה‏להסיק‏ששימוש‏יעיל‏בעמדת‏המטפל‪,‬‏הנוטה‏להפחית‏אצל‏‬ ‫מטופלים‏דפוסי‏הימנעות‏וניתוק‏ולהגביר‏חמלה‏עצמית‪,‬‏היה‏יכול‏להיות‏לעזר‏למטופל‏זה‪.‬‏בנוסף‪,‬‏מומלץ‏‬ ‫היה‏להגביר‏התערבויות‏התנהגותיות‪,‬‏שנמצאו‏כמפחיתות‏התייחסות‏עצמית‏מחמירה‏אצל‏מטופלים‪.‬‏‏‬ ‫המודל‏השני‏שכונה‏כמטופל‏המבולבל‪,‬‏אופיין‏במעברים‏ניכרים‏בין‏התייחסות‏עצמית‏מחמירה‏‬ ‫לעמדה‏שקולה‏וחמלה‏עצמית‪,‬‏אשר‏תרמו‏לאי‏יציבות‏של‏המטופל‪.‬‏כמו‏כן‪,‬‏המטופל‏אופיין‏במודל‏קשרים‏‬ ‫מסועף‏בין‏המודים‪,‬‏ושימוש‏מרובה‏במגוון‏דפוסי‏התמודדות‏בלתי‏מסתגלים‏שתרמו‏גם‏הם‏לחוויית‏‬ ‫הבלבול‪.‬‏באופן‏ספציפי‪,‬‏המטופל‏עשה‏שימוש‏מוגבר‏בהימנעות‏וניתוק‏אשר‏גרם‏לו‏להיות‏עוד‏פחות‏‬ ‫נגיש‏בטיפול‪.‬‏מודל‏זה‏הוביל‏למסקנה‏שמטופל‏זה‏היה‏מרוויח‏מהתערבויות‏המקדמות‏יציבות‪.‬‏מומלץ‏היה‏‬ ‫שהמטפל‏יעשה‏שימוש‏רב‏יותר‏בטכניקות‏קשיבות‏ואימון‏להגברת‏סבילות‏למצוקה‏(להרחבה‏ראה‏עמ'‏‬ ‫‪507‬‏אצל‏יאנג‏ושות'‪,‬‏‪,)0225‬‏כמו‏גם‏יגביר‏שימוש‏בהתערבויות‏המבוססות‏על‏עמדת‏המטפל‏(בהתבסס‏‬ ‫על‏ממצאי‏מחקר‏‪)0‬‏אשר‏עשויות‏היו‏להפחית‏את‏דפוסי‏ההימנעות‏של‏המטופל‪.‬‏‬ ‫המודל‏השלישי‏שכונה‏כמטופל‏הפתוח‪,‬‏אופיין‏בנוכחות‏בולטת‏ויציבה‏של‏עמדה‏שקולה‏וחמלה‏‬ ‫עצמית‪,‬‏לצד‏נוכחות‏בולטת‏למדי‏של‏התייחסות‏עצמית‏מחמירה‪,‬‏כמו‏גם‏בולטות‏של‏מגע‏עם‏פגיעות‏‬ ‫ושימוש‏תדיר‏(אם‏כי‏לא‏מוקצן)‏בהימנעות‏וניתוק‪.‬‏בנוסף‪,‬‏רשת‏הקשרים‏בין‏המודים‏עבור‏מטופל‏זה‏‬ ‫היתה‏דלה‏ביחס‏לשני‏המטופלים‏האחרים‪.‬‏מודל‏זה‏הוביל‏למסקנה‏שמטופל‏זה‏היה‏נגיש‏לעבודה‏‬ ‫טיפולית‏והיה‏פתוח‏יותר‏מהאחרים‏ליהנות‏ממגוון‏ההתערבויות‏שיש‏ל‪ST -‬‏להציע‪.‬‏יחד‏עם‏זאת‪,‬‏נראה‏‬ ‫שמטופל‏זה‏היה‏מרוויח‏משימוש‏נוסף‏בהתערבויות‏התנהגותיות‏(בהתבסס‏על‏ממצאי‏מחקר‏‪)0‬‏אשר‏‬ ‫יכלו‏לסייע‏במיתון‏הנטייה‏להתייחסות‏עצמית‏מחמירה‪.‬‏‏‬ ‫מחקר‏‪5‬‏הדגים‏את‏היתרונות‏הגלומים‏בחקר‏מודלים‏אידיוגרפים‏המתייחסים‏לתהליכים‏‬ ‫המתרחשים‏במטופל‏הבודד‪.‬‏אפיון‏רשת‏הקשרים‏בין‏המודים‏ותהליכי‏השתנותם‏בטיפול‏ברמת‏המטופל‏‬ ‫היחיד‪,‬‏אפשרו‏לזהות‏מוקד‏טיפולי‏ו"לתפור"‏הצעה‏להתערבויות‏מותאמות‏לקוח‪,‬‏שעשויות‏היו‏לקדם‏את‏‬ ‫המטופל‏הספציפי‪.‬‏‏‬ ‫לסיכום‪,‬‏שלושת‏המחקרים‏המרכיבים‏דיסרטציה‏זו‏חדשנים‏בהיותם‏הראשונים‏לחקור‏תהליכים‏‬ ‫המתרחשים‏בתוך‏מפגש‏טיפולי‏ב‪,ST-‬‏וכל‏אחד‏מהם‏הוביל‏למסקנות‏ייחודיות‏ויישומיות‏הרלוונטיות‏‬ ‫לגישה‏זו‪.‬‏מחקר‏‪0‬‏תאר‏את‏מאפייני‏המודים‏של‏מטופלי‏‪APD‬‏במהלך‏מפגשי‏‪,ST‬‏ודן‏בהשלכותיהם‏‬ ‫האפשריות‏על‏ניהול‏הטיפול‪.‬‏מחקר‏‪0‬‏חשף‏את‏הקשרים‏בין‏התערבויות‏המטפל‏להשתנות‏המודים‏של‏‬ ‫המטופלים‏ממקטע‏אחד‏לשני‏בטיפול‪.‬‏לראשונה‏דווחו‏השפעותיהן‏המיידיות‏של‏התערבויות‏ספציפיות‏ב‪-‬‬ ‫‪.ST‬‏לבסוף‪,‬‏מחקר‏‪5‬‏הדגים‏את‏התועלת‏היישומית‏בחקר‏מודלים‏אדיוגרפים‏של‏השתנות‏המודים‏עבור‏‬ ‫ח‬ ‫כל‏מטופל‏בנפרד‏כדרך‏לזהות‏מוקד‏טיפולי‏ו"לתפור"‏הצעה‏להתערבויות‏טיפוליות‏מותאמות‏לקוח‪.‬‏‏‏‏‬ ‫התרומה למחקר והטיפול בהפרעת אישיות הימנעותית‪.‬‏עבודה‏זו‏עוסקת‏ב‪,APD-‬‏ומחדשת‏‬ ‫בכמה‏תחומים‏לגבי‏ה"א‏שכיחה‏זו‏אשר‏זכתה‏לתשומת‏לב‏מחקרית‏מועטה‏ ;‪(Sanislow et al., 2012‬‬ ‫‪.)Zimmerman et al., 2005‬‏‏‬ ‫מחקר‏‪0‬‏מצטרף‏לקומץ‏מחקרים‏עדכניים‏(למשל‪Koenigsberg et al., 2014; Shafran et al., -‬‬ ‫‪)2016; Snir et al., 2015‬‏המצביעים‏על‏כך‏ש‪APD-‬‏מאופיינת‏באי‪-‬יציבות‏יחסית‪.‬‏בניגוד‏ל‪DSM-5 -‬‬ ‫‏)‪(APA, 2013‬‏ומהדורותיו‏הקודמות‏שלא‏ציינו‏קריטריון‏של‏אי‪-‬יציבות‏עבור‏ה"א‏הימנעותית‪,‬‏‬ ‫המחקרים‏המדווחים‏מצאו‏שמטופלי‏‪APD‬‏מאופיינים‏באי‏יציבות‏מובהקת‏רבה‏יותר‏ביחס‏לקבוצת‏‬ ‫ביקורת‏של‏נבדקים‏בריאים‪,‬‏ובאי‏יציבות‏נמוכה‏יותר‏ביחס‏למטופלי‏‪.BPD‬‏מחקר‏‪0‬‏בדיסרטציה‏מצא‏‬ ‫ששלושת‏המודים‏הבולטים‏ביותר‏במטופלי‏‪APD‬‏(המגן‏נמנע‪/‬מנותק‪,‬‏הילד‏הפגיע‪,‬‏וההורה‏‬ ‫הדיספונקציונלי)‏אכן‏אופיינו‏באי‏יציבות‏ניכרת‪.‬‏‏‬ ‫מאידך‪,‬‏ממצאים‏נוספים‏ממחקר‪0‬‏מספקים‏תמיכה‏למרבית‏הקריטריונים‏הפנומנולוגים‏של‏הפרעה‏‬ ‫זו‏ב‪-‬‏‪.DSM-5‬‏מטופלים‏במחקר‏זה‏נמצאו‏במוד‏הנמנע‪/‬מנותק‏בכ‪-‬‏‪5/4‬‏ממקטעי‏הטיפול‪,‬‏כפי‏שהיה‏צפוי‏‬ ‫בהתאם‏לאבחנתם‪.‬‏יתרה‏מכך‪,‬‏מוד‏הילד‏הפגיע‏נכח‏ביותר‏ממחצית‏המקטעים‏בטיפול‪,‬‏ממצא‏התומך‏‬ ‫בתיאור‏של‏ה‪DSM-‬‏לגבי‏"רגישות‏יתר‏להערכה‏שלילית‏שמתחילה‏בבגרות‏המוקדמת‏ונוכחת‏בקשרים‏‬ ‫שונים‏(עמ'‏‪)675‬‏[‪]...‬‏לעיתים‏קרובות‏מקורה‏בינקות‏או‏בילדות‏המאופיינת‏בביישנות‏(עמ'‏‪.")647‬‏מוד‏‬ ‫ההורה‏הדיספונקציונלי‏נכח‏ביותר‏משליש‏המקטעים‪,‬‏ממצא‏התומך‏בקריטריון‏‪6‬‏(עמ'‏‪)675‬‏המציין‏‬ ‫שהמאובחנים‏ב‪APD-‬‏נוטים‏לראות‏עצמם‏כלא‪-‬מתאימים‏חברתית‪,‬‏מעוררים‏דחייה‏ברמה‏האישית‪,‬‏‬ ‫ונחותים‏ביחס‏לאחרים‪.‬‏‬ ‫מחקר‏‪0‬‏הצביע‏על‏התערבויות‏טיפוליות‏יעילות‏עם‏מטופלי‏‪.APD‬‏נמצא‏שעמדה‏טיפולית‏‬ ‫חומלת‪,‬‏חמה‪,‬‏כנה‪,‬‏אכפתית‏המאזנת‏בין‏גמישות‏לנחישות‪,‬‏סייעה‏בהפחתת‏התנהגויות‏הימנעות‏וניתוק‏‬ ‫של‏המטופלים‏וקידמה‏אצלם‏עמדה‏שקולה‏וחמלה‏עצמית‪.‬‏כמו‏כן‪,‬‏נמצא‏שכשמטופלי‏‪APD‬‏הופכים‏‬ ‫כועסים‪,‬‏עוינים‪,‬‏שתלטניים‏או‏דרשנים‏כלפי‏אחרים‪,‬‏התערבויות‏חווייתיות‏סייעו‏להם‏להיות‏במגע‏עם‏‬ ‫צרכי‏הליבה‏והפחיתו‏את‏האגרסיביות‏שלהם‪.‬‏באופן‏דומה‪,‬‏כשמטופלים‏אלה‏הגיבו‏באגרסיביות‏לקרעים‏‬ ‫בברית‏הטיפולית‪,‬‏התערבויות‏התייחסותיות‏המבוססות‏על‏הדדיות‏סייעו‏בהפחתת‏עמדתם‏האגרסיבית‪.‬‏‬ ‫לבסוף‪,‬‏כשהמטופלים‏היו‏בעמדה‏מחמירה‏כלפי‏עצמם‪,‬‏התערבויות‏התנהגותיות‏סייעו‏בהפחתת‏עמדה‏זו‪.‬‏‬ ‫מחקר‏‪5‬‏הדגים‏הטרוגניות‏במאפיינים‏של‏מטופלי‏‪.APD‬‏במחקר‏זה‏הוצגו‏שלושה‏מודלים‏שכונו‏‬ ‫המטופל‏הנוקשה‪,‬‏המטופל‏המבולבל‪,‬‏והמטופל‏הפתוח‪.‬‏שונות‏זו‏בטיפוסים‏של‏מטופלי‏‪APD‬‏מהווה‏אתגר‏‬ ‫טיפולי‏המצריך‏"לתפור"‏התערבויות‏מותאמות‏לקוח‪.‬‏רעיון‏זו‏עומד‏בקו‏אחד‏עם‏התנועה‏לעבר‏רפואה‏‬ ‫אישית‪,‬‏אשר‏ממליצה‏להתאים‏את‏הטיפול‪,‬‏התרופה‏והמינון‏ללקוח‏בהתאם‏למאפייניו‏( & ‪Hamburg‬‬ ‫‪.)Collins, 2010; Rosmalen et al., 2012‬‏‬ ‫תרומתן של השיטות הסטטיסטיות בדיסרטציה למחקר בפסיכותרפיה‪.‬‏דיסרטציה‏זו‏מצטרפת‏‬ ‫לזרם‏עדכני‏במחקר‏המתמקד‏בתהליכי‏השינוי‏המתרחשים‏במהלך‏הפסיכותרפיה‏( ;‪Greenberg, 2007‬‬ ‫‪)Gumz et al., 2014; Kazdin & Nock, 2003; Kazdin, 2009; Pascual-Leone et al., 2009‬‏‬ ‫ט‬ ‫ומה‏יעיל‏עבור‏המטופל‏הבודד‏(למשל‪,‬‏ ;‪Barlow & Nock, 2009; Boswell et al., 2014‬‬ ‫‪.)Rosmalen et al., 2012‬‏‬ ‫מחקר‏‪0‬‏עשה‏שימוש‏ב‪MSSD-‬‏כדי‏להעריך‏את‏היציבות‪/‬אי‪-‬יציבות‏בקרב‏מטופלי‏‪.APD‬‏‬ ‫‪MSSD‬‏הינו‏ניתוח‏סטטיסטי‏מומלץ‏להערכת‏תנודתיות‏בפסיכופתולוגיה‏( ‪Ebner-Priemer et al.,‬‬ ‫‪.)2009‬‏אכן‪,‬‏מספר‏מחקרים‏עשו‏שימוש‏ב‪MSSD-‬‏בחקר‏תנודתיות‏בהפרעות‏כגון‪,‬‏חרדה‏חברתית‪,‬‏‬ ‫דיכאון‪,‬‏הפרעה‏בי‪-‬פולרית‪,‬‏פסיכוזה‪,‬‏הפרעה‏גבולית‪.‬‏אולם‪,‬‏נראה‏שמחקר‏‪0‬‏הוא‏הראשון‏לעשות‏שימוש‏‬ ‫בשיטה‏זו‏להערכת‏תנודתיות‏במהלך‏פגישות‏טיפוליות‪,‬‏ובוודאי‏בקרב‏מטופלי‏‪.APD‬‏‏‬ ‫מחקר‏‪0‬‏עשה‏שימוש‏ב‪MLM-‬‏כדי‏לחקור‏את‏הקשרים‏בין‏התערבויות‏המטפלים‏לשינויים‏‬ ‫במודים‏של‏מטופלי‏‪APD‬‏במהלך‏מפגשי‏‪.ST‬‏‪Kahn & Schneider‬‏(‪)0205‬‏טענו‏ש‪MLM-‬‏הינה‏‬ ‫שיטת‏הניתוח‏המומלצת‏להערכת‏דפוסי‏שינוי‏בפסיכותרפיה‪,‬‏ואכן‏נעשה‏שימוש‏בשיטה‏זו‏בחקר‏גישות‏‬ ‫טיפול‏שונות‏ובהפרעות‏שונות‪.‬‏אולם‪,‬‏מחקר‏‪0‬‏עשה‏צעד‏נוסף‏והתמקד‏בניתוח‏מיקרו‪-‬אנליטי‏של‏‬ ‫שינויים‏המתרחשים‏ממקטע‏אחד‏לשני‏בתוך‏השעה‏הטיפולית‪.‬‏בכך‪,‬‏מחקר‏זה‏הוא‏חדשני‏הן‏בשדה‏ה‪-‬‬ ‫‪ST‬‏והן‏בחקר‏‪.APD‬‏‏‬ ‫מחקר‏‪5‬‏עשה‏שימוש‏ב‪TSPA-‬‏כדי‏לחקור‏מודלים‏אידיוגרפים‏של‏קשרים‏בין‏מודים‏והשתנותם‏‬ ‫לאורך‏הטיפול‪,‬‏עבור‏מטופלי‏‪APD‬‏ספציפיים‪.‬‏‪TSPA‬‏מאפשר‏בדיקת‏קשרים‏בו‪-‬זמניים‏ועוקבים‏בין‏‬ ‫משתנים‏בתוך‏פגישות‏ובין‏פגישות‪,‬‏ולוקח‏בחשבון‏שונות‏בין‏נבדקים‪.‬‏יש‏לציין‪,‬‏שרק‏קומץ‏מחקרים‏‬ ‫עשה‏שימוש‏ב‪TSPA-‬‏כדי‏לחקור‏מסלולים‏של‏מנגנוני‏שינוי‏בפסיכותרפיה‪.‬‏עד‏כה‪,‬‏מחקרי‏‪TSPA‬‏‬ ‫התבססו‏על‏נתונים‏שנאספו‏משאלוני‏דיווח‏עצמי‪,‬‏או‏ממחקרי‏יומנים‏יומיים‪,‬‏או‏כאלו‏שנאספו‏ממפגש‏‬ ‫טיפולי‏אחד‏למשנהו‪.‬‏מחקר‏‪,5‬‏הוא‏הראשון‏המשתמש‏ב‪TSPA-‬‏כדי‏לחקור‏תהליכי‏שינוי‏המתרחשים‏‬ ‫בתוך‏פגישה‏טיפולית‪,‬‏על‏בסיס‏פערי‏זמן‏של‏‪9‬‏דקות‏ממקטע‏טיפולי‏אחד‏למשנהו‏והראשון‏שמתבסס‏על‏‬ ‫הערכות‏שופטים‏בלתי‏תלויים‏(ולא‏דיווח‏עצמי‏של‏נבדקים)‪.‬‏השימוש‏ב‪TSPA-‬‏איפשר‏לתאר‏‪5‬‏מודלים‏‬ ‫אידיוגרפים‏מובחנים‏של‏קשרים‏בין‏מודים‏בקרב‏מטופלי‏‪.APD‬‏מודלים‏מובחנים‏אלה‏הובילו‏להגדרת‏‬ ‫מוקד‏טיפולי‏ספציפי‏ו"תפירת"‏המלצות‏להתערבויות‏מותאמות‏לקוח‏)‪.(Rosmalen et al., 2012‬‏‏‬ ‫לסיכום‪,‬‏דיסרטציה‏זו‏מצטרפת‏לזרם‏מחקרי‏עכשווי‏העוסק‏בניתוח‏מיקרו‪-‬אנליטי‏של‏תהליכי‏‬ ‫שינוי‏בפסיכותרפיה‏באמצעות‏שימוש‏בשיטות‏מחקר‏חדשניות‏כגון‪,‬‏קידוד‏מקטעי‏טיפול‏באמצעות‏‬ ‫שופטים‏בלתי‪-‬תלויים‏ומגוון‏ניתוחים‏סטטיסטים‏(‪.)MLM, MSSD, TSPA‬‏‏‏‬ ‫מושג המודים ויעילותו בחקר פסיכופתולוגיה ופסיכותרפיה‪.‬‏מושג‏המודים‏שהוצג‏לראשונה‏‬ ‫ע"י‏יאנג‏ושות'‏(‪,)0225‬‏מציע‏דרך‏לתאר‏את‏האישיות‏על‏מאפייניה‏רבי‏הפנים‪.‬‏תיאוריות‏אישיות‏‬ ‫עדכניות‏טוענות‏שמאפייני‏האישיות‏הינם‏תלויי‏הקשר‏ומשתנים‏בהתאם‪.‬‏מכאן‪,‬‏שחלקי‏עצמי‏של‏‬ ‫האישיות‏הן‏בהגדרה‏מצביים‏)‪.(Dunlop, 2015; Fleeson, 2007; Mischel & Shoda, 2010‬‏מושג‏‬ ‫המודים‏מאפשר‏טקסונומיה‏מתאימה‏לתיאור‏מצבי‏עצמי‏אלה‏ויתרה‏מכך‪,‬‏פותח‏דרך‏למדוד‏אמפירית‏את‏‬ ‫מאפייניהם‪.‬‏לדוגמא‪,‬‏מחקר‏‪0‬‏הדגים‏דרך‏למדוד‏את‏התדירות‪,‬‏העוצמה‏והתנודתיות‏של‏כל‏מוד‏המאפיין‏‬ ‫את‏ה"א‏ההימנעותית;‏מחקר‏‪0‬‏הדגים‏דרך‏למדוד‏שינויים‏במודים‏הקשורים‏להתערבויות‏טיפוליות‏‬ ‫מסוימות;‏מחקר‏‪5‬‏הדגים‏דרך‏למדוד‏קשרים‏הדדיים‏בין‏מודים‏אצל‏המטופל‏הבודד‏וסיפק‏דרך‏לאפיין‏‬ ‫י‬ ‫ואריאציות‏במאפיינים‏האישיותיים‏של‏מטופלי‏‪.APD‬‏‬ ‫מושג‏המודים‏יכול‏להוות‏מימד‏טראנס‪-‬דיאגנוסטי‏שאינו‏חייב‏להיות‏תלוי‏תיאוריה‏(כמו‏‪.)ST‬‏‬ ‫במקום‏זאת‪,‬‏מושג‏המודים‏מאפשר‏את‏תיאור‏האישיות‏של‏כל‏אדם‪,‬‏כמו‏גם‏של‏מגוון‏הפרעות‏נפשיות‪.‬‏‬ ‫מושג‏זה‏מאפשר‏השוואה‏בין‏פרטים‏ובין‏קבוצות‪,‬‏ומאפשר‏את‏חקר‏הדינאמיקה‏של‏יחסים‏בינאישיים‏‬ ‫(בהם‏מודים‏של‏האחד‏משפיעים‏על‏מודים‏של‏האחר)‪.‬‏לסיכום‪,‬‏מושג‏המודים‏מציע‏מגוון‏אפשרויות‏‬ ‫היכולות‏להעשיר‏את‏חקר‏האישיות‪,‬‏אינטראקציות‏בינאישיות‪,‬‏פסיכופתולוגיה‏ופסיכותרפיה‪.‬‏‏‬ ‫מגבלות ותחומי מחקר עתידיים‏‬ ‫הנתונים‏בעבודה‏זו‏נאספו‏ממטופלים‏שאובחנו‏ב‪.APD-‬‏ההתמקדות‏ב‪APD-‬‏לא‏אפשרה‏השוואת‏‬ ‫הנתונים‏למדגם‏בקרה‏לא‏קליני‪,‬‏או‏מדגמים‏של‏הפרעות‏אחרות‪.‬‏העבודה‏מבוססת‏על‏נתונים‏שקודדו‏מ‪-‬‬ ‫‪649‬‏מקטעי‏טיפול‪.‬‏למרות‏מספרם‏הרב‏של‏המקטעים‪,‬‏מקורם‏במספר‏מצומצם‏של‏משתתפים‏(‪)N=15‬‏‬ ‫ועל‏כן‏ממצאים‏אלה‏טנטטיביים‏עד‏שיבוצעו‏מחקרים‏עם‏מדגמים‏גדולים‏ומגוונים‏יותר‪.‬‏‏‬ ‫מגבלה‏נוספת‏של‏העבודה‏נוגעת‏במטפלים‏אשר‏היו‏מתמחים‏בפסיכולוגיה‏עם‏ניסיון‏טיפולי‏‬ ‫מוגבל‪.‬‏סביר‏להניח‏שנתונים‏ממחקרים‏נוספים‏שיערכו‏עם‏מטפלי‏‪ST‬‏מנוסים‏יניבו‏דפוסים‏שונים‏‬ ‫במידה‏כזו‏או‏אחרת‪.‬‏‬ ‫שני‏הסולמות‏החדשים‏שבאמצעותם‏קודדו‏הנתונים‏(סולם‏להערכת‏המודים‏וסולם‏להערכת‏‬ ‫התערבויות‏המטפל)‏הראו‏מהימנות‏טובה‏בין‏שופטים‪,‬‏אך‏יש‏מקום‏למחקרי‏תיקוף‏נוספים‏וכניסה‏‬ ‫לפירוט‏מדויק‏יותר‏בסולמות‏עצמם‪.‬‏למשל‪,‬‏הקידוד‏להתערבויות‏חווייתיות‏של‏המטפל‏משקף‏מגוון‏‬ ‫אמצעים‏(עבודה‏בדמיון‪,‬‏עבודה‏בכיסאות‪,‬‏משחק‏תפקידים‏היסטורי‪,‬‏כתיבת‏מכתבים)‪.‬‏מחקרים‏עתידיים‏‬ ‫עשויים‏להתמקד‏בחקר‏השפעתם‏של‏כל‏אחד‏מאמצעים‏אלה‏בנפרד‪.‬‏באופן‏דומה‪,‬‏משתנה‏‏עמדת‏המטפל‏‬ ‫מכיל‏בתוכו‏מספר‏מרכיבים‏טיפוליים‏(הורות‏חלקית‏מתקנת;‏הבנה‏ומכוונות‏ל"מציאות‏הפנימית"‏של‏‬ ‫המטופל;‏שיתוף‏פעולה‪,‬‏משוב‪,‬‏ומיקוד‏המפגש;‏איזון‏וגמישות‏לצד‏נינוחות‏וביטחון‏של‏המטפל)‪.‬‏מחקרים‏‬ ‫עתידיים‏עשויים‏להאיר‏אלו‏מהמרכיבים‏בעלי‏השפעה‏הרבה‏ביותר‪.‬‏באופן‏מיוחד‪,‬‏מעניין‏היה‏לבחון‏את‏‬ ‫ההשפעות‏הספציפיות‏של‏הורות‏חלקית‏מתקנת‏ושל‏העימות‏האמפאטי‪.‬‏‏‬ ‫בנוסף‪,‬‏עבודה‏זו‏עשתה‏את‏הצעד‏הראשון‏בחקר‏מסלולים‏אידיוגרפים‏של‏מטופלי‏‪.APD‬‏בשל‏‬ ‫מספרם‏המוגבל‏של‏המטופלים‪,‬‏לא‏ניתן‏היה‏להתקדם‏לרמה‏הנומותטית‏שיכלה‏לתאר‏את‏הקבוצה‏‬ ‫כמכלול‏ולהגיע‏לתיאור‏תתי‏סוגים‏מובחנים‏של‏מטופלי‏‪.APD‬‏‏‬ ‫לבסוף‪,‬‏עבודה‏זו‏חקרה‏תהליכי‏שינוי‏המתרחשים‏ב‪ST-‬‏למטופלי‏‪.APD‬‏מאחר‏והוצע‏שמושג‏‬ ‫המודים‏יכול‏לשמש‏מעבר‏לאבחנות‏וגישות‏טיפוליות‪,‬‏מחקרים‏עתידיים‏על‏מודים‏עשויים‏לתרום‏רבות‏‬ ‫להבנת‏תהליכי‏שינוי‏המתרחשים‏בפסיכותרפיה‏באופן‏כללי‪.‬‏‬ ‫יא‬ ‫‏‬ ‫תוכן עניינים‬ ‫תקציר‏באנגלית_______________________________________________________‏‬ ‫‪i‬‬ ‫‏מבוא______________________________________________________________‏‬ ‫‪0‬‏‬ ‫הפרעת‏אישות‏הימנעותית_____________________________________________‏‬ ‫‪0‬‏‬ ‫מבוא‏לסכמה‏תרפיה________________________________________________‏‬ ‫‪4‬‏‬ ‫צרכי‏ליבה‏רגשיים______________________________________________‏‬ ‫‪4‬‏‬ ‫סכמות‏מוקדמות‏בלתי‏מסתגלות_____________________________________‏‬ ‫‪9‬‏‏‬ ‫דפוסי‏התמודדות‏בלתי‏מסתגלים_____________________________________‏‬ ‫‪9‬‏‬ ‫מצבי‏סכמה‏(מודים)_____________________________________________‏‬ ‫‪6‬‏‬ ‫אסטרטגיות‏התערבות‏בסכמה‏תרפיה_____________________________________‏‬ ‫‪7‬‏‬ ‫מחקר‏בסכמה‏תרפיה________________________________________________‏‬ ‫‪5‬‏‬ ‫מודלים‏של‏מודים‏עבור‏הפרעות‏אישיות‏ותמיכה‏מחקרית________________________‏‬ ‫‪02‬‏‬ ‫סכמה‏תרפיה‏להפרעת‏אישיות‏הימנעותית__________________________________‏‬ ‫‪00‬‏‬ ‫תכנון‏הפרויקט‏ושיטה_______________________________________________‏‬ ‫‪00‬‏‬ ‫מחקר‏‪.0‬‏יציבות‏או‏חוסר‏יציבות‏בהפרעת‏אישיות‏הימנעותית‪:‬‏תנודתיות‏של‏מודים‏במפגשי‏סכמה‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‬ ‫תרפיה‏____________________________________________________________‏‬ ‫‪05‬‏‬ ‫כלים‏ושיטה_____________________________________________________‏‬ ‫‪07‬‏‬ ‫משתתפים___________________________________________________‏‬ ‫‪07‬‏‬ ‫הכשרה‏בסכמה‏תרפיה‏ומהלך‏הטיפול________________________________‏‬ ‫‪02‬‏‬ ‫כלים______________________________________________________‏‬ ‫‪02‬‏‬ ‫כלי‏הערכה‏לאבחנות‏פסיכיאטריות________________________________‏‬ ‫‪02‬‏‬ ‫סולם‏להערכת‏מודים‏של‏המטופל‏(‪_________________________)CMRS‬‏‬ ‫‪02‬‏‬ ‫הליך‏הקידוד_________________________________________________‏‬ ‫‪05‬‏‬ ‫ניתוח‏נתונים_________________________________________________‏‬ ‫‪05‬‏‬ ‫תוצאות________________________________________________________‏‬ ‫‪02‬‏‬ ‫שכיחות‏ועוצמה‏של‏המודים________________________________________‏‬ ‫‪02‬‏‬ ‫תנודתיות‏המודים_______________________________________________‏‬ ‫‪00‬‏‬ ‫דיון___________________________________________________________‏‬ ‫‪00‬‏‬ ‫יציבות‏וחוסר‏יציבות‏בהפרעת‏אישיות‏הימנעותית_________________________‏‬ ‫‪05‬‏‬ ‫תיאור‏מבוסס‏מודים‏של‏מטופלים‏עם‏הפרעת‏אישיות‏הימנעותית_______________‏‬ ‫‪04‬‏‬ ‫יעילות‏השימוש‏במושג‏המוד‏כלקסיקון‏לתיאור‏מצבי‏האישיות‏וחוסר‏יציבותם______‏‬ ‫‪06‬‏‬ ‫השימוש‏בקידוד‏מקטע‏אחר‏מקטע‏במפגש‏טיפולי‏להערכת‏שינויים‏אצל‏המטופל____‏‬ ‫‪07‬‏‬ ‫מגבלות‏המחקר‏וסיכום______________________________________________‏‬ ‫‪02‬‏‬ ‫מחקר‏‪.0‬‏התערבויות‏המטפל‏ושינויי‏מודים‏במהלך‏מפגשי‏סכמה‏תרפיה‏להפרעת‏אישיות‏הימנעותית_‏‬ ‫‪05‬‏ ‏‬ ‫סכמה‏תרפיה‏להפרעת‏אישיות‏הימנעותית________________________________‏‬ ‫‪52‬‏‬ ‫טכניקות‏התערבות‏במודל‏הסכמה‏תרפיה_________________________________‏‬ ‫‪50‬‏‬ ‫ניתוח‏מיקרו‪-‬אנליטי‏של‏תהליכי‏מטפל‪-‬מטופל_____________________________‏‬ ‫‪50‬‏‬ ‫השערות______________________________________________________‏‬ ‫‪55‬‏‬ ‫שיטה____________________________________________________________‏‬ ‫‪54‬‏‬ ‫מבט‏על______________________________________________________‏‬ ‫‪54‬‏‬ ‫משתתפים____________________________________________________‏‬ ‫‪54‬‏‬ ‫הכשרת‏מטפלים‏ומהלך‏הטיפול______________________________________‏‬ ‫‪56‬‏‬ ‫כלים_______________________________________________________‏‬ ‫‪56‬‏‬ ‫‏כלי‏הערכה‏לאבחנות‏פסיכיאטריות________________________________‏‬ ‫‪56‬‏‬ ‫סולם‏להערכת‏מודים‏של‏המטופל‏(‪__________________________)CMRS‬‏‬ ‫‪56‬‏‬ ‫סולם‏להערכת‏התערבויות‏מטפל‏סכמה‏תרפיה‏(‪__________________)STIRS‬‏‬ ‫‪57‬‏‬ ‫הליך‏הקידוד_________________________________________________‏‬ ‫‪52‬‏‬ ‫ניתוח‏נתונים_________________________________________________‏‬ ‫‪52‬‏‬ ‫תוצאות________________________________________________________‏‬ ‫‪40‬‏‬ ‫דיון__________________________________________________________‏‬ ‫‪45‬‏‬ ‫עמדת‏המטפל________________________________________________‏‬ ‫‪45‬‏‬ ‫התערבויות‏ממוקדות‏רגש________________________________________‏‬ ‫‪49‬‏‬ ‫התערבויות‏התייחסותיות_________________________________________‏‬ ‫‪46‬‏‬ ‫התערבויות‏קוגניטיביות_________________________________________‏‬ ‫‪47‬‏‬ ‫התערבויות‏התנהגותיות‏לשינוי‏דפוסים_______________________________‏‬ ‫‪42‬‏‬ ‫חקר‏והערכה‏של‏הסכמות________________________________________‏‬ ‫‪45‬‏‬ ‫יישומים‏קליניים______________________________________________‏‬ ‫‪45‬‏‬ ‫מגבלות‏המחקר‏וכיוונים‏עתידיים______________________________________‏‬ ‫‪92‬‏‬ ‫סיכום________________________________________________________‏‬ ‫‪90‬‏‬ ‫מחקר‏‪.5‬‏קשרים‏על‏ציר‏הזמן‏בין‏מודים‏בסכמה‏תרפיה‪:‬‏ניתוח‏מודלים‏(‪__________)TSPA‬‏‬ ‫‪90‬‏‬ ‫מצבי‏עצמי_________________________________________________‏‬ ‫‪95‬‏‬ ‫הפרעת‏אישיות‏הימנעותית_______________________________________‏‬ ‫‪99‬‏‬ ‫מחקרי‏‪TPSA‬‏וניתוחים‏אידיוגרפים________________________________‏‬ ‫‪96‬‏‬ ‫שיטה________________________________________________________‏‬ ‫‪95‬‏‬ ‫משתתפים__________________________________________________‏‬ ‫‪95‬‏‬ ‫הכשרת‏מטפלים‏ומהלך‏הטיפול____________________________________‏‬ ‫‪62‬‏‬ ‫כלים_____________________________________________________‏‬ ‫‪62‬‏‬ ‫כלי‏הערכה‏לאבחנות‏פסיכיאטריות__________________________________‏‬ ‫‪62‬‏‬ ‫סולם‏להערכת‏מודים‏של‏המטופל‏(‪____________________________)CMRS‬‏‬ ‫‪60‬‏‬ ‫הליך‏הקידוד___________________________________________________‏‬ ‫‪60‬‏‬ ‫ניתוח‏נתונים___________________________________________________‏‬ ‫‪60‬‏‬ ‫תוצאות‏ודיון_____________________________________________________‏‬ ‫‪65‬‏‬ ‫מטופל‏א'_____________________________________________________‏‬ ‫‪65‬‏‬ ‫מטופל‏ב'_____________________________________________________‏‬ ‫‪67‬‏‬ ‫מטופל‏ג'_____________________________________________________‏‬ ‫‪70‬‏‬ ‫סיכום‏ומסקנות___________________________________________________‏‬ ‫‪70‬‏‬ ‫דיון‏כללי___________________________________________________________‏‬ ‫‪76‬‏‬ ‫התרומה‏למחקר‏והטיפול‏בסכמה‏תרפיה_______________________________________‏‬ ‫‪76‬‏‬ ‫התרומה‏למחקר‏והטיפול‏בהפרעת‏אישיות‏הימנעותית______________________________‏‬ ‫‪20‬‏‬ ‫התרומה‏של‏השיטות‏הסטטיסטיות‏שהיו‏בשימוש‏בעבודה‏לחקר‏הפסיכותרפיה_____________‏‬ ‫‪20‬‏‬ ‫יעילות‏מושג‏המוד‏למחקר‏פסיכופתולוגיה‏ופסיכותרפיה____________________________‏‬ ‫‪29‬‏‬ ‫מגבלות‏וכיוונים‏עתידיים________________________________________________‏‬ ‫‪26‬‏‬ ‫רשימת‏מקורות______________________________________________________‏‬ ‫‪25‬‏‬ ‫נספחים‏‬ ‫סולם‏להערכת‏מודים‏של‏המטופל‏(‪___________________________________)CMRS‬‏‬ ‫‪020‬‏‬ ‫סולם‏להערכת‏התערבויות‏המטפל‏בסכמה‏תרפיה‏(‪_________________________)STIRS‬‏‬ ‫‪002‬‏‬ ‫תקציר‏בעברית______________________________________________________‏‬ ‫א‏‬ ‫‏‬ ‫‏‬ ‫‏‬ ‫‏‬ ‫‏‬ ‫‏‬ ‫‏‬ ‫‏‬ ‫תודות‬ ‫להוריי‪,‬‏רינה‏וצבי‪,‬‏שאהבתכם‏וחוכמתכם‏מלווים‏אותי‏בכל‏אשר‏אפנה‏וזמינים‏לי‏בכל‏עת‪.‬‏ממרום‏גילכם‏‬ ‫ולאורך‏כל‏הדרך‪,‬‏אתם‏תמיד‏שם‏עבורי‏במעשה‏וברוח‪.‬‏אבא‏–‏עבורך‪,‬‏השכלה‏היא‏נכס‏שלא‏ניתן‏לנשל‏‬ ‫את‏האדם‏ממנו‪,‬‏ואמא‏–‏עבורך‪,‬‏הקשבה‏לאדם‏ויצירת‏שבילים‏אל‏ליבו‏היא‏התורה‏כולה‪.‬‏ניסיתי‏לשלב‏‬ ‫בין‏השניים‏בעבודה‏זו‪.‬‏‬ ‫לאחיותיי‪,‬‏דפנה‏ואירית‪,‬‏על‏הקשר‏האמיץ‏שאינו‏תלוי‏בדבר‪.‬‏‬ ‫לאשכול‪,‬‏שהנחת‏אותי‏בתבונה‏ורגישות‪,‬‏ראית‏למרחוק‪,‬‏חייכת‏ברוגע‏והפכת‏דרך‏מפותלת‏למסע‏מרתק‪.‬‏‬ ‫לערן‪,‬‏מנהל‏המעבדה‪,‬‏שבשנינותך‏יצרת‏עמי‏את‏הגשר‏מפסיכותרפיה‪,‬‏למבחנים‏סטטיסטים‪,‬‏לממצאים‪.‬‏‬ ‫למתמחים‏שטיפלו‏במסירות‪,‬‏לצוות‏המעבדה‏שסייע‏באיסוף‏ועיבוד‏הנתונים‪,‬‏ותודה‏מיוחדת‏למטופלים‏‬ ‫שהסכימו‏להשתתף‏במחקר‏ובזכותכם‏למדתי‏כה‏רבות‪.‬‏‬ ‫ולבסוף‪,‬‏למשפחתי‏האישית‪:‬‏לרעייתי‏האהובה‪,‬‏עירית‪,‬‏על‏כל‏הטוב‏שאת‏מרעיפה‏עלי‏והשותפות‏המלאה‏‬ ‫מזה‏כחצי‏יובל‪,‬‏על‏התמיכה‪,‬‏העידוד‪,‬‏והגיבוי‏בכל‏הימים‏והלילות‏המרובים‏שהייתי‏שקוע‏במחקר;‏‬ ‫ולילדיי‏הבוגרים‪,‬‏נועה‏ועמרי‪,‬‏שלהיות‏אבא‏שלכם‏שווה‏את‏הכל‪.‬‏‏‬ ‫עבודה‏זו‏נעשתה‏בהדרכתו‏של‏פרופסור‏אשכול‏רפאלי‏מן‏המחלקה‏לפסיכולוגיה‏ומרכז‏גונדה‏לחקר‪-‬‬ ‫המוח‏של‏אוניברסיטת‏בר‪-‬אילן‪.‬‏‏‬ ‫‏‬ ‫תהליכי שינוי בטיפולי סכמה תרפיה‬ ‫למטופלים המאובחנים בהפרעת אישיות הימנעותית‏‬ ‫חיבור‏לשם‏קבלת‏התואר‏"דוקטור‏לפילוסופיה"‬ ‫מאת‪:‬‬ ‫עופר‏פלד‬ ‫המחלקה‏לפסיכולוגיה‬ ‫הוגש‏לסנט‏של‏אוניברסיטת‏בר‪-‬אילן‬ ‫רמת‏גן‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏‏ניסן‪,‬‏תשע"ו‬