ISST Bulettin June 2016
ISST Bulettin June 2016
ISST Bulettin June 2016
Rita Yonan works extensively within a group schema therapy framework. She looks at novel
creative and experiential opportunities that are available within group schema therapy context. In
addition, she discusses how experiential and emotional components of therapeutic work can be
enhanced within a group format.
Chris Hayes is involved in research investigating the use of imagery respiting for childhood
trauma. His article discusses imagery re-scripting within schema therapy context, and looks at
Young et al. (2003) instruct therapists to help patients battle and defeat their internalized
dysfunctional parent modes. Many patients and therapists find combating the parent voices
makes them needlessly critical and punitive themselves. The hierarchy of confrontational
interventions enables matching the intervention to the severity of the dysfunctional parent
mode. As with real parental coaching, when the parent-child relationship is not that
devastating, the hierarchy starts with empathic confrontation.
Empathic confrontation (Young et al., 2003) enables therapists to acknowledge the past
circumstances that led patients
develop their schemas and coping strategies (the empathic component), while pushing for
reality testing, distinguishing past from present and confronting the need for change (the
confrontational component). I would emphasize that the empathic component should
validate the core emotional
needs underlying the
schema; the confrontation
should address the
maladaptive coping
behavior. Validation makes
patients feel genuinely
understood by the
therapist and appreciate
their core emotional
needs and thus more
receptive to the
confrontational part which
helps patients change their
behavior to better realize
their needs in the preset
relationships.
Most parents mean good and try to balance between their children's needs and their own.
Validating this attempt allows patients to maintain their link to their formative support
structure (e.g. parent, family, community, culture) and meet the core emotional need for
connectedness. The confrontational component emphasizes the patients' right to move away
from the harmful aspects of the parent mode and seek for getting their emotional needs met
more appropriately. The therapist takes proportional action that moves from coaching (in the
mild level) to expelling the internalized parent mode (in the extreme level). The hierarchy
contains 3 levels of severity and 8 dysfunctional parent modes:
At this level it is quite easy to validate the internal parent's good intentions. Usually the
internalized parent lacks the knowledge and skills to appropriately and effectively meet the
C h a r a c t e r i s 0 c s : This
internalized parent is
immature, naïve, easil y
influenced by others, tends
to accept people and
circumstances as they are.
The therapist can This mode fails to teach right from wrong, anticipate
consequences, provide guidelines for handling everyday
validate the parent's life situations, and supply sense of safety.
acceptance of the Pa0ent's unmet needs: Protection, guidance, realistic
enthusiasm to spend Therapist stance: The therapist can validate the parent's
acceptance of the child and their enthusiasm to spend
time with the child, time with the child, as well as feeling puzzled when they
need to provide guidance to the child: "I can see how
as well as feeling happy you are to spend time with your child until it gets
puzzled when they more complicated and then you feel puzzled. Is there
someone with enough experience that you can consult
need to provide with? If there is no one I will be happy to guide you how
to meet your child developmental needs".
guidance to the child
2.The Anxious Parent Mode
Characteris0cs: This internalized parent is highly anxious, worries things will go wrong, and
overwhelmed with images of bad outcomes. This mode becomes over protective, intrusive,
and fails to let the child mode practice some sense of competence and separation.
Therapist's stance: The therapist can validate the parent wish for an inner sense of safety
regarding the child, while understanding that the child must develop the ability to take good
care for him/her self. The therapist can instruct this mode to practice anxiety regulation
techniques and guide them to encourage self efficacy and resilience in the child by helping
them to take calculated risks and develop problem solving skills: "Of course you care for your
child’s safety and yet you want him to become a self reliant adult with full ability to take good
care for himself. To achieve this precious goal we, the parents, need to contain our fears,
acknowledge them without acting upon them, and bit by bit free our child to experience life
and develop some sense of competence. I know that can be difficult. Will you try that for the
sake of your child?"
Characteris0cs: This internalized parent is more like a friend of the child. Usually holds a
stance that children have to fallow their inner inclination with minimum interruptions from
their environment. The parent tends to praise, admire and even aggrandize the child but sets
almost no standards of mature behavior, self regulation and discipline, expectations for
sustaining immediate gratification for the sake of long term achievements. This mode
resembles Baumrind's indulgent parenting style (Baumrind, 1967).
Therapist's stance: The therapist can validate the parent’s great joy in watching their child
develop authentically, while setting realistic limits: "it is great that you care for your child
authenticity in his relations with himself and with others; I can see how much you genuinely
love who he is, as he is. But every child needs to learn to regulate their affect and behaviors,
and develop the ability to tolerate frustration in order to achieve their long-term goals,
effectively communicate with others, and recognize and respect their own inclinations
without violating the feelings of others. Self regulation is developed through modeling and
teaching from care givers, who need to find a balance between “freedom” and realistic limits.
How do you think we can achieve this goal?”
At this level it is more difficult to validate the internal parent's good intentions. Usually the
internalized parent blames the child for his/her own wishes, or pushes him/her to meet
unrelenting standards. The internalized parent lacks empathy for the child's emotions and
may become more argumentative or rigid when someone expresses disagreement with them.
At this level the therapist is more assertive in providing guidelines for the treatment of the
vulnerable child, and may need to set limits to protect the inner child.
Characteris0cs: This internalized parent believes that others are responsible for his/her bad
experiences; feels entitled and demands being taking care of; or uses his/her suffering to keep
others emotionally tied to him/her. This parent mode depends on the vulnerable child to feel
safe, belong and loved. When the vulnerable child tries to stand for his/her rights the
internalized victim-like parent mode turns to accusation, emotional or sick-role behaviors to
restore his/her grasp upon the vulnerable child.
2018 Conference
The conference
shortlist includes 5.The demanding and critical parent mode (Young et al., 2003)
At this level little if any room is left for validating the internal parents’ intention. These
dysfunctional parent modes cause such profound harm that immediate action is needed to
stop and expel them in order to save the vulnerable child mode. Usually these parent modes
are internalizations of a very disturbed significant figure that is not capable of taking care of
the inner child. The therapist needs to intervene immediately and engage other authorities
such as social services, police etc.
Characteris0cs: This internalized mode is aloof, disengaged, and practically neglects the
child's emotional basic needs and assumes little if any parental responsibility. This parent
mode is based on Maccoby & Martin (1983) neglectful parental style.
Pa0ent's unmet needs: No emotional needs are met, especially those for secure attachment,
realistic limits and self-control.
Therapist's stance: The therapist needs to set limits and provide psycho-education about a
child’s emotional needs for secure attachment, stability, guidance etc. The therapist limits or
minimizes the impact of the chaotic parent mode by engaging healthier figures (such as
relatives) to protect and nurture the vulnerable child mode. The social services may need to
arrange foster care: "I can see you have a lot on your mind and you are in a great need for help
which I'm willing to arrange for you. But right now we have to take good care for little
(child)’s need for stability and a sense of security. Mr./Mrs. Y (healthier relative) will take care
for little X (child). You may be in contact with your child under the supervision of Mr. Y.
Youneed to put yourself together and take some professional help. The social services will be
Distressing
Parent Mode - Naive, Anxious & Permissive
Grave
Parent Mode - Victim Like, Demanding & Critical
Critical
Parent Mode - Neglecting, Chaotic, Abusive &
Punitive
part of this program to help you and protect little X".
Characteris0cs: This internalized mode is the worst form of the dysfunctional parent modes.
Almost always this figure is severely mentally disturbed or suffers from severe personality
disorder and is not capable of parenthood. This internalized mode humiliates exploits,
intimidates, physically/sexually abuses and is very cruel toward the inner child. It is
unbearable to live next to this figure. This is an extreme version of Young's punitive parent
mode (Young et al., 2003).
Pa0ent's unmet needs: All the emotional needs are unmet but most of all the need for a
secure attachment.
Therapist's stance: The therapist needs to stop immediately the harm this abusive mode
causes and take the vulnerable child to a secure place. There is no other way than getting help
from the social services and the police in order to protect the little child. The therapist can
say: "I need you to stop right there what you are doing to little X (the name of the patient). It
is wrong and you are not allowed to do this. Obviously you have great troubles and you need
professional help that I can arrange. But right now little X cannot stay with you. The social
services and the police are here to protect little X. If little X will need to see you it will be
only under supervision of the authorities.”
Let‘s imagine, there is a boy named Felix. His parents notice that something is wrong with
him. His teacher says that he tends to be aggressive. They decide that he needs some help.
They look for a therapist who can help Felix. Then, Felix gets to know Chris. He is a
psychologist and therapist for children and adolescents. After Felix‘s parents have asked him
to help, he meets up with Felix. Chris encourages Felix to talk about himself and his world.
He is especially interested in all the different
sides of Felix that come out at different times.
He calls these different sides „parts“ or
„modes“. He asks him: Felix, I am really
interested in finding out about you, and about
all of your different sides, or „modes“ as I call
them. Which different sides of yourself have
you noticed? Let‘s write that down, okay?“
Felix creates his own mode-sketch.
Once we have a picture of all of the different sides of Felix, he then chooses a finger puppet
for each mode.
Hello! I go first, to get the least favourite over and done with: I‘m a part of Felix that many
people consider to be too sensitive. As you can see, I‘m already pretty scruffy. I don‘t like that
at all, because in fact, I want to be pretty and strong. However, in reality I‘m very, very
sensitive. A lot of people call me the „vulnerable or hypersensitive Felix“.
Hello from me as well! I am the contented, sometimes happy, part of Felix. I come out when
Felix feels good, and I look like joyfulness, giggling, and lots of fun and happiness.
Good day! I am another part of Felix. In fact, I am the clever & wise part. I know an answer
to everything, and know about Felix‘s needs or what might help him in difficult situations. I
usually look after him well, however sometimes I just don‘t know what to suggest to him.
Hi! I am the „aggressive“ Felix. Nearly everyone shys away when I come out. I let Felix rage
and yell. This often results in some problems... But he feels proud because NO ONE else is as
powerful and strong as me.
Hey! I am the imaginative and fanciful part of Felix. When I am there, he is a fountain of
fantastic ideas. Well, the others are „louder“ than me for sure and try harder to get his
attention, but without me Felix would be SO BORED. And I help him with ideas to solve a
lot of his problems, too.
[quiet] Ohhh, I hardly dare to speak. But I‘ll try... Hello... I am Felix‘s anxious and scared
side. When I come out, Felix usually backs away. He feels insecure and sometimes he also
feels ashamed and almost completely loses confidence in himself.
Good day! I am the angry part of Felix, as you can tell from my facial expression. I often
come out when others are being unjust, unfair, or mean. I SIMPLY CANNOT STAND
PEOPLE BEHAVING LIKE THAT, ESPECIALLY TOWARDS FELIX.
After Felix has talked about his modes and assigned finger puppets to them, Chris comes into
play as a miniature figure. First, Chris turns to the scruffy, bedraggled, Raven, the vulnerable
Felix, and comforts him, soothing the pain from all the difficult, horrible, times he has
experienced. He provides the vulnerable Felix with a big patch and asks him, „what would
help you to feel better right now?“ „At last, someone is taking care of me, and noticing all my
pain and struggles!“, says the Raven, „First of all, I simply need your attention and comfort.“
The others don‘t even care about that!“ Chris sticks the patch on the Raven‘s upper body, like
a medal, as he replies, „I would very much like to give you my attention and comfort. I‘d also
like to help you get to know a bit more about your vulnerability and sensitivity, so I can help
you to understand more and even feel a bit better about yourself. Would that be okay with
you?“ And, as Felix nods his head, Chris begins to explain to him…
… that his "vulnerability" is actually a special gift. A superpower called the “Super Sensor”
that lets him feel what others are thinking and feeling, and also to notice if anything is wrong
or unjust. Chris presents Felix with an antenna labelled "Super Sensor" as a sign of this special
gift, this superpower.
The vulnerability or sensitivity, which many people have made out to be a bad thing, has now
become a (positive) sensitivity, a “Super-Sensor” superpower. This already sounds much better
to Felix. And because the “Super-Sensor" has done such a good job and reported all the
injustice that took place in the world, Chris gives him an award: The Golden Antenna! He is
really proud now!
However, Felix does not like to brag about things so he decides to take the award off the
antenna and place it out of sight. He knows about the award, others don’t need to see it, and
it is more important to him that the wounds are well protected. Therefore a bandage is
First of all, he learns from the aggressive Felix that he prevents Felix from feeling like a misfit
in class. He lets Felix roar and rage, in order to gain more respect from the others. Chris
thanks him for his openness and also for trying to gain respect for Felix. However he makes
clear that Felix will get into a lot of trouble, and that the respect is not so much respect as
fear, and because of the fear, many children will be too scared to get close to Felix. Then
Chris talks to the angry Felix, who made friends with the aggressive Felix in order to draw
attention to himself. Unlike his parents and teacher, Chris praises the presence of the angry
mode. In fact, feelings of anger are a natural reaction to injustice. These are at least partly
legitimate. But he also makes it clear that the legitimate anger should make friends with other
modes, otherwise Felix - if he only expresses his anger through the aggressive Felix - will
always be the one who gets into trouble. Then Chris turns his attention to the anxious and
scared Felix, who is scared of looking like a fool in front of the other children and becoming a
victim. Chris now focuses on reducing how often the anxious and scared part comes out,
while also helping angry Felix to make friends with, and receive support, from the other
modes.
Now Chris turns his attention to all the other modes and calls a mode council. It's like an
inner family meeting, where all the important things can be discussed openly and safely. The
mode council mainly discusses the vulnerable Felix who is "wounded" and in need of
protection, and certainly does not deserve to be laughed at or ignored. And it is discussed
that the vulnerable Felix has to be acknowledged as a “Super-Sensor", thus as a very
important source of information! Without him the other modes would have no idea what
kind of injustice is happening in the world out there, and that vulnerable Felix does not want
to be the weak and unpopular mode all the time. That's just not fair, because he is doing such
The contented, imaginative and especially the clever & wise mode explain to the aggressive
mode that they are going to take more care of the vulnerable, fearful and angry modes, and
they apologize for having neglected the vulnerable, fearful and angry modes in the past. Then
all the modes come together, led by clever and contented modes, who celebrate the
importance of the vulnerable and sensitive mode. Everyone agrees that the raven can wear
the Golden Antenna with pride and celebrate his achievements! And after a long, long time
the vulnerable Felix finally feels that everything is okay with him. That he is not a pushover,
loser or hypersensitive person.
But he also understands now that he must learn to ask the others for help when he
experiences injustice in the world outside. Thus all the modes can come together as friends,
as a team led by the clever and wise mode, and all together can help to do something about
injustices.
www.schematherapysocie
ty.org/Research-Blog
The advantage of doing emotion focused work within a
group setting is that affect can be amplified by the presence
of more people in the therapy space. Similarly to individual
ST, emotional material can be explored and used as a
Below are a few interventions that one could use within a group format as per Group Schema
Therapy (GST) with Borderline Personality Disorder (BPD) protocol by Farrell & Shaw
(1994).
Imagery work is a powerful experiential intervention used in Schema Therapy for healing the
Vulnerable Child Mode. In GST imagery change work or rescripting can be delivered in two
main ways: individual rescripting with group involvement and group as a whole rescripting.
Needless to say it is crucial to establish safety before doing any imagery work with patients
who present with a history of trauma and neglect. For patients with BPD connecting with
their Vulnerable Child Mode is usually met with negative and rejecting feelings. Therapeutic
stories of little children in situations where they have needs are often used to assist patients
in having compassion for a child’s emotional needs. This slowly paves the way for patients to
consider how helpless children can be and how dependent they are on a good parent to have
core needs met including feeling safe, secure and predictable. Through the story patients are
encouraged to think about what messages the child in the story would have taken from the
experience about her self-worth and the normality of needs being met by the adults in her
world. Patients are then encouraged to think about their Vulnerable Child and their needs in
This story provides an example of the kind of situations in childhood where needs were not
met and schemas and modes develop. It does not need to be a situation of abuse, rather a
time when a child was left on his or her own to deal with intense feelings before he/she had
the resources to do so. In such situations a version of fight, flight or freeze will occur. One of
the most common child responses in the thunderstorm story is Detached Protector. Another
possible response would be Angry Child. The use of stories however, really encourages a
discussion around children and needs in a safe way for participants, and encourages self-
disclosure.
The importance of spontaneity and play in child development has been well documented as
well as the importance of evoking and strengthening the Happy or Contented Child Mode
(summarized in Lockwood & Shaw, 2012). Play and creativity facilitate healthy emotional
development and provide the earliest learning about social interactions. In the case of
patients with BPD spontaneity and play were invariably not met, and not present in their
family environments. Through play when adult schema’s like Emotional Inhibition can be
The use of Happy Child Imagery is also a good way to deal with a group that is stuck or in
need of a shift in affect. This must be done with a significant amount of enthusiasm, and
He a l t h y Ad u l t
Representation – Group
B a s e d Tr a n s i t i o n a l
Object
In a group session, therapists provide patients with a selection of inexpensive beads and
group members and therapists select a bead for each member that represents a personal
characteristic of him or her that they like or value. The “identity bracelet” for each person is
built by group members taking turns to presenting a bead and making a statement about what
it represents. This process continues until all patients have a completed bracelet. A
visualisation exercise follows in which patients are instructed to connect with the positive
feelings of receiving the bracelet in imagery while wearing the bracelet and putting their hand
over it. In this way the bracelet can be a physical anchor upon which to build a more stable
positive identity supported by their positive peer group. Beads can be added over the life of
the group to represent important experiences like a moment of belonging in their VCMs.
This activity is likened to the behaviour seen in adolescents who often trade pieces of
jewellery or clothes with best friends as part of bonding and identification process that
underlines identity formation. This emotional learning experience was usually one missed for
patients with BPD who grow up in invalidating or abusive childhood environments without a
sense of belonging to a healthy peer group or any group at all.
how the needs could be met. The rescript developed by the group members is checked out
with the therapist presenting the memory and additions or subtractions are made. The other
therapist then instructs the group with him/her to close their eyes connect with their VCM
and listen to what is said as a good parent to the therapist with the memory. They are told to
try to take in the positive reparenting messages and listen to the therapist’s tone. At the end
the group discusses how this went and the effects. The therapist sharing the memory
describes the new message she can take away from the rescripted experience. The group s
then asked who among them has a similar level of difficulty memory they would like the
group to rescript. Over time the group can also be involved in the implementation of the
rescripted memory. They may join a lonely child on the school playground or help rescue a
child from abusers. This use of selective self-disclosure from the therapist strongly facilitates
patients being willing to rescript their memories. It shows them that IMRS is not as scary as
they thought and that they do not need to re-experience trauma, rather stop before the
trauma actually happened and experience a rescue or what should have happened. The
therapist rescript also provides the corrective emotional experience of being treated as if they
have worth and value, i.e. they can contribute something to the therapist.
I’d like to thank Joan and Ida for their training, supervision and help in program development
in GST and their input for this tiny window into the wonders of delivering Experiential
Strategies in a Group Setting.
One of the most important questions in therapy is how can the brain unlearn something? Think
of one of your patients with early abuse or neglect. Or trauma. Or low self-esteem. Or
dysfunctional relational patterns. This is often the focus of therapeutic efforts and it is
frustrating how much the brain resists any change, even of early learning which is inherently
irrational and completely dysfunctional. And it can last a lifetime driving dysfunctional
patterns of behaviour.
Emotional Learning (EL) is something like a ‘bad tenant’. The person pays no rent and keeps
trashing your house. You want to evict them but nothing works. Even when you hand them a
We will call this approach ‘old therapy’, like Bruce’s children used to say ‘old school’, and
unfortunately most current therapies are counter-active. The counter-active techniques include
relaxation strategies superimposed on anxiety, new behaviours to overcome a sluggish lack of
motivation and thought blocking to oppose negative thinking. It is like trying to evict the
unwanted tenant by wearing down their resistance to leaving.
But what needs to happen to effect real and lasting change? Change must happen at the level of
Emotional Learning.
A Scientific Advance
Now some welcome news. There has been some remarkable, if somewhat obscure, research in
memory reconsolidation. Memory consolidation is when something is learned and later
strengthened; memory reconsolidation is when something new is learnt in place of what was
previously learned. Obviously both are central to the concept of Emotional Learning.
In the following discussion of theory and research I have cited some relevant studies so that
you can look at the neuroscientific evidence. It is hard to follow, but worth the effort.
This memory research found that once an emotionally charged memory was formed, certain
later circumstances provide an opportunity for change (Pedreira, et al., 2002). The surprising
discovery was that the brain is able to wipe-out and change an established belief (Pedreira, et
al., 2004). This research was initially done with animals, such as the sand crabs used by
Pedreira, but it demonstrated an important neurological mechanism in which an animal can
unlearn something and re-learn it (Perez-Cuesta & Maldonado, 2009). The stimulus with the
sand crabs was of a predator (Pedreira, et al. 2004) which produced a trauma-like response –
which could be unlearned and safety re-learned. A similar mechanism has been found in
human memory research (Forcato, et al., 2007). The process of memory formation
(consolidation), retrieval and re-consolidation has now been well described and it would
appear that a number of different types of reactivation, such as waking reactivation (Walker et
al., 2003), can lead to reconsolidation (Alberini & LeDoux, 2013; also Lattal & Wood, 2013).
An interesting by product of this line of inquiry is how to match certain drugs to gain a similar
effect (discussed in Alberini & LeDoux, 2013). This could have important implications for the
practice of psychiatry. Nader & Einarsson (2010) have provided a useful review.
About Therapy
All this has revolutionary implications for therapy. Bruce Ecker has incorporated principles of
memory reconsolidation into his Coherence Therapy, the “reactivation of a well-consolidated,
longstanding implicit memory appeared to have rendered the stored emotional learning
susceptible to dissolution.” (Ecker, 2012, p. 18; also Ticic, et al., 2015). What came to be
appreciated was that a reactivation can de-consolidate a memory into a flexible state, which
was temporary and could be followed by a relocking or reconsolidation with new learning if
some mismatching information was present. The new ‘over-writes’ the old. Arntz mentioned
memory reconsolidation in his key note address at Istanbul, 2014.
At the risk of overstating a claim, memory reconsolidation is the ‘holy grail’ of psychotherapy.
Of course there will need to be future research to establish or contradict this explanation of
effective therapeutic change. But few would deny its considerable potential or applicability to
the most intransient of therapeutic problems.
Miss-match
Reconsolidation is highly selective and affects only the memory that is being mismatched,
whatever that memory might be. This appears to be an inbuilt mechanism to allow flexibility
and change in learning. The change mechanism requires both:
(b) Mismatch (an experience that mismatches the target memory or what EL expects).
Sally is a senior military officer. She is highly respected in her field and had responsibility for
hundreds of soldiers in a training camp. She thought that her life was “travelling well. I had
what I thought was a loving husband, two teenage children and some very close friends. I also
had a range of people I knew through a family movie club I attended with my children.”
In a few months things deteriorated. Her husband announced he was leaving her. He had been
in an affair, which shocked her, and he went to live with his new partner. Sally survived all this
but about six months later her three closest friends, for a variety of reasons, ended their
friendship with her. One started to gossip about her at church, another moved to another city to
pursue graduate studies and the last became over-involved in romantic relationship. The new
relationship took precedence and the girlfriend objected to his friendship with Sally.
All this devastated Sally. She became acutely suicidal and had to be admitted to a psychiatric
facility. She was seeing a counsellor who did some good work on Sally’s grief, but became
worried about the suicidal crisis. I saw Sally at that point and worked closely with her family
doctor and a psychiatrist who prescribed anti-depressant medication.
Over the next year I saw Sally more or less weekly. Some of my graduate students were also
involved in counselling support. She made great progress. She was able to return to her
military duties through a variety of psychological interventions including exposure therapy.
She seemed like she was almost fully recovered and we were thinking about completing
therapy. But then I thought about how intensely suicidal she had been. It was as if she held her
life ‘lightly’. Almost with no value. I worried that a similar crisis might occur in the future and
then she would be highly at risk of suicide. It had been a ‘close thing’.
So I used sentence completion about why she felt she had to kill herself. I had the sentence
completion “I need to kill myself because …” The result was very surprising:
I wrote this on a card and she said that every word resonated as true for her. She was asked to
read the card once a day for the next week. A week later she reported a huge shift. She said that
the first sentence “I am of value only to the degree I am helpful to others” felt about 40% true
but the rest “not at all true” and was rated 0% true. She saw that previously her sense of self-
worth was extrinsic and was shifting to be intrinsic, and she felt “freer”. She revised her
emotional learning to the following statement, “I am a valuable person because I have my own
values which I can satisfy without needing affirmation from others. I can make a valuable
contribution without needing it recognized.”
I had Sally visualize saying this to a crowd that included her ex-husband, children, parents and
siblings. She had made some new supportive relationships and they were included as well. I
asked if anyone was missing and she said, “I want to see me there too.” She added, “I need to
hear myself say it.” I could see a profound shift and I was finally satisfied that the risk of
suicide was in the past. Her recovery from risk of suicide was as complete. Indeed I have seen
her in follow-up sessions since this turbulent period and while she has faced challenges, she is
emotionally stable.
In one session, Martine expressed her wish to go out for a weekend with her boyfriend, but at
the same time was literally terrified to inform her mother about it. After this intense fear was
clarified, the therapist asked her to close her eyes, visualize herself informing her mother,
focus on her somatic sensations while doing so, ending up by an affective bridge to past
experiences with such sensations (discovery work). The patient retrieved childhood memories
of physical assaults from her mother. This led us to the following formulation of a fundamental
emotional learning (punitive parent - abuse).
“Mom, when you’re angry at me, I’m afraid that you’ll grab me by the throat to kill me,
I’m terrified of dying. I become a little defenceless girl. That is what is triggered in me
whenever someone is angry with me or demands something from me.”
The daily reading of this emotional belief which was written on a card (integrative work)
triggered mismatching experiences (error detection under spontaneous mind processing). Two
situations confirmed an emotional memory modification: Martine didn’t experience fear when
she informed her mother of her plan of the weekend, and subsequently discarded her mother’s
objection to her personal decision. Martine was astonished that this was done without
extensive effort, a complete turnaround from her historical reactions.
But a few weeks later, Martine reported fear again while anticipating another situation. She
wanted to stop one of her voluntary work commitments. She had many such commitments and
had a hard time saying no to new solicitations (self-sacrifice schema) — this had led her to
burnout in the past. But the anticipation of saying to collaborators that she would conclude this
specific commitment triggered a fear anticipation. The intensity of this fear was close to terror
and it told us that our previous work left another memory track untouched. Metaphorically,
work with memory reconsolidation is like a laser beam intervention, you have to make sure
you are on the right memory track in order to modify it.
So, we extended our discovery work to this anticipated situation and ended up with the
following emotional belief, which added a subtle nuance to the previous one:
“Mom, you’re too strong for me. When you squeeze my arms, grab me by the throat and
threaten to kill me, I can’t do anything. If I try to defend myself, you will kill me.”
Spontaneously, Martine came out with a mismatching belief (another emotional belief—not a
cognitive disputation):
“Today, it is no longer true that I can’t do anything. I would be able to defend myself
and stop you from killing me.”
This second emotional belief referred to a situation in which, as an adult, she prevented her
mother from grabbing her by the throat. We then asked her to read alternatively both emotional
beliefs and check out how much they felt true to her (juxtaposition phase). She reported that
after a few days, the first one didn’t feel true to her anymore. Moreover, the fact that she didn’t
experience terror or fear with anticipation or actual announcement of her decision to end her
voluntary work with the group, confirmed the emotional memory modification. This was done
in just a few sessions and the new emotional belief maintained itself effortlessly.
Conclusion
The quest to find what works in therapy has has drawn both of us to the edges of therapy. The
needs of our patients have kept us unsatisfied with our answers. Of course we have to
preference evidence based therapy, but we would never advance to new EBTs unless we are at
some level dissatisfied. So in this brief paper we have presented a process for therapeutic
change using memory reconsolidation from the neurosciences. There are a lot of edges but
thankfully we do not live on a ‘flat world’ so we will not fall off if we go there!
WITH FIVE BIKERS?!”. I looked around the room as if I was looking for an invisible
guiding colleague to appear!
In my mind I have an image of me saying: “Hello chaps…. I’m wondering if you can get out of
here, this child is afraid of you… I have a university degree you know!!”
Thankfully, over the years I’ve been able to continue to develop my skills using imagery
rescripting....
Imagery rescripting is a powerful experiential technique that uses the power of imagination
and visualisation to identify and change meaningful and traumatic experiences in the past,
resulting in transformation in the present. Typically those who are developing skills in schema
therapy specifically find imagery work an exciting, but often daunting clinical option.
Accessing corrective emotional experiences that a client has often never experienced (such as
XXXX) is often a powerful intervention. However, imagery rescripting is an intervention
often postponed or deferred in favour of more “safer” options.
In this article, I hope to provide five practical ideas to help fine tune and develop imagery
work within Schema Therapy.
Affect and meaning are the longitude and latitude for effective targeted float-backs. Clients
can often initially note that they feel “bad”, “overwhelmed”, and “not good”. Here the
therapist needs to increase attunement, and really “get” the experience, meaning, and themes
for the client.
If the therapist takes as face value the described “bad” feeling (“so hold on to that bad feeling
and get a bad feeling as a child”), clients can access a number of “bad” childhood experiences.
Greater attunement allows for clearer links to past events. For example, “So is that bad
feeling like you don’t matter, like you’re overlooked, and no one is interested?” “Hold on to
that feeling and the sense that you don’t matter and get a childhood image where you felt the
same”.
Here, the therapist suggests to the client that they are making a memory “search” into their
mental “search engine” for a particular belief or schema, e.g. “I’m worthless, bad” (aka
defectiveness).
Similar to internet search engines, clients are encouraged to suggest several memories that
may be a part of their “search,” with the top “posting” most linked to the desired search. The
therapist may encourage the client to complete such a task in his or her own time as a
homework assignment, and use the exercise to “prime” the imagery work, or make links
throughout the session. Such key memories can then be used for future imagery work.
In order to create a sense of empowerment and strength, protective devices such as Tasers,
Pepper Spray (Mace), or in some cases weapons could be used (particularly with violent
antagonists). The therapist can also manipulate the size and form of the therapist (make me
9-foot tall), or the antagonist (make him smaller in size and put him in a glass box).
It’s important for the therapist to keep in mind what is the corrective emotional experience
required in the imagery scene. For example, a client that feels subjugated, dominated, and
disempowered in an image may initially need a sense of empowerment and safety. If the
therapist enters the image focusing on reattribution towards the antagonist (“What’s wrong
with you?, you’re the problem”), this may not provide the key ingredients for a corrective
experience. It may be pertinent for therapists to have in mind, “what does the client need?”
and “what is the corrective emotion experience that I’m trying to provide for the client?”.
Such awareness will act like a compass for rescripting work, resulting in attuned responses.
Often when tackling antagonists, it can be challenging for therapists to initiate effective
responses to both antagonists and clients. Figure 1, notes possible responses based on
rescripting themes.
In contrast, if the client is overwhelmed (or hyper-aroused), the therapist can help the client
to use the image itself to “down regulate” affect. For example, the therapist can ask for the
image to be “paused” or “to rewind,” or for the therapist to enter the scene (“I’m there with
you, can you see me, I’m here to protect you”). Hence using the imagery itself as an affect
regulation tool (rather than asking the client to open their eyes, etc.).
And so, back to our initial circumstance with the bikers and my client, what happened next….
I asked the frightened child client, “What do you need right now?”. She replied, “I need
someone to protect me and get these bikers out of my house.”
I entered the image, made myself larger, brought along a Taser, a can of pepper spray, and an
elite police team dressed in body amour and police dogs…
Despite my own imagined incapacity to “take on bikers” and protect the child, my client
noted, “this was the first time I ever felt someone could stand up to them….” A good result…
Fine Tuning Imagery Re scripting- a new DVD set from Remo Van Der Wijngaart and
Chris Hayes (available at www.schematherapytraining.com and www.schematherapy.nl)
The ISST board is very pleased to announce the 2016 conference to be held in Vienna,
Austria on June 30 - July 2 2015 at the Messe Wien Exhibition & Congress Centre.
The conference will be the focal point of of schema therapy practice and research and
will host a number of key note speakers from around the world.
In the next issue we will be bringing you then best from Vienna’s ISST conference!
References
A Hierarchy of Confrontational Interventions Facing 8 Dysfunctional Parent
Modes
Baumrind, D. (1967). Child care practices anteceding three patters of preschool behavior.
Genetic Psychology Monographs, 75, 43–88.
Maccoby, E. E., & Martin, J. A. (1983). Socialization in the context of the family: parent-
child interaction.In P.H. Mussen (Edt.) Handbook of Child Psychology : Formerly
Carmichael’s Manual of Child Psychology.. Retrieved from http://agris.fao.org/agris-
search/search.do?recordID=US201301452933
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema Therapy: A Practitioner’s
Guide. New York: The Guilford Press.
Arntz, A. & Gendern Van, H. (2013). Schema Therapy for Borderline Personality Disorder.
Wiley – Blackwell.
J. M. Farrell, & I. A. Shaw (2012). Group schema therapy for borderline personality disorder:
A step-by-step treatment manual with patient workbook. John Wiley & Sons
Farrell, J. M., Reiss, N., & Shaw, I. A. (2014). The Schema Therapy Clinician's Guide: A
Complete Resource for Building and Delivering Individual, Group and Integrated Schema
Mode Treatment Programs. John Wiley & Sons
De Jongh, Ad, Erik ten Broeke, and Steven Meijer (2010). "Two method approach: A
case conceptualization model in the context of EMDR." Journal of EMDR Practice
and Research 4, 12-21.
Ecker, B., Ticic, R., & Hulley, L. (2013) Unlocking the emotional brain: Eliminating symptoms
at their roots using memory reconsolidation. New York: Routledge.
Forcato, C., Burgos, V., Argibay, P., Molina, V., Pedreira, M. & Maldonado, H. (2007).
Reconsolidation of declarative memory in humans. Learning and Memory, 14, 295-303.
Lattal, K. M., & Wood, M. A. (2013). Epigenetics and persistent memory: Implications for
reconsolidation and silent extinction beyond zero. Nature Neuroscience 16(2), 124-129.
Nader, K. & Emerson, E. (2010). Memory reconsolidation: An update. Annals of the New York
Academy of Sciences, 1191, 27-41.
Perez-Cuesta, L. & Maldonado, H. (2009). Memory reconsolidation and extinction in the crab:
Mutual exclusion or coexistence? Learning and Memory, 16, 714-721.
Stevens, B. (2016) Emotional Learning: The way we are wired for intimacy. Ebook available
through Amazon.com, Kindle and ibook.
Stevens, B. & Roediger, E. (in press, 2016) Breaking negative relationship patterns, Wiley
Publishers.
Ticic, R., Kushner, E., & Ecker, B. (2015). What’s really going on here? How to navigate life
using the hidden intelligence of our emotional brain. On line publication by Coherence
Psychology Institute.
Van der Kolk, B. (1994). The body keeps the score: Memory and the evolving psychobiology
of post-traumatic stress. Harvard Review of Psychiatry, 1(5), 253-265.
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema Therapy. A practitioner’s guide.
New York: The Guilford Press.