New case conceptualization in Schema Therapy:

Mode map circles and their interrelations

Ofer Peled, PhD. The CBT School & Schema Therapy Center Raanana, Israel

Abstract

A new case conceptualization in Schema Therapy is proposed, that provides a visual

mode map drawing, created collaboratively by the therapist and the client. This
conceptualization specifies the client's presenting problems and their connections to
the origins and the mechanisms maintain them by drawing a mode map.
Collaboratively with the client each mode characteristics are explored and written on
the board under a circle representing its dominance. Arrows are drawn between the
different modes to illustrate their interrelations. Finally, by asking the client guided
questions, the therapist elicits the mode changes that need to take place as therapy
progresses, and draws the therapy plan on the mode map. A dialogue with a client
diagnosed with avoidant personality disorder is presented as a case illustration of
tailoring an idiographic mode map case conceptualization, and then the procedure
section will detail the process step-by-step. This new visual conceptualization tries to
make Schema Therapy psycho-education and conceptualization communicative,
simple yet comprehensive. It also includes a new way of drawing collaboratively the
therapy plan. Further research is needed to explore the contribution of this new joint
conceptualization to the therapeutic alliance and therapy outcomes.

Introduction

Case conceptualization (CC) is considered as the heart of the evidence-based practice

(Bieling & Kuyken, 2003; Kuyken, Padesky, & Dudley, 2008), because it summarizes
the client's presentation and aims for evidence-based interventions. CC in cognitive-
behavioral therapy (CBT) is a process whereby a therapist and client work
collaboratively to form a hypothesis about the mechanisms causing and maintaining
the client’s problems. Based on the CC the therapist develops a treatment plan and
obtains the client’s informed consent to it. Then the therapist uses the CC to guide
intervention selection and other clinical decisions as the therapy progresses
(Jacqueline & Lisa, 2015). CC-driven treatment is extremely important and has better
outcomes comparing to protocol-guided therapy especially when treating clients
with co-morbidity (Persons, Roberts, Zalecki, & Brechwald, 2006). Multiple disorders
pose complex challenges such as whether these disorders are linked together, how
they maintain each other, which disorder to target first or perhaps it would be better
to target common factors simultaneously, and what therapy plan would better suit
this particular client. Since the CC is tailored according to the client's idiographic
characteristics, it provides a comprehensive frame of hypotheses about the
interrelations of the components and better flexibility in adapting interventions to
the client's specific needs.

One of the comprehensive idiographic CCs emerged from Schema Therapy, which
was developed for treating personality disorders, enduring psychopathological
disorders such as chronic depression, as well as co-morbid disorders (Young, Klosko
& Weishaar, 2003; Ball & Young, 2000; Malogiannis et al., 2014). Schema Therapy
(ST) was developed from CBT and incorporated other approaches such as
Psychodynamic and Gestalt therapies to form an integrative model for treating
challenging axis I and Axis II clients. Young et al. (2003) emphasize the importance of
developing an individualized CC and recommended doing so using an integrative
written form that describes the client's early developmental processes, unmet
emotional needs, early maladaptive schemas, coping styles, modes etc. CCs
developed by schema therapists describes which of these components were
consolidated into defeating life patterns, and how they are inter-connected to the
client's presenting problems, and maintain them.

The written CC suggested by Young and his colleagues is very comprehensive yet
complicated and long (often taking up to 10 pages in length), as can be seen in a
filled-in example schema therapy case conceptualization form (International Society
of Schema Therapy, 2018). In recent years, schema therapists have placed greater
focus on a briefer conceptualization, which places an emphasis on modes (rather
than schemas or coping styles). ST defines modes as self-states that represent the
client's set of cognitions, emotions, and behaviors at a given moment (Rafaeli,
Maurer & Thoma, 2014; Peled, Bar-Kalifa & Rafaeli, 2017; Bach & Bernstein, 2019).
As such, each person has several modes (or self-states) characterizing his/her
personality (e.g. child modes, coping modes, internalized parent mode, and healthy
adult mode). {Insert Figure 1 here}.

Arntz (2012) was the first to conceptualize the modes relevant to the client in a
visual drawing and paved the path to a simpler way of explaining the client's mode
repertoire. In these drawings, the modes are represented as circles. Thus, the more
dominant the mode, the bigger is its circle (Figure 1). Rafaeli et al. (2014) used
Arntz's mode drawing to illustrate the sequence of activation and shifting from one
mode to another (Figure 2). By that, they added better understanding of the
dynamic characterizing the client's modes. On the other hand, just as Young et al.’s
(2003) written CC is long and complicated, it seems that Arntz's mode drawing
conceptualization is too minimal. {Insert Figure 2 here}.

This paper suggests a new ST case conceptualization that combines elements from
Young and Arntz CCs into a visual mode map drawing created collaboratively by the
therapist and the client, in a way that explains the client's presenting problems and
their connection to the origins and the mechanisms maintaining them. Then, such a
CC allows the therapist to draw a construct of a therapeutic plan by asking the client
guided questions such as which modes need to get strengthened and which should
be weakened in order to address those problems in healthier ways.

The next section will start with an illustration of a therapeutic dialogue that
summarizes information from the assessment phase (for further reading on ST
assessment see Young et al., 2003) and draws upon it to create this new visual CC.
Note the guided questions the therapist uses in order to characterize the different
modes, their functions, and to elicit the client's names for them [the ST generic name
appears in brackets]. Then, a drawing of the therapy plan will describe the mode
changes that need to take place as therapy progresses. The procedure section will
detail the process of eliciting the mode map and the therapy plan and the last
section will summarize this paper.

Case Illustration

David (D) is a 32-year-old, single man, who works part-time as a private music
instructor. He is diagnosed with avoidant personality disorder, and lives with his
parents. He sought therapy because he felt lonely and stuck in his life.

The therapist (T) focuses on the presenting problems and writes them on the board.
As the dialogue with the client progresses, the therapist draws each mode and writes
its unique characteristics, and draws arrows to describe the interrelations between
modes.

{Insert Figure 3 here}

T: In this session I would like us to summarize the problems that bother you, their
origins, what keeps maintaining them, and in the end what should be changed in
order to pursue your goals.

D: OK

T: Let's start with the current problems. 1. You feel lonely, and you find it difficult to
make friends. You would like to have a romantic relationship, but you avoid
connecting with other people. 2. You wish to study, have a career, and live in your
own place, but your avoidance of people and of new situations holds you back. Is
there anything else?

D: No, you describe it well. That is what I meant when I said I feel lonely and stuck.

T: So, we can write these on the board. Let's see how these difficulties developed
and what happens today. This circle represents a part in you, a mode, which contains
some innate traits. For example, you are very smart and talented in music. This part
also needs some time to warm up before you feel comfortable enough to connect
and explore your surroundings. This is probably your innate temperament.

Additionally, this mode contains the basic emotional needs relevant to all of us. In
your case, you really need to feel secure, loved, and welcomed in order to form
relationships. You also need to feel competent and self-reliant to initiate things, but
instead you said you feel lonely, sad, rejected, and inferior in comparison to others.

These feelings are related to some schemas we explored last time, such as:
Emotional Deprivation ("no one is really interested in me"); Defectiveness and
Shame ("I have so many flaws; if someone will know me, he'll reject me"); and
Failure ("I can't do it, it won't work"). How would you like to call this part?

D: I don't know… maybe Lonely David.

T: Yes, it captures well what you feel in this part. Since when were you aware of this
part?

D: I guess since childhood, somewhere around elementary school I really felt lonely
and rejected.

T: So, would it be right to call it – Little Lonely & Rejected David [The Vulnerable
Child Mode]?

D: Yes, it seems accurate.

T: Would you agree that there is this other part in your life that causes Little David
feel so lonely and rejected? When you are in this mode, I heard it saying "David - you
are so stupid, weak, fat and ugly. What’s going to become of you? No one is really
interested in you. Look at everybody else, they are all better than you".

D: Yes, I hear this part shouting loudly in my head most of the time. But I really think
it is right.

T: So, I guess a big circle should represent this mode. And you said it shouts loudly.
What does it sound like?

D: It should get the biggest circle. It sounds harsh, punitive, degrading.

T: Who used to shout at you this way and call you these names?

D: Mostly my father and my big brother, and even some kids at school.

T: What name you would like to call this part?

D: The Degrading Voice [The Punitive Parent Mode].

T: That is a perfect name for this mode. The Degrading Voice came from your father,
brother, kids at school, and today many others seem to you as taking on this voice,
and you do it to yourself as well. This degrading part constantly attacks Little Lonely
David and makes him feel rejected, insecure, and sad.

D: I never thought about it this way, but it is exactly what happens inside me. No
wonder I feel so miserable most of time, if this is the way I treat myself.

T: I am glad you said that, and we will need to see what you should do with this
degrading voice. But for now, let's see the coping side in you, which usually prefers
to avoid situations. What does this part say?

D: It is better not to try to initiate anything; don't speak, nobody will listen anyway;
staying home will hurt less, there is nothing to do to change the way things are. Here
I really feel hopeless, helpless, and defeated.

T: So, in a way this part comes to help Little David not to have any desires that The
Degrading part will then mock. But, on the other hand it doesn't connect to Little
David, and keeps him lonely, incapable and it reinforces the schemas inhabited
there. How would you like to call this part?

D: I guess The Pessimistic Avoiding Voice [The Avoiding Protector Mode].

T: Yes, you are very right, this side is very pessimistic, and holds you back from
meeting your needs for close relationships, to belong, and pursue your goals. Maybe
we'll draw a barrier to illustrate how the pessimistic avoiding voice blocks
opportunities to fulfill Little David's emotional needs. Instead, it invests its efforts to
avoid situations that might trigger The Degrading Voice.

D: Wow, this is exactly what happens inside me. I always knew that I avoid situations
because it feels less stressful. But in the end of the day it just empowers The
Degrading Voice and gives no chance to the real me to grow and become the man I'd
like to be.

T: You phrase it so nicely. It really moves me. Yet, you have another part, which is
very generous, compassionate, warm and caring especially for people in need.

D: Yes, I almost forgot this part. I believe these people deserve a chance and they can
do much better if only they will get some attention. When I work with my guitar
students, I always see that when I'm patient and encouraging they do much better
and play things they never tried before.

T: It is fascinating how much you can invest in your students. But which part of you
will take good care of Little David? How would you like to call this part?
D: Maybe Caring David [The Healthy Adult Mode]... But I don't like Little David. I
never thought I am the one who needs to take good care of this Little David. I don't
know how to do it.

T: Caring David is a great name, and it seems that Caring David should take a bigger
role in your life. What should he do with the other modes?

D: Now that I look at this board I need to find a way to stop the Degrading Voice, and
replace the Pessimistic Avoiding Voice with more encouraging messages and
assertive behaviors. Not that I have a clue how to make it happen.

T: And what about Little Lonely David? What does he need from Caring David?

D: He needs to grow up and have better care. How will all of this happen?

T: This is exactly our therapy plan. As you said, Caring David should stop the
Degrading Voice; and should make the Avoiding coping mode less prominent by
conveying more encouraging messages, taking more calculated risks in initiating
things and by using more assertive behaviors; and most importantly, the Caring
Mode needs to connect to Little David in a warm and caring way to foster him. We
will work very hard to identify moment-to-moment which mode is present; what the
mode does and what it doesn't do for you at that moment; and we will use various
techniques to promote the desirable changes. What do you say?

D: I would really want to get there.

{Insert here Figure 4}

Procedure

The CC is usually presented by the therapist around session five as a summary of the
therapy assessment phase (Young et al., 2003). Based on Young's particular
collaborative way of constructing the client's mode model, in this new CC the
therapist opens the summary assessment session with a suggested agenda by
conveying a rationale such as "In this session I would like us to summarize the
problems that bother you, their origins, what keeps maintaining them, and in the
end what should be changed in order to pursue your goals". With the client's
collaboration the therapist starts with the main presenting problems and writes
them on the board. Then, along with the client, the therapist organizes, step by step,
the client's story into a mode tale in clear language by using the client's own words
as much as possible.

If the client has difficulties getting in touch emotionally with his/her vulnerability and
relies heavily on overcompensation strategies (as is often the case with individuals
who have Narcissistic, Antisocial, Paranoid, Obsessive-Compulsive personality
disorders, etc.), the therapist might consider starting with the most prominent
coping mode. Otherwise, it might be better to start with The Vulnerable mode and
describe it in a gentle, warm, appreciating tone of voice, as a good parent would do
(see Limited Reparenting in Young et al., 2003). With this mode, the therapist first
addresses the client's innate strengths and some of his/her innate difficulties. Since
The Vulnerable mode is strongly connected to the core emotional needs, the
therapist relates to the client's unmet needs and reassures them as universal human
ones. These unmet needs lead to the emotions characterizing The Vulnerable mode
and to the client's core believes as described in his/her early maladaptive schemas
(EMSs). All this information is written in one corner of the board in headlines
(Temperament, Core Emotional Needs, Feelings, and Schemas) under a circle
representing the size of this mode. In order to identify this mode as a child mode,
the therapist can ask the client "since when were you aware of this part in you?"
Assisted by the therapist, the client is asked to name this mode in his/her own words
(as will happen with each of the other modes) to make the CC more personal.

From The Vulnerable mode the therapist moves on to describe The Dysfunctional
Parent mode, in order to emphasize its destructive attitude towards the vulnerable
side. The therapist starts with describing a side in the client's life that causes him/her
to feel those vulnerable painful feelings. By addressing this depriving mode in the
third person the therapist implies that, although this mode is strongly internalized,
its origins were derived from repeated harmful interactions with significant others.
The therapist repeats in the second person ("you are…") some of the harmful
statements the client has expressed towards him/herself in the previous sessions, or
that have been hurled at him/her from others over the years. These sentences draw
on some EMSs (for instance the punitive schema) that color the unique features of
this mode. The therapist says these statements in an unpleasant and harsh voice to
mimic the tone in which they have been delivered probably again and again over the
years. Then the therapist writes them on the opposite corner of the board under the
Messages headline. With some guided questions (such as "what does this voice
sound like?"; "who used to talk to you this way?"; "how does this mode affect the
vulnerable side?") the therapist helps the client to recognize the tone of voice, the
origins, and the ways this dysfunctional mode hurts his/her vulnerable mode. This
gathered information is written in headlines close to a usually big circle that
represents the heavy dominance of this internalized Dysfunctional Parent (and/or
environmental) mode. The client is asked to choose a name, and an arrow is drawn
to connect the two and to illustrate the negative impact of this mode on the
vulnerable side. This procedure paves the way to gradually externalizing this harmful
mode.

After drawing this miserable internal mode relationship, the therapist presents the
coping modes that have been established in order to handle those unbalanced
internalized forces. With some guided questions (such as "what does this part say?";
"how does it feel when you are on this side?"; "how does this side help/protect
you?"; "what are the disadvantages of this part?") the therapist elicits from the client
the cognitions, emotions, and behaviors typical for these coping modes and write
them in the middle of the board (under the headlines: Thoughts, Feelings, and
Behaviors). The therapist uses Empathic Confrontation when dealing with the coping
modes (Young et al., 2003). On the one hand, the therapist is empathic to the client's
motive to protect his/her vulnerable side from the internalized Dysfunctional Parent
mode and external perceived threats. On the other hand, the therapist gently
confronts the coping strategies that perpetuate the client's enduring problems and
prevent opportunities to get his/her needs met appropriately. In case there is more
than one coping mode (e.g. overcompensating, avoidant/detached,
compliant/surrender modes) each one of them gets a circle according to its
dominance. These modes are placed in the middle of the board to illustrate their
defense functions and their role in the relationship between the unmet emotional
needs and the perceived threats represented by the Dysfunctional Parent mode. An
arrow is drawn from the coping mode to the Dysfunctional Parent mode to illustrate
the defense orientation against internal and/or external threats, while a barrier may
be drawn between the coping mode and the vulnerable mode in order to
demonstrate how it neglects the unmet core needs.

Finally, the therapist turns to describe The Healthy Adult mode, which represents the
client's strengths, resources, and prominent good qualities, as well as his/her
matured and balanced strategies to handle situations. The therapist lists these
virtues in an admiring voice to empower this mode. Often the client is
compassionate with some others in need, yet these qualities are inaccessible when it
comes to how he/she treats him/herself. As with all the other modes the client is
asked to identify this mode by naming it. On the board, under the headlines Tone,
Thoughts, and Behaviors, the therapist fills-in this mode's characteristics under a
circle sized according to its prominence. The Healthy Adult mode is placed below The
Dysfunctional Parent mode and in alignment to the other modes to mark it as a
better alternative.

After the client goes through the visual representation of all his/her modes and their
current interrelations, the therapist approaches the final step, that of eliciting the
therapy plan. The therapist poses several questions relating to the different modes
by using the unique names the client chose (such as "which of these modes could
take a good care of the little… [The vulnerable mode]?"; "what little… [The
vulnerable mode] needs from… [The Healthy Adult mode]?"; "what would you like to
do with… [The Dysfunctional Parent mode]? and with… [The coping modes]?";
"which mode is better to be more attuned to?"; "how would you like this map to
look like at the end of therapy?"). Based on the client's answers the therapist draws
on the same board, with a different color, the therapy plan by changing the sizes of
the modes, stretching new arrows from The Healthy Adult mode to each of the other
modes and by adding + or – to mark which one needs to be strengthened or
attenuated as the therapy progresses.

This step-by-step procedure creates a collaborative idiographic CC and a therapy

plan as a joint product. Often clients are deeply moved by this session and feel really
understood from within, and usually the therapeutic alliance grows. The client is
encouraged to have a copy of this drawing and this CC serves as an evolving point of
reference along the therapy journey.

Summary

This paper proposed an evolution in ST therapy case conceptualizations and

suggested a new CC which combines important information from the assessment
phase with a visualized drawing of the modes and their interrelations. The case
illustration focused on a client diagnosed with an avoidant personality disorder, and
described some of the most common modes in this diagnosis (Arntz, 2012; Bamelis,
Renner, Heidkamp, & Arntz, 2011; Peled et al., 2017). On the same basis, other
modes common in a different diagnosis (such as The Angry Child mode, The Over
Compensating Modes, The Compliant-Surrender Mode etc.) can be drawn and
contain their special characteristics. The procedure section detailed the craft of
collaborative elicitation of the client's idiographic mode map, the guided questions
the therapist adjust to each mode, his/her differential therapeutic stance and the
vocal tone utilized to address each distinct part, and finally the joint path of drawing
the therapy plan.

This new conceptualization tries to make ST psycho-education and conceptualization

communicative, simple yet comprehensive. This new CC also includes another step,
that of drawing the therapy plan and how the modes need to change as the therapy
proceeds. The practice of creating this CC is made in collaboration with the clients,
according to the ST spirit, with the inherent purpose of empowering the therapeutic
alliance. Further research is needed to compare this new CC and existing ST CCs and
their contributions to the therapeutic alliance and therapy outcomes.
Figure 1: Mode model of avoidant personality disorder (from Arntz, 2012)
Figure 2: Illustrative model of a client's characteristic mode activation sequence
(from Rafaeli et al., 2014)

The Degrading
Current Problems:
Voice (father,
The 1. Lonely, few
brother,
Pessimistic friends
others)
Avoiding 2. Stuck in life:
Voice study, career,
Little Lonely Rejected
David Messages: You are living on your
Temperament: Smart, stupid, weak, fat, ugly; own
Thoughts: It is better
talented in music, slow what would become of
not to initiate Caring
to warm up David you; no one is
anything; don't
Core Emotional Needs: interested in you;
speak, nobody
1. To feel secure, others are better than
listens anyway;
loved, welcome Tone: warm, you.
staying home hurts
2. To feel compassionate, Tone: Loud, harsh,
less; nothing can be
competent, self- caring punitive, degrading,
done to change
reliant Thoughts: people
things.
Feelings: lonely, sad, Feelings: hopeless, deserve a chance
rejected, inferior and attention
helpless, defeated.
Schemas: Emotional and they'll do
Behavior: avoid
Deprivation (no one is situations; keep better
really interested in me); Behaviors:
silent; refrain from
Defectiveness and encouraging,
initiating
Shame (I have so many takes care
flaws, others will reject
me); Failure (I can't do
it, it won't work)
Figure 3: Mode circles and their interconnections
 The Degrading Current Problems:
Little The Voice (father, 1. Lonely, few
Pessimistic
David Avoiding
brother, friends
voice others) 2. Stuck in life:
Temperament: Smart, - -
study, career,
living on your
talented in music, slow
to warm up + Thoughts: It is better
Messages: You are own
Core Emotional Needs: stupid, weak, fat, ugly;
not to initiate Caring what would become of
3. To feel secure, anything; don't
loved, welcome David you; no one is
speak, nobody interested in you; others
4. To feel
listens anyway; are better than you.
competent, self- staying home hurts
reliant Tone: Loud, harsh,
less; nothing can be Tone: warm,
Feelings: lonely, sad, punitive, degrading
done to change compassionate,
rejected, inferior things. caring
Schemas: Emotional Thoughts: people
Feelings: hopeless,
Deprivation (no one is helpless, defeated. deserve a chance
really interested in me); Behavior: avoid and attention and
Defectiveness and they'll do better
situations; keep
Shame (I have so many silent; refrain from New Behaviors:
flaws, others will reject Confronts degrading
initiating
me); Failure (I can't do messages, acts
it, it won't work) assertively, takes
calculated risks,
fosters Little David

Figure 4: The Therapy Plan - Mode Changes

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