Schema Therapy: An Experiential Approach to Dealing with Maladaptive Schema Mode

Early adverse childhood events lead formation to maladaptive schema and schema modes. Maladaptive schema modes are triggered by life events in adult life causing intense unpleasant emotions. Schema therapy provides an experiential approach to understanding and changing schema and modes.


Introduction
Schema is formed in an individual and is influenced by interactions with others, culture and upbringing. Schema is present in everyone with or without psychological disorders. Early maladaptive schema was proposed by Jeffrey Young as a pervasive dysfunctional pattern of emotions, thought and sensations associated with one's relationship with others, developed as a result of early aversive childhood events [1]. These significant unpleasant early experience leads to formation of maladaptive schemas that is linked to maladaptive schema modes. Schema mode refers to transient emotional and behavioral response to a live event [2]. Schema mode often triggers strong unpleasant emotions. The types of schema and schema mode are listed in Table 1 [3].

Schema Therapy
Schema therapy is one of the proposed solutions to deal with early maladaptive schema [4,5]. Schema therapy focused on dealing with maladaptive modes through cognitive and experiential techniques [4]. Schema therapy uses imagery rescripting to allow patient to re-experienced early traumatic event in a controlled manner whereby needs are met without being overwhelmed by negative emotions related to the event. Imagery rescripting is a visualization process used to change meaning and emotions related to a past traumatic event. [6,7] The process allowed emotions to be processes while providing unmet needs, care and support experientially. In addition, imagery rescripting assist patient in building healthy adult mode via modeling provided by the therapist.
Other general therapeutic techniques used in schema therapy includes schema diary, chair work, limited reparenting, attunement and behavior pattern breaking. Limited reparenting involves providing warmth, care and acceptance to meet core needs of the patient. It also involved identifying and limit undesired behavior.
Limited reparenting essentially assists in emotional healing while building healthy adult mode [2]. Attunement refers to empathy and understanding expressed by the therapist via verbal and nonverbal responses to patient's emotional distress [8].

Benefits of Experiential Approach in Therapy
Cognitive behavioral therapy has been repeatedly proven to be an effective treatment for depression [9]. Nevertheless, there are studies that showed up to 50% of individuals do not respond fully [10]. Many depressed patients are stuck in maladaptive coping mode despite being able to intellectually understand their cognitive errors. Schema therapy may be an alternative therapy for dealing with maladaptive coping style related to depression via a more experiential approach. Experiential approach in therapy provides an opportunity for patients to experience unmet needs being met during therapy and thus soothe emotional distress. In addition, patients are able to experience the link between automatic thoughts and negative emotions and thereby reinforcing their understanding of the connection. Schema therapy also allow patients to learn ways to confront cognitive errors through a more experiential approach in chair work and imagery rescripting. This is especially useful for patients who have difficulties dealing with automatic thoughts cognitively.

Vulnerable Child and Avoidant Protector Mode
A 25 years old lady presented with symptoms of Major Depressive disorder following an accidental discovery of her own adoption. She no longer enjoys social gatherings and preferred to spend most of her free time in her room away from friends and from her adopted family. Her concentration was also greatly affected. She first discovered that she was adopted when she lost her birth certificate at the age of 13. However, her adopted parents insisted that the officer of the National Registration Department made a mistake. After persistent and repeated enquiries, her adopted parents finally revealed the truth to her about her adoption. Upon learning that she was adopted, her siblings and extended family demanded her to be left out of the will. Her adopted parents obliged to their demand. Her extended family no longer involved her in any family gatherings. In addition, she often felt hurt by negative passing remarks made by them about her. She found herself finding every opportunity to stay away from home and reduced the time spent with her adopted family (Schema mode: avoidant protector) At the age of 20, she made attempts to track down her biological parents based on the address given by the National Registration Department only to find out from her maternal aunt, who now lives there, that both of her biological parents had passed away in an accident a month ago. Her depression worsens when she discovered the passing of her biological parents. She lost hope in ever finding out why she was put up for adoption. Further exploration revealed that she had been battling with suppressed anger towards her biological parents for abandoning her (Schema mode: Angry protector). She felt unwanted by both her biological and adopted family and was no longer able to trust them. She felt that she no longer belongs to her adopted family. She felt irritated even just by looking at members of her adopted family. Nevertheless, she felt extremely guilty for feeling angry towards her adopted parents and thus often kept her anger hidden. She tried to intellectualized that she should be grateful to her adopted parents who raised her, provide her with food, shelter and education. The feelings of guilt were further reinforced by strong element of filial piety in Asian culture whereby anger towards parents were perceived as negative and unacceptable.
She was sensitive towards others perception of her and often worried that others would know about her adoption. She was particularly touchy whenever the word 'adoption' was mentioned. It triggered feelings of inadequacy, unwanted and unloved (Schema Mode: Vulnerable child). She also had difficulty forming meaningful romantic relationships due to fear of betrayal and abandonment (Schema mode: vulnerable child). She found herself withdrew and avoid being close to any potential suiters (Schema mode: avoidant protector).

Figure 1:
Interplay between early traumatic experience, schema and schema modes * Perceived others will abandon her [3]. **Perceived others as not trustworthy and unreliable [3]. ***Obliged to the control or needs of others and ignore own emotion of needs [3]. Patient underwent schema therapy to deal with her experience. As part of the therapy, patient was asked to record daily stressful events that triggered strong unpleasant emotions in schema diary. Following that, related schema and schema mode were explored and identified. The interplay between schema, schema mode and maladaptive responses in adulthood was shared with patient to help her understand her distress. (Figure 1) Unpleasant childhood memories triggered when schema mode was activated were identified. Attunement during exploration of unpleasant memories allows tracking of patient's emotions and psychological needs. Patient was encouraged to give feedback during session to foster a collaborative approach in therapy. This helps reinforced therapeutic alliance. Good therapeutic alliance is important for further therapeutic work such as imagery rescripting and chair work in schema therapy.
Imagery rescripting of unpleasant childhood incidents were done over several therapy sessions. Imagery rescripting focus on rectifying emotional experiences related to the event by meeting the patient's needs to feel wanted and belong during therapy session. Chair work was done on avoidant protector mode. Chair work allows dialogue between patient and avoidant protector mode to bring awareness of the impact it has on patient's life. Initial focus of therapy session was on restructuring maldaptive schema mode. Patient was coached to form healthy response to avoidant protector mode via modeling. Limited reparenting was also useful to reinforced formation of healthy adult mode.

Conclusion
Maladaptive schema and schema modes are often found in patients with depressive disorder. Careful exploration of childhood history may reveal series of related significant childhood emotional trauma. Schema therapy deals with these challenging maladaptive schemas modes via an experiential approach which allows restructuring of schema mode and development of healthy adult mode.