When might a clinician choose to use a mode approach rather than the simpler schema approach described thus far? In our practice, the higher functioning the patient, the more likely we are to emphasize “standard” schema terminology (as described in the earlier chapters of this book); the more severely disordered the patient, the more likely we are to emphasize mode terminology and strategies. For patients in the middle range of functioning, we tend to blend the two approaches together, referring to schemas, coping styles, and modes.
We might shift from a simple schema approach to a mode approach when the therapy seems stuck and we cannot break through the patient’s avoidance or overcompensation to the underlying schemas. This might happen with a patient who is very rigid and avoidant or almost continuously in an overcompensating mode, such as patients with obsessive-compulsive or narcissistic disorders are likely to be.
We might also shift to a mode approach when the patient is rigidly self-punitive and self-critical. Usually this is an indication of an internalized dysfunctional parent who is punishing and criticizing the patient. The clinician and patient can then join forces, allying against this Punitive Parent mode. Labeling the mode in this way helps the patient externalize the mode and make it more ego-dystonic.
We might shift to modes with a patient who has a seemingly unresolvable internal conflict: for example, in whom two parts of the self are locked in opposition about a major life decision, such as whether to leave a long-term relationship. Each part of the self can be labeled as a mode, and the two modes can then conduct dialogues and negotiate with one another. Finally, we generally emphasize modes with patients who display frequent fluctuations in affect, such as often occurs with patients with BPD who repeatedly flip from anger to sadness to self-punishment to numbness.