We illustrate the seven steps of schema mode work with the case of Annette. The following excerpts are from a consultation interview Dr. Young conducted with Annette, who was already being treated by another schema therapist named Rachel. At the time of the interview, Annette had been in therapy with Rachel for about 6 months.
Annette is a 26-year-old woman. She is single and lives alone in an apartment in Manhattan, where she works as a receptionist. At the start of therapy, her presenting problems were depression and alcohol abuse. She also reported a history of problems in relationships and at work: She had drifted from one relationship to another and from one job to another and had trouble disciplining herself to complete tasks at work.
Thus far in therapy, Rachel has approached Annette’s treatment with a combination of cognitive-behavioral strategies for her depression and alcohol abuse (in combination with Alcoholics Anonymous) and schema therapy. Rachel has had only limited success. Annette has realized that she is emotionally disconnected from other people and that she uses drinking and partying to blot out her feelings and fill the emptiness. Although she has gained in self-awareness, she is still depressed, and she continues to have episodes of alcohol abuse.
We considered Annette a good candidate for mode work, mainly because the therapy seemed stuck. Annette’s Detached Protector mode was so strong that she could not acknowledge any vulnerable feelings. Her inability to access her vulnerable feelings—her schemas—was blocking the therapy. This is an example of a common type of case in which the therapist can make headway through schema mode work: The patient is highly avoidant or overcompensated and cannot access schemas emotionally. In the following interview, Dr. Young uses mode work to break through the Detached Protector and reach the underlying schemas of the Vulnerable Child.
In this first segment, Annette describes her current goals in therapy.
THERAPIST: Can you tell me a little about your goals in therapy now?
ANNETTE: Well, I’d like to be happy. I’m depressed.
THERAPIST: I see. So mostly it’s the depressed feeling that’s bothering you?
ANNETTE: Yeah. I’m trying to change my lifestyle.
THERAPIST: Do you know what it is about your life that is making you depressed?
ANNETTE: Well, now I do.
THERAPIST: What have you learned that it is?
ANNETTE: Well, I don’t know how to show my feelings or talk about them. My family, they don’t discuss their feelings.
THERAPIST: So none of them can discuss, really, their feelings.
ANNETTE: Right. I’m close to my mother, but we’re more like friends.
THERAPIST: But like friends who don’t share feelings?
ANNETTE: Right.
THERAPIST: I see. Do you have girlfriends that you would share your feelings with?
ANNETTE: No.
THERAPIST: No. So you’ve always been a very private person?
ANNETTE: Uh-huh.
Without actually using mode language, Annette connects her depression to her Detached Protector mode. It is because she is emotionally disconnected from other people that she feels depressed.
THERAPIST: I see. Another thing you mentioned was not feeling good about yourself.
ANNETTE: Yeah.
THERAPIST: What are some of the ways you don’t feel good about yourself?
ANNETTE: Well, when I get depressed, I drink.
THERAPIST: I see.
ANNETTE: I just don’t feel good about myself.
THERAPIST: If you stop drinking, do you think you will then feel good about yourself?
ANNETTE: Well, like now I’m not drinking, but I don’t feel good about myself.
THERAPIST: So what is it? What do you think is underneath that you are not happy with about yourself?
ANNETTE: It’s just like, you know, my family and friends, and just, like, my lifestyle. It’s just really lame.
THERAPIST: I see.
ANNETTE: I need to change it.
Annette goes on to describe her romantic life. She had been having an affair with a married man but broke it off, and she is now dating a man who is stable and loving but who bores her: “Yeah, he’s like stable and normal and I lose interest.”
The therapist proceeds to the first step in mode work, identifying and labeling the patient’s modes.
This is typically a process that arises naturally as the therapist observes the patient’s thoughts, feelings, and behaviors from moment to moment. The therapist notices shifts in the patient and begins to identify modes associated with each state. As the modes appear in sessions or in the material the patient presents, the therapist starts to label the modes for the patient.
Therapists should be careful to ensure that a mode has been accurately identified before labeling it. The therapist should therefore gather a substantial amount of evidence and examples to illustrate the mode—both by repeatedly observing the mode in sessions and by listening attentively to the patient’s descriptions of incidents outside the session. Once the therapist has identified a mode, he or she obtains feedback from the patient about whether it seems to fit. It is rare for patients to deny the existence of a mode that has been identified correctly by the therapist. With rare exceptions, the therapist does not try to persuade patients to accept modes that they cannot intuitively recognize. Similarly, the patient plays an integral role in naming a mode. The incorporation of a mode as a “character” in the therapy is always a collaborative process.
The therapist and patient work together to individualize the name of each mode to capture the specific strategies the individual patient utilizes. Usually we do not use the exact names for the modes that we listed previously. Rather, we work with patients to find names for modes that more precisely fit their individual thoughts, emotions, or behaviors. For example, the Compliant Surrenderer mode might be relabeled the “Good Girl.” Instead of referring to the “Vulnerable Child” mode with a given patient, we might call the mode the “Abandoned Child” or the “Lonely Child.” Rather than the “Detached Protector,” we might call the mode the “Workaholic,” the “Wall,” or the “Thrill-Seeker.” Rather than the “Overcompensator,” we might call this mode the “Dictator,” the “Bully,” or the “Status-Seeker.” We try to work with the patient to find a name that captures the essence of what the patient is doing or feeling in the mode.
Most patients relate well to the concept of modes. When the therapist asks the patient, “Which mode are you in right now?” the patient can say, “Right now I’m in my Compulsive mode,” or “Right now I’m the Angry Child.” The model tracks the patient’s internal experience of shifting affective states.
In the following segment, the therapist helps Annette begin to identify and label her principal modes. As the segment begins, Annette is describing her feelings of boredom. The therapist explores what lies underneath her boredom.
THERAPIST: So you are craving some kind of stimulation all the time?
ANNETTE: Uh-huh.
THERAPIST: You always want things to be new and different. When you start to feel really bored, what does that feel like? Have you ever let it go on enough time to feel that emotion?
ANNETTE: I’m, like, really hyper. I mean I get wound up. Like if I stay home, let’s say, all weekend.
THERAPIST: Yes. Let’s say you stayed home all weekend.
ANNETTE: Yeah. I did that last weekend.
THERAPIST: What was that like?
ANNETTE: I was, like, a little depressed. I was losing my mind.
THERAPIST: I see. So what’s interesting is that you were telling me you were bored, but now you’re saying you were really depressed.
ANNETTE: Well, I was both.
THERAPIST: Yeah, I’m wondering if “bored” is the term that you use to yourself to not have to acknowledge the fact that you’re really depressed underneath?
ANNETTE: Probably.
Underneath Annette’s boredom lies the depression of the Vulnerable Child mode. The therapist will explain this to Annette later.
The therapist helps Annette identify the mode that she and the therapist call “Spoiled Annette.” (We do not usually use pejorative labels, but the patient alluded to this idea herself.) This mode is a variation of the Impulsive/Undisciplined Child. Although Annette has been somewhat successful recently in fighting this mode, it still creates problems for her by causing her to do whatever feels good in the moment—such as drinking and partying—rather than what is beneficial in the long run, such as developing more lasting intimate relationships or a career.
The therapist continues to explore the depression underneath Annette’s boredom. The interchange leads to the identification of Spoiled Annette.
THERAPIST: So what’s happening is that, when things are too calm, there’s time to think about the depressed feelings underneath. When things are active and stimulating, it sort of pulls you away from having to think about those painful things.
ANNETTE: (in an annoyed tone) Well, I don’t always think about them, it’s just too much work.
THERAPIST: I see. (Pause) When you say it’s too much work, what does that mean? Is it just too much of a nuisance?
ANNETTE: (still annoyed) Well, because I used to, when I was bored, I would go out with my friends and get drunk and I wouldn’t have to think about anything. Now it’s just, I have to have all these feelings and stuff, and I’m not used to it.
THERAPIST: So, this sounds like you resent that you even have to do it.
ANNETTE: (Laughs.)
THERAPIST: You know what I mean, like you shouldn’t have to do this. Can you tell me more about that side that shouldn’t have to do this?
ANNETTE: (half-joking) I shouldn’t have to do anything I don’t want to do, right?
THERAPIST: I see. You said, “right,” as if you expected me to agree.
ANNETTE: Well, aren’t you going to agree?
The therapist explores the thoughts and feelings of this entitled part of Annette.
THERAPIST: You mentioned how both your parents let you do anything you wanted to do. But you said you realized it wasn’t right.
ANNETTE: I wouldn’t do it if I had a kid; I wouldn’t do it now because I can see the damage.
THERAPIST: But, even though intellectually you see the damage, emotionally you still have the feeling that you shouldn’t have to do anything you don’t want to.
ANNETTE: Yeah, ’cause I have a temper. It’s like, if I don’t get what I want, I just have, like, a fit.
THERAPIST: I see, like a kid throws a tantrum.
ANNETTE: I don’t go around throwing things.
THERAPIST: What would it be like?
ANNETTE: If I can’t get my way, like with my parents, I just won’t go with them. I’ll go off by myself.
THERAPIST: Like you’re punishing them?
ANNETTE: (animated) Yeah, that’s it. I punish them. That’s exactly it.
THERAPIST: I see. You punish them because they’re not giving you what you want?
ANNETTE: Yeah. Exactly. I mean, I only spite myself. I suffer for it, nobody else does, but I do it anyway.
In the next segment, the therapist labels “Spoiled Annette” as a mode.
THERAPIST: So there is a part of you, I don’t want you to hear this as a criticism, but it sounds like a spoiled part of you.
ANNETTE: (Laughs.)
THERAPIST: Does that seem, feel, right? There’s a part of you that feels you should be able to do whatever you want to?
ANNETTE: (Laughs.) Are you saying that I’m a brat?
THERAPIST: No, I wasn’t saying a brat. I’m saying there is a part of you that was spoiled by your….
ANNETTE: (Interrupts.) Oh, yeah, I was kind of spoiled, I guess.
THERAPIST: I wasn’t saying that it’s the only part of you, because we’re going to talk about the other parts of you. But it is one part of you.
ANNETTE: Yeah, definitely.
By making the “spoiled” part of Annette into a mode, the therapist is able to acknowledge this part of her while still remaining allied with her. This ability to confront patients while preserving the therapeutic alliance is an advantage of the mode approach: the therapist can confront the dysfunctional aspects of the mode without condemning the patient as a whole person.
As the interview continues, a second mode arises that proves to be both more difficult and more important than Spoiled Annette. This is the mode the therapist calls “Tough Annette,” a variant of the Detached Protector.
In the first segment following, the therapist continues speaking to Spoiled Annette. In the excerpt following that, the therapist tries to access the Vulnerable Child, but the way is blocked by Tough Annette.
THERAPIST: How did you feel about having to do this form? Did that, too, feel like a waste of time? Boring?
ANNETTE: I just felt, “Why do I have to fill out another form?” I filled out forms you already have to look at.
THERAPIST: So you felt resentful?
ANNETTE: I did it, but, you know, it was hard to get started.
THERAPIST: So you pushed yourself to do it because you knew you were supposed to?
ANNETTE: Well, because, you know, I was being nice. I was being nice because Rachel [her therapist] wants me to be nice.
In the next excerpt, the therapist tries to discuss Annette’s attachment to her therapist, Rachel, as an inroad to reach the Vulnerable Child.
THERAPIST: Well, that goes back to my question, whether part of the reason you’re being nice is for Rachel?
ANNETTE: Well.
THERAPIST: There’s nothing wrong with that, if that’s part of the reason.
ANNETTE: I don’t know. I like Rachel, she helps me, so I want to change and get better.
THERAPIST: Do you want her to be proud of you?
ANNETTE: I don’t know.
THERAPIST: It sounds like you’re afraid to admit you have an attachment to Rachel over this time. Is it hard for you to acknowledge feeling like that?
ANNETTE: I don’t know. It’s just different.
The therapist identifies “Tough Annette” to the patient, the part of her that is reluctant to acknowledge that she depends on other people for help.
THERAPIST: You know, you have this kind of a tough act. I don’t know what you want to call it, but you come across a little bit tough.
ANNETTE: I am tough. It’s not an act.
THERAPIST: I see. But, on the other hand, you also look a little bit nervous.
ANNETTE: (more vulnerable) I am nervous.
THERAPIST: So there must be another part of you underneath that doesn’t feel as tough as you look. So I’m feeling your toughness is partly an act or partly a mechanism to look strong to other people.
ANNETTE: It’s just what I’m used to. I’ve always done this.
The therapist labels “Tough Annette” as a mode and distinguishes her from the core person. It is the Vulnerable Child—the one who is “nervous”—who is core.2 Tough Annette is an “act” or a “mechanism to look strong to other people.”
As part of the second step in mode work, the therapist helps patients understand and empathize with their modes. Together the therapist and patient explore the origin of each one and the function it has served. Many modes have had some adaptive value for the patient. The therapist asks questions to guide the patient: “When do you first remember feeling this way?” “Why do you think you developed this mode as a child?” “How is the mode affecting your life now?”
We return now to Annette to illustrate this second step. Having identified Tough Annette, the therapist helps Annette explore the childhood origins of the mode.
THERAPIST: Are your mother and father tough, too?
ANNETTE: No, my father, he is, I don’t know what he is, we’re not really close. But my mother is nice; she doesn’t have a tough act at all.
THERAPIST: When do you think you developed this sort of tough front? Do you remember at what age?
ANNETTE: I don’t know. I can just always remember, I’ve always been just tough.
THERAPIST: Like in the crib? (Laughs.) A tough baby?
ANNETTE: Yeah, I was tough (smiles). I don’t know, I mean I’m not sure, but probably ’cause I always want to protect my mother, so I have to appear that way. I don’t want anybody messing with her. So that’s probably why I’m like that.
THERAPIST: I see. Did your father mess with her? Did he mistreat her?
ANNETTE: No, I mean, they got married really young. So, I don’t know, they’re just different.
THERAPIST: What are you protecting her from then?
ANNETTE: I don’t know. Everyone, I guess. She’s just so nice. I don’t want anyone…. She’s kind of naive, like she’ll do something out of just kindness, and people will take advantage, and I don’t like it, so….
THERAPIST: I see, so you’re protecting her from other people who take advantage of her?
ANNETTE: Right.
THERAPIST: How do you think you got in that role of the protector?
ANNETTE: I don’t know.
THERAPIST: Maybe that goes back to you and your mother being so close. You got close, and maybe it wasn’t quite like a friend. Maybe she actually turned to you like you were a mother. Is that possible?
ANNETTE: Yeah. Well, you know, Rachel and I, we talked about that, if, like, I’m her mother.
Tough Annette originated in her childhood with her mother, who was weak and fragile, and her father, who was angry and seemed dangerous. Annette became her mother’s protector. The mode began as a way of shutting down her vulnerable emotions so that she could be strong for her mother. Tough Annette does not share her vulnerable emotions with anyone—she keeps other people at a distance.
It is important to show patients how their modes are creating problems in their current lives and how their modes are linked to their presenting problems. This gives patients a rationale for treatment and helps build motivation to change.
For example, if a patient says he is coming to treatment because he is drinking too much, then the therapist links this problem to the Detached Protector mode. The therapist says that drinking is one of the ways the patient avoids experiencing his anger about the abandonment, abuse, or deprivation that he felt as a child. The patient drinks in order to avoid his negative feelings and to switch into the Detached Protector mode. If the therapist and patient can work with the patient’s Vulnerable or Angry Child modes, then the patient can learn to cope with his emotions and get his needs met. He will then have much less need to drink to avoid his emotions, his schema-driven drinking will be reduced. (The therapist advocates Alcoholics Anonymous in addition, because many components of alcoholism are not schema-driven and need to be addressed independently.)
Annette connects Spoiled Annette to her difficulties sustaining a job, and the therapist uses this as an opportunity to link the mode to her current problems at work.
ANNETTE: Well, I don’t have patience, you know. I don’t like to have to do things I don’t really want to do.
THERAPIST: Uh-huh.
ANNETTE: You know, like, say at work and stuff like that. I don’t know, I just get aggravated.
THERAPIST: So, if they give you something that’s boring to do, for example, and you’re not interested in it, you resent having to do it?
ANNETTE: Yeah.
THERAPIST: I see. And what would you be saying to yourself to drum up your anger?
ANNETTE: I’d probably just say, “I want to get out of here. I want to leave.”
The therapist helps the patient explore the mode in connection with her problems at work. The therapist sets up a dialogue in which Annette plays Spoiled Annette and the therapist plays the Healthy Adult.
THERAPIST: OK, I’m going to try to play this sort of “healthy” side. I want you to make the best case you can for this more entitled side, so I can hear what it would really say. OK, first I’m going to be like the boss telling you what you have to do. I want you to tell me what you’re thinking inside as I’m saying these things, OK?
ANNETTE: OK.
THERAPIST: (as boss) “Well, Annette, you know you have to get this stuff done. It’s part of your job. We’re paying you money here, and you’re just not working hard enough.”
(as therapist) So what’s going through your mind? I want you to say out loud what you’re thinking. Tell me what you’re thinking to yourself.
ANNETTE: I would just think, like, you know, “Why do I have to work in general? I mean, it’s all just boring anyway,” you know?
THERAPIST: OK, now I’m going to be this other voice of, sort of, “health,” and so I’ll say, “Well, look, that’s just the way the world is. The world is set up so that, if you want to get something, you have to give something. We call it reciprocity. If you expect people to give to you, you have to give them something back. So why should you get clothing, food, and a nice place to live if you’re not giving anything back to the world? It’s only fair that you have to work to contribute your share.” Make the best case for why that’s not true.
ANNETTE: I wouldn’t understand. I would just say, “Why? Why does it have to be that way? Why do I have to do things? I can get things from my parents.”
THERAPIST: Yeah, well, maybe your parents won’t be alive forever? One of your fears is your mother dying. I think you said that.
ANNETTE: Probably.
The preceding dialogue helps Annette experience her Spoiled Annette mode. The therapist then summarizes what he believes is Annette’s primary conflict related to the Spoiled Annette mode and the Healthy Adult:
THERAPIST: So there is a real struggle. Because there’s a real strong part of you that really believes you should just be able to have fun and do what you want.
THERAPIST: Because?
ANNETTE: (sulkily) I can’t do any of that stuff. I have to go to work, and I used to miss work a lot, a lot. Now I’m like there, and I hate it.
THERAPIST: Yes, it sounds like it’s been imposed on you, the way you just said now, “I’m not supposed to.”
ANNETTE: (Laughs.)
THERAPIST: It sounds like someone has sort of pushed you, forced you.
ANNETTE: I wonder who that would be? (Laughs and looks over at Rachel.)
THERAPIST: Is that Rachel?
ANNETTE: She has pushed me.
THERAPIST: I see. Does it feel like you’re doing it to please her, or does it feel like the right thing to do and that’s why you’re doing it?
ANNETTE: No, I mean, I don’t know what’s exactly right, but I’m depressed, so I have to change, you know. I want to be different. ’Cause if I stay the same, I’m going to continue to be miserable.
THERAPIST: So the healthy part of you knows if you go in the direction you were going, you would get worse and worse and feel miserable. But this more spoiled, entitled part feels you shouldn’t have to be doing that. It’s a waste of time and you should be able to have fun and party.
ANNETTE: Right.
THERAPIST: And these sides are in conflict. The two sides in you are fighting each other.
ANNETTE: All the time.
THERAPIST: All the time. And what side wins most of the time lately?
ANNETTE: Lately I’m behaving. I go to work and I don’t go out and have any fun. Not that I don’t have fun, but I don’t go out with any of my friends. You know, that side is, like, winning lately, but I’m not exactly thrilled about it. It’s not that much fun.
The dialogue enables the patient to access her thoughts and feelings both when she is in the Spoiled Annette mode and when she is in the Healthy Adult mode, challenging Spoiled Annette.
In the next segment, the therapist goes from Tough Annette to Little Annette. Little Annette is the Vulnerable Child, the central figure in the mode work. The therapist has to get past Tough Annette to reach Little Annette. As the segment begins, the therapist is discussing how Annette defended her mother against her father when she was 7 years old.
THERAPIST: You were supplying your mother with the strength she didn’t have to stand up to him and to stand up to the world. So that’s your role.
But now the question is, “What happened to Little Annette?” So we have this tough girl who is 7 years old protecting her mother. And then we have the spoiled part of you, too, who’s able to do whatever she wants. Now what about the little girl who wants someone to hold her?
ANNETTE: She’s lost.
THERAPIST: Yeah.
ANNETTE: She’s nowhere.
THERAPIST: Can you feel her at all?
ANNETTE: Sometimes.
THERAPIST: When can you feel her? Can you feel her right now?
ANNETTE: A little bit. I’m a little vulnerable right now because I agreed to come here.
The therapist follows her vulnerable feelings.
THERAPIST: Actually, it is hard to do this in front of people. What does the vulnerable side feel about being here?
ANNETTE: I just feel like my family is all right. They’re obviously messed up, but they are not that bad, you know. So I just feel like a failure, like, from my family, ’cause they would never come and do this. And they don’t go to therapy, so I just feel like, I’m like the failure. I’m all messed up and they just seem to go on like everything is always OK, it doesn’t seem to bother them, but it bothers me.
The patient expresses feelings of defectiveness triggered by the therapy situation. In her family she is the “identified patient.” No one else is seeking therapy. The therapist allies with the Vulnerable Child against the family to offer her support.
THERAPIST: Yeah, well, let’s look at that idea that everything is okay with them, though. You said your mother is being taken advantage of all the time by people. Your father is closed off, inhibited, and critical of other people. They’re fighting all the time. That doesn’t sound that great.
ANNETTE: Right, but they don’t seem to get depressed by it like I do.
THERAPIST: Yes, because they let it out all the time through their anger; so, I mean, they’ve traded one set of symptoms for another.
ANNETTE: (angry at herself) They just accept it, like, for what it is, and I don’t. That’s the difference.
THERAPIST: (pause) What do I think is probably wrong with the way you grew up?
ANNETTE: What do you think?
THERAPIST: Yeah, what do I think is wrong?
ANNETTE: Well, my parents, they never talked about how they felt or … I told Rachel I can’t think of one time when my mother hugged me. We don’t even, I don’t even go near them. I mean I don’t even go this close to them ’cause I just feel strange about it.
But the way I look at it now, you see, my mother was just a kid herself when she got married and had kids. How can a kid take care of a kid?
Annette alternates between acknowledging the emotional desolation of her childhood and protecting her mother: She alternates between the Vulnerable Child in touch with her needs and the Detached Protector denying her needs are valid.
THERAPIST: Right. So that’s the problem. There was no one there to take care of you. But is that your fault that there was no one to take care of you, or is that …?
ANNETTE: (Interrupts.) No, it’s not my fault.
THERAPIST: So you are the victim of parents who were unable to adequately take care of your emotional needs. You grew up without affection, without empathy, without someone to listen to you and understand you. So you grew up alone, isolated in a room. That is very, very hard because really the most basic needs of children, other than food and clothing, are to be held and loved and cared for. So your most basic emotional needs never got met when you were a child. So no wonder you’re unhappy underneath. And no wonder it’s hard for you to reach out to other people. Does that make sense to you?
ANNETTE: Yeah, it makes sense.
Much of the progress in mode work derives from getting past the Mal-adaptive Coping modes, accessing the Vulnerable Child, and then re-parenting the child. Because the Vulnerable Child mode contains most of the core schemas, much of the schema healing takes place during work with this mode. The therapist attempts to demonstrate the advantages to the patient of modifying or giving up modes that are interfering with access to the Vulnerable Child.
Imagery often proves the most effective way for the therapist to establish a line of communication with the Vulnerable Child. The therapist asks the patient to access an image of the Vulnerable Child; the therapist then comes into the image as the Healthy Adult and talks to the Vulnerable Child. The therapist helps patients in the Vulnerable Child mode to express their unmet needs while the therapist tries to provide for these needs—safety, nurturance, autonomy, self-expression, limits—through “limited reparenting.” (We use this same exercise routinely, even when we are not doing “formal” mode work.)
The therapist asks Annette to form an image of Little Annette, the Vulnerable Child, but Annette refuses. The therapist helps her identify the sources of her resistance: Spoiled Annette and Tough Annette are refusing. Spoiled Annette does not want to work at something unpleasant; Tough Annette believes it is weak to be vulnerable and is blocking painful emotions to protect Little Annette. The therapist uses mode work to break through these two maladaptive modes to access the Vulnerable Child mode.
THERAPIST: How would you feel about trying an exercise in imagery to get to that child side of you?
ANNETTE: I can’t do it.
THERAPIST: Would you be willing to try?
ANNETTE: I don’t know. Rachel and I try to do it all the time. It doesn’t work.
THERAPIST: Sometimes, even if it doesn’t work, it might help me to figure out why, so that I can give some suggestions later on on how to get it to work for the next time. So even if it didn’t work, that wouldn’t be a problem.
All we need to do right now is figure out what’s making you resist it. We don’t necessarily have to overcome it today. Even if I could just understand why it’s hard for you to do the imagery, that would be helpful. Wouldn’t you like to help me to try to explore why it’s hard to do imagery for you?
ANNETTE: I guess.
THERAPIST: OK, so what are you feeling right now?
ANNETTE: I just don’t like to do it.
THERAPIST: Be that side of you that doesn’t want to do it so I can hear it.
ANNETTE: I don’t know. I just don’t want to do it. I don’t like to do things that I don’t really want to do.
Here Spoiled Annette is resisting doing imagery, because she does not want to do anything she does not feel like doing The therapist begins a dialogue with Spoiled Annette, empathically confronting her.
THERAPIST: OK, I’m going to play the Healthy side and say, “Well, you know I know it’s not easy for you, but sometimes it’s only by trying hard things that you can reach something that’s really important, that you can’t get to otherwise.” Play the other side so I can hear what it says back.
ANNETTE: I don’t like to do difficult things. It’s too much work.
THERAPIST: Would you try it anyway?
ANNETTE: I guess.
THERAPIST: All right. We’ll do it for 5 minutes and if you really hate it….
ANNETTE: (Interrupts in a tough, defiant voice.) If I hate it, I’ll tell you, don’t worry. How’s that?
THERAPIST: Just keep your eyes closed for 5 minutes and then, if you hate it, you can open your eyes and stop.
ANNETTE: (Half-laughs.) I can’t even sit still for 5 minutes, much less keep my eyes closed for 5 minutes.
THERAPIST: I think you’re just saying that to resist doing it, because you’ve sat very still for 35 minutes already, so you’d probably be able to sit still if you wanted.
ANNETTE: I just don’t want to do it.
THERAPIST: Yeah, that’s what I think. And I think that the reason you don’t want to do it, though, is that you don’t want to get down to that other side of you, the side of you that’s in pain, that’s depressed and lonely. You don’t want to know that side.
ANNETTE: Yeah, because it’s bad.
As she refuses to try imagery, Annette alternates between being entitled and being tough—not acknowledging her Vulnerable Child, which she thinks is a bad part of her. Her feeling that her vulnerable side is bad is coming from her Defectiveness schema. The therapist persists nevertheless. In the next section, the Detached Protector proves to be the major obstacle making it difficult to connect to the Vulnerable Child. The Detached Protector does not want her to appear weak to others, because they might hurt her.
THERAPIST: Bad, like …?
ANNETTE: I don’t know, just bad stuff. I feel bad enough, why do I want to remember that?
THERAPIST: Because the only way you’re going to get better is by getting to know those feelings and trying to heal her. My feeling is that Tough Annette is not letting Little Annette let anyone love her or be close to her. That’s her role.
ANNETTE: (Sighs deeply.)
THERAPIST: She’s keeping everyone away. So Little Annette keeps feeling lonely and lost and uncared for. Unless I can help Tough Annette let up a little bit, there’s no way Little Annette is going to get the love she needs from people. She’s going to keep feeling lonely. So the only way really to help is by convincing Tough Annette to step aside a little bit so we can find Little Annette and get her what she needs. But Tough Annette doesn’t want to look at Little Annette.
So I want you to let go of Tough Annette enough to do the exercise. And what I think is that Tough Annette doesn’t want to do the exercise because she doesn’t want me to see Little Annette.
ANNETTE: What if there is no Little Annette?
THERAPIST: Then you wouldn’t be depressed and you’d be like the rest of your family. Everything would be fine. We know there has to be a Little Annette or you wouldn’t feel lonely and depressed. You wouldn’t be in therapy. So Little Annette is the part of you that’s sad. Tough Annette isn’t sad. Spoiled Annette isn’t sad. So the only one left that’s feeling sad is Little Annette.
ANNETTE: (Sighs deeply.)
THERAPIST: But you don’t want to look at her, even though she has all the pain. She carries around all the pain that you’re feeling.
ANNETTE: It’s not that I don’t want to look at her; I don’t know her. I don’t know where she is.
THERAPIST: By resisting doing imagery, you’re resisting looking at her. And I’m saying to you, let up a little bit on her. Let’s see what she’s like. Don’t fight her so hard. Nothing that terrible is going to happen by looking at her and seeing what she’s like. I think it’s not going to be as bad as you think it’s going to be to look at her and to figure out what she’s feeling. We could try it.
ANNETTE: I guess.
The patient finally agrees to try to picture an image of Little Annette. Note how the therapist continues to push Annette to get her to this point—not criticizing her, but continuing to convince her—through empathic confrontation. The therapist keeps empathizing with the pain it causes Annette to access her vulnerability but nevertheless keeps pushing her to do it.
At classes and conferences, therapists often express surprise at how much we push patients to do experiential work. They believe that patients are too fragile to handle being pushed this way—that patients will decompensate or leave. However, we believe that many therapists exaggerate how fragile most patients are or how likely they are to leave if they are pushed in this way.
We would certainly not push this hard at the beginning of therapy, nor would we push this hard with more fragile patients, such as those with BPD or who have suffered serious trauma or abuse. However, we would push this hard with higher functioning patients, such as Annette, who have no history or indication that they are at risk for significant decompensation. We find that it is extremely rare for patients to decompensate or leave because we push them to do experiential work if they have been screened appropriately. On the contrary, what usually happens is that, when emotionally avoidant patients experience the more emotional parts of themselves, they experience a profound sense of relief. They feel less empty, more alive, less depressed. Finally they know why they are so numb. For the most part, we have observed that, if patients really do not want to do imagery or feel they are at high risk, they will not do it, even when they are gently but persistently pushed.
In the next segment, the therapist accesses Little Annette.
THERAPIST: All right, then, I’m going to ask you to close your eyes, and I’m going to ask you to keep them closed for five minutes.
ANNETTE: (Closes her eyes.)
THERAPIST: OK. After 5 minutes, if you want to open them, it’s OK. But, at least for 5 minutes, try to really force yourself to get in touch with her. Close your eyes and get an image of Little Annette, the absolute youngest that you can picture her. This is yourself as a child. Just tell me what you see, OK?
ANNETTE: Like what do I see, like how?
THERAPIST: Just try to get a picture as if you’re looking at her as a little child. She doesn’t have to be doing anything. Just sort of picture her face or picture her body. Just picture her somehow, picture a photograph if you can’t get her as a live person.
ANNETTE: OK.
THERAPIST: What do you see?
ANNETTE: I see somebody like, maybe, 5 years old.
THERAPIST: Where is she right now? Can you see where she is?
THERAPIST: I see. Can you tell me what room she’s in?
ANNETTE: In her bedroom.
THERAPIST: And is she alone?
ANNETTE: Yeah.
THERAPIST: Can you look at the expression on her face and tell me how she’s feeling?
ANNETTE: I don’t know. She’s just quiet.
THERAPIST: Can you ask her how she’s feeling and tell me what she says to you? I want you, as the Adult Annette, to talk to Little Annette and ask her how she’s feeling, and tell me what she says.
ANNETTE: Um, I don’t know, she’s nervous.
THERAPIST: She’s scared about something?
ANNETTE: Yeah.
THERAPIST: I see. Can you ask her what she’s scared about? Does she know?
ANNETTE: She knows.
THERAPIST: Can you tell me?
ANNETTE: Um, well, she’s scared ’cause like, um, her parents, they fight a lot.
THERAPIST: Is she worried about her mother? What is she worried is going to happen?
ANNETTE: I don’t know. Her father has like, sort of, a temper.
THERAPIST: How bad does the temper get?
ANNETTE: Well, I mean, he doesn’t hit her or her mother, or anything like that, but he, like, yells a lot.
THERAPIST: And what is she scared will happen if her father’s temper goes out of control? What is she scared will happen?
ANNETTE: She’s scared of, like, I don’t know, like he’ll beat somebody up or kill somebody.
THERAPIST: Is she worried she’ll get hurt herself?
ANNETTE: Maybe.
THERAPIST: So is she hiding in her room so she’s safer?
ANNETTE: Yeah.
The therapist was able to speak indirectly to the Vulnerable Child (through Adult Annette) and find out what she was feeling. He learned that Little Annette is afraid of her father. Next, the therapist asks Annette to bring her mother into the image.
THERAPIST: Can you let her mother come into the room now and tell me what you see happening?
ANNETTE: Her mother is upset. She’s always upset.
THERAPIST: Upset like sad, or upset like angry?
ANNETTE: She looks scared.
THERAPIST: And how does Little Annette feel seeing her mother so scared and upset?
ANNETTE: Scared, too.
THERAPIST: So they’re, like, scared together?
ANNETTE: Uh-huh.
THERAPIST: They both would like someone to protect them?
ANNETTE: Yeah.
THERAPIST: But there is nobody strong enough, or now is Little Annette going to have to get involved?
ANNETTE: I guess she will. I don’t know if she knows how. She’s little.
THERAPIST: I see. What’s going through her mind? Tell me out loud what’s going through her mind as she sees how scared her mother is.
ANNETTE: She just thinks her mother is sad and depressed.
THERAPIST: She’s worried about her?
ANNETTE: Uh-huh.
THERAPIST: Does she want to do something to help her, or does she feel she wants some help herself?
ANNETTE: No, she feels like she wants to help her mother.
THERAPIST: So to do that she has to be strong, though; she can’t let herself show that she’s scared. Is that right?
ANNETTE: Yeah.
THERAPIST: So she is going to have to act tough for her mother so her mother doesn’t see that she is scared.
ANNETTE: Yeah. She doesn’t want her, you know, to be upset. She doesn’t want to upset her mother more.
Once the therapist is able to get past Tough Annette in the image, the mode that comes to the surface in the image—as commonly happens—is the Vulnerable Child. Now the therapist can work on the core schemas that are part of Little Annette: her underlying feelings, memories, needs, and beliefs. What we find underneath is the fear of her father’s anger and the wish to protect her mother. There is nobody strong who can protect Annette: Her father is dangerous and her mother is weak. The core schemas are Mistrust/Abuse, Self-Sacrifice, and Emotional Deprivation.
Once the Vulnerable Child and the Healthy Adult are established as characters in the patient’s imagery, the therapist brings the patient’s other modes into the imagery and sets up dialogues. The therapist helps the modes to communicate and negotiate with each other. For example, the Healthy Adult might talk to the Punitive Parent, or the Vulnerable Child might talk to the Detached Protector. The therapist serves as the Healthy Adult (or Healthy Parent) whenever patients are unable to do so on their own.
To review, the Healthy Adult serves several functions in these mode dialogues: (1) to nurture, affirm, and protect the Vulnerable Child; (2) to set limits for the Angry Child and the Impulsive/Undisciplined Child; and (3) to battle, bypass, or modulate the Maladaptive Coping and Dysfunctional Parent modes. This can all be done in imagery, or the therapist can use the Gestalt technique of changing chairs. The therapist can assign each mode to a chair and have the patient switch chairs while role-playing the modes. Once again, the therapist plays the Healthy Adult whenever the patient is unable to do so. (The therapist usually plays the Healthy Adult for several months before the patient is able to take over this role.).
In the following segment, a continuation of the previous one, the therapist helps the patient conduct a dialogue between the Healthy Adult and the Vulnerable Child. As the segment begins, the patient is still in her bedroom with her mother as a little girl. The therapist asks Annette to bring Rachel into the image to talk to the Vulnerable Child rather than himself, because Rachel has a much stronger connection with Annette after many months of working together. The therapist plays the role of Rachel, even though Annette is uncomfortable showing her vulnerability.
THERAPIST: Can you bring Rachel into the image now?
ANNETTE: How?
THERAPIST: Just stick her right in the middle of that image with you.
ANNETTE: When I’m small?
THERAPIST: Yeah, and get everyone else out. Get Tough Annette out, get your mother out, so now it’s just Little Annette and Rachel. Can you see that?
ANNETTE: Yeah.
THERAPIST: Can you say to Rachel what you just said to your mother?
ANNETTE: (adamantly) No!
THERAPIST: Why?
ANNETTE: I don’t know, I just can’t.
THERAPIST: What does it feel like? Like she’s going to be judgmental? Or she is going to think badly of you for saying that?
ANNETTE: I don’t know. She’ll think I’m weird. I don’t know, I don’t know what she’ll think.
The patient cannot imagine being so vulnerable with Rachel. Because the patient is blocked, the therapist steps in to help. The therapist shows empathy for the feelings of the Vulnerable Child by supplying the words for Rachel.
THERAPIST: Let me put Rachel in and I’ll supply words for Rachel. OK?
ANNETTE: OK.
THERAPIST: (as Rachel) “Annette, you know it’s understandable that you feel scared right now, with your family fighting and your father’s temper, and you have a right to have somebody who’s strong for you and cares about you and who feels you matter and listens to you and hugs you and takes care of you. You have a right to that right now, and I’d like to do that as much as I’m able to do it as your therapist, because I think you never had anyone to do that before. And if you could do that, you wouldn’t have to be so tough all the time, because you could let someone else take care of you once in a while.” What does Little Annette feel when I say that?
ANNETTE: I don’t know. She doesn’t feel comfortable.
THERAPIST: What is she feeling? Can you verbalize what she’s feeling?
ANNETTE: She just feels like, “Why does she deserve all that stuff?”
The therapist affirms the rights of the Vulnerable Child, but the patient disagrees. The excerpt resumes.
THERAPIST: All right, now I’m going to be Rachel: “Because you’re a good girl. You’re trying so hard to help everyone. You’re such a lovable girl. You’re a nice girl and you’re trying so hard to help the rest of your family and protect your mother. You deserve to be taken care of and to be treated nicely and you deserve affection. Every child deserves it, and you’re a particularly good child.”
ANNETTE: Maybe I’m not that good. Maybe I’m bad.
THERAPIST: (as Rachel) “If you were so bad, you wouldn’t be trying so hard to protect your mother. If you were that selfish, you’d be thinking only about yourself. You’d be getting just what you needed. But that’s not what’s happening. You’re actually sacrificing yourself for her, to keep her safe. That is what a very, very sensitive, caring child does. So I don’t think you’re a bad child at all. You maybe have a spoiled side of you when you’re getting things, things you can buy; but when it comes to emotional things, you’re not selfish at all. You’re in fact very sacrificing. In fact, you’re the one who has been cheated emotionally. You haven’t gotten what you deserve. You haven’t got very much emotionally.” What are you feeling now?
ANNETTE: I just feel confused. I don’t understand.
THERAPIST: Does my explanation feel right to you?
ANNETTE: No.
The therapist engages the part of Annette that rejects his explanation.
THERAPIST: Be the part of you that doesn’t believe it. Is it your mother who doesn’t believe that? Or is it Tough Annette that doesn’t believe that?
ANNETTE: It’s Annette, Tough Annette.
THERAPIST: All right. You be Tough Annette who doesn’t believe this.
ANNETTE: (as Tough Annette) “I don’t see the point to, you know, affection, and, you know, talking about your feelings. Why is it necessary, you know?”
The therapist plays the roles Annette has the most difficulty playing: the Vulnerable Child and the Healthy Adult.
THERAPIST: I’ll be Little Annette, then Healthy Annette.
(as Little Annette) “But, look, I’m a little child, and I’m scared, too. You’re an adult, and every child needs to be hugged and kissed and listened to and respected. These are basic needs of every child.”
(as Healthy Adult) “We’re born that way, and the only reason you don’t feel you deserve it is because you never got it. But we all need this. And you became tough because you couldn’t see any way to get it. So you said, ‘I might as well be tough and pretend I don’t need it.’ But really, you know you need it as much as I do. You’re just afraid to admit it, because you think there’s no way you’re ever going to get it.”
ANNETTE: (as Tough Annette) “It’s a flaw.”
THERAPIST: What’s a flaw?
ANNETTE: (as Tough Annette) “You know, being that needy.”
THERAPIST: No, it’s a part of human nature. Everyone’s that way. Have you ever seen a little child who didn’t want to be helped or didn’t need to be held? Would you say that every child that wants to be held is flawed? Is every infant a flawed infant because he or she wants to be held?
ANNETTE: No, I guess not.
In the next segment, the therapist asks Annette to get angry at her mother in the image. This is done in order to help Annette battle her Emotional Deprivation schema by asserting her rights to her mother. The mother is behaving in an emotionally depriving way—she is not protecting Annette, and she is not giving her the emotional care that she needs.
THERAPIST: Can you be Little Annette now, and say to your mother what you need for yourself? Just say it out loud?
ANNETTE: What Little Annette needs?
THERAPIST: Yes. “I need….”
ANNETTE: I don’t know. I guess I need a hug. I’m so scared.
THERAPIST: How does it feel, saying that?
ANNETTE: I don’t know It doesn’t feel good.
THERAPIST: What does it feel like?
ANNETTE: It just gives me anxiety.
THERAPIST: How does your mother react when you say you need a hug?
ANNETTE: If I was to say that?
THERAPIST: Yes, be her now.
ANNETTE: (Speaks scornfully.) She wouldn’t say anything. She would probably just look at me.
THERAPIST: And tell me what’s going through her mind as she looks at you like that.
ANNETTE: She would think, “Why does she need a hug? I’m the one who has all the aggravation. What does she need a hug for?”
In the image, the mother denies Annette’s needs, focusing instead on what she regards as her own, much greater needs. The therapist remarks that the mother’s response is selfish.
THERAPIST: Are you angry with your mother for saying that?
ANNETTE: (agreeing emphatically) Yeah.
THERAPIST: Let Little Annette get angry at your mother for saying that. (Long pause.) You could start with, “I’m only five years old.”
ANNETTE: (Laughs.) Um, I don’t know. You know, “I’m only five years old. I need someone to take care of me.” (Long pause.)
THERAPIST: Tell her what kind of care you need. Do you need hugs?
ANNETTE: Yeah. I need hugs. I need someone to tell me how they feel about me.
THERAPIST: Do you need praise?
THERAPIST: Someone who can be strong for you, so you don’t have to worry so much?
ANNETTE: She just wants someone to tell her that she matters.
The therapist helps Annette verbalize what she needed as a child from her mother. Annette was taught that she should not need or ask for anything. She should be tough. She should protect other people. She should not ask anyone for love or help. It is thus no wonder that, as an adult, she does not turn to significant others with an expectation that they will want to comfort or help her.
The final step is to help patients generalize from working with their modes in sessions to working with their modes when they arise in their lives outside sessions. What is happening when the patient shifts into the Detached Protector or the Punitive Parent or the Angry Child? How can the patient stay centered as the Healthy Adult?
The therapist uses self-disclosure about his own childhood to help Annette accept her vulnerable side and become more willing to express it. Annette comments that her Vulnerable Child is too needy.
THERAPIST: Do you think that the little child part of you is all that different from the little child part of me, or the little child part of Rachel?
ANNETTE: Maybe. Maybe you had affection, and it’s different.
THERAPIST: I didn’t have much affection either as a child. That’s why I know how important it is to get that affection. I know what it means to not have affection.
ANNETTE: (Speaks accusingly.) You’re just saying that to get me to relate.
THERAPIST: You don’t believe me. I don’t say things just to manipulate you, believe me. I’m telling you something that’s true. I didn’t have that either, and I know what it feels like not to have it. And I’m telling you that everyone needs it. I grew up believing that I didn’t need it. That all I had to do was be good in school, and be good with other people, and be socially appropriate, and do all the right things, and that’s all I’d need to be happy.
Annette later told her therapist, Rachel, that this was the most important part of the session for her. The therapist’s self-disclosure served as a powerful form of reparenting.
The therapist helps Annette generalize mode work to life outside therapy sessions. What are the implications of what she has learned? They discuss her love relationships and why it has been hard for her to connect to men. She has been unable to accept love. Like most people with a strong detached side, she has been drawn to men who are emotionally depriving. Even though it is uncomfortable for her, one goal of therapy is for Annette to seek and stay with men who are emotionally giving.
THERAPIST: So when someone hugs you, it feels awkward. It feels like it’s not right. You have to overcome that feeling entirely.
ANNETTE: How? How do you overcome it?
THERAPIST: By letting someone do it and trying to stay there and saying to yourself, “This doesn’t feel comfortable, but it’s what I need. It’s what’s right.”
ANNETTE: Even if it freaks you out?
THERAPIST: It will freak you out at first, because you’ve never had it. At least not since you can remember.
ANNETTE: I have nightmares of people hugging me.
THERAPIST: I don’t doubt it. And I’m saying to you, if you get over that, if you would let some people do it and stay there and say to yourself, “This feels unfamiliar to me, but I need it anyway. If I could just stay with it long enough, I’ll get over it. If I let the affection in, then I’ll feel better.” And you just fight the part of you that feels uncomfortable with it.
Ultimately, the goal is for Annette to recognize her unmet needs and ask appropriate significant others to meet them. In this way she can connect emotionally to other people at a deeper, more fulfilling level.
The therapist ends the interview by summarizing the implications of the mode work for her goals in therapy.
THERAPIST: You need to acknowledge Little Annette and believe that her needs are good and not bad and that they are normal. And you have to help her get them met, not try to pretend that she doesn’t need anything. Because if you keep pretending she doesn’t have any needs, you’ll keep feeling depressed and lonely and isolated.
And that means that you’ll have to tolerate uncomfortable feelings, like doing this imagery was uncomfortable. But if you don’t tolerate the discomfort of feeling close to people, you won’t get over this, and I’m saying it is a phase. The “uncomfortableness” is a phase. It’s a phase you’ll get over. Then eventually it will feel good to have someone hold you and touch you and listen to you.
Annette’s goal is to form intimate relationships with significant others who are capable of meeting her emotional needs and then to allow them to do so. In mode terms, her goals are to build a Healthy Adult mode that can nurture, affirm, and protect Little Annette; to set limits on Spoiled Annette; and to learn to bypass Tough Annette most of the time.