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The term emotional dysregulation refers to an impaired ability to regulate unwanted emotional states. Scientific evidence supports the idea that emotional dysregulation underlies several psychological disorders as, for example: personality disorders, bipolar disorder type II, interpersonal trauma, anxiety disorders, mood disorders and post-traumatic stress disorder. Emotional dysregulation may derive from early interpersonal traumas in childhood. These early traumatic events create a persistent sensitization of the central nervous system in relation to early life stressing events. For this reason, some authors suggest a common endophenotypical origin across psychopathologies. In the last 20 years, cognitive behavioral therapy has increasingly adopted an interactive-ontogenetic view to explain the development of disorders associated to emotional dysregulation. Unfortunately, standard Cognitive Behavior Therapy (CBT) methods are not useful in treating emotional dysregulation. A CBT-derived new approach called Schema Therapy (ST), that integrates theory and techniques from psychodynamic and emotion focused therapy, holds the promise to fill this gap in cognitive literature. In this model, psychopathology is viewed as the interaction between the innate temperament of the child and the early experiences of deprivation or frustration of the subject’s basic needs. This deprivation may lead to develop early maladaptive schemas (EMS), and maladaptive Modes. In the present paper we point out that EMSs and Modes are associated with either dysregulated emotions or with dysregulatory strategies that produce and maintain problematic emotional responses. Thanks to a special focus on the therapeutic relationship and emotion focused-experiential techniques, this approach successfully treats severe emotional dysregulation. In this paper, we make several comparisons between the main ideas of ST and the science of emotion regulation, and we present how to conceptualize pathological phenomena in terms of failed regulation and some of the ST strategies and techniques to foster successful regulation in patients.
Keywords: emotion regulation, schema therapy, experiential techniques, personality disorder, psychotherapy, cognitive behavioral therapy
The term “Emotional regulation” refers to a series of strategies aimed at modulating and adjusting unpleasant emotional experiences (John and Gross, 2004; Gross, 2011). Emotional regulation is a multidimensional construct composed of the following traits: (1) awareness and acceptance of emotions; (2) skills to engage in behaviors aimed at a target; (3) flexible use of appropriate strategies to modulate the context’s intensity and the duration of the emotional response (Pedersen et al., 2014). Deficits in these areas are considered indicative of emotional dysregulation and are an indicator of psychopathology (John and Gross, 2004). Adopting effective strategies of emotional regulation is considered one of the fundamental aspects of individual adaptation. In fact, different scientific evidence demonstrated that emotional dysregulation is one of the main important factors in different disorders as, for example: cluster b personality disorder, bipolar disorder, interpersonal trauma, anxiety disorder, mood disorder, and post-traumatic stress disorder. Schema Therapy (ST) is a relatively new treatment approach to treat chronic Axis I and Axis II disorders (Young et al., 2003). According to this model, stable and enduring Early Maladaptive Schemas (EMSs) are at the core of chronic Axis I and Axis II disorders (Young et al., 2003). The term “schema” is derived from the theory of information processing, which maintains that the information is sorted in human memory by theme (Williams et al., 1997; Vonk, 1999). The idea is that the experiences are stored in our autobiographical memory by means of diagrams from the early years of life (Zajonc, 1980, 1984; Conway and Pleydell-Pearce, 2000). The patterns consist of sensory perceptions, experience, emotions, and the meaning attributed to them, so that early childhood experiences are stored at a non-verbal level (Freeman, 1981; Greenberg and Safran, 1989; Christianson and Engelberg, 1999; Young, 2005; Rijkeboer and Huntjens, 2007). Schemas act as filters through which individuals order, interpret and predict the world. EMSs have been shown to mediate the relationship between adverse childhood experiences and adult psychopathology (Carr and Francis, 2010). Because EMSs are considered ego-syntonic, therapists believe that clients with chronic difficulties lack the motivation to change them. Young incorporated a range of technique from Gestalt and Emotion-Focused Therapies (Perls and Baumgardner, 1975; Safran et al., 1988; Greenberg and Safran, 1989), particularly imagery work and empty chair dialogs (Kellogg, 2004) for treating and changing EMSs. Recent insights have lead to the view that complex Personality Disorders (PD) are not characterized by one set of pathogenic EMSs, but by different sets of EMSs activated by the same trigger, and having the same purpose, that can be activated as a group of schemas. In therapy, dealing with many schemas at the same time can result very difficult. For this reason, Young introduced the concept of Schema Modes in 2002. Schema Modes (from here, we will simply name them Modes), are relatively independently organized patterns of thinking, feeling and behaving that underlie the different states of consciousness; they can be directly observable and measurable, because they represent the moment-to-moment emotional and cognitive states and coping responses that are active at a given point in time. Modes are triggered by emotional events and an individual may shift from one mode into another very rapidly (oscillating dyads in psychodynamic terms). Modes were introduced to ST in order to explain the abrupt changes in thoughts, feelings and behaviors displayed by patients with severe PD (Young, 2002). In this way, the mode concept describes the rapid shifting in emotion and behavior demonstrated by patients suffering from severe PD (Young et al., 2003; Lobbestael et al., 2007). Compared to standard CBT, ST assigns a central role assigned to the concept of reparative therapeutic relationship (e.g., limited reparenting) and emotion-focused experiential techniques (e.g., imagery rescripting and chair work). These relational and experiential techniques can overcome some of the limitations of the standard CBT approach such as the poor attention given to elaborate and problematic emotional states. Improved cognition does not necessary mean improved emotion regulation (Grecucci and Job, 2015; Grecucci et al., 2015a, 2016). Greenberg and Safran (1984) provided evidence that rational cognitive language-based systems are independent from emotion based systems. To understand this, the model of Interacting Cognitive Subsystems was proposed (ICS; Teasdale, 1993; Waltz and Rapee, 2003), which distinguishes between two systems: the propositional coding system of meanings – that is based on language, which can be assessed and directly influenced by sensory information – and the implicational coding system of meanings – that elaborates experiences from a wide variety of sources, including specific patterns of indirect sensory input -. It follows that, if a therapist wants to change dysfunctional behavioral patterns, he/she has to work on the level of this implicational coding system and activate target emotional states. Following other psychotherapeutic approaches (Bowlby, 1969; Singer, 1974; Samuels and Samuels, 1975; Pope and Singer, 1978; Singer and Pope, 1978, 1980; Shorr, 1983; Sheikh, 1984; Burke et al., 1992; Frankel, 1993; Guntrip, 1995; Field and Horowitz, 1998; Fonagy, 1998), ST implements several emotion focused techniques rather than simple cognitive techniques, to foster emotion regulation. There is now empirical evidence that imagery work can have more impact than rationalist methods in fostering emotional change (see for example, Holmes et al., 2007). Another key factor in ST is the role of the therapeutic relationship. ST focuses on painful childhood experiences that were central to the development of the patient’s EMSs. Thus, ST involves the endeavor to re-experience and communicate the most vulnerable states of childhood, those in which the child desperately needed the care of adults but was not getting it (Young et al., 2003). The aim of this paper is to summarize theoretical implications of this model, empirical evidence and clinical application of ST in the management of emotional dysregulation, and to build bridges with the science of emotion regulation. We believe ST holds the promise to provide means to modulate severe dysregulated emotions as shown by PDs.
In the last decades, emotion regulation has been increasingly considered as a focal point to address psychological disorders. In ST emotions and emotion regulation are strictly linked to the concept of schema mode. This concept is the essential and most complex aspect of the theoretical model proposed by Young et al. (2007; Lobbestael et al., 2005, 2008, 2009). A mode is an intense predominant dysregulated emotional state linked to a pattern of thinking, feeling and behaving based on a set of specific frustrated needs. Usually the modes are activated by external stimuli or internal states, are transient by definition and may comprise both adaptive and maladaptive responses (Young et al., 2007; Lobbestael et al., 2010). In socio-cognitive terms, the modes are the conception of the self that are active at a given time. They are the part of the self, or the identity of that person, that leads the way in which the subject him/herself anticipates, sees, and responds to the world around him/her (Kellogg and Young, 2006). In psychodynamic terms, a mode can resemble the concept of the object relation dyad active in the interpersonal situation (Clarkin et al., 2007). In particular, a dysfunctional mode is characterized by maladaptive schemas or coping responses erupting into distressing emotions, avoidance responses or self-defeating behaviors that influence an individual’s behavior and control his/her emotional functioning. The mode theory’s basic concept is that different mental states have different purposes and are related to different basic needs. The therapist’s first goal is to understand and conceptualize the subject’s model of functioning. This is done to simplify the work with the patient without being simplistic, helping him/her to understand his/her way of functioning. In the next paragraphs we show how every Mode is associated with either (1) Dysregulated emotions, or with (2) Dysregulatory strategies.
There are four Mode macro-categories (Young, 2002). The first macro-category of modes is the maladaptive Child Modes that developed when certain basic emotional needs were not adequately met in childhood. In terms of the science of emotion regulation, Child Modes are characterized by specific dysregulated emotions (anger, shame, sadness, etc.). With dysregulated emotions we indicate an exaggerated aspect of on of the components of the emotional response (onset, duration, strength, type or expression). The second macro-category of modes is the dysfunctional Coping Modes that reflect dysfunctional regulatory strategies or coping styles (overcompensation, avoidance or surrender). In terms of the science of emotion regulation, Coping modes are problematic regulatory strategies that may produce a momentary relief on the short run (for example, avoiding a situation that triggers the emotions associated with the EMS), but cause and maintain dysregulated emotional states on the long run (lack of interpersonal intimacy and attachment). The third macro-category of modes is the dysfunctional Parent modes that reflect internalized attitudes and opinions of the parents (or other significant persons or even social and peer groups) toward the patient as a child. Parent modes are the primary source of dysregulated emotions. In terms of emotion regulation science, these Modes are dysregulatory mechanisms that generate the most severe dysregulated emotions (for example, a Punitive parent Mode that induces self-hate and contempt toward the self). The last macro-category of modes is the integrative adaptive modes, that encompasses the Healthy Adult mode, which includes functional cognitions, thoughts and behaviors (Arntz et al., 2012), and the Happy Child, which feels at peace because all core emotional needs are currently met (Simeone-DiFrancesco et al., 2015). In terms of the science of emotion regulation, Happy Adult may be viewed as a collection of self-soothing, positive reappraisal like-, and acceptance based- regulatory strategies that regulate emotions and produce a Happy Child state of mind.
The first macro-category, concerning the Child modes, includes different emotional states. It includes three categories (Arntz et al., 2012).
The first category of Child Modes is named Vulnerable Child mode. It encompasses most EMSs and most of the suffering felt by patients. From this mode many modes that belong to the other two categories of child modes can derive, as well as dysfunctional coping modes (Arntz and Jacob, 2012). Exaggerated emotions of sadness, anguish, and shame characterize the mode of this category.
Lonely Child. In this mode the patient feels emotionally empty, lonely and socially unacceptable, not worthy of being loved. Dysregulated sadness characterizes this mode.
Abandoned and Abused Child. In this mode the patient feels sad, scared, alone, unworthy and unlovable: he/she feels the enormous pain and fear of abandonment caused by his/her abusive history, which expresses itself through depressive, fearful, desperate, and inferiority feelings. This mode can be evoked by perceptions of threatened abandonment and abuse. Severe anguish characterize this mode.
Humiliated and Inferior Child. In this mode the subject feels incapable of managing responsibilities. The person in this mode shows strong regressive tendencies, he/she wants to be taken over. Usually we observe this mode in people who have developed poor autonomy and poor self-sufficiency. Dysregulated shame characterizes this mode.
Dysregulated anger, with different levels of expression, characterizes the second category of Child modes:
Angry Child. This mode is characterized by feelings of anger, frustration and impatience because the patient’s needs have neither been considered nor satisfied. He/she may rebel against this alleged grievance, making pretentious or flawed demands, but does not attack others.
Stubborn Child. This mode is a subtype of the Angry Child. Individuals feel angry but do not show anger openly. Instead, they persist passively, so stubborn in their positions or requests that they are deemed unreasonable by others.
Enraged Child. In this mode the subject experiences stronger levels of anger that lead to uncontrolled aggression like hurting people or damaging objects. Aggression is out of control, and its goal is to destroy or eliminate the alleged assailant. The patient shows affectivity similar to that of a furious and uncontrollable child.
Dysregulated impulsivity characterize the third category of Childs modes:
Impulsive Child. This mode refers to a person in which all locked emotions discharge impulsively, immediately and directly in order to meet his/her needs or desires, without being able neither to postpone their gratification nor to predict the consequences of his/her actions.
Undisciplined Child. This mode describes an extremely frustrated person, unable to make efforts in order to fulfill routine or boring tasks, who, consequently, easily decides to give up.
See Table Table1 1 for a summary.
Categories of dysregulated emotions in relation to modes and therapeutic strategies: child modes.
| Modes category (subcategory) | Dysregulated emotion | Dysfunctional regulation strategy | Effects | Therapeutic strategy |
|---|---|---|---|---|
| Vulnerable Child (Lonely Child, Abandoned and Abused Child, Humiliated and Inferior Child) | Exaggerated sadness Anxiety | Self blame | Vulnerability Fragility Deprivation Exclusion | Imagery rescripting Reparenting in and extra-session Cognitive or behavioral techniques Limited reparenting |
| Angry Child (Angry Child, Stubborn Child, Enraged Child) | Exaggerated anger | Blame others | Impulsivity Interpersonal problems | Venting anger Limiting destructive expressions of anger or rage Increase ability to tolerate frustration Limited reparenting Cognitive techniques (e.g., using a diary to identify mode triggering situations) Behavioral techniques (e.g., role playing present situations etc.) |
| Impulsive Child Undisciplined Child | Emotions displayed with no control | Attack Interrupt Blame others Ignore others | Impulsivity Frustration Spoiled behavior Impatience Lack of control | Increase ability to find a realistic way to meet hedonistic needs Increase ability to tolerate frustration Therapeutic relationship |
The second macro-category focuses on maladaptive coping modes. Parallels can be made with the concepts of defense mechanisms in psychodynamic terms, and with dysfunctional regulatory strategies (Gross, 2011; Grecucci et al., 2013; Grecucci and Job, 2015). It includes three categories.
The first category of dysfunctional Coping modes concerns the Avoidance strategy:
Detached Protector. This mode is characterized by emotional and psychological withdrawal of the individual, who suppresses his/her feelings, depersonalizes him/herself and does not feel linked to or in contact with others. Therefore, feelings of emptiness, boredom and abulia are typical in this context.
Detached Self-soother. This mode refers to an emotionally detached person, who tries to suppress and silence his/her emotions by compulsively and excessively committing to distracting and soothing activities, such as eating, watching TV, abusing drugs and having promiscuous sex.
Angry Protector. In this mode the patient usually covers what he/she is really feeling with a stream of resentment and anger. They use a ‘wall of anger’ to protect themselves from others who are perceived as threatening. Displays of anger serve to keep others at a safe distance to avoid being hurt.
Avoidant Protector. In this mode the patient usually avoids triggering by behavioral avoidance; he/she keeps away from situations or cues that trigger distress. The difference between Detached Protector and Avoidant Protector is that the former tends to inhibit or decrease the feeling of emotions, whereas the latter is characterized by interpersonal and situational avoidance.
In terms of emotion regulation science, these coping strategies belong to the class of “distancing” strategies, and produce an excessive down-regulation of (positive and negative) emotions (Grecucci et al., 2013, 2015a).
See Table Table2 2 for a summary.
Categories of dysregulated emotions in relation to modes and therapeutic strategies: dysfunctional coping modes.
| Modes category (subcategory) | Dysregulated emotion | Dysfunctional regulation strategy | Effects | Therapeutic strategy |
|---|---|---|---|---|
| Compliant Surrender | Reduced anger Assertiveness | Passivity Self defeating | Abuse acceptance Submission Masochism | Chair work to bypass and overcome avoidance coping mode Validation and empathic confrontation Identification and reappraisal of the mode through cognitive and experiential techniques |
| Detached Protector (Detached Protector, Detached Self-soother, Angry Protector, Avoidant Protector) | Down regulation of every emotion | Interpersonal detachment Isolation of affect Passive aggressive stance | Detachment Not caring Withdrawal Emptiness Depersonalization Self soothing behaviors | Chair work to bypass and overcome avoidance coping mode Validation and empathic confrontation Identification and reappraisal of the mode through cognitive and experiential techniques |
| Over-compensator (Self-Aggrandizer, Bully/Attack, Attention Seeker, Over-Controller, Manipulator, Predator) | Exaggerated grandiosity Anger Sense of dominance | Devaluing others Attack others | Arrogance Control Dominance Manipulation Exploitation Attention seeking | Chair work to bypass and overcome overcompensator coping mode Validation and empathic confrontation Identification and reappraisal of the mode through cognitive and experiential techniques Limit placing |
The second category of dysfunctional Coping modes, diametrically opposed to the Avoidance coping strategies, is the Overcompensation that is composed of six modes:
Self-Aggrandizer. In this mode the patient acts egoistically, shows little empathy for the needs and feelings of others and thinks he/she should not follow the rules like others do. He/she behaves competitively, hatefully, abusively. The subject is quite self-absorbed, craving the admiration of others, and showing superiority. Usually the emotion associated with this mode is anger, activated when someone threatens his/her status.
Bully/Attack. This mode is characterized by the will to strategically harm others physically, psychologically, verbally and through antisocial or criminal actions. The emotion that characterizes this mode is often anger and the feeling of pleasure experienced when others are harmed.
Attention Seeker. In this mode the patient attempts to get the attention and approval of others, with extravagant, inappropriate or exaggerated behaviors. Usually he/she tries to compensate for feelings of sadness and loneliness.
Over-Controller. In this mode the patient tries to protect him/her-self from danger, real or perceived, by focusing on external details and brooding. There are two distinct subtypes: the Perfectionist Over-Controller, focused on perfectionism to gain control and prevent critical or misfortunes, the Paranoid Over-Controller, which is suspicious and focuses on supervision and is concerned by the malicious intent of others’ controlling behavior. Both these modes usually face the demanding parents’ attempts to make the child feel incompetent and not good enough.
Manipulator. This mode manipulates, lies and frauds to obtain a specific goal that is usually to damage others or to avoid punishment
Predator. This mode is focused on the elimination of a threat, a rival, an obstacle, in a merciless, cold and calculating way. Unlike the bully attack mode that is a hot mode of expressing anger, the predator instead is very cold and ruthless.
In terms of emotion regulation science, these coping strategies may be seen as variations of reappraisal strategies (Gross, 2011), as the individual reinterpret himself in an excessively positive way and interpret others in a devaluing way. This causes excessive emotions of power, dominance attributed to the self, as well as excessive negative emotions toward others (e.g., disgust, rage etc.).
The third category of dysfunctional Coping modes is the Surrender strategy:
Compliant Surrender. This mode refers to a passive, servile, submissive behavior of someone constantly looking for everyone’s approval. Fearing conflict or refusal, the individual could even tolerate abuse and silence his/her needs or desires.
In terms of emotion regulation science, this coping strategy causes excessive fear of abandonment; often it causes also rage, that in this mode can be expressed only in a passive way.
See Table Table3 3 for a summary.
Categories of dysregulated emotions in relation to modes and therapeutic strategies: dysfunctional parent modes.
| Modes category | Dysregulated emotion | Dysfunctional regulation strategy | Effects | Therapeutic strategy |
|---|---|---|---|---|
| Punitive Parent | Exaggerated guilt Shame Contempt Disgust | Self attack Self devaluation Self punishment Self blame | Self directed abuse | Chair work to deal and overcome punitive parent mode Imagery rescripting to become aware of emotional needs and help the patient modify the situation in order to adequately meet needs Helping to express emotions and needs using healthy ways to deal with emotions Identification and reappraisal of the mode through cognitive and experiential techniques Active confrontation by the therapist to deal and overcome punitive parent mode using limited reparenting |
| Demanding or Critical Parent | Exaggerated sense of responsibility Guilt | Striving for high status Self neglect Humility Efficiency Rigidity Work addiction Lack of spontaneity Lack of pleasant activities | Chair work to deal and overcome punitive parent mode Imagery rescripting to become aware of emotional needs and help the patient modify the situation in order to adequately meet needs Helping to express emotions and needs using healthy ways to deal with emotions Identification and reappraisal of the mode through cognitive and experiential techniques Active confrontation by the therapist to deal and overcome punitive parent mode using limited reparenting |
The third macro-category of modes includes the figures concerning the Dysfunctional Parent: the Punitive Parent and the Demanding Parent. These modes usually derive from parents or other attachment figures (Young et al., 2003). Nevertheless, they can derive also from internalized social or religious authority, peers, etc. (Simeone-DiFrancesco et al., 2015). They intrude as negative automatic thoughts (Beck and Emery, 1985) and can be theorized as toxic parental introjects (Freud, 1917), that patients hear as “voices inside the head.”
Punitive Parent. This mode represents the interiorized voice of very critical and punitive attachment figures. This mode makes the patient afraid he/she did something wrong, sees him/herself as evil and worthless because of his/her feelings and desires. As a consequence, self-directed anger and hate develop and the patient punishes him/herself in one or another way.
Demanding Parent. This mode represents the interiorized voice of very demanding and impossible to please attachment figures. This mode makes patients constantly feels under pressure, for he/she aims at reaching excessively high standards and goals. This mode constantly tells to you that you have to be perfect in order to be accepted by others. Moreover, others’ needs are almost always considered as more important and overriding than their own. While Demanding Parent makes one feel always wrong, Perfectionist Over-controller makes one feel loved and accepted.
These Parent modes are in our view the source of primary emotion dysregulation in the patient, and may be seen as a class of self-attacking/self-blaming strategies (in psychodynamic terms) that creates unbearable negative affects inside the patient.
The last macro-category of mode encompasses Healthy Adult and Happy Child modes:
Healthy Adult. This mode presents significant adaptive and mediation functions between the different identified elements. It harbors and embraces the Vulnerable Child’s vulnerability; sets strict limits and boundaries on the Angry and the Impulsive Child’s behaviors; encourages and supports the Happy Child’s functionality; fights to replace the maladaptive coping strategies and, finally, neutralizes or limits the influence of his/her dysfunctional parents. Moreover, this mode also accomplishes appropriate adult functions, such as working, adopting care-giving behaviors and taking responsibilities. Furthermore, it engages in pleasant and stimulating adult activities, such as sex, cultural and esthetic interests and sports.
Happy Child. This mode allows a person to feel loved, accepted, understood, safe and spontaneous because his/her core needs are been fulfilled.
When the patient is in these modalities, no dysregulatory strategies, nor dysregulated emotions are observed.
Another aspect to be considered when analyzing modes is the degree of dissociation they have between each other. This concept is extremely important in determining the severity of the patient’s pathology. The dissociation between modes in ST might be described in terms of structural organization of the personality and concerns the divisions and the organization of the personality or consciousness (i.e., structural dissociation), as originally advocated by Janet (1907). Dysfunctional schema modes are essentially ‘facets of the self’ that have not been integrated into a cohesive personality structure and therefore operate in a dissociated manner (Johnston et al., 2009). The constant alternation of the modes is directly related to their dissociated nature. The higher the dissociation between modes, the higher the emotional instability of the person. Moreover, the higher the dissociation between one mode and the others, along with the dissociation between modes and healthier aspects of the Self, the more they become increasingly maladaptive (Young et al., 2003). For example, some patients with Narcissistic PD show a constant activation of the Self-Aggrandizer mode. When alone, they activate the Detached Self-soother mode. These coping modes try to avoid contact between the subject and the Lonely Child mode. If the subject is aware and capable of accessing the latter mode, this is a sign of low levels of dissociation, meaning the subject understands his/her needs and how to satisfy them. Individuals that have a higher awareness of their modes’ way of functioning don’t show pathological symptoms, even if their personality structures are quite similar to ones seen in some PDs. Another problematic aspect of dissociation is when dysfunctional dissociated modes are integrated each other. In particular, for emotional dysregulation, when the Impulsive Child mode is associated with the Abandoned and Abused Child mode. In this case the trigger events are able to evocate a disruptive behavioral reaction and the person is not able to have an emotional control over behavior.
Based on the assumption we made in paragraph 2, every Mode is associated with dysregulated emotional states or a dysregulatory strategies, the therapist works with Modes, in order to foster emotion regulation. The overarching strategy and steps to regulate emotions in ST are the following: (1) Mode identification . If the patient experiences a dysregulated emotional state in the session (but also outside the session), the therapist tries to find out the Mode responsible for that state (for example, “Punitive Parent”). (2) Mode work . Once the Mode is recognized, the therapist uses a series of specific techniques to resolve that Mode (“Chair work” to fight the Punitive Parent). (3) Mode change . Once the Mode is deactivated, the experience of a more functional modality is facilitated (for example, the activation of the “Happy Adult”). As an effect of step 2, the patient experiences a down-regulation of negative emotions, and as an effect of step 3, he/she experiences an up-regulation of positive, self-soothing emotions. The techniques belonging to Steps 2 and 3 are different and depend on the Mode that is active in that moment. Every Mode is characterized by up- or down-regulation of specific emotions. When intervening, the clinician must monitor the presence of exaggerated or blunted emotions or even their apparent absence (say for example, an excessive distant and cold attitude of the patient). This can guide the clinician to understand which Mode is active in that moment (in this example, the Coping Mode “Detached Protector”). Sometimes the type of emotion is not sufficient to distinguish between Modes. The therapist has to also assess the way that emotion is expressed and its function. Some examples follow: Anger is an indicator of the Angry Protector mode or of the Angry Child mode. To disambiguate between the two, the clinician must observe the way anger is expressed. The Angry Protector mode is an avoidant coping style, aiming, for example, to keep the psychotherapist away from accessing certain experiences. During a psychotherapeutic session, the therapist may ask the patient to explore a specific traumatic life experience. If the Angry Protector mode is active, the patient may react in aggressive manner, saying for example: “Why do we have to talk about this bullshit all the time? It’s useless! You still can’t understand how I feel? What kind of therapist are you?” The patient usually feels fear to face certain traumatic memories that were not correctly elaborated because of their nature. In this way, this avoidance coping strategy prevents re-experiencing and re-elaborating these memories. Consider that the Angry Protector mode activates a sense of bewilderment, guilt or inadequacy in the therapist, sometimes even activating his/her coping strategies. The activation of the therapist’s coping strategy could be followed by a “dysfunctional interpersonal cycle.” The result of this vicious circle is that painful issues are pushed away from the session – this does not allow a further processing of these memories.
The Angry Child’s anger, instead, is reactive to frustration of a basic need. For example: the patient has an explosion of anger when the therapist arrives late to the session: “I’ve been waiting for 15 min, is this the care and attention you have for your patients? I wonder what the one before had to say! I knew I couldn’t trust you, I refuse to pay for the whole session!” In this case the anger is reactive to the frustration of a specific need: the need to be respected, seen and considered by the therapist. The Angry Child’s reaction might be understandable, if it were not so excessive. The patient’s anger is one of the few emotional strategies that the patient is able to use to meet his/her needs in this situation. The patient does not want to create a distance like in Angry Protector mode. If this mode is to be investigated, sadness is felt before anger, because the patient did not feel seen, heard or understood.
On the other hand, the anger of the Bully and Attack mode is a rage with the purpose of annihilating the person the patient is facing. This type of mode can be found in patients with severe PDs or forensic patients. This rage usually serves the purpose of ending the ongoing relationship, typically when the subject feels like his/her rights haven’t been respected. In this last case this mode is quite similar to the Angry Child mode, with the difference that the latter never actually harms others, since it reflects a need to be seen, not a need to break relationships.
Along with modes that share the same emotion, there are also modes that imply a deletion or modification of emotions. This is the case of the Detached Protector and the Detached Self-soother modes. Those two modes have the purpose of keeping the subject away from emotions. This doesn’t allow him/her to use emotions as a feedback, therefore hindering the comprehension of his/her needs.
A telltale sign to spot the Detached Protector mode is when, during the session, traumatic or strongly depriving life events are narrated without the subject showing any emotions about them. If asked to explain this lack of emotion, the patient usually answers with statements like: “Yes, it was very sad at the time. But it’s all over now.” When this mode activates the therapist usually feels boredom, detachment and coldness in the therapeutic relationship. Everything is filtered through rationality, the Detached Protector’s sharpest tool. This detachment doesn’t allow the patient to activate some incorrectly elaborated traumatic memories.
This protector is one of the most frequently seen coping modes in Borderline PD (BPD). BPD is one of the first PD on which ST efficacy has been tested (Giesen-Bloo et al., 2006). The Detached Self-soother mode has the Detached Protector mode’s same goal, i.e., to keep a safe distance from emotions and emotional needs. It reaches this objective by occupying the subject’s mind with repetitive activities. Subjects that report substanceless addiction (e.g., compulsive shopping, pathological gambling, Internet addiction, work addiction) show an active Detached Self-soother mode when they act out the addiction-related ritual. Compared to the Detached Protector mode, the Detached Self-soother mode also employs a finer strategy for emotional control. The former silences emotions with logic and emotional detachment. The latter, on the other hand, proposes a different emotion associated to the activity it uses to distract the patient’s mind from the feeling of vulnerability. As an example, a subject who has often felt loneliness and abandonment in childhood may try to stop the feeling of emptiness and sadness with pornographic material when alone. So, in this example, the Detached Self-soother mode replaces the negative feelings with sexual excitement.
Once the Mode has been clearly detected (Step 1), the clinician may want to use one or more specific techniques designed to rework the active Mode. In this work, the main techniques are grouped in three main clusters (see Tables 1–4 ).
Categories of dysregulated emotions in relation to modes and therapeutic strategies: functional modes.