Schema Therapy: A Gestalt-Oriented Overview

Scott H. Kellogg
New York University and The Schema Therapy Institute

Gestalt!
Volume 10; Number 1
2009
Published by
Gestalt Global Corporation and the Gestalt Training Institute of Bermuda

Consult also:
Gestalt! Discussions for continued dialogue on issues of interest arising from articles in the journal

Stuff2Know for news of events and announcements of interest to gestalt therapists, consultants, and coaches.

Contents of 10(1)

Home

Schema Therapy: A Gestalt-Oriented Overview

Response to Schema Therapy from Dan Bloom

Response to Schema Therapy from Iris Fodor

Response to Schema Therapy from Philip Brownell

Working Corner

Initial information about Continuity and Change: Gestalt Therapy Now

The Emergent Self
An Existential-Gestalt Approach
by
Peter Philippson
(click link to look inside)

This book tracks a particular understanding of self, philosophically, from research evidence and in its implications for psychotherapy. At each step, the author includes first the theory he is working from, then the clinical implications of the theory, followed by some links to the philosophical outlook inherent in the theory, and finally a more extended case example.

"This book tracks a particular understanding of self as emergent from the relational field: philosophically, from research evidence and in its implications for psychotherapy. At each step, Peter Philippson includes first the theory he is working from, then the clinical implications of the theory, followed by some links to the philosophical outlook inherent in the theory, and finally a more extended case example. The author takes the view that the continuing self is partly an illusion, partly a construct, and that we, in fact, have to work to stay the same in the face of all the different possibilities the world offers us. We do this for two reasons. First of all, continuity allows deeper contact: friendships, loving relationships with partners and families. Secondly, and balancing this, the predictable is less anxiety-producing, and we avoid this existential anxiety by acting in a stereotyped way and avoiding some of the depths of contact. This dual nature of continuing self, in one context deepening contact and in another context avoiding contact, has an important place in Peter Philippson’s understanding of psychotherapy. As gestalt therapy enters the twenty-first century, it shows its continuing importance by the intelligent work of such people as Peter Philippson. In this book, Philippson brings gestalt therapy face to face with contemporary understandings in related fields– such as physics and cognitive neuroscience. Most importantly, he offers a fresh, updated perspective on the meta-theory of gestalt therapy. This book is worthy of serious consideration by practitioners and students, whatever their area of study or psychotherapeutic modality."

Dan Bloom, President, Association for the Advancement of Gestalt Therapy,
Fellow and Past President, New York Institute for Gestalt Therapy

"Peter Philippson draws on his extensive knowledge of chaos theory, quantum mechanics, mathematics, Zen Buddhism and Gestalt psychotherapy theory to expertly guide readers towards the notion of the Self as an Emergent Process. This is an exciting read and I found I needed to hold on tightly as Phillipson whisked me through new and exotic ways of thinking; a visceral equivalent to riding pillion on a Harley-Davidson and going slightly too fast round some of the bends. I recommend it highly: he shows why Gestalt theory has remained at the leading edge of developments in counselling and psychotherapy; possessing a relational, and emergent theory of self that is supported by the latest research in physical and neurosciences."

Sally Denham-Vaughan, AFBPsS, Chartered Clinical Psychologist,
Gestalt Psychotherapist, Trainer and Supervisor

Authors' Note
Scott Kellogg, Ph.D., New York University and The Schema Therapy Institute


I would like to thank Arnoud Arntz for his assistance.

Correspondence concerning this article should be addressed to Scott Kellogg, Department of Psychology, New York University, 6 Washington Place, Room 302, New York, NY 10003. 
E-mail: scott.kellogg@nyu.edu

ABSTRACT

This paper provides a comprehensive overview of the contemporary use of schema therapy in both of its forms – schema-focused therapy and schema mode therapy.  An integrative approach that draws from the cognitive, behavioral, psychodynamic, gestalt, and ego-state traditions in psychotherapy, there has been an increasing use of gestalt and experiential techniques as this therapy has developed.  Originally created for patients with personality disorders and Axis I disorders that were nonresponsive to treatment, this treatment is now used for a wide array of problems.  As an example, the model for treating borderline personality disorder is presented along with a case example using schema mode therapy.  Potential areas of overlap and interaction between schema therapy and gestalt therapy are outlined, and dialogues between the two approaches are encouraged

Introduction
The goal of this paper is to provide an introduction to an overview of schema therapy (Young, 1990; Young, Beck, & Weinberger, 1993; Young & Klosko, 1993; Young, Klosko, & Weishaar, 2003) within the context of a journal dedicated to gestalt therapy.  Schema therapy is an integrative psychotherapy that draws very deeply from the gestalt and experiential traditions.  The areas to be covered include the history of the approach, an overview of the schema model, an introduction to both schema-focused and schema mode therapies, a case example of mode therapy, and points of connection between schema therapy and gestalt therapy.

History
Schema therapy has been a developing therapeutic form for over 20 years.  This approach began as an outgrowth of cognitive-behavioral therapy, and it is currently evolving into a free-standing, integrative psychotherapy.  Dr. Jeffrey Young, the creator, first trained with Dr. Aaron Beck in Philadelphia in the ‘70’s.  During his years there, Young became interested in, and focused his attention on, those patients who did not respond well to cognitive-behavioral therapy.  Either they were nonresponsive to treatment or they relapsed repeatedly.  On closer examination, these patients frequently had very rigid cognitive structures, had histories of severe trauma, and/or had clearly defined Axis II disorders such as Borderline Personality Disorder.

It was in the effort to find ways to treat these “difficult” cases that schema therapy was developed.  This work would involve moving from the “here-and-now” focus of CBT to an exploration of childhood.  Early on, the power of experiential techniques was recognized and these approaches were incorporated.  An analysis and exploration of the problematic themes that these patients presented with began to move the model toward object-relations (Greenberg & Mitchell, 1983) and attachment-theory-oriented (Ainsworth & Bowlby, 1991) conceptualizations.  The interpersonal difficulties that were so frequently an issue with these patients also connected the model to psychodynamic conceptualizations of relationship, transference, and countertransference.

Current Developments
Schema therapy has gone through two major developments.  The first was called schema-focused therapy.  This was an integrative approach that, while using gestalt techniques as a central component, still had clear links to cognitive-behavioral perspectives.  The patients for whom this approach was ideally suited were those who had rigid schema structures that could either touch all or some areas of an individual’s life in a destructive or counterproductive manner.  For example, an Emotional Deprivation schema (i.e., “I have not had someone who really listens to me, understands me, or is tuned into my true needs and feelings” [Young, 2005]) could play havoc in the interpersonal realm, while the Failure schema (i.e., “Most other people are more capable than I am in areas of work and achievement” [Young, 2005]) could be very problematic in the work realm.  Rigidity of style in many situations is one of the defining characteristics of a personality disorder, and this model is appropriate for many patients.  It was popularized in the book, Reinventing Your Life (Young & Klosko, 1993).  This is a self-help guide to schema therapy that is routinely recommended to patients in treatment.  This book outlines many of the schemas and provides guidelines for change that parallel those that take place in the therapy process.

Efforts to treat Borderline Personality Disorder (BPD), and to a lesser degree, Narcissistic Personality Disorder, led to a major revision of the model.  In contrast to other personality disorders that are marked by rigidity, BPD is more frequently categorized by fluidity of self.  It is the rapid change of mood that can be so problematic.  While there may be a temperamental component to the disorder, borderline patients frequently present with histories of trauma and abuse.

This has led to the development of schema mode therapy, an approach that is, if anything, more rooted in the use of gestalt and experiential techniques.  As will be discussed below, this model emphasizes multiplicity and multivocality (Elliott & Greenberg, 1997; Stiles, 1999), and it bears some conceptual resemblance to aspects of Ego State Therapy (Berne, 1957; Watkins & Watkins, 1981).

The third phase of development involved a reworking of the schema-focused model to be one that is more mode oriented.  This means that the therapy has moved closer to the gestalt world and further away from the cognitive-behavioral one.

The Schema Model
Schemas, like working models (Ainsworth & Bowlby, 1991) are interpretive structures that provide the individual with an understanding of the nature of the world and the nature of the self.  While schemas may develop about different aspects of living, for the purposes of psychotherapy, there is primary interest in what are known as Early Maladaptive Schemas (Young et al., 2003).  These are schemas that have “developed primarily as a result of toxic childhood experiences” (p. 7).   The current definition of a maladaptive scheme includes the following characteristics:

The actual schemas or themes chosen were first developed through clinical observation of the problematic themes that patients were presenting in therapy.  Since then, there have been extensive research efforts to test and validate the schema model.  At present, there are 18 schemas in the model. 

A brief synopsis of the schemas are presented in Table 1.  A complete list of definitions can be accessed at http://www.schematherapy.com/id73.htm

For many patients, these are more readily experienced as feelings, images, or memories.  The schema structure and conceptualizations provide a helpful language for therapists, patients, and researchers.  This does not, however, mean that they are primarily experienced by patients in a cognitive manner.  
                     
Early maladaptive schemas develop when the basic needs of the child are not met.  Young has outlined five core emotional needs that the developing child has.  To the degree that these are not met, there is an increased possibility of a maladaptive schema being developed.  These five needs are:

Both clinical work and research investigations have brought us to a point in which there are now 18 schemas that can be grouped under 5 domains.  As can be seen in Table 1, the five domains are the negative polarity of the needs.  They are: (1) Disconnection and Rejection; (2) Impaired Autonomy and Performance; (3) Impaired Limits; (4) Other Directedness; and (5) Overvigilance and Inhibition (Young et al., 2003, p. 14-16).  For example, Mistrust/Abuse and Emotional Deprivation are found in Disconnection and Rejection, Dependence/Incompetence and Failure are listed under Impaired Autonomy and Performance, Entitlement/Grandiosity and Insufficient Self-Control/Self-Discipline are in Impaired Limits, Self-Sacrifice and Subjugation are part of Other Directedness, and Emotional Inhibition and Unrelenting Standards/Hypercriticalness are examples of Overvigilance and Inhibition.  Patients may have a few schemas or many, and schema patterns may cross domains and some schemas may co-occur in a logical way.  Ratto and Capitano (1999) give an example of how a Defectiveness schema, a sense that one is fundamentally flawed, can underlie Emotional Deprivation, a belief that one’s emotional needs will not be met, and Incompetence, a sense that one cannot function in a responsible manner.

Given this framework, there are four mechanisms through which schemas can develop.  The first, which is known as a “toxic frustration of needs” (Young et al., 2003, p. 10), consists of a general and repeated pattern of failing to meet the needs of the child.  The second is through experiences of trauma and abuse.  In this case, patients may be able to recount clearly disturbing events, while in the first the stories may be more about absence or lack, rather than specific, dramatic experiences.  The third is the opposite.  Here, it is a case of “too much of a good thing” (p. 10).  This dynamic may be involved in Dependence/Incompetence or Entitlement/Grandiosity.  Here, the parents failed to address the needs for autonomy or were unwilling or unable to set necessary limits.  The final mechanism is through “the selective internalization or identification with significant others” (p. 11).  In an extreme form, a patient who has grown up with an abusive parent, internalizes that parent and behaves in a similar manner. 

The schemas develop in difficult situations and are often survival strategies that are functional within that setting.  The problem is that they are maladaptive in other situations or at later stages of development.  Subjugation, or the feeling that we must give our personal power to authority figures, may be adaptive when living with a tyrannical parent figure.  It may be less appropriate in work situations, especially if one is using a passive-aggressive coping strategy.

Schema Coping Modes
The manifestation of the schema may take varying forms.  In what is probably one of the more difficult concepts in schema therapy to fully grasp, patients will manifest their schemas through the use of what were originally called coping styles (Young & Klosko, 1993) and are now called coping modes.  These broadly correspond to the strategies of surrender, avoidance, and overcompensation.  A person with a given schema may use a different coping mode depending on the situation, but a dominant coping pattern is likely to occur. 

In many respects, it is the coping modes that are problematic for the patient.  Either the modes do not ultimately lead to the desired outcome on a consistent and predictable basis and/or they lead to strong negative reactions from others.  In the expanded schema mode vision, there has been an expansion of the coping repertoires.  Representing the surrender strategy, the Compliant Surrenderer is the dominant mode in people who take a subservient role.  They are “dependent, submissive, clinging”, and they are conflict avoidant.  They also do not try to get their needs met (Young, 2002).  The avoidant modes include the Detached Protector Mode, who seeks to remain emotionally uninvolved and may engage in self-soothing activities such as substance abuse, excessive internet surfing, or other addictive behaviors to avoid or block feelings.  The Isolated/Avoidant Protector takes a more interpersonal strategy in that these patients will be more actively wary of interpersonal engagement and keep a wall around them.  The overcompensating modes include the Approval- or Attention-Seeker, the Controlling or Manipulating Mode, the Entitled or Special Mode, and, more commonly found in forensic settings, the Aggressive Mode (Young, 2004).  Each of these last are attempts to get others to meet their needs.  As these modes emerge in the therapy, patients are encouraged to name them in ways that are personally meaningful.

Schema Assessment
In cases that are more appropriate to a schema-focused approach, an assessment process usually takes place at the onset of psychotherapy.  It is important to keep in mind that all schema and mode work must ultimately connect to the presenting problems of the individual.

Schemas are assessed in a variety of ways.  This is a particularly important issue because the coping modes may obscure the underlying schemas.  While patients may present with a similar style, be it anger or disengagement, the underlying schema structure can be different.  In addition, patients who have been through similar experiences may, nonetheless, have different schema structures, or if they have the similar schema structures they may use different coping modes.  Ultimately, the healing process takes place in the connection to and work with the schema, not the coping style.

Reflecting its cognitive-behavioral background, patients are given the Young Schema Questionnaire (YSQ) (Young, 2001).  This is a clinical inventory that has questions covering all 18 schemas.  This is a straightforward assessment of schemas that asks patients about their experiences and their expectations.  The questions corresponding to each schema are rated on a scale of 1 to 6, and clusters of high scores are indications of a possible schema.  After the questionnaire is filled out, the patient and therapist will review the answers to better understand the meaning and situations connected to the response.

A second questionnaire that is quite useful is the Young Parenting Inventory (YPI) (Young, 2003).  This questionnaire asks about parenting style and parenting behavior that is thought to be related to the development of a schema.  There are several statements for each schema.  For example, each parent would get rated on how true the following statements were for each of them: “Lied to me, deceived me, or betrayed me” (Mistrust/Abuse), “Controlled my life so that I had little freedom of choice” (Subjugation), “Didn’t teach me that I had responsibilities to other people” (Entitlement”, or “Would call me names (like “stupid” or “idiot”) when I made mistakes” (Punitive) (Young, 2003).  Each descriptor is rated 1 to 6.  Even one rating of 5 or 6 is considered to be particularly pathognomonic.  Sometimes a patient will endorse few if any of the items on the YSQ in a significant way.  This may be due to an avoidant coping style.  However, the YPI may provide information that contrasts with the YSQ and which may be more revealing of the schema.

Moving to the gestalt and experiential traditions, imagery is a core technique in both assessment and treatment.  Assessment imagery involves first creating an imagined “safe space” with the patient.  After this is established, the patient is asked to bring up a problematic or difficult memory with their mother, their father, other significant caregiver, and peers, as appropriate.  Early memories are most desired, but some patients can only provide ones from later parts of their life–a fact that may be significant in itself.  The image is conjured up, the circumstances are described, and a dialogue is encouraged between the child and the parent or other significant person in the situation.  The goal is to get the child to express his or her needs and desires to the parent.  Hearing the parent’s response is significant as well.

In a very moving training tape, Dr. Young, while working with a very grandiose and narcissistic man, asks him to bring up an image of his mother.  In the image that emerges, he is a little boy who tells his mother that he loves her and that he wants her to love him.  She, however, is a statue and is preoccupied with her own issues and is unavailable to him.  In this vignette on can see the power of imagery as a way to uncover a schema.  For this particular patient, the pain of the emotional deprivation at the core of his narcissism was made clear.

In another taped interview that is also featured in the schema therapy text (Young et al., 2003), a patient is operating in a mode that is called Tough Annette.  Her presenting problems include depression, alcohol abuse, and problematic relationships in professional and personal settings.  Her “tough” coping style, a manifestation of the Detached Protector, may be one of the factors that keeps others at bay.  After extensive negotiations, she agrees to do imagery work.  The story that appears is one of a little girl huddling with her mother as they both live in fear that her enraged father will kill the mother.  Tough Annette is an overcompensating mode for dealing with the underlying Mistrust/Abuse and Subjugation schemas that are operating at her core.

The fourth way that schemas can be assessed is by listening to the patient discuss their lives and the difficulties that they have encountered.  This can be augmented through the use of such life history instruments as the Multimodal Life History Inventory (Lazarus & Lazarus, 1991).  The final way that schemas are usually determined is through the therapeutic relationship.  This approach is connected to the psychodynamic roots of the therapy.  For example, one patient told Dr. Young that he seemed tired, and that to help him feel better, she was willing to forgo her session; she would, however, pay him in any case.  This looked to be a manifestation of a Self-Sacrifice schema.

For the assessment to be complete, it is important that both patient and therapist are clear not only about the schema, but also about the coping style and the possible role of temperament.  With a clear and shared diagnostic perspective, the therapy can move forward.

Schema-Focused Therapy
In the classic schema-focused therapy approach, there are a series of cognitive, behavioral, and gestalt/experiential interventions that can be used to help change the schema.  Specific strategies for 18 schemas have been presented in detail in Schema Therapy (Young et al., 2003; see also Young & Klosko, 1993).  This discussion will review basic techniques and look at a few examples.

In the original model, there were a series of steps that could be seen as a guideline.  The first was to identify and label the schemas.  This brought them more clearly into awareness and provided a conceptual framework for the therapy.  The next step is to tap into the childhood experience that led to their creation.   The third phase involved making a rational case against the schema.  When was it true and when was it not true?  Did it appear to be a helpful or unhelpful model for operating in the world?  As a form of gestalt cognitive restructuring, chair dialogues can be created between the schema side and the healthy side.  Since schemas are resistant to change, this can be done in gradual steps.  At first, the patient can do the schema voice and the therapist can do the healthy one.  Next, the two of them can switch roles with the patient taking the healthy view.  Lastly, the patient can alternate chairs and do both sides.  From a gestalt perspective, the patient would be seen as “owning” the schema voices.

The fourth step involves writing letters to those who played a role in the development of the schemas.  These letters are read out loud.  The purpose is to break through the prohibition against speaking out.  “We want to give your inner child a voice – to allow your inner child to express his or her pain” (Young & Klosko, 1993, p. 48).  These letters are not sent as the goal is not the transformation of the other person, but the healing of the patient.  After this internal work has been done, the next step is to change the behavioral patterns that accompanied it.  For patients who avoid certain situations, these would be gradually approached; for those who were too demanding, strategies to implement behavior based on reciprocity will be developed, and for those who allowed others to take advantage of them, assertiveness will be practiced and tested in social situations.

The last step involves the forgiveness of others.  It is important that patients not rush into forgiveness.  For schemas to heal, there needs to be a time of anger and grief.  Many patients naturally start to forgive their parents or the persons who were responsible for the creation of their schemas; they see then as suffering from and acting on their own schemas.  As Dr. Vera Paster used to say, “Everyone is a victim.”  This kind of letting go helps the patients move on with their lives.

Within this framework, imagery work can play a central role.  Some schemas are about absence and loss while others are about the pain-inflicting activities of others (i.e., Mistrust/Abuse), and different imagery strategies may be appropriate during this phase.  In situations in which there has been violence or mistreatment, the goal is to empower the patient.  The basic structure of the intervention is to elicit an image of the child in the difficult situation.  In this image, the therapist, after asking for permission from the patient and the inner child, can enter the image and comfort and protect the child.  The patient than follows suit.  The patient can defend the child by using whatever he or she feels is necessary – sticks, guns, explosives – whatever they need to feel strong and in control.  This is also an opportunity for them to express their rage and anger about what was done to them.  It is therapeutic for them to express as much anger as possible.  As Young et al. (2003) have written: “The schema represents a world gone wrong, and anger sets the world right again” (p. 123).

There are two caveats involved here.  Patients may have experienced greater or lesser amounts of trauma, and their capacities to engage in this kind of confrontational work may vary.  Some will need to do this in a more gradual fashion in which small amounts of exposure are followed by a period of processing and working through.  The second caveat is that patients with actual histories of serious violence should not be doing this kind of work (Young et al., 2003)

For other patients, the dominant schemas may be more about loss or rejection (i.e., Abandonment, Emotional Deprivation, Social Isolation).  Here the issue may be one of creating an imaginal dialogue in which the patient expresses the anger and grief that they have about not be not being loved, valued, cherished, and accepted by the other.  They can also clarify what they internalized from this experience, as in Redecision Therapy (Goulding & Goulding, 1997), and then make a decision to reject the schema.  They can offer examples from their life that conflict with the message from the abandoning object and they can state their intent to replace the maladaptive schema with a healthier one.  Clearly, this kind of work can be done both in imagery and using chairwork (Greenberg, 1979; Greenberg, Rice, & Elliott, 1993; Kellogg, 2004; Perls, 1969, 1973, 1975).

With patients who suffer from Insufficient Self-Control, a different approach is taken.  The patient will bring up in imagery situations in which they behaved impulsively.  The therapist will enter the scene as a Healthy Adult and help the patient develop self-control.  The patient will then do the same.  Significant others who did not set limits or who encouraged this kind of behavior can be confronted in imagery as well.  Again, the goal is for the patient to develop an internalized Healthy Adult.

Integrating mode work here involves seeing the schemas and the pathogenic personalities that were instrumental in creating them as external voices or as a part of the self.  By doing this, patients can begin to get some distance from these experiences and they do not have to be overwhelmed by them.  It allows for dialogues and a greater degree of self control.  This will be elaborated more in the discussion about BPD, but it is a central part of this work as well.

The “voice” of the schema that insults and demoralizes the patient can be transformed into a mode and then labeled and confronted.  As noted above, patients are encouraged to label modes in ways that are meaningful to them.  The child that was the recipient of the mistreatment can also be transformed into a mode and then labeled and confronted.  Often, this part is named “Little Sam” or “Little Madeline.” Dialogues can then be done using imagery or chairwork.

As noted above, the behavioral aspect of this kind of schema therapy typically involves assertiveness and some kind of hierarchical system of exposure to difficult situations or the gradual implementation of new behaviors.  Assertiveness training fits in well with the development of an internalized Healthy Adult.  For those whose schemas did not allow for the expression of needs (i.e., Subjugation, Self-Sacrifice, and Emotional Inhibition) or for those who did not feel that the world would provide them with what they need (i.e., Emotional Deprivation), assertiveness training can help them develop a “voice” that will better enable them to get their needs met.  For those whose schemas (i.e., Entitlement/Grandiosity) or whose overcompensating coping styles lead them to expect or demand things from others, assertiveness may be a more successful way to get one’s needs met within a framework of reciprocity (Young et al., 2003).

Constructing a hierarchy of feared or difficult situations is a helpful way to re-engage patients in the world in a more successful manner.  The healing of such schemas as Social Isolation/Alienation and Dependence/Incompetence will of necessity involve the patients putting themselves in situations that will elicit some anxiety.  By creating a hierarchy of activities based on their difficulty and anxiety-arousing potential, patients will be able to titrate their discomfort.

Schemas And Relationships
Certainly one pattern that therapists of all persuasions encounter is that of patients choosing partners who seem to re-enact the traumas and difficulties that they had previously experienced.  Freud (1914/1953) referred to this as the repetition compulsion.  A core aspect of this idea is that people who have been through traumas seek to recreate them in an attempt to master them.

People who activate our schemas can, paradoxically, be quite exciting.  This is known as schema chemistry (Young & Klosko, 1993).  Patients with Emotional Deprivation get involved with cold and aloof partners, patients with Enmeshment issues connect to smothering caregivers, and patients with Mistrust/Abuse spend their time with disrespectful individuals.

As patients begin to get better and start rebuilding their lives, the issues of relationships and intimate connections are likely to come up.  One way to assess this is to ask patients to rate the attractiveness of potential partners on a scale of 1-10.  Unfortunately, potential partners who will invoke the schema that they are trying to heal will often receive a 9 or 10.  Healthier and more appropriate partners may be seen as “boring” and receive low ratings.  Therapists will work with patients to help them find partners who do not re-enact the schemas yet do provide some kind of compatibility and excitement.  The goal here would be to find partners in the 6-8 range.  With partners who fall below this, there is not sufficient energy for a romantic relationship.  While the moderately high group does not provide the extreme intoxication of the 9-10 group, over the long term, they are much more likely to bring happiness and fulfillment.

Therapist Stance
In both the schema-focused and schema-mode approaches, the fundamental therapist stance is one of empathic confrontation or empathic reality testing (Young et al., 2003).  This means a sense of understanding that patients have typically been through difficult struggles and that there are reasons why they feel and behave the way that they do.  However, the therapist is still intent on working with them to help them change.  This stance seeks to intertwine the empathy that comes from the relational and psychodynamic therapies with the therapist-as-change-agent tradition of the cognitive and behavioral therapies, as well as the Perlsian tradition of gestalt therapy (Kellogg, 2004).

As noted elsewhere, the therapy relationship is both a means of assessment and a vehicle for healing.  With some patients, the schema will be clearly enacted in the relationship.  In one of the more controversial aspects of schema therapy, there is an emphasis on limited reparenting.  This is especially true in the treatment of BPD, but it can be a factor in schema-focused work as well.  In the imagery work, the therapist takes on the role of protector and nurturer.  In the relationship, the therapist, using the schema as a guide, attempts to provide the patient with that which the parent or caregiver did not.

For example, when a patient with Emotional Deprivation asks for advice, the therapist will try to provide something.  This is because not only do the patients suffer from deprivations in nurturing, but also they do not believe that their attempts to find this in the world will be successful.  On the other hand, when patients with Dependence/Incompetence as for advice, which they frequently do, it is better that the therapist not provide it.  This is not done out of cruelty; rather, it is done in the understanding that many of these patients were not encouraged or allowed to develop competence or strength through taking action, making decisions, and living through their mistakes.  Here, the therapist is empathic about the anxiety that they are feeling while affirming that is only by making decisions and building on their consequences that they will develop a sense of autonomy.

Schema Mode Therapy
As has been alluded to throughout this paper, schema mode therapy developed in response to the different needs of patients with borderline features.  The model that evolved was more gestalt and experiential in nature.  To properly convey this, an expanded discussion of modes is necessary.

Modes
The modes can be distinguished from the schemas in that they are manifestations of the mood or state that an individual is in at any give time, as opposed to a schema, which is more of a trait or an enduring aspect of the person.  A mode has been defined as “those schemas or schema operations–adaptive or maladaptive–that are currently active for an individual” (Young et al., 2003, p. 37).  Mode therapy involves listening to patients speak about their lives and experiences and watching their emotions, energy, language, and position shift.  This is probably closely related to the gestalt approach of listening for what is figure for a patient.  In the schema model, the shifts will be given names.

Modes that are particularly problematic may be accompanied by high levels of emotion and rigidity.  They may involve unintegrated aspects of the self (Perls, 1973).  Also, with higher levels of disturbance there is likely to be greater schema or mode “flipping”; that is, rapid and abrupt shifts in mood.

Modes can be divided into three groups – child, parent, and coping.  The child modes include the Vulnerable Child, the Contented Child, the Angry Child, the Impulsive, Undisciplined Child, and the Pleasure-Seeking, Spontaneous Child.  The child modes relate to Freud’s concept of the id, Jungian archetypes of the child (Abrams, 1990), Transactional Analysis’ vision of the child (Harris, 1969), the gestalt idea of the “Underdog” (Perls, 1973) and recovery movement literature (Whitfield, 1987).  The Contented Child and the Pleasure-Seeking, Spontaneous Child represent those aspects of ourselves when we feel safe and affirmed, and we are able to take pleasure in life.  In therapy, there will greater concern about the Vulnerable, Angry, and Impulsive Child modes.  The schemas and the pain that goes with them reside in the Child modes.

The Parent Modes represent internalized aspects of parents and other authority figures.  These modes connect to psychodynamic conceptualizations of the Superego, and what some writers have termed the “Inner Critic” (Elliott & Elliott, 2000; Firestone, Firestone, & Catlett, 2002).  They also relate to the gestalt idea of the “Top Dog” (Perls, 1973).  These modes include the Punitive, Critical Parent, the Inhibited Parent, the Demanding or Rigid Parent, the Indulgent, Permissive Parent, and the Self-Sacrificing, Caregiving Parent.  From the names alone, one can see the schema themes at work.  The modes are sometimes directed at the behavior of the self, the behavior of others, or both.  In general, the Punitive Parent or Inner Critic will be a major factor in the therapeutic situation.  One of the goals here is to create a Parent Mode based on the Healthy Adult.

The third group of modes is made up of the coping modes.  These were reviewed earlier in relationship to manifestations of schema activation.  The Detached Protector mode, in particular, will be explored further in the treatment of borderline patients.

Perl’s (1973) work with “Top Dog–Bottom Dog” can be seen as a kind of overarching rubric for mode conflicts in many neurotic patients.  Greenberg’s (Greenberg, 1979; Greenberg et al., 1993) further refinement of the chairwork model as a way to integrate the personality and to end what would be called “mode flipping” is very helpful here as well.  With less troubled patients, conflicts among the different parts of the self can be resolved through dialogues.  At their most basic, these conflicts take the form of “want” versus “should” or the form of “want” versus “should” and “fear”.  In this context, integration may be possible.  In fact, when the mode model is applied to patients who would be appropriate for schema-focused therapy, the mode model is relatively simple–typically consisting of a Child, Parent, and Coping mode.  With more troubled patients, the number of modes may increase and the interactions among them become more complex.

In addition, with more disturbed and traumatized patients, the Punitive Parent or Inner Critic is frequently a pathogenic voice that needs to be battled, not integrated.  Others have written on the extremely damaging impact of this voice in addiction (Tatarsky, 2002), depression, and other disorders (Elliott & Elliott, 2000; Firestone et al., 2002).

Borderline Personality Disorder: A Mode Conceptualization
In schema therapy, borderline phenomena is seen as sharing common attributes with Dissociative Identity Disorder (Young et al., 2003).  The borderline patient is seen as being motivated by four or five modes that make up an inner theatre that is filled with pain and conflict (Kellogg & Young, 2006).  The five basic modes are: (1) the Abused/Abandoned Child (a variant of the Vulnerable Child); (2) the Angry/Impulsive Child; (3) the Detached Protector; (4) the Punitive Parent; and (5) the Healthy Adult.  Typically the Healthy Adult is only marginally represented at first.  One of the main goals of therapy is that the patient will internalize this from his or her work with the therapist.

The Abandoned/Abused Child is the core of the patient.  This is a child who lives in fear and terror and who has no allies in the world.  Patients in this mode may look quite frightened and troubled.  Young (Young et al., 2003) repeatedly stresses that psychologically and emotionally, borderline patients are little children around the age of 4 or 5.  In times of difficulty, it can be helpful for therapists to try to see them as children instead of adults.  Connection, for the Abandoned/Abused Child, is a matter of survival, and this drives much of the intensity that is found in the relationships of these patients.

The Punitive Parent is the internalization of all of all of the cruel, abusive, and critical forces in the person’s life.  This hurtful voice affirms the “badness” of the patient and seeks to punish him or her.  Some of the destructive behavior of these patients–from cutting themselves to masochistic sexual experiences–is driven by this inner critical voice.  Tragically, not only did these patients live through what they did, but the torment goes on within.  (It should be noted that there are some patients who have this same kind of inner dynamic who do not appear to have been through abuse experiences.  Perhaps the concept of the Inner Critic is preferable to Punitive Parent in that case.  Nonetheless, the Inner Critic is a great source of suffering and pathology and needs to be confronted in much the same way as the Punitive Parent.)

One of the ways in which they survive is through the utilization of the Detached Protector mode.  Despite a general impression of borderline patients as people characterized by high levels of emotional expression and dramatic gestures, Young describes this mode in the following way:                           

In the Detached Protector Mode, patients may feel numb or empty.  "They may adopt a cynical or aloof stance to avoid investing emotionally in people or activities.  Behavioral examples include social withdrawal, excessive self-soothing, fantasizing, compulsive distractions, and stimulation-seeking..." (Young et al., 2003, p. 275) While a survival mechanism, the mode will be problematic in therapy.  The mode protects the Abandoned/Abused Child; however, healing can only take place when the psychotherapist is able to make contact with the wounded part of the patient.

In most abusive situations, children are not allowed to speak about the pain that is being delivered to them.  The Angry Child represents that part of the personality that is in touch with the pain that they have endured, with the needs that have been unfulfilled, and with the fury that they experienced what they did.  The Angry Child may be  kept at bay at times by the Detached Protector and by the Punitive Parent.  However, this mode does emerge at times; frequently with an intensity and destructiveness that can be frightening and self-defeating.  This is the part of the borderline syndrome that most family members, friends, and professionals find to be so difficult to cope with.  The paradox here is that while the patients are justified in being angry about what has happened to them, the anger can threaten to destroy the therapy.

Lastly, the Healthy Adult mode is a underdeveloped aspect of the personality.  Again, this is the part that is embodied in the therapist and it is a voice that will, hopefully, be internalized by the patient.

The therapy typically covers three phases.  The first phase of treatment is one in which the goal is the development of an affirming relationship with the patient.  During this period, discussions and explorations about current difficulties and experiences is a good place to start; the past can be tackled next.  The YPI is a good instrument to use as a catalyst for further exploration.  Open-ended questions are favored.  The aim is to be able to create experiences in which the Abandoned/Abused Child and the psychotherapist are in contact.  This kind of contact is beneficial in and of itself.  This is not a problem-solving phase.  The development of a bond is important because it will help both parties to withstand the stresses that are likely to come.

Another goal during this phase is to keep the patient out of the Angry Child mode, as no work can get done when this is activated.  When the patient is in a more vulnerable state, the limited reparenting activities of the therapist can be implemented.

This is also a time in which self-destructive behavior can be explored and strategies for managing it can be instituted.  This would include understanding the needs and feelings that precipitate such acts as suicidality, substance abuse, cutting, and self-mutilation.  Intertwined through all of this is the delineation and characterization of the voices (Elliott & Greenberg, 1997) and needs that are at play.  Imagery work in connection to this exploration of the self can help clarify their identity and purpose.

The second phase of treatment is that of schema mode change.  One critical aim is to maintain contact with the Abused/Abandoned Child.  In contrast to the Punitive Parent, the therapist praises and affirms the child.  While this may trigger the Punitive Parent to strike out, the child part will, nonetheless, hear the message.

As noted above, the Detached Protector is a coping and survival mode.  The dilemma is that this mode prevents the therapist from gaining access to the child mode, which, in turn, impedes therapeutic process.  There are a number of ways that this issue can be addressed.  The first is to label this defense as a mode when it emerges in the interaction.  The therapist and the patient can then discuss the advantages and disadvantages of allowing this mode to dominate.  Since the therapist is consistently working to protect and affirm the Abused/Abandoned Child, the Detached Protector may feel more confident about relaxing his or her grip.

The Detached Protector mode can also be turned into an image and the therapist can dialogue directly with the mode (as opposed to discussing it with the patient).  If the therapist can get the patient to bring up an image of the child directly, the Protector can be circumnavigated.

Once this mode has receded, it is important to protect the Child mode.  There is a reservoir of pain and unexpressed emotions within these patients.  If it all comes flooding out, the patient may feel overwhelmed and the Detached Protector will take over again.  Instead, the therapist needs to closely regulate the amount of pain that is being processed in each session, session, perhaps taking small steps. 

Ultimately, to protect and heal the Abused/Abandoned Child, the therapist will need to engage the Punitive Parent or Inner Critic.  This is done in several ways.  To start, the voice is turned into a mode and is give a name that is meaningful by the patient.  Turning it into a mode creates some space between the patient and this aspect of themselves.

The therapist, in imagery or in the dialogue, will ask the patient to verbalize what the oppressive voice is saying and will then attack it.  In many respects, the therapist will be the voice for the Angry Child.  The needs that were not met and the right to have them met will be affirmed.  This dialogue will be done repeatedly.

Next, using imagery and chair dialogues, the patient will do the same.  This can involve confronting the mode and delineating all of the damage that it has done to the patient (Greenberg et al., 1993).  The patient can also set limits on its behavior in the future, i.e., “I won’t let you talk to me like that” (Young et al., 2003, p. 345).

In this process, a Healthy Adult mode is developed and strengthened.  This part affirms the needs of the child.  Again, letters can be written to the abuser stating what that person had done to them, what their emotional reaction had been, and how they were going to end the abusers negative impact on their life. 

As discussed above, in cases where there was actual abuse, imagery work can be done to replay and work through the abuse.  This needs to be titrated so as to not overwhelm the patient.  The therapist will protect the Abandoned/Abused Child against the abuser and will then help the patient do the same.

The Angry Child
As noted above, the Angry Child mode has the potential to derail the therapy and
is often experienced as the most unpleasant part of the therapy experience.   There are three places where this mode can be activated–in the therapeutic relationship, in the recounting of the traumatic experiences, and in interpersonal relationships outside the room.

For anger in the therapeutic context, the therapist wants to stress two points: “The first is that the therapist wants to hear the patient’s anger; the second is that the patient needs to express the anger within appropriate limits” (Young et al., 2003, p. 349).   There are four steps involved here:

The exception to this is in imagery work, especially with those who hurt them.  “In imagery work, patients are encouraged to express their anger fully.  They can yell and  can hit the couch, use a bataka, or create other safe ways of expressing their feelings” (Kellogg & Young, 2006).  Role-playing and letter-writing can be used to release anger as well.  As noted above, those with histories of violence should not do violent imagery or hit things in session.  Verbalizing their feelings is a better vehicle for them.

Autonomy
Autonomy is the third stage in the treatment process.  Here, the focus moves from the inner world to the external, interpersonal world.  The two main areas of work are interpersonal relationships and identity development.

Interpersonal relationships are examined to see which modes are in operation.  The goal is for there to be balance and reciprocity.  Situations in where the patient is receiving excessive amounts of disrespect or is rageful and demanding are problematic and will need to be addressed.  Developing an assertive, strong, but respectful voice will be best.

A lack of a sense of identity is one of the diagnostic criteria for BPD.  The model here involves helping the inner child with the process of growing up.  Maturation involves developing a set of values, a set of likes and dislikes.  Therapist will work with patients to help them explore the world and develop preferences.  Young worked with a woman who, at the age of 27, discovered what her favorite color was.  This discovery helped to strengthen her sense of self (Young et al., 2003).

Philosophy And Case Management
Issues concerning the balance between the needs of the patient and the needs of the therapist, countertransference, anger, and managing suicidal crises have been explored at length in Young et al. (2003) and will not be pursued here.  There is, however, one key point that is worth mentioning.  In the schema therapy model, borderline patients are seen as “needy, not greedy” (Young et al., 2003, p. 322).  Psychologically and emotionally they are little children who have been abandoned.  This leads to the emotional intensity that they often express.  Schema therapy believes that compassion and nurturing are the answer, not limit setting and viewing the patients as spoiled and demanding.

A Case Example
In what may be the first published case study of schema mode therapy, Bamber (2004) used the approach in the treatment of “Jimmy”, a 47-year-old man who reported a 30-year history of debilitating agoraphobia.  This wonderful case history is well worth reading in full.  Some of the highlights will be focused on here.

Prior to entering schema mode therapy, Jimmy had undergone multiple therapeutic experiences, including pharmacotherapy, psychodynamic therapy, hypnosis, and standard CBT, all of which had proven to be unsuccessful.  In terms of his personal history, his father was an emotionally and physically abusive man and his mother tended to protect him from the outside world and helped him avoid challenges.  He made some attempts to engage the world and was even married briefly, but bouts of anxiety began to play an increasingly paralyzing role in his life.

Jimmy and Bamber worked out the modes in the following way.  The Detached Protector was called the “Black Knight”.  He was “a mercenary who had a job to do, and that was stop any hurt or pain getting through” (p. 432).  The Vulnerable Child was “Defenceless Jimmy”, who was seen internally as a newborn child.  “He got easily overwhelmed and could not cope with very much at all and was unable to take any risks” (p. 432).  The Punitive Parent was known as “The Multi-Headed Hydra.”  It was described “as an aggressive bully…[and] as critical, controlling, withholding and frightening to Defenceless Jimmy” (p. 432).  This figure was seen as a combination of his father and his brother.

The Healthy Adult first took the form of Charles Darwin, who was chosen for his knowledge and wisdom.  He was later replaced with Sean Connery, the actor.  Sean Connery, in his off-screen life, is very actively involved in charity work for the benefit of children and it was this aspect of the man (not James Bond) that appealed to the patient and was chosen to represent the Healthy Adult.

The paper gives an overview of 19 sessions that were primarily focused on mode work.  At the beginning of the process, the hydra is strong, the child is weak, and the Black Knight steps in and tries to shut down the therapy.  This mode is bypassed and Charles Darwin, who was ineffectual in his attempts to fight the hydra, is replaced with Sean Connery.  He goes to battle with the hydra.  In the imagery work, “flying harpies” are brought in to assist in the battle and Sean Connery attacks the logic of the hydra.

After this, things begin to change.  Defenceless Jimmy begins to fight the hydra as well.  He defends himself and challenges the hydra.  As he does this, he experiences himself as “strong” and “brave”.  Behaviorally, he starts leaving the house more.  He makes contact with old classmates, contacts a woman that he knew in the past, and he has his first sexual experience in 13 years.

The hydra tries to attack this progress through criticism and ridicule.  Jimmy finds that the Black Knight is too weak to help him, so he relies instead on Sean Connery and the harpies.  He begins to feel that the Punitive Parent is weakening.  He also gets bolder in his attacks on the hydra.  He now feels that he has reached the age of 10.

In a reparenting stage, he imagines going places and doing things with Sean Connery.  Sean Connery models how he would behave in the different situations and Jimmy tries this out in real-life.  CBT techniques are also used to help him with his phobias.  As this continues, he describes himself as “coming out of a frozen wasteland after three decades” (p.435).  He is taking much better care of his appearance, driving, working a little, seeing friends, and pursuing his romantic interests.  He reports that the Black Knight is dead and there is a concomitant return of his affective life; he cries for the first time in years.

He feels that the inner child has now reached puberty and, by the end of this period of work, he reports that he is engaged to be married.  Pre-and Post-therapy YSQ assessments show dramatic reductions in schema scores.  Clearly, this is a creative and effective use of the mode model.  As a result of Bamber’s efforts, this man’s life was saved.

Empirical Data
There has been a major study of schema mode therapy in the treatment of BPD.  Dr. Arnoud Arntz and his research team did a three-year treatment study of borderline personality disorder in the Netherlands.  Schema therapy was compared with Kernberg’s (2004) transference-focused therapy.  Preliminary findings presented on a conference suggest that schema therapy had a significantly better retention rate and, using an intention to treat sample, significantly more patients were “recovered” or “clinically improved” with schema therapy (Arntz, Giesen-Bloo, van Dyck, Spinhoven & van Tilburg, 2005). It is our hope that the publication of this study will help further the spread of schema therapy, especially among those who emphasize the importance of evidence-based treatments.

Schema Therapy and Gestalt Therapy
Hopefully, the extensive use of gestalt and experiential techniques by schema therapists has been made clear.  The ones discussed here have been imagery, chairwork, and letter-writing.  Awareness interventions were not discussed, but they are used to a lesser degree.  Of central importance, however, is the understanding that the use of gestalt techniques is not random or intuitive; they are used within the context of a strong conceptual base.  This distinguishes schema therapy from other therapies that use these interventions in a less or non-systematic way (Melnick & Nevis, 2005; Yontef, 2005). 

An exploration of the gestalt therapy literature seems to point to the presence of two polarities within that tradition.  The first polarity is based in the 1951 publication of Gestalt Therapy by Perls, Goodman, and Hefferline (“The 1951 polarity”).  This book has connections to psychoanalysis and is centered on awareness as the key therapeutic healing vehicle.  This would later be described in a famous paper by Beisser (1970) as the “paradoxical theory of change.”  This work is also connected to Eastern philosophical and religious traditions and to the work of the phenomenologists.

The other polarity is centered in the later work of Fritz Perls.  This would include his activities during the sixties at Esalen and would include his chairwork interventions and his dreamwork technique (“The 1969 polarity”).  These efforts have been captured in The Gestalt Approach/Eyewitness to Therapy (Perls, 1973), Gestalt Therapy Verbatim (Perls, 1969), and Legacy from Fritz (Perls, 1975).  This work appears to be more connected to the psychodramatic tradition.  Recent discussions (Bowman, 2005; Melnick & Nevis, 2005; Yontef, 2005) on the current status of gestalt therapy appear to reflect a therapy that is much more centered on the "1951 polarity" than on the "1969 polarity."

However, therapists who have sought to integrate gestalt techniques and perspectives into other ways of working have typically found the 1969 polarity to be a better source of material.  Despite his emphasis on awareness, Kellogg (2004), perhaps looking backward with a more contemporary lens, felt that Perls, during this period, was a modifying therapist, to use Greenberg’s (Greenberg, Safran, & Rice, 1989) facilitating versus modifying dichotomy.  His emphasis on polarities and integration can be re-envisioned as a kind of cognitive-behavioral therapy.  There are two examples that capture this.  In Linda’s dream in gestalt Therapy Verbatim she is first focused on images of a lake that is drying up and a license plate that has expired.  There is a feeling that things are at an end and a sense of impotence in her images and in her language.  She does, however, make a shift when she discovers: “When I soak into the earth, I become a part of the earth–so maybe I water the surrounding area, so…even in the lake, even in my bed, flowers can grow (sights)…New life can grow…from me (cries)…” (Perls, 1969, p. 82; see also Edwards, 1989).  In another case example, Perls uses the image of a beached whale that emerged in a dream of an obese and depressed woman.  This image brings up stories of isolation and loneliness.  He then switched polarities.  “When Perls told her, as her tears dried, to become the sea in her dream, her huge shape seemed for a moment not just the visible burden of her self-hatred but an indication that she could be teeming with life” (Miller, 1992, p. 2-3).

In both cases, Perls has moved them from death images to life images.  This work is purposeful and directed.  In these and other instances, Perls has switched into the role of the caring, heroic father therapist, a role for which he was much loved (i.e., Baumgardner, 1975).

It was this direct and confrontational work that lent itself to adoption by other therapeutic traditions.  Probably the most successful of the early attempts was Redecision Therapy (Goulding & Goulding, 1997).  The Gouldings integrated gestalt therapy with transactional analysis and were very successful in the use of chairwork and imagery and in re-working traumatic situations that their patients had been through.

Conceptually, there are a number of places of meeting between schema therapy and gestalt therapy.  Fodor (1987, 1996a, 1996b, 1998), in a series of papers, has sought to make a connection between gestalt therapy and the constructivist aspects of cognitive therapy.  A central aspect of this work is the argument that gestalts are schemas.  This is an important bridge concept for integrationist efforts.  It also opens the door to reconceptualizing gestalt interventions in ways that are more easily assimilated by schema and constructivist therapies.  On the other side, gestalt therapy, both in its research and in its case conceptualizations, could use the language of the schemas to good purpose.  The fact that there are empirically supported measures allows for greater cognitive conceptualizations by both therapists and patients.

Young and Klosko (1993) report a case of a patient who left a gestalt practitioner for schema therapy.  The central complaint was that the here-and-now experiential work was not providing him with a coherent understanding of his problem.  Fodor (1996a) has addressed this issue in her emphasis on the crucial interplay between experience and its interpretation.  Traditionally, gestalt therapy has emphasized experience and awareness, while the cognitive therapies have emphasized beliefs and interpretations.  It is our perception that schema therapy is, in fact, bridging the two.

Turning to the interventions, Edwards (1989) makes the significant point that gestalt chairwork and imagery exercises are forms of cognitive restructuring.  This clearly provides a rationale for the use of these techniques within a cognitive-behavioral framework (see Goldfried, 1988, 2003).  Zinker (1977), coming from the other side of the equation, sees gestalt work as a kind of in-session form of behavior modification.  He sees the experiments (chairwork and imagery) as a systematic way to do this. 

Greenberg’s (Greenberg, 1979; Greenberg et al., 1993) extensive work on the chair paradigms easily lends itself to a cognitive-behavioral and schema therapy work. 

Another area of contact is that of multiplicity.  Perls (1969, 1973, 1975) would have different aspects of the person, including body parts, dialogue with each other.  Simkin (Simkin, Simkin, Brien, & Sheldon, 1986) wrote: “We are all different people, at different times, in varying polarities.  …gestalt therapy gives attention to the observation and awareness of our different parts” (217).  Elliott and Greenberg (1997) spoke about a model of multivocality in their emotion-focused therapy, and, as has been seen, the mode model is based on multiplicity (Stiles, 1999).  Kellogg (2004) felt that the metaphor of multiple voices may be the vehicle for integrating these two approaches.  One historic difference is that the cognitive-behavioral (i.e., Bishop, 2001) and schema therapy practitioners are willing to create new voices, while the gestalt practitioners tend to favor working with what is there.

Schema therapy, in addition to assessment instruments and a language of pathology, offers gestalt therapists a way to make bridges to other therapeutic traditions.  To use a gestalt dictum, they can go from an either/or stance to an and/both one.  Lastly, while Dr. Young and the present author have studied with gestalt practitioners, ongoing dialogues and interactions with gestalt therapists, who are experts in the use of experiential techniques, would only serve to improve the power and effectiveness of schema therapy. 

Conclusion
This paper sought to give an overview of the contemporary application of schema therapy.  This included a look at both the schema-focused and the schema-mode models.  The model for the treatment of borderline personality disorder was presented and case example outlining its use was provided.  Finally, points of contact between the two approaches and the possible benefits of schema therapy-gestalt therapy dialogues were detailed.

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Yontef, G. M. (2005).  Gestalt therapy theory of change.  In A. L. Woldt & S. M. Toman
(Eds.).  Gestalt therapy: History, theory, and practice (pp. 81-100).  Thousand Oaks, CA: Sage.

Young, J. E. (1990).  Cognitive therapy for personality disorders: A schema-focused approach.  Sarasota, FL: Practitioner’s Resources Series.

Young, J. E. (2001).  Young Schema Questionnaire: Special Edition.  New York: Schema Therapy Institute.

Young, J. E. (2002).  Maladaptive schema coping styles.  New York: Schema Therapy Institute.

Young, J. E. (2003).  Young Parenting Inventory.  New York: Cognitive Therapy Center.

Young, J. E., (2004).  Schema mode listing, October 2004 revision, third draft.  New York: Schema Therapy Institute.

Young, J. E. (2005).  Young Schema Questionnaire-3[Short form].  New York: Schema Therapy Institute.

Young, J. E., Beck, A. T., & Weinberger, A. (1993).  Depression.  In D. H. Barlow (Ed.) Clinical handbook of psychological disorders (2nd ed.), (pp. 240-277).  New York: The Guilford Press.

Young, J. E., & Klosko, J. S. (1993).  Reinventing your life.  New York: Dutton

Young, J. E., Klosko, J. S., Weishaar, M. E. (2003).  Schema Therapy: A practitioner’s guide.  New York: The Guilford Press.

Zinker, J. (1977).  Creative process in Gestalt therapy.  New York: Vintage Books.

Postscript: Schema Therapy 2009 – Scott Kellogg, PhD
This article was originally written in 2005 and schema therapy has progressed greatly since then. At that time, the Dutch study on the effectiveness of schema therapy in the treatment of borderline personality disorder could not be fully discussed as the official study had not yet been published. As intimated in the main section, this study was a watershed event. When compared with the 42 patients who were randomized to treatment with Transference-Focused Therapy, the 44 patients receiving schema therapy were:

1. Significantly more likely to have a full recovery (46%:24%)

2. Significantly more likely to show clinical improvement (66%:43%) The schema therapy patients also reported better quality of life and lower levels of psychopathology (Giesen-Bloo et al., 2006).

These findings have been of great interest to those who are concerned about borderline personality disorder and schema therapists alike. Since then, exciting work is emerging on ways of working with narcissistic personality disorder (Behary, 2008) and antisocial personality disorder (Bernstein, Arntz, & de Vos, 2007).

The American Psychological Association (2007) released a DVD on schema therapy that featured Jeffrey Young working with a borderline-spectrum patient. Of relevance to this discussion, there are some extremely powerful moments in which he uses imagery and empty-chair techniques to help the patient, Pam, confront her history of mistreatment and abuse.

On the organizational front, there have been efforts to form a central organization that seeks to promote the advancement of schema therapy. After meetings in Sweden, the Netherlands, and Portugal, the International Society for Schema Therapy was formally created in 2008. It currently has its headquarters in Germany, and it includes members from all over the world.

In terms of web-based resources that are useful for those interested in schema therapy, relevant sites include:

1. Schema therapy homepage: this website contains a great deal of information about schema therapy theory and practice; in addition, there is information about the International Certificate Program in Schema Therapy. www.schematherapy.com

2. The International Society of Schema Therapy is the home of the new international organization. The goal is for it to become a central resource for schema therapists. www.isst-online.com

3. The New Jersey Institute of Schema Therapy is the training site of Wendy Behary, the therapist who has done centrally-important work on using schema therapy to treat narcissistic disorders. http://www.disarmingthenarcissist.com/institute.php

4. Transformational Chairwork Training. This is a training program that empowers psychotherapists to use the chairwork technique while drawing on the insights of gestalt therapy, schema therapy, and a wide range of integrative psychotherapists. This training has been popular with schema therapists. www.transformationalchairwork.com

Hopefully, this brief update has given a sense of the vibrant energy that is now moving through the schema therapy world.

References
American Psychological Association (Producer). (2007). Schema therapy with Jeffrey E. Young, PhD [Motion picture]. (Available from the American Psychological Association, 750 First Street, NE, Washington, DC 2002-4242).

Behary, W. T. (2008). Disarming the Narcissist: Surviving and thriving with the self- absorbed. Oakland, CA: New Harbinger.

Bernstein, D., Arntz, A., & de Vos, M. (2007). Schema focused therapy in forensic settings: Theoretical model and recommendations for best clinical practice. International Journal of Forensic Mental Health, 6, 169-183.

Giesen-Bloo, J., van Dyck, R., Spinhoven, P., van Tilburn, W., Dirksen, C., van Asselt, T., et al. (2006). Outpatient psychotherapy for borderline personality disorder: Randomized trial of Schema-Focused Therapy vs Transference-Focused Psychotherapy. Archives of General Psychiatry, 63, 649-658.