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Schema Therapy for Children and Adolescents (Loose, Graaf & Zarbock, 2013) - FOR PERSONAL USE ONLY -

Exerpt of Chapter 7: Authors: Peter Graaf & Christof Loose, revised by Erin Bulluss (06.10.2016) page 1

Schema Therapy for Children and Adolescents

(Loose, Graaf & Zarbock, 2013)

Chapter 7: Child-related techniques and procedures Authors: Peter Graaf & Christof Loose; revised by Erin Bulluss

7.1 Introduction to the application of Schema Therapy with children and

adolescents

Working therapeutically with children, adolescents, and their families can be a fun, positive, and

rewarding experience for all involved. However, there are some clinical issues and barriers to

engagement that are specific to working therapeutically with children, adolescents, and their families,

and successful therapeutic intervention requires a specialized approach that incorporates an

understanding of child development and family dynamics. When starting therapy, children often feel

that their parents or teachers want the therapist to change who they are in order to fix them. Most

children have not yet developed a clear distinction between self and behavior, so this sense of needing

to be changed or fixed unsurprisingly and paradoxically leads children to strongly resist changing

anything in the early stages of therapy. Further, most children (and many adults, for that matter) dislike

feeling intense emotion or discussing uncomfortable topics. Some children are yet to develop the

ability to delay fun, play, and gratification in order to deal with unpleasant topics or feel intense

emotions. Instead, most children simply choose not to deal with unpleasant topics, thus avoiding

painful feelings for as long as possible until a situation activates a schema and the child is overwhelmed

by feelings. As such, when a child first presents to therapy they are usually in Detached Protector Mode

and rarely in the Clever-Competent-Caring Child Mode. This means that the Vulnerable Child Mode,

who is essential to therapeutic growth and can be thought of as the “place of therapy” (Berbalk, 2010,

personal communication), is not readily accessible. Further, while psychoeducation may encourage

adult patients to accept intense emotion as a necessary part of the therapeutic process, it is often

much more difficult to encourage a child to accept intense emotion as a necessary part of the

therapeutic process. Often children struggle to grasp this concept, experiencing confusion and disbelief

that feeling bad is part of feeling better, and often therapists find it difficult to explain this concept to

children in a manner appropriate to developmental level. Another consideration when engaging

children in a therapeutic context is the loyalty children usually feel towards their parents, regardless

of context and family dynamics. Children are often fearful of the therapist questioning or undermining

this loyalty. This is underpinned by a fear that, in a broad sense, the family’s unity and security will be

threatened, and often leads children to be suspicious or avoidant of any direct questions or

investigations into the family unit. When children feel that they must align with either the therapist or

their family unit, they will almost always choose to align with and protect their family unit, regardless

of any dysfunction (though this may change later in adolescence, when children are more

developmentally ready to individuate from the family). As such, it is important to find a less direct

method to investigate the child’s feelings and experiences, such as established play-therapy methods



which allow the child to follow their need for playful self-expression in the therapy situation. In or

clinical experience, this allows children to communicate uncomfortable feelings, difficult relationships,

and painful memories, while also eliciting and exploring the child’s main coping modes. The techniques

described in this chapter form an innovative bridge between classic play therapy and a cognitive-

behavioural therapy approach to engage children in a fun and flexible, yet structured, therapeutic

process. This is important, as the precise structure and orientation of schema therapy helps keep both

parents and children present and understanding the content in the therapeutic process, and prevents

all involved from becoming lost in a wandering, unstructured therapeutic approach. Our mode based

schema therapy approach gently and playfully builds a solution-oriented bridge between the child’s

experience and the corresponding changes to be made in day to day life, allowing growth and positive

change without fixating on symptoms and difficulties.

7.2 Mode-work: basic elements and materials

Mode work plays a key role in children’s therapy. The mode model is different from the schema model,

and is closer to the child's play and experience. Even without therapeutic intervention, many children

intuitively choose imaginary friends or helpers to assist in meeting core emotional needs, consistent

with the idea of an Allied Protector Mode, Clever-Competent-Caring Child Mode, and/or Wise

Observer Mode. Therefore, most of the techniques described in this book focus purely on mode work

with children, in order to match the child’s developmental level and experience. On the other hand,

both schema- and mode-based interventions are suggested when working with parents, who can likely

manage a more complex, abstract form of therapy. The basic tenet of the treatment is the re-

orientation of dysfunctional mode constellations as the basis for a change in behavior. We assume that

children and parents are indeed capable of “surface” change through short-term behavior

modification, but changes to the "deeper" mode level are - in our opinion - more effective and

sustainable, as they encapsulate a more complex mechanism consisting of body reactions, thoughts,

feelings, and behavior, which then leads to more pervasive, lasting change.

Child and parents become aware of their “current states” in the therapy and test- both inside and

outside of the therapy situation- the use of functional modes as an alternative way of coping with

difficult situations. Patients are encouraged not to automatically surrender to a dysfunctional mode

and to instead develop sufficient insight and maturity to make a wise or clever choice, thus improving

self-regulation. Jeff Young said, in reference to patients with borderline personality disorder, “bring

the modes together, don’t go so deeply into the mode” (Young, ISST-Congress 2010, Berlin). This

statement is also applicable when working with children and their families. We are not aiming to

eliminate any modes, but rather to avoid diving as deeply into dysfunctional mode based states. By

practicing keeping one’s head above the water, so to speak, we then create space for choice that

allows selection of the mode that suits the particular situation. All of the modes can be useful in

particular situations, however a mismatch between the triggered mode and the situation creates

dysfunction.

Basic elements of mode work

In the following we give an overview of the basic elements of mode work, inspired by Berbalk’s (2009)

steps for mode work with dolls. Our list is intended as a guide for therapists and provides a common

thread to allow creative implementation of mode work through pictures, toys, puppets, stories, chairs,

and other media. Examples of these specific interventions are described later in this chapter. It is not



necessary (nor generally possible) to process every step in one session and, in practice, these processes

do not occur in a fixed order nor one at a time. Rather, the patient is guided and supported forwards,

backwards, and sideways through these processes by the therapist. The five basic elements of mode

work are listed below, with examples of the processes that occur within each element.

1 Identify the modes

• Identify and name important modes (e.g., by assigning the mode to a finger puppet).

• Ensure essential modes are included- Vulnerable Child Mode, Happy Child Mode, Competent-Clever-

Caring Child Mode- as well as additional modes specific to the child.

• Bring the mode to life (e.g., the finger puppet talks and plays and thus gives the mode a living form).

• Working out the emotions, body sensations, behavioral tendencies, and cognitions associated with

each mode.

2 Connecting to the Vulnerable Child Mode

• With the child’s permission, conduct a dialogue between the therapist and the mode.

• Exploration of needs, "What does Little Felix need?”

• Consolation, validation, and offer of protection towards all modes, including internal demanders,

criticizers, or punishers. In child and adolescent work, all modes are worthy of care and protection.

3 Determine the mode’s functionality (in dialogue)

• Explore the mode’s origin and function. What are the specific core emotional needs driving the

modes?

• Establish connection between the modes and the current problems: how do the modes influence my

life? How are they connected to difficulties I am facing?

• Identify situations, feelings, people, and other stimuli that trigger modes.

• How are the modes related to each other? How do the other modes effect the Vulnerable Child

Mode?

• Identify advantages (strengths) and disadvantages (difficulties) of each mode.

• Evaluation of functional and dysfunctional mode constellations for day to day life by linking each

mode constellation with its short term and long term consequences. Reduce shame and stigma by

acknowledging that dysfunctional modes may be functional in extreme or unusual circumstances, just

not all day, every day.

4 Reorientation by strengthening positive, functional modes, while disempowering problematic,

dysfunctional modes, and integrating separated modes

• Explore and play out alternative mode constellations for day to day life.

• How is a different relationship or dynamic between the modes possible?

• Explore dialogue between different modes.



• Acknowledgement of dysfunctional modes as temporary stopgaps that are serving an important

purpose until functional modes and support people can take over serving the purpose in day to day

life. Integrate the positive aspects of different modes and allow them to work together.

• Encouraging the Clever-Competent-Caring Child Mode to assert themselves age-appropriately and

reasonably. The Clever-Competent-Caring Child Mode becomes the leader of all the modes and assists

in choosing which modes will be active, thus promoting age-appropriate self-regulation.

• The internalized Caring Parent Mode is supported or an internal Allied Protector Mode activated. The

helping modes are introduced as loving, caring, and protective supports standing by the Vulnerable

Child Mode's side (i.e., the redemption of the vulnerable child).

• Help for the Angry Child Mode to an appropriate and constructive expression of feelings and needs

instead of destructive impulses.

• Disempowerment of the Inner Critic/Punisher Modes, analogous to punitive/demanding parent

mode (Young et al., 2005). The therapist empathically confronts these modes, rather than banishing

the modes forcefully. This parallels the approach taken with families and other systems, where these

modes may have originated. It is important to promote cohesion within these systems, which is

reflected in the approach taken to the Inner Critic/Punisher Modes.

• Change perspective from inward to outward: "If something like this was done to your friend, what

would you think?”

• Guidance for the Undisciplined Child Mode to improve self-control.

5 Transfer/bridge to everyday life

• Planning and implementation of specific steps. Find examples of everyday life: where do we go from

here?

• Which modes would best suit which situations?

• Preparation for everyday life communication (dialogue of modes with real people in imagery or in

structured role-play).

• Involvement of the system or family members: how could they be affected by a different mode taking

charge of the situation? How can they adapt to a different kind of "interaction"? How can we make

this work for everybody and set the child up for success?

• Provide reminders for everyday life: flash cards, visual aids, transitional objects, or tactile cues (e.g.,

for the pocket) to support the activation of certain modes.

• Set a homework tasks to practise consciously changing between modes.

• Mode monitoring: practise monitoring the modes as modes must be identified before a choice to

change modes can be made; conduct experiments and structured role-plays with video feedback in

the therapy sessions, possibly also with exaggerated application of certain body postures. In everyday

life, use of worksheets that help detect typical signs and cues of both functional and dysfunctional

modes.



Disempowerment vs. banishment: Dealing with dysfunctional parent modes in children

Working with dysfunctional parent modes is one of the key differences between applying schema

therapy with adult populations and applying schema therapy with children, adolescents, and their

families. Jeffrey Young and colleagues (2005) speak of banishing the dysfunctional parent modes.

These modes are not intended to reflect the parent as a person, but rather to put a name to the

dysfunctional behaviours of the parent (or other) which have been internalized as an inner

dysfunctional parent mode, often termed Demanding or Punitive Parent Mode. While this is

appropriate for adults who have individuated from their family unit and have the cognitive ability to

understand the difference between an actual parent and a parent mode, this concept can create a

conflict of loyalty in children who are yet to clearly differentiate people from their behaviours.

Furthermore, given children depend on their parents to meet their needs in a developmentally

appropriate manner, risking further disruption to this relationship during childhood is generally not in

the best interests of the child. As such, the therapist should refrain from using the terms Demanding

and/or Punitive Parent Mode, but rather create separate labels such as Inner Critic Mode or Punisher

Mode. The therapist also gently points out that the Inner Punisher and/or Critic modes are unhelpful

in solving problems and therefore clearly rejects the content of their messages (but without rejecting

the original source of the messages/the parents themselves). These punitive and critical messages are

also addressed in parallel with the parents, and linked to the parents own schemas and mode

constellations. The aim here is to have a reduction in critical and punishing behaviour from parents by

disempowering the Critic and Punisher Modes within the parents, while also reducing the power of

already internalized critical and punishing behaviours by disempowering the Inner Critic and Punisher

Modes within the child. It is also important to strengthen the internalized Caring Parent Mode by

encouraging, coaching, and highlighting the positive, caring, fun parts of the parents- the aspects of

the parents that are able to meet the child’s needs- for example, through "islands of good memories"

(Peichl, 2007). This involves increasing the parent’s connection to this part within themselves to

encourage caring behavior, while also helping the child to notice these moments. The therapist can

then assist in strengthening memories of these times when the parents were meeting the child’s

needs, and the child felt happy, safe, secure, protected, and carefree, in order to assist the child to

internalize these aspects of their parents, which eventually will contribute to the rounded

development of the child or adolescent patient’s own Healthy Adult Mode in adulthood.

By now, cognitive behavioral therapists will have recognized some similarities between the elements

mentioned above and traditional CBT (eg. Borg-Laufs & Hungerige, 2010; Schlarb & Stavemann, 2011;

Walter & Döpfner, 2009; Zarbock, 2011). For example, Walter and Döpfner’s program (SELBST, 2009),

includes techniques that are used when working with modes, including the correction of unhelpful

thoughts through analysis and exploration of the biographical experiences underpinning the

development of the thoughts.

A key difference between CBT and mode work, however, is that CBT tends to address thoughts,

feelings, body sensations, and behaviour as separate components. In mode work, we view the mode

as a specific yet complex pattern of thoughts, feelings, body sensations, and behaviour that can be

triggered by relevant situations. In addition to environmental triggers, the whole mode can also be

triggered by experiencing one part of the mode. For example, the body sensation of having stomach

pain can automatically activate the feeling of fear, the thought, "I cannot do this", and avoidance

behaviours as part of a complete mode package. While traditional CBT may successively touch upon



thoughts, feelings, body sensation, and behaviours; mode work more deeply captures the experience

of all four facets at once, thus promoting a deeper characterological change rather than superficial,

symptom-level change. In CBT, it can be difficult to encourage children to identify their own cognitions,

let alone analyse them. Further, viewing each of the above components (thoughts, feelings, body

sensation, and behaviour) as separate, yet linked, involves psychoeducation and assumes a certain

level of verbal and cognitive development. Therefore, it is often easier - at least at the start of therapy,

and with younger children - to work with the overall mode rather than taking out single components

and changing them in isolation, or linking discrete components together. The entire experience of a

mode can be described in one label, reducing the complexity of the verbal language needed to

communicate with the child. Further, the label can be part of a shared therapeutic language that has

been developed in collaboration with the child, thus allowing the therapist to expand his or her

vocabulary to fit with how the child sees the world, rather than expecting the child to expand his or

her vocabulary to fit with how the therapist sees the world.

Therapeutic materials

There are no set materials that must be used in mode work with children and adolescents; therapeutic

materials in mode work are limited only by the therapist’s imagination, availability of resources, and

occupational health and safety! The therapeutic materials to be used in a session are chosen based

upon the patient’s interests, needs, and developmental level. We use common materials from play

therapy work, and supplement this with a variety of puppets, dolls, and figurines as representations of

modes and also representations of real people (therapists, parents, peers). For adolescents, the use of

worksheets may also be appropriate. We often mix materials, using different methods and

interventions to address the same idea, combining experiential work with a written worksheet, or even

taking photos of experiential activities for the patient to keep. Keepsakes (e.g., worksheets, photos, or

transitional objects) linked to experiential mode work can serve as a helpful reminder when dealing

with maladaptive schemas and modes, even years after therapy. The examples of therapeutic

interventions later in this chapter will provide more specific information about the nature of materials

used in mode work.

7.3 Relationship-building as an essential feature in Schema Therapy

With the co-operation of Petra Baumann-Frankenberger

Relationship building is an important part of all therapeutic approaches, however the level of emphasis

on the therapeutic relashionship differs greatly between approaches. While traditional symptom

focused CBT emphasizes the importance of establishing a working alliance between therapist and

patient to facilitate engagement in therapy, Young and colleagues (2008, p 226) state: "The schema

therapist views the therapy relationship as a vital component of schema assessment and change." As

such, the therapeutic relationship in Schema Therapy is viewed not only as a component that facilitates

engagement in therapy, but is viewed a key component of the therapy itself. We will now discuss

relationship-building in schema therapy when working with children, adolescents, and their families,

as it differs from relationship-building with adult clients who have individuated from the family of

origin.



7.3.1 Relationship-building with the patient

Since children are still developing their core sense of identity, clinical symptoms such as anxiety,

depression, conduct disorder, ADHD, and so forth are often experienced as part of the core self. For

example, a therapist could say to child with ADHD, "I want to help you reduce your attention deficit

problems, impulsivity, and psychomotoric restlessness, but apart from that I think you're great and

you can stay the way you are." However, the child might also hear in this statement: "I want to change

you," because he experiences these behavior patterns as a given part of himself and cannot

differentiate the behavioural patterns from the rest of himself. It is often much easier for a child to see

an acute physical injury, such as a broken arm, as separate from their core self and that the resulting

medical intervention is specifically targeting the physical injury. The child can easily comprehend, “I

fell and broke my arm. The broken arm needs to be fixed, because it hurts and I can’t use my arm

properly when it is broken. Putting my arm in a cast will help fix the bone by keeping it still. I am me

with a broken arm. The cast will help to heal my arm, and I will still be me.” However, given the sense

of cause and effect in therapy is much less clear and much more abstract, the child may view the offer

of support from the therapist as a kind of ruse, “Although my therapist says they want to help me to

fix problem xy, they are trying to change other unrelated parts of my life without asking (e.g. family,

social, emotional, cognitive aspects). I can’t see how problem xy is separate from me, and I can’t see

how changing my thoughts and talking to my parents is fixing problem xy. They are secretly trying to

change me, who I am, and my family.” This may not be experienced as a fully formed, explicit train of

thought- an implicit feeling of being disregarded and encroached upon is enough to impact the

therapeutic relationship, and also violate the child’s needs for autonomy and independence. The

aforementioned goal to reduce ADHD symptoms can therefore - no matter how well intentioned –

have the potential to be interpreted as a direct, aversively-experienced attempt to change the identity

of the child. This can then lead to a cautious or half-hearted attitude (e.g., recurrent failure to complete

homework, frequent cancelling of appointments), a lack of compliance (e.g., refusal to talk during

therapy), or even termination of treatment. Additionally, often in child and adolescent psychotherapy

the decision to attend therapy has been made by the parents, not the child, and therefore is externally

motivated. Moreover, sometimes therapy has previously been threatened as a form of punishment in

the family setting: "If you cannot behave yourself, we’re going to a therapist!" In this case, an already

societally stigmatized view of psychotherapy (“Psychotherapy? Only psychos have therapy!”) is made

even less appealing, as it is also seen as an aversive punishment.

The initial therapeutic contact is key in beginning to reduce these barriers to engagement. The therapy

room has to be a "safe place"; the therapist must be a warm, caring representative for the parents so

that the underlying causes can be explored and addressed without a focus on symptom reduction. This

requires the child to have a high degree of trust in the therapist, especially when attachment

uncertainties, disturbances, or loaded biographical events such as trauma exist.

Limited reparenting: In the course of diagnosis and treatment the schema therapist should repeatedly

bear in mind what kind of reparenting, if any, the patient requires. Since the child will usually have at

least one consistent caregiver, the ideal situation is to coach and support the caregiver to begin to

meet the previously unmet needs. Here, the therapist must be aware that they can only be satisfy

unmet needs within certain limits. If the caregivers are not able to learn to meet the child’s emotional

needs (for whatever reasons), it is the therapist's job to do this under the "limited reparenting" concept

as empathically as possible. It is, however, important to ensure that professional boundaries in the



relationship between the therapist and the patient are maintained. If, for example, the mother or

father has withheld physical affection, it is not appropriate for the therapist to provide direct physical

affection in the context of limited reparenting. Instead, the therapist can reflect how precious and

endearing the child is through verbal and non-verbal communication, rather than physical affection,

or use puppets and dolls to act out physical affection such as hugging, as appropriate.

Therapeutic requirements: Young and colleagues (2008) postulate therapist qualities of empathy,

warmth, acceptance, and authenticity as fundamental to building an emotional connection and

rapport with the patient. We agree and would also like to include the therapist quality of patience.

When caregivers have a strong demanding or critical mode, or when the therapist has their own strong

internal demanding or critical mode, the therapist may be tempted to focus on quick behavior change

in order to demonstrate effectiveness and appease the aforementioned demanding and critical modes.

However, the therapist should also recognize the limits of their therapeutic abilities and be aware that

insufficient relationship-building can reduce the effectiveness of interventions and undermine the

therapeutic process. Also, the premature use of front-line behavioral methods before the family

system is ready to successfully implement such strategies may also produce negative expectations

regarding efficacy of therapeutic interventions (e.g. "We already know about reward systems, they

have not helped..."). A trusting and genuine connection with the child and key family members is

fundamental and provides a secure foundation for all other components of therapy, including

behavioral and schema therapeutic interventions.

Strengths based approach: Particularly with children and adolescents, strengths based work that

highlights already-achieved goals has been found to be beneficial (see Resource Analysis by Borg-Laufs,

2011, p. 85). The message is: "Immerse yourself in the wonderful world of your patient! Let yourself

be inspired by what the child is already able to do and what they have already learned." Talking about

problems, symptoms, and difficulties is not part of this approach. Instead, the therapist focuses on

achievements and capabilities so much that eventually the child asks, "When do we actually start

therapy?" The therapist may then explore this statement as an invitation to dicuss more

uncomfortable topics with the child. This provides a solid foundation of relationship-building, upon

which the therapist can begin to work on problematic behavior through individualized mode based

interventions. Highlighting strengths and capabilities also sets a foundation for identifying and further

building the child’s Clever-Competent-Caring Child Mode.

7.3.2 Relationship-building to parental caregivers

Relationship-building with parents/caregivers plays an equally important role and must be adapted to

the age of the child. The following rule applies: the younger the patient, the more parental work is

required. It is necessary for the caregivers, especially the primary caregiver, to feel comfortable with

the therapist. Parents also need to perceive and acknowledge the therapy room as a "safe place" and

the therapist as a confidential person to whom they can be sufficiently open and to address shame-

inducing or taboo subjects. Without empathy, warmth, acceptance, and authenticity, a sufficient basis

of trust cannot be established. In the introductory phase it may be useful to offer a weekly

appointment to the parents as well as the children. As a rule, parents must first be encouraged to let

go of feelings of guilt while strengthening self-worth until they are ready to talk about underdeveloped

parenting skills and gaps in the care and welfare of their child(ren). Often parents also have

maladaptive schemas and modes that need to be addressed to help the family unit, and ultimately the

child.



It is important with adolescent patients to proceed carefully with the parental work and cooperate and

collaborate with the adolescent. Conflicts often exist between the parent and the adolescent child,

and often parents see the therapist as an extended arm of their interests (e.g., to ask for tips on what

to do when the adolescent disregards family rules). It is important that the therapist remains a trusted

and secure base for the adolescent client, while guiding the caregiver to parent appropriately to meet

the client’s needs. As such, outsourcing these concerns (e.g., limit-setting) to an appropriate resource

like a parenting course or text can be useful in order not to strain the therapist-adolescent patient

relationship.

7.4 Empathic confrontation

The idea behind empathic confrontation is to create a balanced and thoughtful approach that meets

the patient with human warmth, acceptance, and authenticity, while also confronting the patient with

the impact of their maladaptive modes and schemas. Young and colleagues (2008) also speak of an

empathetic reality check. This is not about a technique but rather a therapeutic approach. The

therapist empathizes with the patient’s experience and titrates the quality and quantity of the

confrontation carefully, to create an optimal balance of empathy and confrontation. Here, the

definition of “optimal” changes not only depending on the patient, but also depending on the day or

the situation. For this reason, the therapist must prioritise attunement and assess moment by moment

whether there is a balance of empathy and confrontation, and readjust accordingly. An emphasis on

empathy to the detriment of reality checking prevents the patient from understanding the

consequences of behavior arising from particular modes. As such, simply understanding and consoling

might bring the patient short-term relief, but prevents long-term change. On the contrary, harsh or

sudden confrontation of the problematic behavior and its consequences may trigger intense feelings

of low self-worth, anger, shame, and shock, unless a balance of empathy, understanding, and genuine

warmth is simultaneously felt radiating from the therapist to the patient. An imbalance in empathy

and confrontation can cause a strain on therapeutic relationship, which can lead to resistance to the

therapeutic process. The following two case studies illustrate how to proceed when children do not

want to engage in therapy nor relationship-building with the therapist.

Annika. Annika, an 8-year old girl, attended third grade at a primary school where she frequently

attracted attention for disobeying the rules and disturbing class, while also demonstating distractibility

and attention problems. She refused to participate in any discussion about her problematic behavior

in the first five outpatient diagnostic sessions. She had the impression that teachers and classmates

were unfair, and that she was the class scapegoat. Consistent with empathic confrontation, the

therapist initially empathized with Annika’s subjectively described emotional experiences in order to

hear Annika’s narrative, thus gaining information while encouraging connection: "It is horrible when

so many people grumble about you, I would feel sad and angry as well". From this subjectively-colored

plateau, the therapist then explored the situation further: “What do they blame you for?" "Ah, so I

understand, they think that you ...” The therapist took the perception, thoughts and feelings of others

from Annika’s description, summarized them, and reflected the differing perspectives in Annika’s

narrative back to Annika. This was done in a playful and fun way, collecting and piecing together hints

and clues, making reference to fictional detective characters and solving mysteries. Annika was then

gently confronted with accounts of her behaviour from the school and her grandparents, thus

providing more hints and clues, and she was gradually able to form a basic understanding of the

perspectives of others around her. She was then able to collaborate with the therapist in order to



address her role in the difficulties experienced in the classroom, while the therapist also worked with

family and school systems to meet Annnika’s needs and support her to make change.

Fynn. Fynn is an 11-year-old boy presenting with features of ADHD. As in the case of Annika, here the

therapist begins by focusing on empathizing with Fynn’s point of view. However, unlike Annika, Fynn

was not able to understand the perspective of others and instead continued to stubbornly express his

own position. He repeatedly asserted that he felt he had been treated unfairly by teachers and

classmates. His parents were apprehensive, stating, "Fynn is saying this with such conviction, he sounds

like he is telling the truth, I really don’t think he is making it up.” Fynn had refused to engage in therapy

previously and experienced the five first outpatient diagnostic sessions as a great injustice. Empathic

confrontation as implemented in Annika's case was not possible with Fynn at this stage. As such, the

therapist instead applied the principles of empathic confrontation with Fynn's parents: "It has just

become clear to me how difficult it must be for you to hear such different accounts of this situation.

You probably don’t know whom or what to believe, right?" After the parents confirmed feelings of

ambivalence, the therapist proposed, "Let's say the teachers’ descriptions of disruptive classroom

behavior are true, and we assume at the same time that your son is telling the truth from his point of

view - which may be somewhat slanted, okay, but- from his point of view- still true. This is possible, for

both sides to be telling the truth, but seeing things quite differently. If this were the case, then, perhaps,

instead of focusing on finding the truth it could be our goal to encourage Fynn to make different choices

when he feels a sense of injustice? Choices that don’t get him into trouble?" By experiencing empathy,

Fynn's parents felt that they and their child had been understood and supported, without having to

gather facts and determine exactly what had actually happened and which circumstances may have

motivated Fynn's behavior. On this basis, they were able to encourage willingness to cooperate from

their son for the first time without suggesting that he was being untruthful. With coaching from the

therapist, Fynn’s parents conveyed emotional warmth and understanding towards Fyn’s perspective,

but also the firm expectation of respecting the perspective of the others (in this case the teachers).

And because it is not always easy to respect differing perspectives, they let Fynn know that they

expected a willingness to participate in the therapy. Fynn cdid not accept this at first, he accused his

parents of "betraying" him. His parents responded by reiterating their unconditional love for Fynn, and

then calmly and empathetically expressing the concern that the current situation could impact on his

future schooling. Fynn’s parents clearly stated this was not what they wanted for Fynn, as they care

so much about him and his future. They continued (after consulting with the therapist first) that their

concern was so great that they would agree to a possible inpatient stay for diagnosis and initiation of

therapeutic measures if he could not engage with the therapist. After an initial emotional reaction, a

clear and unambiguous framework had been firmly put in place that made clear to Fynn that the

cooperation was actually necessary and desired by the parents. It was Fynn’s parents’ warm, clear,

and resolute message to Fynn that made it possible for him to come to terms with attending and

engaging in therapy.

With another child who constantly and consistently executes his or her own view and is completely

closed to new ideas, the empathic confrontation might look like this: "When I listen to you, I can see

how much the situation worries/upsets/annoys you, and that you don’t like hearing different people’s

opinions on the situation. Is that true?" ... "My problem is now, as a therapist, I would really like to

suggest a different way of looking at the situation, but I am getting the impression that you wouldn’t

like that at all. Is that true?"... “The thing is, part of my job is to propose new ideas and perspectives

from time to time and to discuss them with you. If I have to be really careful about what I say because



some of my ideas are absolutely not ever allowed to be discussed, then I feel very small, and I feel

worried because I have to watch everything I say to make sure I am not saying what I really want to be

able to say. Do you know situations in which you are not allowed to say anything, but really want to?

How does it feel?" With such a patient, a willingness to listen and accept different points of views needs

to be created at first. The therapeutic approach here is characterised by an empathic understanding

that makes gentle, supportive, patient, and above all persistent contact possible with the patient. Here,

we also think of the concept of parental presence (Omer & von Schlippe, 2002) which retains the goals

of being similarly patient, appreciative, and persevering. In practice, for the therapist, it will look like a

continuation of relationship-building and strengths based work, while gently and repetitively

reiterating the wish to provide a different perspective on the problem behavior.

When a child behaves aggressively towards strangers, open reflection of the problem behavior is

suggested: "It is not okay for you to yell and insult me. It is okay to be angry, but not okay to be

aggressive. We will work on safe ways to vent your anger, but I do not want you to continue to hurt

others, and at the moment you are hurting me."... "If I let that happen, I would not be doing my job

properly. I want you to learn to express your anger but without harming yourself or your friendships."

"I do not want you to go on like this, because if you keep hurting your friends then they won’t want to

play with you, and you're such a kind and loving boy... you do not deserve to be alone. I want you to be

able to have fun with your friends.” Here, a reparenting in terms of setting limits is necessary. No fear

or physical intimidation should be used to draw the boundary, but instead the concern of social

contacts and thus the future of the child to be able to deal with intense feelings. This is only possible

with compassion, empathy, care, and a lot of determination- not with emotional escalation, raised

voices, or an abrupt end to therapy, "The child is not capable of an outpatient treatment". The principle

of parental or therapeutic presence also applies: as long as the child comes to therapy-regardless of

the emotional state- there is a chance to connect with the child.

Basic rule: authenticity

It is important that the therapist is authentic in their exploration of the child's viewpoint, and that the

therapist takes the role of the learner- rather than the expert- when exploring the world of the child.

During the initial phase of building the therapeutic relationship, the therapist defines their role by

consistently acting as an authentic advocate for the child’s core emotional needs rather than as an

extended arm of those who want to change the child’s behavior. Once the child has recognized and

accepted the therapist in this role, then the therapist may begin to introduce alternative viewpoints

and gently suggest potential consequences of continuing behavioral patterns, while carefully

monitoring the therapeutic relationship and maintaining a balance of connection and confrontation.

This often the most difficult step when working therapeutically with children and adolescents who

have been externally motivated to attend sessions. It is important that the child’s viewpoint is not seen

as wrong, but rather alternative perspectives are gently introduced in an honest and genuine manner.

This allows the child to broaden their perspective while experience authentic validation and

understanding, without the therapist colluding with the child and further strengthening schema/mode

based responses or dismissing and invalidating the child’s viewpoint. Slowly, gently, and gradually-

perhaps even over several hours of therapy- the child is guided in developing a willingness to compare

their viewpoint with that of others, and consider alternative courses of action. Any talk about choosing

alternative behaviors ought to be in the service of meeting the child’s needs, rather meeting the needs

of those who want to change the child’s behavior. It is imperative that the therapist is wholly authentic



in their focus on meeting the child’s needs, as this is characteristic of a schema therapeutic approach

as opposed to therapeutic approaches that aim for more surface level behavioural change.

7.5 Mode-oriented play therapy

Play is the most common yet intensely expressive medium of childhood, far beyond the infant, toddler,

and pre-school years. Even at one and a half years of age, children are using symbols within their play.

Therefore, it follows to use the medium of play to facilitate communication and expression in behavior

therapy across a wide range of ages. Although behavior therapists often engage in play with their

patients, they generally use play for relationship-building and/or as reinforcement to encourage

therapeutic “work”, rather than as a medium for the therapeutic work. On the other hand, protocols

for play as a therapeutic medium have been formulated explicitly for the nondirective (Axline, 2002),

analytical (Freud, 2010; Klein, 1973), and client-centered play therapy (Schmidtchen, 1974). Mode-

oriented play therapy supports the expression and fulfillment of the child’s core emotional needs

through the therapeutic medium of play. We encourage the child to express feelings such as anger or

sadness through symbolic and pretend play. Free play is an imaginative space for the growing

awareness of needs and represents an abundance of opportunities for the child to express their inner

world in a non-confrontative manner. For children up to primary school age it is suitable to play with

animal figures or dolls to represent recurrent situations, family dynamics, and roles, though this mode-

oriented play therapy framework is primarily intended for preschool aged children.

Axline (2002) notes that in the framework of classic non-directive play therapy, many children will use

play to reproduce unprocessed experiences. Similarly, we have observed that children often present

their previous coping patterns and modes in a stereotypical manner as if the story always had to run

according to the same pattern. Whilst playing, the child may also address experiences that occurred in

pre-linguistic time or are somehow unspeakable. As the director of the stories within a play context,

the child has some control over unprocessed experiences. On the one hand, being the director allows

the child to remain at a safe distance, while also having freedom to explore past experiences. Thus,

one can interpret the child's presentation as an attempt at self-healing. Therein lies the creative

potential of dramatic play as a platform upon which stories can be reinvented and rescripted, much

like the Schema Therapy technique of “Imagery Rescripting” often implemented with adult clients.

Similar to directors, screenwriters, or other artists, the child externalizes aspects of their internal world

through various figures and takes over protagonists’ roles to display different modes. This process

often does not seem creative and free, but rather fixated on problems- repeatedly playing out

tragedies intended to produce pain and sadness in the audience (including the therapist), but that do

not offer a solution or a hope for change in the future. When this occurs during unstructured play

based therapy, therapists easily become participants in endless repeating loops that can strengthen

dysfunctional schemas or coping patterns. In Schema Therapy, child's play is harnessed to promote

schema change, and to correct dysfunctional mode constellations. The therapist does not take the role

of passive spectator to destructive actions in the child’s drama, but rather translates schema therapy

techniques into dramatic play. Although the therapist will often witness an ambiguous event being

played out, they ultimately direct the happenings according to schema therapeutic principles. The

game table or carpet is often the place where the core needs of the child first appear and are satisfied

symbolically, the place where primary emotions may be expressed and validated by the therapist. Play



is a space for experimenting with different modes, a place for the integration of dissociated parts. Play

allows the development of alternative, adaptive responses to meet core emotional needs through trial

and error. Schema relevant situations can be investigated through play, rather than avoided. When

the child plays out compensating coping patterns, the therapist brings alternatives into play. When the

child discusses vulnerability, the therapist responds with limited reparenting (as in the classic imagery

work with adults), providing protection and care. In the mode of the mature and caring adult they can

find words for the previously unspeakable. They should actively seek access to the abandoned or

vulnerable child in the play scene by choosing the role of a soothing, caring, nurturing character. The

therapist can respond to the angry child in the play scene and guide them towards an appropriate

anger expression, while also limiting aggressive responses by protecting play materials or other dolls.

Therefore, the child can be provided with corrective emotional experiences in the game that facilitate

the weakening of certain schemas or modes. Threatening, harassing, or distressing figures are

disempowered and limited in their movement (as an alternative to killing or destroying). Thus, for

example, an evil dragon can be locked up in a sack, a monster can be made immobile with heavy leg

irons, and a ghost can be laughed at or have his own fear ascribed to him, "Help, there are people and

they are laughing at me... " Vulnerable animals can elicit caring and kindness, which are then

internalized to assist in building self-compassion, “I am taking care of this bunny, I need to take care

of myself as well.” Therapeutic play also has emotion-regulating functions. With over-regulated and

inhibited children the therapist can begin initiating lively scenes (such as a knight battle or even a game

of catch) in a free play situation. He can support the expression of child’s feelings, for example: "Isn’t

it fun moving around? In this game, puppets might sometimes be silly, or fight, or dance around just

because they feel like it, and that’s okay." With under-regulated children who react by externalizing

with an excess of open aggression, the therapist encourages the child to follow the rules of the game

in order to have fun.

Basic elements of mode-oriented play therapy

Identification of the modes: Identification of the modes occurs when the child takes a figure and talks

to it, or brings it to life. Children can often “flip” between different modes easily within the context of

the game. The therapist names the characters and interviews the child, or the figure itself, about their

thoughts, feelings, bodily sensations and behaviours.

Connecting to the Vulnerable Child Mode: Vulnerable child modes are usually placed in the victim

role. Thus, the therapeutic task is to identify and support the characters representing the Vulnerable

Child Mode. Where there is a victim role, there is usually also a perpetrator role. However, it is often

unclear whether the child is reflecting a part of themselves, someone else, or their environment. A

gorilla might represent the angry father. A turtle may be the distant sibling. A giant bird may illustrate

the unpredictable in the child's environment. Not every threatening figure is attributable to a specific

person, but often as a symbol for a world that is naturally hard to understand and unpredictable

through a child’s eyes. As such, while the Vulnerable Child Mode is often seen in the victim role,

caution must be taken when exploring the origin or symbolism of the character in the perpetrator role.

Determine functionality of the modes: The diagnostic classification of a child's character selection is

often only possible after observing many "cycles" of acted scenes - and by exploring their functionality.

As a player or an observer, the therapist can ask appropriate questions: "Who are you, where do you

come from? What powers do you have? What are you fighting for? Who do you want to protect? How

does the story go on?" The therapist can also describe or ask about the advantages and disadvantages



or strengths and difficulties of certain play characters or animals. The connection to the child’s current

problems is not necessarily revealed in play therapy. Preschoolers or younger children may not be

developmentally ready for interpretations or explanations; these may decrease the child’s willingness

to engage. Remarks such as, "You act like a gorilla sometimes," may elicit shame or anxiety, and strain

the therapeutic relationship. Instead of linking the gorilla directly to the child, the therapist can

highlight the gorilla’s positives and help offer ways of understanding the gorilla, "Maybe he is just

trying to make sure that no one laughs at him…"

Reorientation: The therapist takes care of the Vulnerable Child Mode, looks after them by providing

safe places, and activates other protective and nurturing characters. The therapist stands for justice

and security, confronting any devaluing, humiliating, or randomly punitive or cruel characters.

Education concerning children's needs occurs through casual comments, “every animal has a right to

food, no one should starve, which animal can help him find food?” The therapist can introduce new

characters themselves, such as caring parent modes that can instruct and limit Angry Child Mode in a

non-punitive way.

Transfer/bridge to the everyday life: The transfer of experiences from play to everyday life occurs

through gentle and cautious references to concrete realities in the child’s life. For example, "Just like

the bunny here, everyone wants to be petted sometimes- you too? Does Mommy know about that? The

turtle has a thick shell. Do you also need that? The dog can bark really loudly when it is scared.... What

can you do when you are scared?"

7.6 Schema therapeutic work with stories

Stem stories use storytelling to set a familiar scene, and children are then encouraged to continue to

tell the story using the figures and objects provided. This approach is intended for children aged

between 4 and 7 years. This approach is based on the idea that “[people have the] habit to become

the stories they tell. By repeating these, stories turn into realities, and sometimes they keep the

storyteller trapped within the limits which they themselves helped to create." (Efran et al., 1992, pp.

115, of von Schlippe & Schweitzer, 1997, p 95). "From a narrative perspective, it's about questioning

old, dominant, and restrictive stories, along which you’ve shaped your life, and to find new, more

pleasant ones" (v. Schlippe & Schweitzer, 1997, p 219). This is indeed the purpose of implementing

stem stories in Schema Therapy.

Identification of the modes: The child automatically identifies with relevant characters as they are

introduced in the story, and thus when it is their turn to complete the story they express emotions,

thoughts, body feelings, and behavior patterns that are characteristic of the mode. The therapists may

facilitate the identification by commenting in ways that further describe the modes such as, "What a

caring Mom! she is looking after you so well," or: "My goodness, such a mean Mom! No child needs to

be treated like that." The therapist may also explicitly name the Vulnerable Child Mode, “Now he is

Sad Felix,” then seek to connect further with the Vulnerable Child Mode either indirectly through the

child, "How's Felix now?" or through third person narration "Oh, I don’t think he is feeling good, look-

he’s all alone! What do you think he might want now?” If the child does not respond, the therapist can

create characters to be helpers (e.g., neighbors or grandparents in the story) who turn to the child to

offer care or support in order to offer a corrective experience through limited reparenting.



Determine the functionality of the modes: The functions of modes are not addressed as specifically

in this technique as in other techniques, though the mode triggers can still be explored, "When Dad

yells, Felix goes really quiet, and doesn’t say a word…" The therapist can also explore the pros and

cons "...when Felix thinks that his father will stop yelling… what happens then?" Mode dialogues can

be carried out by encouraging characters representing different modes to talk about their differing

reactions and responses to events. For example, a sibling in the story representing a Clever-

Competent-Caring Child Mode might say, "Don’t kick Dad, that just makes him angrier! It’s better if

we talk to him and tell him we feel sad when he yells.”

Reorientation: The child initiates the reorientation process alone, but often prompted only by the

therapist's questions, "What can Sad Felix do now? Is he able to go and talk to his Dad?" The therapist

recognizes destructive coping modes, "Of course he would love to stick his tongue out at Dad, or run

away and lock himself in a room. But maybe Felix can try something different this time, as a bit of an

experiment, and see what happens?" The therapist disempowers critical or punitive mode through the

character of a neighbor or grandparent, and provides a corrective experience, "Children make

mistakes, sometimes they break things by accident, it wasn’t done on purpose to upset you. It is not

okay to yell and scream at Felix for making a mistake. Children need to be given a chance to say sorry

and make amends. Felix feels terrible that he made a mistake, and would like the chance to make it

better. Yelling is just making everything feel worse for everyone." Destructive modes should also be

limited, if, for example, a boy always uses violence as a coping mode then the therapist can set

appropriate boundaries in the role of a Caring Parent Mode and/or other figures representing Allied

Protector Modes.

Transfer into everyday life: Transfer from play based stories into everyday life can be challenging, as

the imaginative world rarely directly parallels everyday life. It is important that the stories are creative,

imaginative, magical, and fun, thus engaging the child and leaving them wanting more. If the stories

are too close to real life, strong feelings and modes can begin triggering that create a barrier to

engagement, leading instead to avoidance. As such, we hope that the child will internalize the

messages from the fictional story without constructing or changing the story to directly represent

everyday life. In order to facilitate this process, the therapist may gently introduce cross-references by

afterwards reflecting on the play scene with the child, and thus building the Clever-Competent-Caring

Child Mode, "What do you think? Can you do that too, what Felix tried out there? And what might Dad

do then? What do you think he should do then? How could Dad know to do that? Should I ask him if he

wants to try it?” Video recordings give the child and therapist the opportunity to deepen or reflect on

the story, as appropriate. Video scenes can be stopped at any time to discuss feelings or to consider

needs or alternative solutions, thus creating a bridge to everyday life without interrupting the creative

flow of storytelling. These videos can also be used for parent work, provided the video is directly

relevant to coaching the parents to meet the child’s needs and is not too confrontational.

Variations

Stories based upon the child’s history may give the opportunity to process unresolved experiences. In

this approach, the therapist does not wait for the child to take the lead as in a client-centered play

therapy approach, but rather the therapist takes the lead and introduces relevant content in a careful

and gentle manner. The child is then able to reconstruct a part of their own story and perhaps better

understand what they, and the other people involved, may have felt. It is often best to introduce the

story in a general way, rather than stating that it has been taken directly from the patient’s experience.



This can help bypass coping modes that may activate to protect the child from discomfort of being

confronted with their own story.

Example

Four-year-old John is engaging in symbolic play with his mother in the therapist’s office, and has begun

to tell a story about a finger puppet, also named John, going to the park with his Mum. The therapist

intervenes and gently presents a schema triggering scene, "Then John had to go to kindergarten,

because... I wonder how he felt? How you do think he felt? Maybe he felt angry and sad..." The therapist

pauses to ask the child what he thinks John might have wanted to do and how he might have behaved.

The therapist then continues the story based upon one of the child’s possible coping modes, such as,

"Then John screamed at his Mom, and called her all sorts of names, and John would not do what his

Mom wanted him to do. Not even a little bit. And, instead of doing what Mom wanted him to do, John

would tell Mom what to do! When John was being the boss of Mom he felt strong and didn’t feel sad

anymore. What do you think might happen next?"

Use of familiar stories and literature

Fictional characters from fairy tales, literature, film, television, or computer games can be explored

with the child or adolescent and used schema-therapeutically. This is particularly effective when the

child has a vast amount of knowledge regarding a fictional world or character, but is resistant to, or

has difficulty, talking about the real world and their own experience. The child is asked to become the

narrator and "expert" on the character. The therapist asks the child about the story of the character,

including the character’s thoughts, feelings, experiences, behavioural choices, and motivations, such

as, “When Harry Potter fights Voldemort, the bad guy, he is protected by his parent’s love. The love

still protects him, even though his parents are not there, they are gone.” This provides an avenue to

talk about different ways in which people can respond to adversity. "What would Harry say now, if evil

took over?" Story telling and/or imagery work can then allow the child to travel back in time with the

character at their side, or relive events through the eyes of the character, and rescript events with the

character’s response, in order to build a Clever-Competent-Caring Child Mode.

7.7 Psychoeducation

The schema therapy theoretical framework provides an appropriate platform for psychoeducation

aimed at school aged children and adolescents. The manner in which the concepts are presented can

be suited to match the patient’s developmental level.

7.7.1 Material for psychoeducation

Hand or finger puppets or animals - representing internal states and their underlying needs

Dolls

Malleable objects to represent modes (e.g. plasticine, clay, balloons, threading characters, etc.)

Painted figures or paper dolls



Stories from picture books, films, or television series, that parallel the patient’s experience.

Games that involve associating feelings with events or characters

Feeling cards that can be modified to shape different facial expressions, such as by completing with

tears, a furrowed brow, or eyebrows raised in fear

7.7.2 Psychoeducation at different age levels

Pre-school children. Psychoeducation with preschool children is more likely to occur incidentally

during play, rather than in a structured and cognitive manner. Psychoeducation and therapy are not

separate processes, they are a fluid and intertwined; seamlessly flowing together during sessions.

Psychoeducation regarding schemas is not appropriate for preschool children, however they can

differentiate emotional states and their triggers. Preschool children can practise identifying emotions,

expressing them, and problem solving and testing alternative solutions during play. The therapist can

encourage the child to explore underlying core emotional needs connected with the mode states while

also developing alternative coping strategies.

Primary School children. Primary school children are generally able to learn to recognize the

connection between activating events, beliefs, and consequences, consistent with Ellis’ ABC model

depicted in Table 7.1. With the help of concrete “real world” examples, the therapist can make it clear

that the event itself does not cause the respective feelings, but rather perceptions of the event arising

from belief systems and underlying schemas.

<TL> Table 7.1 ABC- Schema according to Ellis, simplified in Borg-Laufs (2011)

A: Activating Event B: Belief C: Consequence

Everyone laughs at me I am dumb I feel ashamed

Everyone makes mistakes I feel okay and keep working

The therapist can then encourage the child to explore whether other people would respond similarly

or differently, and explore the perspectives of different people in the situation. In the above example

(Table 7.1), the therapist might ask what different children might think, believe, and feel if they heard

others laughing. The therapist might even explore the possible thoughts, beliefs, or feelings, of the

people who are laughing. This dialogue opens the possibility that the child could have experienced the

same situation differently. These traditional CBT techniques can then be connected with the core

concepts of schema therapy (basic needs, schema, and mode) through visual developmentally

appropriate materials, such as drawings. This idea is described in more detail in section 7.8 where you

will see we have been inspired by the teaching of Schulz von Thun (1998) and his "inner team", drawing

the child’s modes as characters in their belly with schemas represented as wounds, or sore spots. This

visual representation of schemas and modes then acts as a broader conceptual framework, and

psychoeducation regarding the ABC model becomes one method of working within the broader

framework that can be readily integrated with other techniques.



Adolescents. When working with adolescent populations, the “Inner House” approach may be used to

provide a visual and experiential platform for linking core memories to relevant schemas and modes.

This provides an externalization of schemas and modes, through assigning objects to represent

schemas and characters to represent modes. This approach is detailed in a later section of the chapter.

Visual arts such as painting and drawing are also appropriate platforms for psychoeducation, as is

puppet work.

Example of implementing psychoeducation with children

(1) The patient is shown a comic strip story, in which the child named "Fritz" is shown experiencing

a pleasant event in one cartoon and an unpleasant event in another. Examples of potential unpleasant

events are shown below in Fig. 7.1 and Fig 7.2.

Figure 7.1 Cartoon of Fritz feeling anxious as he overhears his parents arguing.

Will they

break up?



Figure 7.2 Cartoon of Fritz as he recalls his peers laughing at him as he tripped over in the schoolyard

(2) The patient is asked about the possible thoughts and feelings of the child: "What do you think

or feel? What does Fritz think or feel? Why does he feel this way?" The therapist then conveys age-

appropriate information about the link between emotions and situations.

(3) The therapist – and, if possible, also the child - now note appropriate words and symbols.

Patients can draw an expression on the face of the child reflecting a feeling. Or they might assign

certain feeling cards to the scene. Speech bubbles or thought clouds can illustrate possible

attributions: "My parents are going to break up," or "I bet they are fighting because of me."

(4) In this step, the therapist explores needs and coping strategies, as appropriate. "And what

happens next? And how does he feel then? What does he really want?"

(5) The therapist then asks the patient to recall a similar scene from their own experience: "How

would you feel? Have you experienced anything like that before?"

(6) The therapist then explores differing perspectives by asking the patient if everyone would think

and feel exactly the same way in that situation, or whether there might be any alternative viewpoints.

The therapist might also introduce another child who represents Clever-Competent-Caring Child Mode

into the story: "I know a boy who was in a similar situation, and do you know what? He had completely

different thoughts from Fritz. Totally different. Can you believe it? His name was Frank, and he thought,

‘I really don’t like it when my parents argue, but they always stay together. I know that.’ Or: ‘Yeah,

they are laughing because it can look kind of funny when someone trips over. I laugh when I see

someone trip over in a movie. And everyone trips over sometimes.’”

(7) The therapist then explains the formation of a schema: "If Fritz experiences this over and over

again, then the feelings and thoughts become more and more stuck, and become like a part of Fritz."

It can be helpful to introduce metaphors in an attempt to turn this abstract concept into something

more concrete, for example by comparing schema development to "a wound", or a “movie that Fritz

has seen so many times, it is like it keeps playing over and over again inside him”. The therapist-

selected metaphor for the child can also then become a recurring visual representation of the concept

of a schema, such as drawing a wound in the stomach or a film reel/movie in the child's head. This then



helps create a shared language between the child and the therapist that matches the developmental

level and interests of the child. The therapist explains the activation of a schema or mode: "And even

when the child has grown up, the thoughts and feelings are still there, stuck inside him." The therapist

can then visualize this in different ways- by drawing the same child again, only a few years older – with

a smaller “inner child” in his stomach: (Fig. 7.3)

Figure 7.3 Little Fritz within Grown Up Fritz, as Fritz re-experiences schema-linked feelings

"Look, Little Fritz is still there. How do you think Grown Up Fritz reacts now when his parents are fighting

again or children laugh at him again? When those things happen, Grown Up Fritz feels like Little Fritz

did, it takes him back in time to those moments, because the old wound aches, or the old movie starts

again."

(8) The therapist then continues in order to explain schema linked perceptual bias: "When Fritz

still has the past events stored inside him, he sees the world through different eyes. He pays attention

to certain things much more closely. Why is that? [Include child]. Right! Because he is afraid that those

events might happen again, and he is keeping watch for any signs of it starting so he can keep himself

safe. For example, he is worried that people will laugh at him.

They break

up



Figure 7.4 Even small and/or unrelated events can bring up the fear of the past again- such as when

little Fritz was laughed at because he fell down

So then, what does he do? He watches the children around him, to see if there are any signs of laughter.

And if they do laugh, then what does he think? [Include Child] He thinks they are laughing at him."

(9) The therapist then uses Fritz as an example to discuss the tendency to respond to schema

activation with either avoidance, surrender, or overcompensation. The child is asked to predict what

Fritz will do when he feels laughed at, and so on. The child may be encouraged to think of examples of

avoidance, surrender, and over-compensation.

(10) The therapist then discusses with the child how Fritz could choose healthy coping modes that

allow him to meet his core emotional needs, and begin to heal the wound/turn the volume and

brightness down on the movie.

7.7.4 Metaphors for the representation of schemas and modes

Schemas

Metaphors can be a useful way of explaining the complex, abstract concept of schemas in a manner

that is simpler and more concrete. For example, you might suggest that schemas alter perception in a

way that is similar to how lenses or visual filters alter the way we see the world, "If you've ever

experienced something like that, then you were probably wearing some kind of special glasses at that

time- glasses that have been created and molded slowly and quietly throughout your life, without you

even realizing they were there. And, if you don’t know they are there, then how can you possibly know

you are wearing them? You can’t know. And you haven’t known that you have been wearing them-

until now. The thing to understand about these glasses is that they can completely change the

appearance of situations or objects, so some things appeared bigger and more important than they

They are

laughing at me!



would have been without the glasses. They are just like a magnifying glass for certain things – some

small things become quite large. It’s like funhouse mirrors that are curved to make you look really short

and wide, or really tall and thin. Have you even seen them? With the glasses, which we create from our

experiences, it is also sometimes true that the world looks a bit different and we perceive things as

changed. Then it usually comes to misunderstandings, because one person sees one thing and another

person something totally different.”

The special glasses are described as a protective mechanism or survival tool that allows the patient to

watch out for signs of danger- signs that the painful situation might be happening again. It is important

that schemas are always appreciated for their function and the purpose that they served at the time

of schema development. Schemas become maladaptive through over-generalising or remaining when

they are no longer needed, however schemas initially develop to help people adapt and survive in

difficult situations. As such, the glasses themselves are not “bad”. It is about knowing that you are

wearing them, so you can adjust your vision or take them off when they are no longer required. A

conversation can be had about glasses and their suitability for different situations (e.g., wearing

sunglasses inside) and an experiential activity involving looking at the world through different novelty

glasses and noticing differences in perception can also be a fun and concrete way to explain schemas.

Detached Protector Mode

Avoidant modes, particularly Detached Protector Mode, are common when working with children and

families, particularly in the early stages of therapy. Detached Protector Mode may be active when the

child:

Lacks motivation at school

regularly forgets or does not complete their homework

trivializes their feelings (“everything is fine”)

constantly talks about unimportant things that have nothing to do with the problem behavior

feigns confusion/pretends to not understand the question when asked about their thoughts and

feelings

behaves in a very rational, emotionally cool, logical, or intellectual manner;

does not say anything, is distant;

appears bored (or the therapist feels bored listening to the child speak);

just wants to play, not to talk (Detached Self Soother)

is charming, open, easily distracted, absent-minded (Hyperactive Protector Mode)

blames parents, teachers, classmates, etc. for their own misbehavior (Angry Protector Mode)

refuses to talk, appears grumpy or moody (Angry/Oppositional Protector Mode)

These modes can create a barrier to therapeutic engagement and require empathic and age

appropriate intervention, such as through externalizing the mode into a visual form in order to

encourage egy-dystony and explore the function of the mode.

Initially, the therapist could engage the child in a quiz on the subject of protection, as follows:



"Why do people wear clothes? Why do they wear - at least in winter – several sets clothes over each

other, like a T-shirt, shirt, sweater, and a jacket? And why is a T-shirt enough in summer?”

“Let's have a look at this book about knights… Why do the knights wear armor? And why do

motorcyclists wear leather suits and helmets? There is even a law about wearing helmets! Why do you

think we have a law about wearing helmets?”

“Let’s think about road rules and traffic regulations for a moment… What are pedestrian crossings

for? Why is there a speed limit for vehicles? What do we have to wear seat belts, what do turn signals

do, why are there so many traffic lights, why do we have bike paths?”

“Now let's take a look at school… Why are there class rules, like the rule of having to put your hand up

to ask a question? Why do you have a classroom instead of having class outside on the lawn? Why are

there names on your exercise books?”

Overall, the answers should share the common theme of protection as a core need and illustrate how

many protective measures are present in everyday life- even if we are so used to the protective

measures being there that we don’t even pay attention to them anymore. When this concept is

understood, the therapist can introduce more complex and abstract concepts regarding protective

measures, such as the idea that protection is not a binary concept- protection or no protection- but

rather there can be differing degrees of protection. For example, several picture frames covered with

different materials can be placed between the child and a fan. The speed of the fan and the level of

protection can both be changed, in order to provoke discussion about need for protection and levels

of protection (Fig. 7.5).

Figure 7.5: Picture frames are covered with different materials: the first frame is empty, the second

contains flyscreen, the third has rough netting, and the last is wrapped in plastic. The second and third

frame offer partial protection from the air from the fan, while the fourth offers complete protection.

These picture frames are a relatively elaborate method of discussing levels of protection- a similarly

concrete and experiential activity could be carried out in much simpler ways. We encourage readers



to create their own version of this task to suit their own therapeutic style and the resources available.

The goal is to shift from the all-or-nothing thinking and demonstrate different degrees of protection.

For example, an alternative platform might be to discuss protective clothing in a construction worker,

“What happens if they only wear a high visibility vest over their clothes? What protection does high

visibility provide? Is that enough? Why not? How could they add another level of protection?” and lead

the discussion to explore the construction worker wearing different combinations of glasses,

headphones, high visibility vest, and/or a helmet in different situations. This could be implemented

through imagery, or by using pictures or figures to represent the construction worker. Another idea, is

to create an imaginary blind that can be pulled down during therapy sessions when the topics are

uncomfortable or feel threatening. When the blind is pulled down, child can imagine adjusting the slats

of the blind to open or close so that the child can balance safety and connection, as appropriate. In the

figure below (Fig 7.6), the child sits on the chair looks out through the mosquito net. The child is

encouraged to discuss their experience as they sit inside the dark net and the light net, in terms of

protection from the outside world and connection with the outside world. In some situations, the child

may feel that they need the extra level of protection provided by the dark mosquito net and are happy

to be closed off from the outside world. Most of the time, children feel more comfortable in the lighter

net, because they are protected but can also see the outside world and remain connected. If the child

feels particularly safe, they can also open the net and look out, or even completely come out from

behind the net. This experience can then be gently related to the child’s everyday life. “Which net

would you want when….? Are there times when you could peek out from the net? Or even when you

would feel safe enough to leave the net for a while?”

Figure 7.6: Dark mosquito net represents more protection and brighter represents less protection.

The universal need for protection- protection of possessions, cars, houses, plants, animals, adults,

adolescents, and especially protection of young children and babies- should be a recurring theme

through these sessions, and presented repetitively through different media and examples. It is

important that Detached Protector Mode is seen as helpful in offering protection to Vulnerable Child

Mode- but that the level of protection offered by Detached Protector Mode is not appropriate for



every day use. Aim to explore alternative options that might provide appropriate levels of protection

in situations when Detached Protector Mode is offering too much, too little, or unsuitable protection.

7.8 Drawings

Visual representations, most commonly through drawings, provide a platform for complex interactions

regarding feelings and experiences that would not be possible through direct questioning. Exploration

of a child’s drawing can facilitate connection with and allow the therapist to enter the child’s world,

while bypassing protective coping modes and feelings of confusion or shame. The child can actively

participate and shape the interaction, while taking a step back and observing their experiences and

feelings from another perspective. This is itself assist in building introspection and meta-cognitive

skills.

The Schema Therapy mode model offers the opportunity to depict the internal dynamic of difficult

emotional processes in a developmentally appropriate way, by simplifying complex ideas and

concreting abstract concepts. Drawings can also be used as a psychoeducational tool with school aged

children, adolescents, and parents, when introducing and discussing the relationship between

schemas and mode constellations (Fig 7.7).

Figure 7.7 Education of schemas and modes based on drawings

Memories;

inner movies

needs:

attachment, autonomy

self-worth, pleasure/fun

structure

Schemas

(wounds)



Introduction to the schema- and mode work

The therapist can provide psychoeducation while drawing the picture during the therapy session. It is

helpful to draw the figure in collaboration with the child, so the child is involved in the development

of the conceptualization, and the drawing can be adapted to suit the child’s situation and

developmental level. As seen in Figure 7.7, the upper body of a person is drawn in front of the child.

The thickness of the skin can be altered to respresent resilience or sensitivity, and can be based upon

either trait or state characteristics, as clinically appropriate. Possible schemas, or “wounds”, can then

be represented as notches in the skin. An example of therapist dialogue is provided below, however

the phrasing and content would change to suit the child’s developmental level, situation, and level of

engagement.

"See how I am drawing a man with a head and body? Here, I’ll draw the man’s skin. Skin is important,

as it provides some protection. The skin can vary in thickness, depending on how the man is feeling at

that particular time. For example, when he is hungry and tired his skin might be thinner than when he

has eaten and slept well. Let’s say this man is feeling okay today, and draw him with fairly thick skin,

using two lines to show how thick his skin is, like this. Here are his memories [point to the thought

bubble] and here are his experiences [point to the left of the figure]. All these small triangles show ‘sore

spots' from wounds that everyone gets over the course of their life when things don’t go well, for

example, you might get one of these wounds if you are in a situation when someone is very mean to

you. There are different types of wounds, like wounds from a time when you were let down by someone,

or from a time when you were excluded by your friends, or from a time when your parents are fighting

and you cannot tell if they still love you. If something like this is very VERY bad, or happens over and

over again, the sore spots can become deeper. After a while they then form a type of scar that easily

rips open or hurts when you experience something like that again- a sore spot. You become very

sensitive to that type of wound, because you already expect that something like this will happen again,

because it has already happened so many times. That's why most people also have a way of looking at

the world that is like wearing special invisible glasses that magnify any signs of danger. For example,

someone that has had lots of suitation where people have been angry at them and hurt them might

wear glasses that magnify any small signs that someone is angry, making them seem much MUCH

bigger. And so even if someone is not even really angry, but maybe they are frowning because they are

thinking hard, like this [demonstrate], those glasses will make it look like they are angry, so it feels like

they are angry, and that feels really scary. Up here [point to the thought bubble] are also the memories,

stored in the brain like a whole lot of movies. So whenever the sore spot is pressed, or the wound is

opened, it plays one of the old movies. It can feel like being right back there, in the old movie again,

and it is hard to remember that things are different now. You aren’t back there, you are here, in the

now. "

At this point the therapist could gently encourage the child to reflect on their own experiences by

exploring whether any "sore spots" exist or asking for examples of old films that might be playing over

and over in the child’s mind. If the child is resistant to experiencing the discomfort of acknowledging

their schemas and memories, the therapist might offer further explanation, such as the following.



"Sometimes people try to forget their wounds, they cover up their sore spots and do their best to ignore

them. They try to forget that they have movies playing in their mind, and avoid anything that might

remind them of the movie. You want to forget them… But you can’t. They are sticky, and they keep

popping up and coming back, no matter how hard you try to push them away and forget them. But,

here in therapy, we can change the strength and power of the movies. We can look through the old

pictures in your mind, even watch the old movies together – and together we can fade the pictures, and

even rewrite the stories to change the messages. We could try that here, if you have an old picture, or

even a movie, that keeps popping up in your mind… One that you have been trying to forget, too."

The therapist can then encourage the child to draw a scene from a schema-linked core memory. The

child might find that a core memory entered their mind spontaneously during the above dialogue, or

a core memory may be elicited through some gentle questioning and emotional bridging. When the

child expresses their schema-linked core memory through a drawing they become both the creator of

the image and a third party observer of the memory, encouraging the child to build Wise Observer

Mode. This alters the nature of the child’s relationship with their memory and facilitates working with

the therapist to further build up distance and re-evaluate the emotional content.

Foundations of mode work with drawings

The aforementioned examples are presented with older children in mind, however drawings can be

incorporated into a schema therapeutic approach with patients of all ages. This approach is flexible

and can be adapted to match the patient’s developmental level, and can be used as part of

psychoeducation and diagnostic mode exploration, as well as to promote therapeutic change. When

using drawings therapeutically, the therapist should ensure that the investigation of modes occurs on

both emotional and cognitive levels to allow a deeper level of change.

Identifying of the modes: Drawings of the child can be used as a starting point to discuss modes. For

example, if the child draws a picture of themself looking happy, the therapist might say, "So, this looks

like a picture of Happy Fritz! When does Happy Fritz come out? What do you do when Happy Fritz

comes out?" The therapist encourages the child to give examples, then elaborates and builds on the

examples to explore modes. "So, Happy Fritz feels great, has a lot of fun, and smiles and laughs a lot.

But you don’t always feel like Happy Fritz, there are other parts of you, too, that might feel completely

different." Here the therapist aims to create a shared language to describe modes, such as referring to

them as parts or sides. When working with young children, the therapist can also simplify the concept

of modes by referring to them as different moods or feelings in order to create a bridge between the

complex, abstract concept of a mode and the world of the child. However, it is important that the

therapist keeps in mind that modes are more complex states than just moods or feelings, and over

time aims to build the complexity of the mode beyond just the associated feeling. Once the first mode

has been identified and the possibility of further modes opened, the therapist can provide time and

space for the the child to draw other faces and bodies to represent the different part of themself, then

encourage the child to assign colors, symbols, and characteristics to the mode drawings and, if

possible, also to give them names. Different sizes and positions can illustrate their dominance. This

process may involve multiple drawings, and/or cutting out parts from different drawings and gluing

them back together in different constellations. The picture may also be copied and enlarged or reduced

in size, or coloured in different ways to explore the mode. Now the child is invited to identify with a

drawing and imagine that they are in that mode. "Hmmm. I wonder what would Scary Fritz say about



that? I’d like you to really imagine you are Scary Fritz for a moment. Its okay, I know its really you, so I

wont get too scared and run away- I’ll be here with you and Scary Fritz. I’d really like to get to know

Scary Fritz and hear what he has to say." Idiosyncratic messages or catch phrases representing the

modes can then be drawn in speech bubbles. The more time the child takes to draw a mode, the more

detail is included in the picture and the mode exploration, the deeper the therapeutic experience

becomes. As such, it is important to take time in creating and exploring each mode, rather than rushing

to complete the conceptualization.

Connecting to the Vulnerable Child Mode: In the next step, the therapist explores the different modes

through the child’s drawings, in order to connect with Vulnerable Child Mode and explore feelings and

needs. "So this is Clever Fritz, who thinks about things in a very wise way. He makes choices that are

helpful, caring, and kind, and also stands up for himself when he needs to. When does Clever Fritz come

out? And, look, here is Sad Little Fritz. In what moments does Sad Fritz come out? What makes him so

sad? What does he need? Has he always been there? When did it start? This part is so important,

because Sad Fritz can actually feel when Fritz is missing something important. When he gets the chance

to speak, then he can remind Fritz of what he is missing, what he needs. What do you think Sad Fritz

feels is missing? What would he say that Fritz needs to fill the missing part?"

Determine functionality: The therapist explores the different modes that have been elicited through

drawings, recognizes the strengths and weaknesses of each of the modes, describes the group of

modes as a team with different characters, and explains to the child how each of the modes is trying

to help (even if they are not actually very helpful in most situations). The therapist asks the child how

the characters relate to each other and what they might say to each other, creating a mode dialogue.

This encourages the child to become more aware of internal processes and highlight the need for

reorientation (e.g., by highlighting that two of the most active modes always argue and do not make

any progress). At this point, you could then segue to another therapeutic medium, such as chair work,

to further work with the modes.

Reorientation: The child is now encouraged to look at the current constellation of modes, represented

through size and placement of drawings, "When you look at this mode team, does it look like the team

is working well together, or could they work better together by changing something? What needs to

change? Is there anyone who needs to grow and be stronger, and more in charge? Is there anyone who

could perhaps shrink down a little, or take a step back and let someone else take charge? Which mode

do you think your teachers would most like to talk with in class? How could the other modes respond

when The Critic Mode appears? What is he is really really big and taking over? How could the other

modes shrink him back down again, so he isn’t taking over so much? How about creating another

drawing, that shows how you would like the mode team to look one day, a picture that we can work

towards?”

Transfer: In this step, concrete behavioural strategies are drawn out of the mode dialogues and

reorientation, and rehearsed or roleplayed through the drawings before testing them in real life. "My

goodness, you have had some wonderful ideas about how Clever Fritz might grow and take charge

when Sad Fritz is feeling that something is missing. Do you want to try out any of your wonderful ideas

in ‘real life'?"



Speech bubbles can be made from reusable stickers or post-it notes and placed on the mode drawing.

Other people, such as caregivers and teachers, can also be drawn and included in the picture, like a

comic. The conversation can then be roleplayed and rehearsed through different combinations of

speech bubbles. The child can then choose a speech bubble to take with them, like a flashcard, in order

to practise saying the Clever-Competent-Caring Child Mode statement in their day to day life. The

therapist may also include family and school systems in this approach, by coaching caregivers to build

skills to respond appropriately to the child’s statement. This might include roleplaying and rehearsing

the child’s statement and the caregiver’s response in a session with the caregiver. Here, the therapist

acts as a bridge between the child and caregiver, understanding the specific needs of the child as they

were elicited during the mode exploration and connection to Vulnerable Child Mode, so then coaching

the caregivers in responding appropriately to meet the specific need. It is important to ensure that

systems are in place so that when the child first tries a new strategy outside of the therapy room they

receive an appropriate response and experience having their needs met.

Figure 7.8 Mode picture with wave to represent autonomic arousal in response to a trigger

Figure 7.8 shows how physical tension or anger can be drawn as a wave of arousal inside the body.

Many children also love the metaphor of the volcano to represent increasing anger, which you can

then relate to Angry Child Mode. In arguments with other people, some modes might disappear or be

overpowered by the wave, or by other modes. The picture (Fig. 7.8) shows how the Clever-Competent-

Caring Child Mode can stand rock solid, even when there is a big wave crashing through the body. This

also helps encourage the child to separate feelings from behavior, by illustrating how the Clever-

Competent-Caring Child Mode can choose to stand rock solid despite the wave of arousal crashing

around them. While it can be difficult to stand solid while a huge wave rushes past, it is possible, as

the child is separate from the wave. The drawing can help communicate the idea that the wave is a

Enraged child

Competent

child



part of the child, the child is not a part of the wave. This assists in reorienting the power balance

between the child and their strong feelings. The experiences that activate schemas can also be

symbolized with arrows that hit the sore spots or wounds (represented as red triangles).

Figure 7.9 Modes of a 12-year-old boy

Figure 7.9 represents the different modes of a 12-year-old boy. In this drawing it is clear that the inner

parts "ashamed" and "anxious" are separated into different facets of the Vulnerable Child Mode. This

makes sense because the patient experiences fear or shame as different states that have been

subsumed theoretically under the Vulnerable Child Mode. It is important to acknowledge both the

patient’s experience and the theoretical concepts as separate but overlapping components. The

child’s experience of their internal world will not necessarily fit neatly and exactly with the theoretical

model of Schema Therapy, and it is important to be flexible and fit the mode conceptualization to the

child’s experience, while also staying true to the conceptual model. Dividing Vulnerable Child Mode

into different flavours of Vulnerable Child, such as “Scared [name]” and “Ashamed [name]” is

appropriate, as long as the therapist bears in mind that they are both aspects of Vulnerable Child Mode

and works with them accordingly. The therapist may wish to encourage the child to merge these parts

into one mode, however it is more important that the working mode conceptualization resonates with

the child than fits exactly with the therapist’s expectations based on a theoretical model.

In the first two sessions, the parts were not yet visible, but hidden under Detached Protector Mode,

named “Camouflage” by the child (see Figure 7.10). The child is encouraged to draw this mode on a

self adhesive post-it note that then can be swung open to reveal the hidden parts. Naming this mode

“Camouflage” is an example of allowing the child to lead the therapist into their world, by creating a

shared language to describe the modes. Here, the therapist refers to the mode as “Camouflage” in the

therapy sessions, while bearing in mind that this term represents Detached Protector Mode as

described in the theoretical model.

ashamed

anxious



Figure 7.10 Mode image of the 12-year-old boy with camouflage

Variations of the mode work with images

Modes as playing cards: A set of mode playing cards can be created using prefabricated index cards or

A6 size cardstock printed with semi-finished drawings of modes for coloring in/individualization by the

child. The child shapes the basic drawings of figures into representations of their own modes, through

adding colour, drawing additional features, and even writing information or statistics about the mode.

These cards can be spread on the table or kept in a container in the therapy room, and referred to as

appropriate. The child can also take them home and or keep them in their pocket to assist with

identifying and understanding modes. The cards can be made to look similar to the popular Yu-Gi-Oh!

or Pokemon cards that represent different characters with unique characteristics in battles against one

other. The unique characteristics of modes can be included on the card, and characteristics such as

strength can be updated as the mode constellation changes during the course of therapy. The child

can be put into the expert role when it comes to trading cards, and can be given some freedom to take

this idea and run with it, even creating mode card games that can then be used to explore mode

dynamics and mode dialogues in a manner that is consistent with the child’s interests.

Drawing all of the modes in one, single picture gives the impression of a fixed constellation. This is not

how modes are usually experienced, the constellation and dynamics between the modes tend to

change throughout the day. This fluidity of experience may be represented through creating different

sized mode cards, so that the changes in the internal dynamic can be illustrated by changing the size

and arrangement of the modes.

Body images. Tracing life-sized body outlines on large sheets of butcher’s paper allows considerable

space to represent internal experiences. The parts of the body can create a platform for free drawing,

or for placement of drawings or mode cards. Modes can be linked with physical sensations in parts of

the body, or placed where they feel like they are most active. For example, Clever-Competent-Caring

Child Mode might be placed within the outline of the head, whereas Vulnerable Child Mode might be

camouflage



placed in the tummy, and even linked to swirls or butterflies representing physical sensations of worry,

or alternatively could be drawn as an antennae linked to the child’s heart. It is important to allow the

child to lead the placement of the modes so as to reflect their own individual experience, with some

gentle guidance from the therapist as needed. The therapist could also provide a treasure chest full of

objects and pictures as symbols or metaphors for strengths and weaknesses (e.g. a small piece of

jewelry, a pair of glasses, a "bright bulb" for clever Fritz, weapons to symbolize danger). The child can

look through the treasure chest and choose objects that resonate and make sense to them, and place

them on the relevant part of the body. At the end of the therapy session, the composition can be

photographed so that the child can take a copy of the image to refer to between therapy sessions. The

selected objects may also serve as a transitional object or memory anchor to connect with a mode

outside of therapy sessions.

Drawing a mode life story. Life stories are a common therapeutic approach when working with

children who have experienced trauma. This approach can also be incorporated into mode work, in

order to explore the origins and development of modes. A timeline can be represented on a poster or

a board with "milestones" or assembled as a collage with old photographs, drawings, and/or pictures

from magazines. These images can be either symbolic or literal representations of events, as directed

by the child. Drawings of modes can then be linked to events and added to the timeline. Below is an

example therapist dialogue based upon the timeline of a boy with separation anxiety: "Oh, look here

on the timeline, this was a wonderful time! The whole family was together. Happy Felix was coming

out almost all of the time. Should we draw him in here? I think Happy Felix is still inside you, somewhere,

but he doesn’t come out as often. It might have something to do with this time. [Point to a different

part of the timeline.] When your parents had this big argument, very Sad Felix probably came out. He

was upset that your parents wanted to break up. Which is natural, almost all children feel upset when

that happens. Do you also want to draw Sad Felix in here? Is that Felix, the Felix who was so sad and

most likely felt really alone, still there? Does he appear again? What if there is such a big argument

that he thinks his parents might break up again? How old does he feel then, maybe 4 or 5? Ah, but,

there is also Clever Felix. He has grown so much since then, and become smarter and stronger! Would

you like to draw him in the picture, too? What would he think about your parents arguing? What would

Clever Felix say to Sad Felix?" Mature, balanced perspectives and healthy actions can be attributed to

the Clever-Competent-Caring Child mode (through speech bubbles, thought bubbles, and writing

actions). Schema triggers can also be depicted as "sore spots" on the timeline to explain why some

situations might elicit intense reactions.

Chair work and drawings. Mode dialogues can also be elicited through drawings that simulate chair

work techniques. Starting with a picture of two empty chairs, the therapist then guides the child to

draw two figures, one representing the child and one respresenting a significant figure in their life. This

technique is from the psychodynamic-imaginative approach (Höfer, 2011, after Krüger & Reddemann,

2009). Once the child has drawn a significant figure in the second chair, the therapist then asks what

that person might say the child: "What do you think [name] would say he likes about you? What would

you like [name] to say to you?” The messages are then written in speech bubbles on the picture. The

child may choose to draw friends, loved ones (e.g., grandparents) or even imaginary friends on the

chairs, all of which can assist in eliciting speech bubbles containing caring, loving statements. In terms

of the mode model we would class this figure as a "Caring/Good Parent Mode", though we would

encourage the child to create their own term for this mode that doesn’t include the word “parent”,



such as “The Caring Side”. The image can be copied, and even reduced to pocket size to create a

flashcard. The therapist can guide the child in drawing figures in the chairs that represent any and all

combinations of modes as appropriate- for example, Angry Child Mode and the Clever-Competent-

Caring Child Mode- in order to elicit pertinent statements that can then be transferred into everyday

life through roleplay and flashcards.

Mode work with masks. Creating custom masks, props, and costumes can add depth to the

exploration of the various coping mode states. Mode exploration can begin when the child starts

creating the mask, such as drawing physical features or facial expressions for the mode and assigning

props that relate to the mode. Once the mask and/or costume is complete, the child can then become

further immersed in the character of a mode while naturally and playfully exploring what the coping

mode might think, feel, say, and do. At the same time, the child is able to recognize that they are still

separate from the coping mode, as it clearly demonstrates the idea of assuming a role for a short

period of time, but still retaining one’s own sense of identity behind the mask. This idea can also be

used to explore dysfunctional parent modes- such as a Critic Mode or Punisher Mode- as the masks

assists the child to see the mode as egodystonic, rather than egosyntonic. Conversely, the innate child

modes may be represented through symbolic objects (such as a bouncy ball to represent Happy Child

Mode) which can then be unmasked when the coping mode or dysfunctional parent mode mask or

costume is removed. This allows the therapist to engage the patient in a fun and playful manner, while

exploring the current mode constellation and potential consequences of altering the mode

constellation in great detail. In a group therapy setting, different group members might wear masks

or costumes to represent different coping modes, in order to generate mode scripts and determine

functionality in different situations.

7.9 Mode work with chairs …

7.10 Mode work with puppets (finger or hand puppets) and other figures

…

7.11 Working on the "inner house"

…

7.12 Imagination Process

…

7.13 Flash cards and diaries

…

7.14 Homework

…



Literature

Aliki, B. (1994). Gefühle sind wie Farben (6. Aufl.). Weinheim: Beltz.

Arntz, A. & van Genderen, H. (2010). Schematherapie bei Borderline-Persönlichkeitsstörung.

Weinheim: Beltz.

Axline, V.M. (2002). Kinder-Spieltherapie im nicht-direktiven Verfahren (10. Aufl.). München:

Reinhardt.

Bauer, J. & Boje, K. (2011): Kein Tag für Juli (3. Aufl.). Weinheim: Beltz.

Berbalk, H. (2009) Behandlungskonzept mit der MAP. Unveröffentlichtes Manuskript.

Blagys, M.D. & Hilsenroth, M.J. (2002). Distinctive activities of cognitive-behavioral therapy: A review

of the comparative psychotherapy process literature. Clinical Psychology Review, 22, 671–706.

Borg-Laufs, M. (2011). Störungsübergreifendes Diagnostik-System für die Kinder- und

Jugendlichenpsychotherapie (SDS-KJ): Manual für die Therapieplanung (2. Aufl.). Tübingen: DGVT.

Borg-Laufs, M. & Hungerige, H. (2010). Selbstmanagementtherapie mit Kindern: Ein Praxishandbuch.

Stuttgart: Klett-Cotta.

Bowlby, J. (1973): Mütterliche Zuwendung und geistige Gesundheit. München: Kindler.

Bretherton, I. , Ridgeway, D. & Cassidy, J. (1990). Assessing internal working models of the attachment

relationship. An attachement story completition task for 3-year olds. In M.T. Greenberg, D. Ciccetti

& E.M. Cummings (Eds.), Attachement in the preschool years (pp. 273–310). Chicago: The University

of Chicago Press.

Cierpka, M. (2001). Faustlos: Ein Curriculum zur Prävention von aggressivem und gewaltbereitem

Verhalten bei Kindern der Klassen 1-3. Göttingen: Hogrefe.

Cohen, J.A., Mannarino, A.P., Deblinger, E. & Goldbeck, L. (2009). Traumafokussierte kognitive

Verhaltenstherapie bei Kindern und Jugendlichen. Heidelberg: Springer.

Döpfner, M. (1993). Grundlegende Interventionsmethoden und ihre Integration. In M. Döpfner & M.H.

Schmidt (Hrsg.), Kinderpsychiatrie Vorschulalter. München: Quintessens.

Eckardt , U. (2012). Schematherapeutische Arbeit mit dem Familienbrett. Unveröffentlichtes Skript. Zu

beziehen bei Frau Ulla Eckardt unter der Mailadresse: [email protected].

Efran, J., Heffner, K. & Lukens, R. (1992). Sprache, Struktur und Wandel. Dortmund: Verlag Modernes

Leben.

Ellis, A. & Grieger, R. (1995). Praxis der rational-emotiven Therapie. Weinheim: Beltz

Fehm, L. & Helbig, S. (2008). Hausaufgaben in der Psychotherapie: Strategien und Materialien für die

Praxis. Göttingen: Hogrefe.

Freud, A. (2010). Einführung in die Technik der Kinderanalyse (8. Aufl.). München: Reinhardt.

Gloger-Tippelt, G. & König, L. (2009). Bindung in der mittleren Kindheit. Das

Geschichtenergänzungsverfahren zur Bindung 5- bis 8-jähriger Kinder (GEV-B). Weinheim: Beltz.



Höfer, S. (2011). Resilienzaufbau – Möglichkeiten des psychodynamisch-imaginativen Ansatzes in der

Kinder- Verhaltenstherapie. Workshop auf den 10. DGVT-Praxistagen der Kinder- und

Jugendlichenpsychotherapie in Hamburg.

Hoffmann, K., von Lilienfeld-Toal, V., Metz, K. & Kordelle-Elfner, K. (2010). STOPP – Kinder gehen

gewaltfrei mit Konflikten um. Bergedorfer Unterrichtsideen (9. Aufl.). Horneburg: Persen.

Jacob, G. & Arntz, A. (2011). Schematherapie in der Praxis. Weinheim: Beltz.

Jacob, G., van Genderen, H. & Seebauer, L. (2011). Andere Wege gehen. Ein schematherapeutisches

Selbsthilfebuch. Weinheim: Beltz.

Kirn, T., Echelmeyer, L. & Engberding, M. (2009). Imagination in der Verhaltenstherapie. Heidelberg:

Springer.

Klein, M. (1973). Die Psychoanalyse des Kindes. München: Kindler.

Kolb, B. & Wishaw, I.Q. (1996). Neuropsychologie. Heidelberg: Spektrum.

Kos, M. & Biermann, G. (1984). Die verzauberte Familie. München: Reinhardt.

Kreul, H. (1997). Ich und meine Gefühle. Bindlach: Loewe.

Krüger, A. & Reddemann, L. (2009). Psychodynamisch Imaginative Traumatherapie für Kinder und

Jugendliche. PITT-KID – Das Manual. Stuttgart: Klett Cotta.

Löffel, H. & Manske, C. (1996). Ein Dino zeigt Gefühle. Köln: Mebes und Noack.

Ludewig, K. & Wilken, U. (2000). Das Familienbrett. Göttingen: Hogrefe.

Moreno, J. (1959). Gruppenpsychotherapie und Psychodrama. Stuttgart: Thieme.

Mrochen, S. (2009). Das RMI-Konzept (Relaxed Mental Imagery). In S. Mrochen, J. Holtz & B. Trenkle

(Hrsg.), Die Pupille des Bettnässers. Hypnotherapeutische Arbeit mit Kindern und Jugendlichen.

Heidelberg: Carl-Auer.

Oaklander, V. (1988). Gestalttherapie mit Kindern und Jugendlichen (4. Aufl.). Stuttgart: Klett-Cotta.

Omer, H. & von Schlippe, A. (2002). Autorität ohne Gewalt. Coaching für Eltern von Kindern mit

Verhaltensproblemen. „Elterliche Präsenz“ als systemisches Konzept. Göttingen: Vandenhoeck &

Ruprecht.

Perls, F. (1969). Das Ich, der Hunger und die Aggression. Stuttgart: Klett-Cotta.

Perls , F. (1992). Grundlagen der Gestalttherapie: Einführung und Sitzungsprotokolle (8. Aufl.).

München: Pfeiffer.

Petermann, U. (2001). Die Kapitän-Nemo-Geschichten: Geschichten gegen Angst und Stress. Freiburg:

Herder.

Petermann, F., Gerken, N., Natzke, H. & Walter, H.-J. (2006). Verhaltenstraining für Schulanfänger (2.

Aufl.). Göttingen: Hogrefe.

Petzold, H. (1993). Therapietagebücher, Lebenspanorama, Gesundheits-/Krankheitspanorama als

Instrumente der Symbolisierung, karrierebezogenen Patientenarbeit und Lehranalyse in der



integrativen Therapie. In R. Frühmann & H. Petzold (Hrsg.), Lehrjahre der Seele. Paderborn:

Junfermann.

Plummer, D. (2009) (Wie) Kinder lernen, sich wertzuschätzen. Tübingen: DGVT.

Plummer, D. (2010) Trau dich! Spiele zur Stärkung kindlicher Selbstachtung. Tübingen: DGVT.

Portmann, R. (2008). Spiele für mehr Sozialkompetenz (6. Aufl.). München: Don Bosco.

Portmann, R. (2008). Spiele, die stark machen (4. Aufl.). München: Don Bosco.

Roediger, E. (2009a). Die innere Botschaft. Einführung in die Schematherapie. Seminar auf den 59.

Lindauer Psychotherapiewochen 2009. MP3-Format: Auditorium Netzwerk.

Roediger, E. (2009b). Praxis der Schematherapie. Grundlagen, Anwendung, Perspektiven. Stuttgart:

Schattauer.

Roediger, E. (2011). Praxis der Schematherapie: Lehrbuch zu Grundlagen, Modell und Anwendung (2.

Aufl.). Stuttgart: Schattauer.

Rosenbusch, K. (2010). Alternative Verfahren zur Erhebung von Schemamodi. Vergleich von

Fragebogenverfahren und MAP (Modusarbeit mit Puppen), Diplomarbeit am Fachbereich

Psychologie der Universität Hamburg.

Sachse, R., Püschel, O., Fasbender, J. & Breil, J. (2008). Klärungsorientierte Schemabearbeitung:

Dysfunktionale Schemata effektiv verändern. Göttingen: Hogrefe.

Schlarb, A. & Stavemann, H.H. (2011). KVT mit Kindern und Jugendlichen. Weinheim: Beltz.

Schmidtchen, S. (1974). Kindzentrierte Spieltherapie. Weinheim: Beltz.

Schmidtchen, S. & Hofbrücker, B. (1978). Effektivitätsprüfung der klientenzentrierten Spieltherapie bei

Kindern aus Erziehungsberatungsstellen. Praxis der Kinderpsychologie, 4, 117–125.

Schulz von Thun, F. (1998). Miteinander reden 3 – Das innere Team und situationsgerechte

Kommunikation. Hamburg: Rowohlt.

Siegner, I. (2002). Der kleine Drache Kokosnuss. München: cbj.

Smucker, M., Reschke, K. & Kögel, B (2008). Imagery Rescripting and Reprocessing Therapy:

Behandlungsmanual für Typ-I-Trauma. Aachen: Shaker.

Steil, R. & Füchsel, G. (2005). IBS-KJ: Interviews zu Belastungsstörungen bei Kindern und Jugendlichen.

Göttingen: Hogrefe.

Thünker, J. & Pietrowsky, R. (2011). Alpträume. Ein Therapiemanual. Göttingen: Hogrefe.

Vogt, M. (2002). Geschichten-Erzähl-Spiel. Therapiespiel für kreative Psychotherapie und Pädagogik

mit Kindern und Jugendlichen. Manfred-Vogt-Verlag. Art.-Nr.: 200602

Walter, D. & Döpfner, M. (2009). SELBST. Leistungsprobleme im Jugendalter. Göttingen: Hogrefe.

Waters, V. (2003). Fritzchen Flunder und Nora Nachtigall. Sechs rational-emotive Geschichten zum

Nachdenken für Kinder, mit Kommentaren und Interpretationshilfen für Eltern und Erzieher. Bern:

Hans Huber.



Young, J.E., Klosko, J.S., Weishaar, M.E. (2008). Schematherapie. Ein praxisorientiertes Handbuch (2.

Aufl.). Paderborn: Junfermann.

Zarbock, G. (2011). Praxisbuch Verhaltenstherapie. Grundlagen und Anwendungen biografisch-

systemischer Verhaltenstherapie (3. Aufl.). Lengerich: Pabst.

Zarbock, G. & Zens, C. (2010). Bedürfnis- und Emotionsdynamik – Handlungsleitende Konzepte für die

Schematherapiepraxis. In E. Roediger & G.. Jacob (Hrsg.), Fortschritte der Schematherapie. Hogrefe:

Göttingen.

Zeek, A., Hartmann, A. & Orlinsky, D. (2004). Intersession processes: A neglected area of psychotherapy

research. Psychotherapie Psychosomatik Medizinische Psychologie, 54 (6), 236–242.

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