Treatment

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See photos referred to in "Schema Therapy and the Role of Joy and Play" from the Wiley-Blackwell Handbook of Schema Therapy

Limited Reparenting
 While cognitive and behavioral strategies are an important part of schema therapy, the process of limited reparenting is the heart of the treatment in schema therapy with patients who have had significant difficulties stemming from early childhood and adolescence. It is one of schema therapy’s most unique and defining elements and so will be the focus of the discussion here. Its centrality and power in work with these kinds of difficulties has been gaining strong empirical support through the results of two randomized control trials of schema therapy. These outcome studies have found that a large percentage of patients with Borderline Personality Disorder can achieve full recovery across the complete range of symptoms. The drop out rate in these studies was extremely low. The patients in these studies attributed a great deal of the effectiveness of the treatment and the low drop out rate to limited reparenting.
 
MEETING NEEDS AND ESTABLISHING SECURE ATTACHMENT
Limited reparenting flows directly from schema therapies assumption that early maladaptive schemas and modes arise when core needs are not met. Schema therapy’s aim is to meet these needs by helping the patient find the experiences that were missed in early childhood that will serve as an antidote to the damaging experiences that led to maladaptive schemas and modes. Limited reparenting, paralleling healthy parenting, involves the establishment of a secure attachment through the therapist, within the bounds of a professional relationship, doing what she can to meet these needs. Research spanning a wide range of disciplines supports the notion that secure attachment is at the root of adaptive functioning, well-being and flourishing.
 
THE BROAD RANGE OF LIMITED REPARENTING
The focus of limited reparenting spans a broad range of needs including early connection, joy, adequate limits, and autonomy. Just as the process of parenting takes widely different forms, limited reparenting may involve warmth and nurturance, firmness, self-disclosure, confrontation, playfulness, and setting limits amongst other things. It takes the form of simultaneous tenderness and firmness through what is called “empathic confrontation”. It will also vary depending upon the phase of treatment. For this reason, schema therapy cannot be typified by a particular stance such as neutrality, firmness or nurturance. It is best typified by the broad range of responses and inclinations on the part of the therapist it incorporates, its flexibility, and the organization of these responses around the core needs of the patient.
 
LIMITED REPARENTING AND TRUSTING NEEDS
The limited reparenting approach to early needs for connection sets schema therapy apart from most other approaches to psychotherapy. The prevailing view is that autonomy is most effectively promoted by teaching patients to regulate their affect through teaching skills or remaining therapeutically neutral and thus keeping the patient from becoming dependent upon the therapist for this regulation. The process of limited reparenting involves welcoming and encouraging this dependency. The therapist’s regulation of the patient’s affect becomes internalized by the patient and forms a healthy adult mode modeled on the therapist’s. This healthy adult mode becomes a strong foundation for the establishment of autonomy. In this way limited reparenting is based upon more trust of these early dependency needs and a belief that is more effective to gratify than fight them.
 
THE KEY STEPS IN LIMITED REPARENTING
Limited reparenting involves reaching the Vulnerable Child Mode and reassuring, being firm with or setting limits on the avoidant and compensatory modes or coping styles that block access to the Vulnerable Child Modes or schemas. In the midst of this, the therapist helps to provide constructive outlets for what is called the Angry Child Mode. In addition, it often requires that the therapist help the patient fight punitive, demanding, or subjugating parent modes or schemas. These steps are usually facilitated by the use of guided imagery; an experiential technique that allows the therapist to establish more direct contact with the various modes and schemas.
 
Commonly Used Techniques
 IMAGERY
The right hemisphere of the brain is the dominant hemisphere during early childhood and, consequently, the hemisphere through which a young child experiences her formative relationships. For this reason, most early maladaptive schemas are believed to be experienced and stored within the patient’s right hemisphere. The right hemisphere has the strongest links with the limbic part of the brain (the seat of our emotions) and, consequently, is directly connected to our deepest and most powerful feelings. Imagery is a primary means by which the right hemisphere organizes and processes information about self, others and affect and, therefore, is often an important means of gaining direct access to the “vulnerable child part” of the patient in relation to significant others and the associated “gut level” feelings that make up schemas. Guided imagery is often used early in schema therapy to more clearly and deeply understand schemas and modes. This is accomplished by:

1. Eliciting upsetting childhood memories in the form of images of experiences with mother, father and other significant people.

2. Asking the patient to carry on dialogues with these people.

3. Asking the patient what she needs from significant others and understanding these needs in terms of the associated schemas.

4. Asking the patient to identify what current situations have the same emotions as the images from early childhood and, thus, clarifying the links between early memories and current triggers of schemas and modes.

Through this process a resonance is established between the therapist’s right hemisphere as she imagines the imagery the patient is describing by way of her vulnerable child mode and the patient’s right hemisphere. This right hemisphere to right hemisphere resonance is believed to deepen and intensify the emotional connection between therapist and patient.

Imagery is also often an important element of the change phase. This involves a process called “imagery rescripting” through which painful memories are revised in ways that allow for the patient to get their needs met. In instances where parents or significant others were, and remain, unable to meet the patient’s needs, this involves the therapist entering into an image and serving as a transitional source of healthy parenting. This leads to a secure attachment developing between the patient and therapist; a form of attachment that is known to lead growth and integration. Imagery during the change phase also involves the patient being encouraged to express anger towards the individuals that have hurt them and helped to assert her rights. This will occur within an image or role-play during a session and not necessarily with significant others. Imagery is also used to help patients grieve for the losses in their life and to overcome trauma. In the case of trauma, imagery rescripting involves a reworking of the traumatic memories in the direction of needs such as safety and protection being met rather than primarily a process of exposure and desensitization. Later in therapy, as the patient’s healthy adult mode becomes stronger, she will enter images that include the vulnerable child mode and take the lead in meeting needs.
 
FLASH CARDS

Flash cards are written statements referred to by the patient in-between sessions. They are developed by the therapist or a co-creation of therapist and patient and are statements that would similar to those made by a parent to a young child at the developmental age that the patient currently experiences their Vulnerable Child mode. They serve as links to the therapist and, as such, as transitional objects; especially in the early phases of treatment of work on problems rooted in early attachment. The messages and sentiments expressed in the cards are gradually internalized and, thus, are very helpful in developing the Healthy Adult mode. Patients who suffer from problems such as BPD often find flash cards to be especially powerful. Flash cards are often developed for each type of challenging situation and phase of treatment. They can take various forms such notes or poems, depending of the creativity of the therapist and the developmental level of the Vulnerable Child mode, and may be carefully thought out or spontaneous gestures.

CHAIR WORK
Chair work involves the patient moving between two chairs as she dialogues between different parts of herself such as a schema side and the healthy side or a Detached Protector Mode and the Healthy Adult Mode. Dialogues can also take place between the patient and imagined significant others for such purposes as reaching closure or practicing assertiveness. Imagery work and chair work are frequently blended with one another.