During imagery rescripting, negative emotions anxiety, sadness, disgust, fear The second is that the healing experience felt gives the patient a different viewpoint of that traumatic situation, a new possibility to experience similar situations in a safe way. With the continuation of treatment, the relationship with the therapist — and the modeling that is created during the imagery — creates a healthy pattern in the patient, an adult mode i.
The dialogs with the chairs, then, are good tools to deal with the coping modes. At the start of the trial the therapist underlines the importance of these modes, forming, in this way, the foundations for a more critical discussion. In fact, validating, comparing, limiting the dysfunctional coping modes, the therapist can make the patient more aware of the role that these modes have always had from childhood, how they developed, and then why the patient perceives them as ego-syntonic. It also allows seeing the disadvantages that these modes have today, in terms of negative interpersonal consequences.
In the former, the patient is able to remember different events or life themes related to different modes. In the latter case, the patient is not able to remember or to be aware about situations with different emotional value experienced in his life when other modes were active. In this way, the chair-work is able to enhance the metacognitive ability to recognize different modes, to be aware about it and about related memories. Moreover, this exercise can also maximize the ability to differentiate different modes when they are integrated.
Usually, we observed the co-activation of different modes, such as Vulnerable Child and Punitive Parent. In this case, the patient experienced strong feelings of guilt, vulnerability and sadness.
With chair-work, the patient becomes aware about the fact that feelings of guilt are caused by a Punitive Parent , an internalization of past interactions with the caregiver that blames the Vulnerable Child , causing feelings of sadness and vulnerability. Having the opportunity to differentiate these modes is the first step to cope with them in a functional way. In ST the therapists also uses some CBT techniques, but only after the first stages of therapy are done.
In fact, using CBT before having dismantled maladaptive coping strategies might reinforce them rather than reduce them. These techniques are derived from more standard CBT approaches and help the patient to cognitively understand their modes, coping strategies, function of emotions and to restructure eventual thinking patterns or break dysfunctional behavioral patterns. Writing flash cards, in which the patient report Modes activation and associated beliefs, and their effects, is an example.
Although some parallels can be made between ST strategies and techniques and Gross cognitive model of emotion regulation CER see Fassbinder et al. According to the CER model, emotions are generated according to a precise sequence in which an individual exposed to a situation: 1 engages it; 2 attends to a particular aspect of the situation; 3 interprets the event; 4 experiences an emotional response with a behavioral action tendency , emotional, and physiological arousal; and 5 modulates that response.
Following this model, emotion regulation or dysregulation can happen at any step in this sequence and every emotion can become dysregulated. The main mechanism of dysregulation is the lack of, or failure to apply, an appropriate regulatory strategy. Within this model and these therapies, emotion dysregulation is treated through behavioral methods, attentional methods, cognitive methods and mindfulness and acceptance methods. Once elicited, emotions have a duration and intensity proportional to the stimulus and automatically self-regulate.
The conscious control or regulation is therefore not required. Emotions are generated, expressed, and channeled into healthy actions and automatically return to baseline. Thus, emotions are not inherently dysregulated. Dysregulation derives from the combination of emotions plus conditioned anxiety, or of emotions with a dysregulatory strategy for example, sadness for failing in an exam plus the intervention of a maladaptive Parent mode that creates shame, guilt, and contempt toward the self; in psychodynamic terms, a defense mechanism of self-attack leading to dysregulated emotional states.
To regulate these states, the clinician must remove the pathological Modes.
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Once removed, automatic emotion regulation follows. For this reason, ST rarely teaches explicit regulatory strategies such as in CBT or DBT , but works on the underlying cause that creates the observed dysregulation. We are going to present a clinical case to give an example of strategies and techniques used in ST for the treatment of emotional dysregulation. When the therapist 1 met the 36 year old Linda in May , she had the impression of having a sad, impulsive, angry and emotionally unstable woman in front of her.
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She was also 15 min late. Linda had decided to see a therapist because she was suffering from strong mood swings, fits of anger, agitation, central insomnia characterized by waking up frequently and anhedonia. These symptoms had taken a turn for the worse after the end of the relationship with her boyfriend, with whom she had been for 19 years. I get really angry, I feel a heat surging from my chest and just coming out! Her parents were often absent, physically and emotionally.
Thus, the last 2 EMSs Self Sacrifice and Unrelenting Standards are developed: both are based on an excessive focus on the desires and needs of others, at the expense of personal needs. The patient lived strong emotions that changed in just a few seconds. This is typical in cases of BPD. For example, when talking about her affective relationship, Linda feels a terrible need to open up and feel loved for the person she is.
When this happens, the Enraged Child comes out, only to be inhibited by the strong Detached Protector. This mode does not allow her to feel any emotions, making her act like a robot and making her avoid situations that trigger these emotions. A strong sense of derealization is seen in this mode, reality appears to be muffled. This happens when criticism is seen as something final and unchangeable. During therapy the patient was taught how to identify and recognize different modes and needs, while also being taught that modes are an adaptive response to attachment needs that have not been satisfied in childhood, adolescence, and the current period.
In order to effectively give Linda this knowledge, the therapist openly asked her questions about her childhood and adolescence, maintaining as much eye contact as possible, showing sincere interest for her life story, and validating her emotional experiences. The only moment in which the patient does not receive validation is when the Punitive Parent emerges: in this case, the therapist makes the patient notice how this part is based on interiorized negative experiences, how this part does not belong to her.
The third phase in therapy is designed to modify emotional dysregulation with limited reparenting: the therapist uses this technique to pose as a new safe and accepting attachment figure, so that a new, healthy operative model can be created for Linda. For example, when Linda started sessions in a detached and cold way, the therapist made her notice that the Detached Protector mode was activated. To bypass it and reach the Abandoned and Abused Child, chairwork was used.
I would like to thank her for protecting you, I know how painful it is for you to talk about these things, so I understand that a part of you tries to protect you from feeling that deep sadness and that sense of emptiness and abandonment again. I know your life, I know what happened to you, you were a small child and you should have had somebody who took care of you.
Unfortunately, nobody was there. I remember when you told me about that time your father was hitting you and your mother was standing there, looking at you without doing or saying anything. No child can bear this anguish, this fear, you had to find a way to avoid feeling it, and Warrior Linda helped you with this. But exactly because I understand what you felt, I have to ask Warrior Linda to let me talk with the part that is suffering, so that I can ask what she needs.
Once contact has been made with the Abandoned and Abused Child, the therapist starts a rescripting exercise that involves reparenting. Linda has to close her eyes to visualize her safe space, where her tolerance to emotions is heightened. By doing this, the triggering of dissociative mechanisms is avoided. When the therapist sees that Linda is in a stable and relaxed mood, she asks her to visualize the past situation that triggered those strong emotions.
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Once the situation is visualized, the therapist focuses on what Linda is feeling, allowing her to feel what she needs and the related emotion. Emotion is used as a catalyst for childhood situations in which Linda has felt a similar emotion. At this point, the therapist asks Linda where she is, how old she is, what is happening, what she looks like, and how she feels.
In this case, the Little Linda mode is fully accessible. The therapist validates the emotions that the child feels, and uses rescripting to stop any aggression, so that Linda can know what being protected feels like. Now that Linda has felt protection and care, she does not feel wrong anymore; instead, she sees her needs and acts to satisfy them in a functional way. In this way, the patient interiorizes a new, healthy model for a relationship. In a more advanced therapeutic phase these imaginative exercises are designed to allow the adult patient to intervene, so that she can protect and validate the needs of her child Self.
This is an important passage in the path of consolidating the internal operational model of the Healthy Adult. The patient therefore becomes capable of recognizing her emotions, of connecting them to her childhood experiences, of expressing and satisfying her needs in the present, self-regulating her emotions in an adaptive way. During therapy the patient often jumps from one mode to the other very rapidly i.
This often begins when a critical or hostile mode emerges, such as Top-of-the-class Linda, that makes Small Linda feel wrong and alone. This emotional state activates Angry Linda, in order to avoid feeling the sadness and sense of powerlessness that Small Linda brings. The therapist uses chair-work to make Linda notice how all these parts activate, what triggers them, how long each part is active for.
Another focal point of chair-work is working on the Top-of-the-class Linda mode, stripping it of legitimacy. By weakening the punishing part, the integration between the Healthy Adult and the Abandoned and Abused Child is strengthened. The patient manages to recognize the punishing part and shut it out, letting the healthy part that recognizes her emotions and needs talk.
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This constant co-activation of her vulnerable part and her healthy part enhances her emotional regulation capability. During therapy the patient says she feels connected to Small Linda, that she needs to protect her and listen to her real life needs and necessities, acting like a Healthy Adult. Linda has often referred effort and difficulty in having to take on negative emotions.
One of the fundamental parts of this therapy has been the therapeutic relationship. The therapist has always been sincere, straightforward, and empathetic. This has allowed Linda to experiment what has probably been her first healthy relationship, along with allowing her to trust the therapist and show her vulnerable side, in order to share it and work with it through mode work. Sessions lasted for 10 months: twice a week for the first 6 months, once a week for the last 4 months.
At the end of this therapy, Linda shows a high level of tolerance for situations that used to trigger dysfunctional modes and emotions. She has also learned to make difficult choices, reducing her fear of abandonment and tolerating negative feedback. All the symptoms that brought her to start a therapy are gone. At the time being, her level of social functioning has allowed her to meet friends and have a relationship of healthy sharing with them.
She has also started a new relationship, in which she feels loved and seen. In the last decades, ST efficacy has been tested in different studies. Giesen-Bloo et al. In Van Asselt et al. In particular, logistic regression analysis with the treatment group and BPD baseline score as covariates showed a significant effect in favor of ST. Societal and informal care costs in the ST patients were lower and recovery rate was higher compared with the TFP group.
From ST has been recommended as one of the evidence based treatments in the Dutch Guidelines on Personality Disorders , and insurance companies reimburse for treatment. After this date the efficacy of ST has been demonstrated also in other PDs. Bamelis et al. This study lasted 3 years and was conducted on patients.
All analyses consistently revealed that ST was superior to other treatments on greater recovery from PDs, as well as when recovery was defined more stringently, and when controlled for assessment instrument. Moreover, the lower dropout rate in ST suggests higher acceptability by patients. An adjacent qualitative study assessing patient and therapist perspectives on ST Bamelis et al.
In particular, in this study Farrell et al. Nadort et al. ST had fewer dropouts, and superior cost-effectiveness. A randomized controlled trial comparing ST for forensic patients with PDs to usual treatment suggests strong effects of ST even in patients with high psychopathic traits Bernstein et al. In these last years the research on the effectiveness of ST moved from PDs to other disorders like depression.
In these studies, researchers using a single case series study design Renner et al. Studies have been conducted to test not only the effectiveness of ST, but also the effectiveness of specific techniques used in ST. In particular, some imaginative techniques, like imagery rescripting, were evaluated in several disorders or conditions Grunert et al.
Although ST was shown to be at least equal and for some measurements, if not superior to other types of therapies Perry et al. As a result of the structural changes, the initial emotional dysregulation due to maladaptive regulatory strategies pathological Modes , gives way to adult emotional regulation. We think that the features of ST and the need of new treatments, that are able to bring about a full recovery for patients, will be a major propulsive boost in exploring new clinical applications of this model.
Along this paper we provided theoretical and clinical implication of ST as a way of treating emotional dysregulation in a wide range of patients. Indeed, ST gives the therapist a set of instruments and techniques to foster emotional regulation through the therapeutic relationship and experiential emotion focused methods. Future studies will test this fascinating hypothesis. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Alexander, F. Psychoanalytic Therapy: Principles and Applications.
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First, CBT methods lend themselves to empirical evaluation. Specific CBT procedures have been developed and implemented for the treatment of myriad psychological problems and disorders. Many intervention procedures have been conducted repetitively and evaluated for efficacy. Furthermore, many cognitivists are researchers and have sought not only to implement their interventions but to conduct controlled outcome evaluations of their efforts. The result is a large body of research lending support to the efficacy of CBT. CQ Press Your definitive resource for politics, policy and people.
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