Case formulation in schema therapy: Working with the mode model

Case formulation is an integral part of Schema Therapy (ST). For every patient treated with ST an individual case formulation is worked out at the start of treatment. This individual case formulation guides the whole treatment process. In this chapter we explain the methodology of case formulation in ST. In the introduction, the underlying theory and central concepts related to case formulation in ST is explained, with a special focus on schemas, coping strategies, and modes. A strong emphasis is placed on the mode model introducing the four main categories of modes (dysfunctional child and parent modes, coping modes, and healthy modes) and explaining the specific modes which are relevant for case formulation with Personality Disorder (PD) patients in detail. In the second part, a guide for clinicians is provided. The mode model provides a clear structure to explain major symptoms and interpersonal problems in patients with severe PDs, and puts them into context with their developmental origins. Although the ST model is a transdiagnostic approach, in most patients a specific pattern of dysfunctional modes can be observed related to their specific diagnosis. These patterns have been summarized as disorder-specific mode models and give a rough frame for case conceptualization. Such models are available for most PDs and some other chronic disorders. In this chapter the disorder-specific model for borderline PD will be presented in detail. Then a step-by-step-guide on how to introduce the mode model to a patient is illustrated with an example of a patient with avoidant PD. Next we show how case formulation affects the therapeutic strategy and helps to select a treatment focus. For each mode there are specific goals that guide a therapist’s behaviour.