A Novel Application of the Schema Therapy Mode Model for Social Anxiety Disorder: A Naturalistic Case Study

Abstract

Social Anxiety Disorder (SAD) is a condition defined by an excessive and persistent fear of negative evaluation in social or performance situations. Whilst Cognitive Behaviour Therapy (CBT) is the gold standard treatment, not all individuals with SAD respond to CBT. The Schema Therapy Mode Model is frequently applied to chronic and hard-to-treat conditions and therefore may be applicable for SAD individuals who are non-responders to CBT. This case study describes how the Mode Model was successfully used to treat a woman in her 20s who presented with excessive fears of negative evaluation and pervasive social avoidance. Experiential techniques, such as chair dialogues and imagery rescripting, resulted in cognitive modification of negative core beliefs, reduced experiential discomfort and increased engagement in social and relational activities. This case offers a preliminary indication that the Schema Therapy Mode Model may be an effective treatment for socially anxious individuals and that further theoretical and empirical study in this area is warranted.

An exploratory investigation of schema modes in social anxiety disorder: Empirical findings and case conceptualization

“…Schema modes bring a valuable nuance to case conceptualization, and are likely an efficient and useful way of conceptualizing individuals with SAD given the current understanding of etiological factors and EMSs associated with the disorder (Mairet et al, 2014;Spence & Rapee, 2016). For example, as described in a case study by Penney and Norton (2021), the experience of ostracism from a close friend may be interpreted as meaning one "does not belong," and is "unlikable,"…”

“…For an example of the mode structure in a socially anxious individual, Penney and Norton (2021) observed a number of coping modes to manage the distress elicited by the individual's Vulnerable Child and Punitive Critic modes. These included a strong Avoidant Protector Mode (characterized by avoidance of interpersonal situations), Detached Self-Soother (characterized by alcohol consumption and passive fantasies about death), and Compliant Surrender (characterized by resignation to the perceived "truth" that she was defective and would never belong).…”

“…ST may be of particular relevance for SAD because of its emphasis on the etiology of symptoms and detailed exploration of defense mechanisms, as well as its inclusion of imagery rescripting, which can target social, developmental, and attachment traumas common to SAD. As an integrative approach, ST for SAD would incorporate best practice CBT techniques as appropriate, while placing emphasis on relational and experiential techniques (e.g., imagery rescripting, chair dialog) as outlined in best practice guidelines to ST (Arntz & Jacob, 2013; also see Penney & Norton, 2021 for a case study integrating cognitive restructuring and behavioral experiments within ST). Additionally, ST demonstrates promise as a treatment for Avoidant Personality Disorder (AvPD; Arntz & Jacob, 2013; Bamelis et al, 2011) and given the hypothesized link between AvPD and SAD existing on the same continuum at different levels of severity (Lampe & Malhi, 2018), it may have similar benefits for SAD individuals who do not respond to CBT.…”

“…Schema modes bring a valuable nuance to case conceptualization, and are likely an efficient and useful way of conceptualizing individuals with SAD given the current understanding of etiological factors and EMSs associated with the disorder (Mairet et al, 2014; Spence & Rapee, 2016). For example, as described in a case study by Penney and Norton (2021), the experience of ostracism from a close friend may be interpreted as meaning one “does not belong,” and is “unlikable,” or “less interesting” than others. This may lead to the development of a social isolation schema, and manifest in modes such as a Vulnerable Child (characterized by fears of negative evaluation and low self‐worth) and a Punitive Critic (characterized by shame‐inducing negative self‐beliefs around unlikability and lack of belonging).…”