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Opinion ARTICLE Provisionally accepted The full-text will be published soon. Notify me

Front. Psychol. | doi: 10.3389/fpsyg.2018.02332

Decoupling internalized dysfunctional attachments: a combined ACT and Schema Therapy approach

  • 1University of Trento, Italy
  • 2Department of Psychiatry II, Ulm University Medical Center, Germany
  • 3Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma, Italy

Decoupling internalized dysfunctional attachments: a combined ACT and Schema Therapy approach for improving parenting
Alessandro Grecucci1, Irene Messina2, Harold Dadomo3
1. Department of Psychology and Cognitive Sciences, University of Trento, Italy
2. Department of Psychiatry and Psychotherapy III, University of Ulm and Universitas Mercatorum, Rome;
3. Unity of Neuroscience, Department of Medicine and Surgery, University of Parma

In the field of attachment research, parental behavior has been described in terms of caregiving behavioral systems, expressed in specific relational patterns. These patterns are meant to provide assurance and comfort for the infants to promote exploration and autonomy by ensuring a "secure base" to return to (Bowlby, 1988). In case of stressful situations for the child, the prototypical behaviour of caregivers is to ensure protection and responding with emphatic emotions. However, not every parent is equally skilled and motivated to be an effective caregiver and individuals may differ in their caregiving-related behaviors. In some cases, caregivers are not able to provide protection for their child and/or they may respond with dysregulated emotions. According to attachment theory, such individual differences can be attributed to mental representation (or Internal Working Models as Bowlby defined them). Caregivers' mental representations of their child and of the self as caregiver influence their behaviour in forms of different relational patterns (George, Solomon, Cassidy, & Shaver, 2008). For instance, George & Solomon (1989; 1996), showed that mothers of secure children have positive representations of the self as caregiver as they perceive themselves as effective and caring, together with a positive and realistic perception of their child. By contrast, mothers of avoidant children have more negative representations of the self as caregiver, and they tend to devalue their child's attachment needs. Mothers of ambivalent children are characterized by uncertainty and confusion, and they tend to promote the dependency of their children. Last, but not least, mothers of disorganized children abdicate caregiving considering themselves as helpless and unable to protect their child (George, 1996). This is a very critical aspect in parent-infant relationship, because internalized dysfunctional attachments in parents (in the form of representations) may generate negative expectations and emotions about self and others, and drive maladaptive coping responses (McKay, Lev, & Skeen, 2012). Unfortunately, these mental representations are transmitted from one generation to the other (Bretherton, 1990). In this paper, we suggest a methodology to stop the repetition of past dysfunctional relational patterns, and assist the parent in developing new caregiving abilities.
Third wave psychotherapy approaches offer interesting tools for the intervention on internal representations, in the direction to limit the influence of negative past representations toward significant others in current relationships (Roediger et al., 2018). We make the point that this consideration applies to parenting style as well. We propose a two-steps procedure based on the integration of theories derived from Schema Therapy (ST; Loose et al., 2016; Roediger et al., 2018; Young et al. 2013), and techniques derived from Mindfulness (Van Vreesvijk et al., 2016), and Acceptance and Commitment Therapy (ACT; Hayes et al., 1999). This integration stems from the fact that these approaches have in our opinion, complementary strengths. On one side, ST provides the conceptual background for an understanding of what is enacted in the current relationship, say a Dysfunctional Parent Mode (e.g. Punitive, Demanding, Critic parent…), coming from past internalized relationships. Therapists may refer to the concept of enactment of specific Modes to help caregivers become aware of roles and relational themes displayed during the interactions with their children. ACT and mindfulness, on the other, have outlined a series of strategies by which clinicians can help the client to attend, observe and stop automatic reactions to dysfunctional mental representations. A combined ST and ACT approach aims to relieve parenting-related difficulties, through the understanding and the limitation of enactments in the parent-child relationship. Previous contributions have considered the integration between ST and ACT or mindfulness approaches, without a specific focus on parental skills (see for example the integration of Schema therapy with mindfulness by Van Vreesvijk et al., 2016; or the incorporation of acceptance-based concepts into Schema therapy by Farrell and Shaw, 2017). These approaches outline effective methods to manage emotional experience in the present moment and to reduce reactivity to dysfunctional emotional schemas (Van Vreesvijk et al., 2016). Moreover, Loose and colleagues (Loose et al., 2016) have proposed a modified version of Schema Therapy (ST), specific for children and adolescents. Although parents are sometimes involved during the therapy, this model focus on children, whereas the issue of helping parenting is only briefly discussed. In contrast to such mentioned models, our discussion is specifically focused on parents, and integrate ST and other third wave approaches.
The first step of the methodologywe propose is pathological modes identification. In Schema Therapy terminology, internalized dysfunctional attachments can be described as coupled Dysfunctional-child-modes (DCM, for example, Angry Child, Impulsive Child), with Dysfunctional-parent-modes (DPM, for example, Punitive parent, Demanding parent, Critic Parent), eventually managed with Dysfunctional-coping-strategies (DCS, for example, detached protector, overcompensating modes, or compliant surrender modes). In daily life, the activation of dysfunctional modes negatively influences parents' attitudes and behaviors toward their child. This is because DCM and DPM are associated with either (1) dysregulated emotions, or with (2) dysregulatory mechanisms (Dadomo et al., 2016; 2018). DPM are the primary source of dysregulated emotions and reflect pathological aspects of the parent that are enacted inside the relationship. In terms of emotion regulation, these DPM are dysregulatory mechanisms that generate the most severe dysregulated emotions (for example, a Punitive Parent Mode that induces in the child self-hate and contempt toward the self). DCM, as a consequence, are characterized by specific dysregulated emotions (Angry Child = anger, Lonely Child = sadness, Anxious Child = fear). DCM develop when certain basic emotional needs are not adequately met in childhood. To complete the picture, DCS are pathological regulatory mechanisms that paradoxically increase dysregulation on the long run.
Based on concepts derived from Schema Therapy (Loose et al., 2016; Roediger et al., 2018; Van Vreesvijk et al., 2016; Young et al., 2013), step 1 helps parents in becoming aware of their internal representations (DPM-DCM), and the pathological strategies they use (DCS) when they activate. This can be achieved as follows:
a) Detection of pathological modes by interviewing parents, or by using self-administered questionnaires (Young Parenting Inventory, Schema Mode Inventory, etc). This is the first step to make explicit relational patterns that are driving dysfunctional parent modes and causing distress to their children.
b) Psychoeducation on specific DPM-DCM, providing information concerning how individuals enact past patterns into their parental relationships. Examination of specific daily life examples may be useful at this step. This may greatly help clients develop a new awareness on how they enact problematic way of relating with their children.
c) Examination of the negative consequences of enacting these modes (DCS) into the parent-child relationship. With this aim, chair work with an empty chair representing the child may promote parents' awareness of DCS and their consequences for the child.
d) Identification of values. This aspect regards the clarification of the kind of parent our patient wants to become. Since values drive patients' behaviors, such clarification may provide a guide and motivation to try new responses. The work on values can also help modifying internal mental representations of the self as parent.
At the end of this phase, we expect the client to be much more aware of her/his DPM. However, an additional phase to reduce DCS and to develop new strategies is necessary. With this aim, we now turn to step 2, taking into consideration third wave cognitive therapies. In step 2, the clinician helps the parent to reduce DCS by using mindfulness and ACT to reduce over-reactivity. We suggest the following steps, as a methodology to promote a change regarding how parents relate with their modes:
a) Mindful exposition and observation (without acting) of DPM and the emotions and action tendencies associated. This encourages parents to attend and reflect on pathological experience. Simulations and imagery techniques can greatly help the parent to activate DCS.
b) Once activated, exposure plus a non-judgmental stance as prescribed by mindfulness and ACT theorists, may help containing the emotional experience. Acceptance and non-reactivity attitude rather than enacting the DCS in response to the child's needs is fundamental to break the cycle. This aspect helps parents in creating a place to reflect on their automatic reactions without enacting them. Research suggests that acceptance decreases avoidance and increases valued actions (Twohig, 2007).
c) Take the distance from modes. Techniques developed by ACT are useful to take distance from DPM. An example is defusion, a technique based on "looking at thoughts rather than from thoughts". This may greatly help parents to disengage from automatic responses (DCS).
d) Valued and committed actions application (according to values as proposed by ACT). Committed actions are values-based actions that may replace old DCS. This final part is the heart of step 2 and it help parents in developing new relational patterns. Chair work and simulation can be very helpful for the development of new relational patterns and for the exploration of positive effects of new behaviors (such as, more caring and protective behaviors in parent-infant relationship).
In sum, in the present opinion paper, we provided insights and technical advices on how to help parents to become aware and to detach from pathological way of relating with their children. Although we don't have yet empirical data to support our model, we believe it is a promising approach to help parenting, as it is strongly grounded in therapy models whose efficacy is now out of doubt (see for example, Hacker et al., 2016; and Taylor et al., 2017). Moreover, some preliminary studies on the integration between ST and ACT or mindfulness-based approaches look promising (Amaro et al., 2010; Gojani et al., 2017), accounting for a probable efficacy of the approach described here. Future studies are needed to provide efficacy data on this combined ST and ACT approach for improving parenting.

Keywords: Schema therapy, mindfulness, Emotion Regulation, Attachment, Parenting

Received: 01 Aug 2018; Accepted: 07 Nov 2018.

Edited by:

Helena Moreira, University of Coimbra, Portugal

Reviewed by:

David Boyda, University of Wolverhampton, United Kingdom  

Copyright: © 2018 Grecucci, Messina and Dadomo. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence:
Dr. Alessandro Grecucci, University of Trento, Trento, Italy, alessandro.grecucci@unitn.it
Prof. Irene Messina, Department of Psychiatry II, Ulm University Medical Center, Ulm, 89075 Ulm, Germany, irene-messina@hotmail.com