case study for schema theory

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The biological level of analysis

General learning outcomes
GLO1 : Outline principles that define...
GLO2 : Explain how principles that de...
GLO3 : Discuss how and why particular...
GLO4 : Discuss ethical considerations...
Physiology and Behaviour
PB1 : Explain one study related to l...
PB2 : Using one or more examples, ex...
PB3 : Using one or more examples, ex...
PB4 : Discuss two effects of the env...
PB5 : Examine one interaction betwee...
PB6 : Discuss the use of brain imagi...
Genetics and Behaviour
GB1 : With reference to relevant to ...
GB2 : Examine one evolutionary expla...
GB3 : Discuss ethical considerations...

The cognitive level of analysis

Cognitive Processes
CP1 : Evaluate schema theory with re...
CP2 : Evaluate two models or theorie...
CP3 : Explain how biological factors...
CP4 : Discuss how social or cultural...
CP5 : With reference to relevant res...
CP6 : Discuss the use of technology ...
Cognition and Emotion
CE1 : To what extent do cognitive an...
CE2 : Evaluate one theory of how emo...

The sociocultural level of analysis

Sociocultural cognition
SC1 : Describe the role of situation...
SC2 : Discuss two errors in attribut...
SC3 : Evaluate social identity theor...
SC4 : Explain the formation of stere...
Social Norms
SN1 : Explain social learning theory...
SN2 : Discuss the use of compliance ...
SN3 : Evaluate research on conformit...

Evaluate schema theory with reference to research studies.

Introduction.

Define schema
Schemas are cognitive structures that organise knowledge stored in our memory.
They are mental representations of categories (from our knowledge, beliefs and expectations) about particular aspects of the world such as people, objects, events, and situations.
Expand on schema
Knowledge that is stored in our memory is organized as a set of schemas (or knowledge structures), which represent the general knowledge about the world, people, events, objects, actions and situations that has been acquired from past experiences.
Types of schemas:
Scripts provide information about the sequence of events that occur in particular contexts (e.g. going to a restaurant, visiting the dentist, attending class).s
Self-schemas organise information we have about ourselves (information stored in our memory about our strengths and weaknesses and how we feel about them).
Social schemas (e.g. stereotypes) – represent information about groups of people (e.g. Americans, Egyptians, women, accountants, etc.).
Define schema theory
Cognitive theory of processing and organizing information.
Schema theory states that “as active processors of information, humans integrate new information with existing, stored information.”
Expand on schema theory Effects
Existing knowledge stored in our memory (what we already know) and organized in the form of schemas will affect information processing and behaviour in specific settings.
E.g. Information we already know affects the way we interpret new information and events and how we store it in our memory.
It is not possible to see how knowledge is processed and stored in the brain, but the concept of schema theory helps psychologists understand and discuss what cannot be seen.
Schema theory can describe how specific knowledge is organised and stored in memory so that it can be retrieved.
State what you are doing in the essay
Schema theory will be evaluated, making an appraisal by weighing up strengths and limitations with some reference to studies on the effect of schema on memory.
Schema theory provides the theoretical basis for the studies reported below.

Supporting Studies

Bartlett – “War of the Ghosts” (1932)
Anderson & Pichert (1978)
Brewer & Treyens – “picnic basket” (1981)
French & Richards (1933)

*Choose three studies from the above studies in the evaluation of schema theory Supporting Study 1: Bartlett (1932) – “War of the Ghost” Introduce Study/Signpost:

A significant researcher into schemas, Bartlett (1932) introduced the idea of schemas in his study entitled “The War of the Ghost.”
Bartlett aimed to determine how social and cultural factors influence schemas and hence can lead to memory distortions.
Participants used were of an English background.
Were asked to read “The War of the Ghosts” – a Native American folk tale.
Tested their memory of the story using serial reproduction and repeated reproduction, where they were asked to recall it six or seven times over various retention intervals.
Serial reproduction: the first participant reading the story reproduces it on paper, which is then read by a second participant who reproduces the first participant’s reproduction, and so on until it is reproduced by six or seven different participants.
Repeated reproduction: the same participant reproduces the story six or seven times from their own previous reproductions. Their reproductions occur between time intervals from 15 minutes to as long as several years.

Results:

Both methods lead to similar results.
As the number of reproductions increased, the story became shorter and there were more changes to the story.
For example, ‘hunting seals’ changed into ‘fishing’ and ‘canoes’ became ‘boats’.
These changes show the alteration of culturally unfamiliar things into what the English participants were culturally familiar with,
This makes the story more understandable according to the participants’ experiences and cultural background (schemas).
He found that recalled stories were distorted and altered in various ways making it more conventional and acceptable to their own cultural perspective (rationalization).

Conclusion:

Memory is very inaccurate
It is always subject to reconstruction based on pre-existing schemas
Bartlett’s study helped to explain through the understanding of schemas when people remember stories, they typically omit (”leave out”) some details, and introduce rationalisations and distortions, because they reconstruct the story so as to make more sense in terms of their knowledge, the culture in which they were brought up in and experiences in the form of schemas.

Evaluation:

Limitations:
Bartlett did not explicitly ask participants to be as accurate as possible in their reproduction
Experiment was not very controlled
instructions were not standardised (specific)
disregard for environmental setting of experiment
Bartlett's study shows how schema theory is useful for understand how people categorise information, interpret stories, and make inferences.
It also contributes to understanding of cognitive distortions in memory.

Supporting Study 2: Anderson and Pichert (1978) Introduce Study/Signpost:

Further support for the influence of schemas of memory on cognition memory at encoding point was reported by Anderson and Pichert (1978).
To investigate if schema processing influences encoding and retrieval.
Half the participants were given the schema of a burglar and the other half was given the schema of a potential house-buyer.
Participants then heard a story which was based on 72 points, previously rated by a group of people based on their importance to a potential house-buyer (leaky roof, damp basement) or a burglar (10speed bike, colour TV).
Participants performed a distraction task for 12 minutes, before recall was tested.
After another 5 minute delay, half of the participants were given the switched schema. Participants with burglar schema were given house-buyer schema and vice versa.
The other half of the participants kept the same schema.
All participants’ recalls were tested again.
Shorter Method:
Participants read a story from the perspective of either a burglar or potential home buyer. After they had recalled as much as they could of the story from the perspective they had been given, they were shifted to the alternative perspective (schema) and were asked to recall the story again.
Participants who changed schema recalled 7% more points on the second recall test than the first.
There was also a 10% increase in the recall of points directly linked to the new schema.
The group who kept the same schema did not recall as many ideas in the second testing.
Research also showed that people encoded different information which was irrelevant to their prevailing schema (those who had buyer schema at encoding were able to recall burglar information when the schema was changed, and vice versa).
This shows that our schemas of “knowledge,” etc. are not always correct, because of external influences.
Summary: On the second recall, participants recalled more information that was important only to the second perspective or schema than they had done on the first recall.

Conclusion:

Schema processing has an influence at the encoding and retrieval stage, as new schema influenced recall at the retrieval stage.
Strengths
Controlled laboratory experiment allowed researchers to determine a cause-effect relationship on how schemas affect different memory processes.
Limitations
Lacks ecological validity
Laboratory setting
Unrealistic task, which does not reflect something that the general population would do
This study provides evidence to support schema theory affecting the cognitive process of memory.
Strength of schema theorythere is research evidence to support it.

Supporting Study 3: Brewer and Treyens (1981) “picnic basket” Introduce Study/Signpost:

Another study demonstrating schema theory is by Brewer and Treyens (1981).
To see whether a stereotypical schema of an office would affect memory (recall) of an office.
Participants were taken into a university student office and left for 35 seconds before being taken to another room.
They were asked to write down as much as they could remember from the office.

Results:

Participants recalled things of a “typical office” according to their schema.
They did not recall the wine and picnic basket that were in the office.

Conclusions:

Participants' schema of an office influenced their memory of it.
They did not recall the wine and picnic basket because it is not part of their “typical office” schema.

Evaluation:

Strengths:
Strict control over variables --> to determine cause & effect relationship
Limitation:
Laboratory setting artificial environment
Task does not reflect daily activity
This study provides evidence to support how our schemas can affect our cognition/cognitive processes, in particular memory.
Our schemas influence what we recall in our memory.
Strength of schema theory – there is many types of research evidence to support it.

Supporting Study 4: French and Richards (1933)

Introduce Study/Signpost:

A further study demonstrating schematic influence is by French and Richards (1933).
To investigate the schemata influence on memory retrieval.
In the study there were three conditions:
Condition 1: Participants were shown a clock with roman numerals and asked to draw from memory.
Condition 2: The same procedure, except the participants were told beforehand that they would be required to draw the clock from memory.
Condition 3: The clock was left in full view of the participants and just had to draw it.
The clock used represented the number four with IIII, not the conventional IV.
In the first two conditions, the participants reverted to the conventional IV notation, whereas in the third condition, the IIII notation, because of the direct copy.
They found that subjects asked to draw from memory a clock that had Roman numerals on its face typically represented the number four on the clock face as “IV” rather than the correct “IIII,” whereas those merely asked to copy it typically drew “IIII.”
French and Richards explained this result in terms of schematic knowledge of roman numerals affecting memory retrieval.
The findings supported the idea that subjects in the copy condition were more likely than subjects in other conditions to draw the clock without invoking schematic knowledge of Roman numerals.
Strict control over variables to determine cause & effect relationship
Define strengths of schema theory:
Supported by lots of research to suggest schemas affect memory processes knowledge, both in a positive and negative sense.
Through supporting studies, schema theory was demonstrated in its usefulness for understanding how memory is categorized, how inferences are made, how stories are interpreted, memory distortions and social cognition.
Define weaknesses of schema theory:
Not many studies/research evidence that evaluate and find limitations of schema theory
Lacks explanation
It is not clear exactly
how schemas are initially acquired
how they influence cognitive processes
how people choose between relevant schemas when categorising people
Cohen (1993) argued that:
The concept of a schema is too vague to be useful.
Schema theory does not show how schemas are required. It is not clear which develops first, the schema to interpret the experiences or vice versa.
Schema theory explains how new information is categorised according to existing knowledge.
But it does not account for completely new information that cannot link with existing knowledge.
Therefore, it does not explain how new information is organised in early life
E.g. language acquisition
Thus schemas affect our cognitive processes and are used to organize our knowledge, assist recall, guide our behaviour, predict likely happenings and help make sense of current experiences helps us understand how we organize our knowledge.
In conclusion, strengths of schema theory:
Provides an explanation for how knowledge is stored in the mind something that is unobservable and remains unknown in psychology
There is much research that supports schema theory
But its limitations are that,
It is unclear exactly how schemas are acquired and how people choose between schemas
It does not account for new information without a link to existing schemas
Overall, with the amount of evidence, schema theory should be considered an important theory that provides insight into information processing and behaviour.
It has contributed largely to our understanding of mental processes.
But the theory requires further research and refinements to overcome its limitations and uncover its unclear aspects

Piaget’s Schema & Learning Theory: 3 Fascinating Experiments

Piagetian approaches to learning as a process of actively constructing knowledge have been particularly effective in education, where they challenged traditional methods of teaching that overlooked the importance of the child’s role as a learner.

In this article, you’ll gain a complete understanding of basic Piagetian theory and the strong body of experimental evidence supporting its application.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises explore fundamental aspects of positive psychology, including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains:

Piaget’s learning theory & constructivism, what are schemas in piaget’s theory 4 examples, assimilation, accommodation, & equilibrium, piaget’s theory vs vygotsky’s, 3 fascinating experiments exploring piaget’s theories, implications in education, 3 best books on the topic, positivepsychology.com’s relevant resources, a take-home message.

Jean Piaget’s theory of cognitive development remains among the most complete and influential theories describing how the human mind shapes and develops through the process of learning.

At the University of Geneva in the 1960s, Piaget employed elegant experimental techniques and keen observational insight to analyze the moving pieces of cognitive development in children (Scott & Cogburn, 2021).

A biologist by training, Piaget took a pragmatic and mechanistic approach to understanding how the advanced architecture of human cognition develops, looking past the intuitive conception of the mind as something apparently complex and unapproachable to see simple and ordered principles of organization lying underneath (Scott & Cogburn, 2021).

At the core of Piaget’s theory are stages of development (Malik & Marwaha, 2021; Scott & Cogburn, 2021), a series of overall states of increasing cognitive sophistication defined principally by how the developing human ‘knows’ (i.e., understands) the world.

Learning is both the cognitive activity that occurs during these stages and the process of moving between stages. In each stage, children use a different set of cognitive tools to investigate and interpret the world and construct knowledge based on that interpretation. This, in turn, unlocks more sophisticated cognitive tools for more sophisticated learning, and so on.

The ultimate goal of this process of learning is to construct the most complete and accurate internal model of the world available at the time (Gandhi & Mukherji, 2021; Scott & Cogburn, 2021).

Sensorimotor period

The first stage occurs between birth to two years of age. In this stage, children understand their world only as far as simple physical interactions allow. For example, the world may be represented as things that can be touched and things that can be thrown .

The development of motor skills during this period allows the physical representation of the sensorimotor period to become more elaborate and finely tuned, with many potential ways of representing the world relating to different actions.

Preoperational period

In the preoperational period, occurring between two and seven years of age, children begin to understand the world using basic symbols and physical actions.

This marks the development of a more complex form of cognition but does not constitute the more advanced mental operations that emerge later in childhood (hence ‘pre-operational’).

Symbols include words, gestures, and simple imagery, and become increasingly governed by logic throughout the period.

Concrete operational period

Between 7 and 11 years of age, children begin to perform mental operations: internalized actions that are abstract and reversible. Children gain the ability to run simulations on their mental model of the world, which can be manipulated freely.

These mental operations follow a strict logical framework, and the content of these operations typically only represent concrete (i.e., ‘real’) objects.

Formal operational period

Between 11 and 15 years of age, children develop their ability to perform mental operations and expand the scope of the content of these operations to include abstract (e.g., mathematical or social concepts) and concrete objects.

Furthermore, they gain the ability to perform mental operations on mental operations themselves, such as evaluating the likelihood of something represented by a mental operation and comparing one mental operation with another.

Constructivism

A recurring theme throughout Piaget’s theory is the notion that learning is a process of construction, where the thing being constructed is the child’s internal model of the world or ‘reality’ more generally. This foundational theoretical assumption is called ‘constructivism’ (Gandhi & Mukherji, 2021).

Constructivism frames learning not as a process of absorbing knowledge that’s already out there in the world, but rather as a process of making knowledge from scratch.

This is done by using whatever cognitive tools learners have at their disposal to interpret incoming information and translate it into knowledge. Before it is interpreted, this incoming information lacks any objective content of knowledge; knowledge is something that is made after the fact.

This is contrary to the more traditional notion of learning as an individual receiving knowledge from a more knowledgeable source, such as a teacher in a classroom.

From the constructivist perspective, teachers are not a source of knowledge, but rather a source of information. Whether that information becomes knowledge or meaningless noise depends on the experience of the learner.

This framework comprises distinct structures of knowledge called schemas, which are organized and generalizable sets of knowledge about certain concepts. They typically contain a set of instructions or logical statements about a concept, as well as knowledge that can be applied to any instance of that concept.

Generalizability highlights the key function of schemas: an up-to-date set of instructions and ideas about as much of the world as possible, which can be used to predict and navigate the world in the future. Considering this, learning could more precisely be described as the process of keeping schemas up to date and developing new schemas where necessary (Scott & Cogburn, 2021).

While schemas are a constant feature of each stage of cognitive development, they change in content and sophistication, just as the stages do.

In the sensorimotor stage, a schema might be chewing, which encodes a set of instructions relating to how to chew and the motivations for chewing (e.g., chewing feels satisfying and stimulates hunger).

Within the schema for chewing are relevant categories of information, such as sets of objects that can and can’t be chewed. Likewise, objects that can be chewed might contain further categories: those that taste good, those that are particularly soft, and so on. All of the pertinent information for chewing is contained in the schema.

A preoperational stage schema might involve instructions for basic forms of communication. For example, a preoperational schema might involve all the information pertinent to waving, including what waving represents in a basic sense, when to wave, and the basic physical actions involved.

In the concrete operational period, schemas contain more detailed representations of the properties of objects. For example, a concrete operational schema for flowers might contain the typical features uniting all flowers, such as shapes, colors, locations, and also features that depend on mental operations, such as when it is appropriate to pick a flower and what to expect when a flower is given to a friend.

Finally, a formal operational schema might describe any number of abstract concepts. An example might be a schema containing abstract instructions for moral behavior that are described not only in basic physical or egocentric terms, but also involving religious ideals, non-egocentric ideas (e.g., empathy), and more abstract consequences and motivations for behaving morally.

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Another constant feature described in Piaget’s theory are the actual processes by which schemas are updated with newly constructed knowledge (Scott & Cogburn, 2021).

Overall, these processes are known as adaptation, which is another way to describe using the most sophisticated cognitive tools available to keep schemas up to date. Adaptation involves two complementary sub-processes: assimilation and accommodation (Scott & Cogburn, 2021).

Assimilation is the process of integrating new knowledge into existing schemas by editing the new knowledge to ensure an acceptable fit.

In other words, assimilation involves updating schemas without changing the structure of those schemas. This is a common process; to an extent, all our cognition is constrained by basic universal rules and principles that create a fundamental unchanging cognitive structure, and it is useful to use these rules to ‘warp’ knowledge in order to fit.

Some schemas are resistant to change due to personal significance or simply because it may be easier to edit new knowledge rather than overhaul the existing mental organization.

Accommodation, in contrast, is the process of adjusting the cognitive organization of schemas in response to new knowledge. This occurs when the existing structure cannot account for the new information, rendering assimilation impossible.

As a simple example, a child may have a schema for birds that includes everything with wings and a schema for mammals that includes everything without wings. When they are presented with a bat, they are faced with a fundamental contradiction of this organization and have to reshuffle their cognitive structures to accommodate and make sense of this shared feature.

These two sub-processes occur in a cycle, as accommodation creates and reshapes the cognitive structure of schemas, which helps assimilate new knowledge, until accommodation is again necessary, and so on.

The goal of this cycle is to maintain as much equilibrium as possible, where there is no conflict between new knowledge and existing knowledge. This state of equilibrium can never be perfect, but learning is the act of trying to make it increasingly stable.

Piaget’s schema – Sprouts

Piaget’s work is commonly compared with that of Lev Vygotsky, another influential learning theorist conducting research at a similar time.

Their theoretical approaches are both primarily concerned with how knowledge is constructed and reject the traditional notion of knowledge as something that is transferred from one individual to another.

However, while Piaget emphasized that knowledge is constructed by the individual and shaped by existing cognitive structures (schemas) that organize the experiences of that individual, Vygotsky saw knowledge construction occurring elsewhere.

Vygotsky’s theory asserts that knowledge is constructed in the individual’s immediate social environment and shaped and interpreted by the individual’s use of language.

In Vygotsky’s theory, language takes the place of Piaget’s cognitive tools and actions. According to Vygotsky, individuals know the world through language, and the extent to which they know the world is mediated by the extent to which they can use language (Stewin & Martin, 1974; Lourenço, 2012).

Importantly, when considering the inherently social aspect of language, it follows that other individuals in someone’s immediate social context would be equally influential in how the individual knows the world.

As a result, in the place of internal stages of development, Vygotsky described external zones of development: social contexts within which individuals can use language to construct knowledge and develop, expanding the scope to include a broader social context for development, and so on.

Piaget and Vygotsky’s approaches are not wholly mutually exclusive, as a Piagetian theorist must acknowledge the influence of context in constructing knowledge, just as Vygotskyian theorists must acknowledge the influence of individual experience in constructing knowledge.

Likewise, this works in reverse, meaning that cognitive development becomes evident through observing how an individual apparently perceives the world.

A foundational experiment underlying Piaget’s theory examines differences in the ability to understand conservation of quantity. Children younger than seven were shown a row of squares and a row of circles of equal quantity. They were correctly able to identify that there were the same number of squares as circles.

However, when the experimenter moved the squares further apart, making a row of greater length, the children now answered that there were more squares than circles.

Because they lack the ability for reversible mental operations developed in the concrete operational stage, changing the appearance of the squares to make the space they occupied larger was sufficient justification for the children to conclude there were more (Kubli, 1979, 1983).

Other experiments have similarly shown how comprehending conservation changes as a function of developmental changes in how the world is represented. For example, another experiment showed children a pair of rods of identical length, placed side by side to demonstrate their equivalence. One of the rods was then displaced so that its position was nearer and therefore appeared longer.

Children younger than six were able to correctly identify the rods as equivalent length when they were side by side, but when displaced, they concluded one rod had become larger. Some slightly older children suggested the rods may become equivalent length again if the displaced rod was returned to its original position, demonstrating their development of reversibility.

Finally, the oldest children concluded that length was an invariant property that was conserved regardless of how the rod was displaced, showing a confident grasp of both reversibility and conservation (Kubli, 1979, 1983).

Another experiment clearly illustrates the development and refinement of schemas that accompany the transition between stages in Piaget’s theory. Children were presented with a picture featuring a bunch of flowers consisting of five asters and two tulips. They were then asked whether there were more asters in the picture or more flowers.

In children younger than roughly eight years of age, the typical answer is that there are more asters, demonstrating that these children have not yet developed the ability to comprehensively categorize the world into schemas of related objects and concepts, and therefore do not recognize that flowers should be a category inclusive of asters (Politzer, 2016).

Here are a few considerations of specific importance (Kubli, 1979).

The development of the ability to comprehend invariance and reversibility defines much of the content of Piaget’s stages . The development of these concepts reflects children’s understanding of rules that extend throughout the world and provide a fundamental basis for reality, and the development of the mental operations necessary to reason based on these rules.

As a result, teachers should adopt an approach that closely follows their students’ search for invariant rules and experimentation with reversibility. Teachers should not adopt a heavy-handed approach where they walk their students through these rules, nor should they become too detached from their students’ development and assume certain types of knowledge that their students may not have discovered yet.

Instead, the process of teaching should be a journey characterized by the discovery and construction of new forms of knowledge.

In an applied education context, teachers should also be careful not to focus too strongly on the theoretical assumptions of constructivism. While constructivism emphasizes the role of the learner as an individual, learning often occurs in a social context alongside a class.

Consequently, although learners are engaged in the construction of their own knowledge, they will inevitably try to model their knowledge on others and form theories about the world that are acceptable and relatable to others. Teachers should, therefore, remain aware that their assumptions and attitudes as educators remain highly influential in a constructivist framework.

To get an in-depth understanding of Piaget’s Schema & Learning Theory, we suggest investing in the following books:

1. The Psychology of the Child – Jean Piaget and Bärbel Inhelder

The Psychology of the Child provides the most accessible means of studying Piaget’s original work underlying his influential theory.

While contemporary writers may do a better job of putting Piagetian theory in context, when it comes to understanding and engaging with the theory itself, there is no substitute to reading about it in the words of the seminal psychologist himself.

Find the book on Amazon .

2. Children’s Thinking – Robert Siegler

Children’s Thinking provides a solid academic reference for a variety of theoretical approaches to cognitive development, including Piagetian theory.

It’s rarely useful to take a single-track approach to psychology, and your understanding and application of Piagetian theory will be improved greatly by learning about other theories of childhood cognition and development, which through their differences or similarities help to delineate Piaget’s ideas.

3. Constructivism: Theory, Perspectives and Practice – Catherine Fosnot

This book by Catherine Fosnot is a comprehensive and practical text analyzing the fundamental assumptions and applications of constructivist epistemology.

Studying the epistemological assumptions underlying psychological theory can seem like a chore, but it is absolutely vital in order to engage with your knowledge and develop a confident and flexible approach to applying Piagetian theory.

Fortunately, Fosnot’s insightful description and commentary are anything but a chore to read.

On our site, we have many relevant resources that will give a more solid theoretical background and also provide practical ways to apply theory. Here are a few recommended reads:

Developmental Psychology 101: Theories, Stages, & Research provides a great alternative to the suggested reading above if you want a more digestible overview of the predominant theories of cognitive development and valuable insight into the broader theoretical context alongside Piaget’s ideas.
Applying Positive Psychology in Schools & Education is a comprehensive guide to applying your knowledge of psychological theory in education. If you are learning about Piagetian theory as an educator, this article will provide essential further reading for developing the ideas you’ve learned here.
Top 37 Educational Psychology Books, Interventions, & Apps is an excellent resource if you want to go beyond the recommended books listed above. Educational psychology is a truly vast topic, with many fascinating ideas to explore in a variety of media, and this article will help you begin your deeper exploration of the topic.

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Piaget’s theory of cognitive development provides a comprehensive and useful theoretical framework for thinking deeply about how information is translated to knowledge in the developing mind.

This has important implications for education, as having a clear theoretical framework for understanding how children learn helps make teaching a more structured and efficient activity for both teachers and students alike.

More generally, Piaget’s ideas also highlight the importance of considering the different ways individuals can have knowledge of the world, depending on their stage of development and methods of learning.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

Fosnot, C. T. (2005). Constructivism: Theory, perspectives, and practice (2nd ed.). Teachers College Press.
Gandhi, M. H., & Mukherji, P. (2021). Learning theories . StatPearls. Retrieved November 5, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK562189/
Kubli, F. (1979). Piaget’s cognitive psychology and its consequences for the teaching of science. European Journal of Science Education , 1 (1), 5–20.
Kubli, F. (1983). Piaget’s clinical experiments: A critical analysis and study of their implications for science teaching. European Journal of Science Education , 5 (2), 123–139.
Lourenço, O. (2012). Piaget and Vygotsky: Many resemblances, and a crucial difference. New Ideas in Psychology , 30 (3), 281–295.
Malik, F., & Marwaha, R. (2021). Cognitive development . StatPearls. Retrieved November 5, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK537095/
Piaget, J., & Inhelder, B. (1969). The psychology of the child. Basic Books.
Politzer, G. (2016). The class inclusion question: A case study in applying pragmatics to the experimental study of cognition. SpringerPlus , 5 (1), 1133.
Scott, H. K., & Cogburn, M. (2021). Piaget . StatPearls. Retrieved November 5, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK448206/
Siegler, R. S. (1997). Children’s thinking (3rd ed.). Prentice Hall.
Stewin, L. L., & Martin, J. (1974). The developmental stages of L. S. Vygotsky and J. Piaget: A comparison. Alberta Journal of Educational Research , 20 (4), 348–362.

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Schema Theory In Psychology

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Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

A schema is a knowledge structure that allows organisms to interpret and understand the world around them. Schemata is a method of organizing information that allows the brain to work more efficiently.
Piaget’s theory of cognitive development put the concept at the forefront of cognitive science. Contemporary conceptions of schema evolved in the 1970s and 1980s.
The widespread use of computers in the last decades of the 20th century also affected theories of how people store and use information in the brain.
There are four main types of schemas. These are centered around objects, the self, roles, and events.
Schemas can be changed and reconstructed throughout a person’s life. The two processes for doing so are assimilation and accommodation.
Schemas have been pivotal in influencing theories of learning as well as in teacher instruction methods.

Historical Background

Schema theory is a branch of cognitive science concerned with how the brain structures knowledge. Schema (plural: schemas or schemata) is an organized unit of knowledge for a subject or event based on past experience.

Individuals access schema to guide current understanding and action (Pankin, 2013). For example, a student’s self-schema of being intelligent may have formed due to past experiences of teachers praising the student’s work and influencing the student to have studious habits.

Information that does not fit into the schema may be comprehended incorrectly or even not at all.

For example, if a waiter at a restaurant asked a customer if he would like to hum with his omelet, the patron may have a difficult time interpreting what he was asking and why, as humming is not typically something that patrons in restaurants do with omelets (Widmayer, 2001).

The concept of a schema can be traced to Plato and Aristotle (Marshall, 1995); nonetheless, scholars consider Kant (1929) to be the first to talk about schemas as organizing structures that people use to mediate how they see and interpret the world (Johnson, 1987).

F.C. Bartlett, in his book Remembering (1932), was the first to write extensively about schemas in the context of procedural memory. Procedural memory is a part of long-term memory responsible for organisms knowing how to control their bodies in certain ways in order to accomplish certain tasks, also known as motor skills.

The Swiss psychologist Jean Piaget , best known for his work on child development, was the first to create a cognitive development theory that included schemas.

Piaget (1976) saw schemas as mental structures altered by new information. In Piaget’s theory, new information can be added or assimilated into current schemas — ideas people have about how the world functions.

However, new information that cannot be integrated into an organism’s current schemas can create cognitive dissonance. When this happens, the schemas must change to accommodate new information.

Characteristics of Schemas

The theorists of the 1970s and 1980s conceptualized schemas as structures for representing broad concepts in memory (Ortony, 1977; McVee, Dunsmore, and Gavelek, 2005).

This definition highlights several important features of schemas, as noted by Rumelhart (1984):

Schemas have variables,
Schemas can be embedded, one within another,
Schemas represent knowledge at all levels of abstraction,
Schemas represent knowledge rather than definitions,
Schemas are active processes,
Schemas are recognition devices whose processing is aimed at evaluating how well new information fits into itself.

Piaget developed the notion of schemata, mental “structures,” which act as frameworks through which the individual classifies and interprets the world. It is these schemas that allow us, for instance, to distinguish between horses and cows by looking for key characteristics.

A schema can be discrete and specific or sequential and elaborate. For example, a schema may be as specific as recognizing a dog or as elaborate as categorizing different types of dogs.

For example, when a parent reads to a child about dogs, the child constructs a schema about dogs.

On a more sophisticated level, the schema allows us to interpret geographical features, understand complex mathematical formulae, and understand acceptable behavior associated with particular roles and contexts.

Piaget argues that, as we grow and mature, our schemata become increasingly more complex and intricate, allowing us access to more sophisticated understandings and interpretations of the world.

A baby, for instance, has only its innate schema through which to interpret and interact with its environment, such as grasping and sucking. As that baby grows, however, new schemas develop and become more complex.

For instance, it will learn to distinguish objects and people and manipulate its surroundings.

As it develops further, the child will develop the schemata necessary to deal with more abstract and symbolic concepts, such as spoken (and later, written) language, together with mathematical and logical reasoning.

Schema and Culture

People develop schemas for their own and other cultures. They may also develop schemas for cultural understanding. Cultural information and experiences are stored and schemas and support cultural identity.

Once a schema is formed, it focuses people’s attention on the aspects of the culture they are experiencing and by assimilating, accommodating, or rejecting aspects that don’t conform.

For example, someone growing up in England may develop a schema around Christmas involving crackers, caroling, turkey, mince pies, and Saint Nicholas.

This schema may affirm their cultural identity if they say, spend Christmas in Sicily, where a native schema of Christmas would likely involve eating several types of fish.

A schema used for cultural understanding is more than a stereotype about the members of a culture.

While stereotypes tend to be rigid, schemas are dynamic and subject to revision, and while stereotypes tend to simplify and ignore group differences, a schema can be complex (Renstch, Mot, and Abbe, 2009).

There are several types of schemata.

Event schema

Event schemas often called cognitive scripts, describe behavioral and event sequences and daily activities. These provide a basis for anticipating the future, setting objectives, and making plans.

For example, the behavior sequence where people are supposed to become hungry in the evening may lead someone to make evening reservations at a restaurant.

Event schemata are automatic and can be difficult to change, such as texting while driving.

Event schemata can vary widely among different cultures and countries. For example, while it is quite common for people to greet one another with a handshake in the United States, in Tibet, you greet someone by sticking your tongue out at them, and in Belize, you bump fists.

Self-schema

Self-schema is a term used to describe the knowledge that people accumulate about themselves by interacting with the natural world and with other human beings.

In turn, this influences peoples’ behavior towards others and their motivations.

Because information about the self continually comes into a person’s mind as a result of experience and social interaction, the self-schema constantly evolves over the lifespan (Lemme, 2006).

Object schema

Object schema helps to interpret inanimate objects. They inform people’s understanding of what objects are, how they should function, and what someone can expect from them.

For example, someone may have an object schema around how to use a pen.

Role schema

Role schemas invoke knowledge about how people are supposed to behave based on their roles in particular social situations (Callero, 1994).

For example, at a polite dinner party, someone with the role of the guest may be expected not to put their elbows on the table and to not talk over others.

How Schemas Change

Piaget argued that people experience a biological urge to maintain equilibrium, a state of balance between internal schema and the external environment – in other words, the ability to fully understand what’s going on around us using our existing cognitive models.

Through the processes of accommodation and assimilation, schemas evolve and become more sophisticated.

In assimilation , new information becomes incorporated into pre-existing schemas. The information itself does not change the schema, as the schema already accounts for the new information. Assimilation promotes the “status quo” of cognitive structures (Piaget, 1976).

For organisms to learn and develop, they must be able to adapt their schemas to new information and construct new schemas for unfamiliar concepts.

Piaget argues that, on occasions, new environmental information is encountered that doesn’t match neatly with existing schemata, and we must consequently adjust and refine these schemas using the accommodation.

In accommodation , existing schemas may be altered or new ones formed as a person learns new information or has new experiences. This disrupts the structure of pre-existing schemas and may lead to the creation of a new schema altogether.

Generally, psychologists believe that schemas are easier to change during childhood than later in life. They may also persist despite encounters with evidence that contradicts an individual’s beliefs.

Consequently, as people grow and learn more about their world, their schemata become more specialized and refined until they are able to perform complex abstract cognitions.

It is important to note, however, that – according to Piaget – the refinement of schemata does not occur without restrictions; at different ages, we are capable of different cognitive processes – and the extent of our schemata is consequently limited by biological boundaries.

Consequently, the reason that 6-year-old rocket scientists are thin on the ground is that the differences between the mental abilities of children and adults are qualitative as well as quantitative.

In other words, development is not just governed by the amount of information absorbed by the individual but also by the types of cognitive operation that can be performed on that information.

These operations are, in turn, determined by the age of the child and their resultant physiological development. Piaget consequently argues that as children age, they move through a series of stages, each of which brings with them the ability to perform increasingly more sophisticated cognitive operations.

How Schemas Affect Learning

Several instructional strategies can follow from schema theory. One of the most relevant implications of schema theory to teaching is the role that prior knowledge plays in students’ processing of information.

For learners to process information effectively, something needs to activate their existing schemas related to the new content. For instance, it would be unlikely that a student would be able to fully interpret the implications of Jacobinism without an existing schema around the existence of the French Revolution (Widmayer, 2001).

This idea that schema activation is important to learning is reflected in popular theories of learning, such as the third stage of Gagne’s nine conditions of learning , “Stimulating Recall of Prior Knowledge.”

Learners under schema theory acquire knowledge in a similar way to Piaget’s model of cognitive developments. There are three main reactions that a learner can have to new information (Widmayer, 2001):

Accreditation : In accreditation, learners assimilate a new input into their existing schema without making any changes to the overall schema.
For example, a learner learning that grass blades and tree leaves undergo photosynthesis may not need to change their schema to process this information if their photosynthesis schema is that “all plants undergo photosynthesis.”
Many teachers even use “metacognitive” strategies designed to activate the learner’s schema before reading, such as reading a heading and the title, looking at visuals in the text, and making predictions about the text based on the title and pictures (Widmayer, 2001).
Another way of pre-activating schema encourages the use of analogies and comparisons to draw attention to the learner’s existing schema and help them make connections between the existing schema and the new information (Armbruster, 1996; Driscoll, 1997).
Tuning : Tuning is when learners realize that their existing schema is inadequate for the new knowledge and thus modify their existing schema accordingly.
For example, someone may learn that a particular proposition is nonsensical in a particular sentence structure and thus need to modify their schema around when it is and is not appropriate to use that proposition.
Scholars have noted that the transfer of knowledge outside of the context in which it was originally acquired is difficult and may require that learners be exposed to similar knowledge in numerous different contexts to eventually be able to construct less situationally constricted schema (Price & Driscroll, 1997).
Restructuring : Finally, restructuring is the process of creating a new schema that addresses the inconsistencies between the old schema and the newly acquired information.
For example, a learner who learns that corn is technically a fruit may need to overhaul their entire schema of fruit to address the inconsistencies between how they had previously defined fruit and this new information.

Unlike Piaget, schema theorists do not see each schema as representative of discrete stages of development, and the processes of accreditation, tuning, and restructuring happen over multiple domains in a continuous time frame (Widmayer, 2001).

According to schema theory, Knowledge is not necessarily stored hierarchically. Rather, knowledge is driven by the meanings attached to that knowledge by the learner and represented propositionally and in a way that is actively constructed by the learner.

In addition to schema, psychologists believe that learners also have mental models — dynamic models for problem-solving based on a learner’s existing schema and perceptions of task demand and task performance.

Rather than starting from nothing, people have imprecise, partial, and idiosyncratic understandings to tasks that evolve with experience (Driscoll, 1994).

Critical Evaluation

While schema theory gives psychologists a framework for understanding how humans process knowledge, some scholars have argued that it is ill-constrained and provides few assumptions about how this processing actually works.

This lack of constraint, it has been argued, allows the theory enough flexibility for people to explain virtually any set of empirical data using the theory.

The flexibility of schema theory also gives it limited predictive value and, thus, a limited ability to be tested as a scientific theory (Thorndyke and Yekovich, 1979).

Thorndyke and Yekovich (1979) elaborate on the shortcomings of a schema as a predictive theory. In the same vein as the criticism about the flexibility of schema theory, Thorndyke and Yekovich note that it is difficult to find data inconsistent with schema theory and that it has largely been used for descriptive purposes to account for existing data.

Lastly, Thorndyke and Yekovich (1979) argue that the second area of theoretical weakness in Schema theories lies in its specification of detailed processes for manipulating and creating schemas.

One competing theory to the schema theory of learning is Ausubel’s Meaningful Receptive Learning Theory (1966). In short, Ausubel’s Meaningful Reception Learning Theory states that learners can learn best when the new material being taught can be anchored into existing cognitive information in the learners.

In contrast to Ausbel’s theory, the learner in schema theory actively builds schemas and revises them in light of new information. As a result, each individual’s schema is unique and dependent on that individual’s experiences and cognitive processes.

Ausubel proposed a hierarchical organization of knowledge where the learner more or less attaches new knowledge to an existing hierarchy. In this representation, structure, as well as meaning, drives memory.

Applications

Schemas are a major determinant of how people think, feel, behave, and interact socially. People generally accept their schemas as truths about the world outside of awareness, despite how they influence the processing of experiences.

Schema therapy, developed by Jeffrey E. Young (1990), is an integrative therapy approach and theoretical framework used to treat patients, most often with personality disorders. Schema therapy evolved from cognitive behavioral therapy.

Those with personality disorders often fail to respond to traditional cognitive behavioral theory (Beck et al., 1990). Rather than targeting acute psychiatric symptoms, schema therapy targets the underlying characteristics of personality disorders.

The schema therapy model has three main constructs: “schemas,” or core psychological themes; “coping styles,” or characteristic behavioral responses to schemas; and “modes,” which are the schemas and coping styles operating at a given moment (Martin and Young, 2009).

According to the schema therapy framework, the earliest and most central schemas tend to originate in one’s childhood. These schemas begin as representations of the child’s environment based on reality and develop from the interactions between a child’s innate temperament and specific unmet, core childhood needs (Martin and Young, 2009).

Schema therapy seeks to alter these long-standing schemas by helping people to:

identify and heal their own schemas,
identify and address coping styles that get in the way of emotional needs,
change patterns of feeling and behaviors that result from schemas,
learn how to get core emotional needs met in a healthy and adaptive way,
and learn how to cope healthily with frustration and distress when certain needs cannot be met.

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REVIEW article

Using schema modes for case conceptualization in schema therapy: an applied clinical approach.

$\r\nDavid John Arthur Edwards,*\r\n$

1 Department of Psychology, Rhodes University, Makhanda, South Africa
2 Schema Therapy Institute, Cape Town, South Africa

This article is situated within the framework of schema therapy and offers a comprehensive and clinically useful list of schema modes that have been identified as being relevant to conceptualizing complex psychological problems, such as those posed by personality disorders, and, in particular, the way that those problems are perpetuated. Drawing on the schema therapy literature, as well as other literature including that of cognitive behavior therapy and metacognitive therapy, over eighty modes are identified altogether, categorized under the widely accepted broad headings of Healthy Adult, Child modes, Parent modes and coping modes which are, in turn, divided into Surrender, Detached/Avoidant, and Overcompensator. An additional category is included: Repetitive Unproductive Thinking. This draws attention to the recognition by metacognitive therapists that such covert behaviors play a significant role in amplifying distress and perpetuating a range of psychological problems and symptoms. In addition to the modes themselves, several concepts are defined that are directly relevant to working with modes in practice. These include: default modes, blended modes, mode suites and mode sequences. Attention is also drawn to the way in which Child modes may be hidden “backstage” behind coping modes, and to the dyadic relationship between Child modes and Parent modes. Also relevant to practice are: (1) the recognition that Critic voices may have different sources and this has implications for treatment, (2) the concept of complex modes in which several submodes work together, and (3) the fact that in imagery work and image of a child may not represent a Vulnerable Child, but a Coping Child. The modes and mode processes described are directly relevant to clinical practice and, in addition to being grounded in the literature, have grown out of and proved to be of practical use in conceptualizing my own cases, and in supervising the cases of other clinicians working within the schema therapy framework.

Introduction

Schema therapy is an integrative therapy that is increasingly being shown to be of value with clinically challenging presentations including moderate to severe presentations of personality disorders and complex trauma ( Giesen-Bloo et al., 2006 ; Jacob and Arntz, 2013 ; Bamelis et al., 2014 ; Talbot et al., 2015 ; Keulen-de Vos et al., 2017 ; Peled et al., 2017 ; Huntjens et al., 2019 ; Simpson and Smith, 2020 ; Yakın et al., 2020 ; Bernstein et al., 2021 ). The identification and analysis of schema modes is central to schema therapy as a basis for case conceptualization and as a guide to practice. Schema modes are recognizable experiential states that express an underlying schema structure. The aim of this article is to present a comprehensive and clinically useful list of schema modes that have been identified in the clinical literature as relevant to conceptualizing psychological problems, and, in particular, to the way those problems are perpetuated, and that have proved to be of practical use in conceptualizing my own cases, and in supervising the cases of others.

Schema Modes as Structural Units

The idea that there are parts of the self was already widespread in Europe in the second half of the 19th century. In 1868, Durand, whom Pierre Janet regarded as one of the founders of hypnotherapy, described how beneath the “ego-in-chief” was a multitude of “subegos” which were out of awareness and “constituted our unconscious life” ( Ellenberger, 1970 , p. 168). Berne (1961 , p. 4), drawing on a concept developed by his mentor, Federn, used the term “ego-states” in his system of Transactional Analysis. He described three broad ego states, Parent, Adult and Child, which, as he pointed out, “are not just concepts but phenomenological realities,” that reflect real differences in the experience and behavior of the individual. This term is also the foundation of John and Helen Watkins’ ego-state therapy ( Watkins, 1993 ; Watkins and Watkins, 1997 ).

There is increasing recognition that a range of distinct modes underpin everyday experience and behavior ( Lazarus and Rafaeli, in press ), and a growing number of current therapy approaches examine how to identify and work with them ( Schwartz, 1997 ; Teasdale, 1999 ; Stiles, 2011 ). Referred to as schema modes within the schema therapy system, these “moment-to-moment emotional states that temporarily dominate a person’s thinking, feeling, and behavior” ( Keulen-de Vos et al., 2014 ) are generated by the system of schemas that is the source of the “understandable patterning of cognition and affect that has developed from the past and structures current experience” ( Stein and Young, 1997 , p. 162). Each mode is based on an underlying “organizational unit” so that an individual can repeatedly exhibit the same cognitive, emotional and behavioral pattern ( Lazarus et al., 2020 ). They are phenomenologically distinct: “each mode ‘feels different’,” observe Lazarus and Rafaeli (in press) , with “distinct subjectively experienced qualities.” Dysfunction occurs when a mode, as “a part of the self” is “cut off to some degree from other parts of the self” ( Young et al., 2003 , p. 40).

Differentiating Modes

When the concept of schema modes was introduced ( McGinn and Young, 1996 ; Young et al., 2003 ) a relatively small number were identified and described. Since then, however, researchers and clinicians have been describing and naming an increasing number. Concern has been expressed at the apparent proliferation of modes. As Roediger et al. (2018 , p. 42) point out, “if we use a close-up lens, we can distinguish an almost endless number of modes,” and this can be confusing for clinicians and clients alike. Lazarus and Rafaeli (in press) , however, point out the need to find “the balance between optimal distinctiveness and parsimony.” As they observe, this depends on the context, and “we don’t know yet” just what that balance is for therapists engaging with complex cases.

Focusing on a limited number of modes can simplify case conceptualization and communication with the client. However, there are also disadvantages. Modes described in broad terms, may appear quite differently from one individual to another, or within the same individual at different times, or may include what are actually sequences of distinct experiential states. Consider Simpson’s (2020, p. 47) account of the Helpless Surrenderer mode, the heart of which is a feeling of being dependent, helpless, and needing to be rescued. The mode also includes, “a mixture of surrender and over-compensatory behaviors,” Simpson suggests, and “can have a resigned or victim tone… [and] can manifest with different ‘flavors,’ e.g., aggrieved, passive-aggressive, histrionic (theatrical, ‘flouncy’), sullen (‘teenager’), entitled, hopeless, negative, or complaining, under a façade of deference or submissiveness.” Furthermore, an item from the scale for measuring this mode ( Simpson et al., 2018 ) includes a further feature, the hypervigilant attachment-seeking that may be a way of coping with abandonment: “I am very possessive and hold on to the people that are important to me.” Simpson is not describing a single, phenomenologically distinct experience, but a collection of modes that might occur together or in sequence. Such sweeping summaries under the heading of a single mode are not uncommon in the schema therapy literature.

Modes and Their Relationships

There is consensus about the broad classification of modes under the headings of Healthy Adult, Child modes, Parent modes and Coping modes. Coping modes are divided into three subcategories: Avoidant/Detached, Overcompensator, and Surrender. There is some similarity between these categories and the coping styles identified by Horney (1945) : moving away from, moving against, and moving toward others. However, there is not a perfect fit, and, as will be seen, there are some coping modes that do not fit clearly within any category system. Arntz et al. (2021) have recently suggested replacing the term Surrender with Resignation and Overcompensator with Inversion, however, the traditional terms will be used here.

First, a few other important concepts will be defined. The several modes or mode categories referred to will all be defined later. Emotion theory ( Greenberg and Pascual-Leone, 2006 ; Elliott and Greenberg, 2007 ) makes a distinction between primary and secondary emotion. A Child mode has, at its center, a primary emotion, such as anger at unfair treatment, sadness at loss or disappointment, or fear in the face of threat. Primary emotions are adaptive when based on accurate appraisal of a current situation, as they provide guides to action. However, when a current situation triggers a schema based on past memories, primary Child emotions are evoked out of proportion to the present reality. These are, in effect, flashbacks and are maladaptive. Secondary emotions, by contrast, result from coping with (and blocking) a distressing primary emotion and are usually maladaptive. Within the schema therapy framework this means they are part of a coping mode and are not associated with vulnerability.

Modes often follow each other in recognizable patterns or mode sequences ( Edwards, 2020 ). For example, a relationship conflict might activate a Vulnerable Child and an associated Parent mode . This might be followed by a switch to a coping mode such as Compliant Surrender or Avoidant Protector or Scolding Overcontroller , and this in turn might lead to a further mode. A client with bulimia nervosa who has been restricting her food intake ( Eating Disordered Overcontroller ) might experience intense craving and purchase a lot of food and eat it ( Detached Self-Soother ). After consuming it, she feels remorseful ( Shamed Child and Punitive Parent ) and determines to further restrict her food intake the next day ( Eating Disordered Overcontroller ). For a fuller example, see Edwards (2020) .

Modes that are relatively stable over time are referred to as default modes (e.g., Lobbestael, 2008 ). Individuals who spend a lot of time in default modes appear to have a relatively stable personality, but this is often an Overcompensator and not the Healthy Adult . Therapists can easily mistake a default mode for the Healthy Adult , especially when it is, for example, a Social Overcompensator or a Pollyanna Overcompensator . Therapists often need to help clients recognize that their default mode is a coping mode and not a fully adaptive way of being. By contrast, some dysregulated individuals display sudden shifts from one mode to another, referred to as mode flipping ( Kellogg and Young, 2006 ). This is often confusing and disconcerting for those with whom the individual is interacting.

The term Blended modes refers to the way that features of more than one mode may appear together at the same time ( Young et al., 2003 ). Blending is quite common and accounts for why, when we ask, “Which mode is the client in now?” the answer is not always straightforward. In the clinical literature authors often refer to child modes that blend separate distinctive experiences, for example, a Lonely Scared Child or an Abandoned-Abused Child . Blending is also common in coping modes: a Self-Aggrandizer often blends with a Paranoid Overcontoller , where self-righteousness and disdain are accompanied by a simultaneous wariness and suspiciousness. From this perspective, Simpson’s reference to “flavors” in the Helpless Surrenderer referred to above suggests how the mode can be blended with, for example, a Self-Pity Victim mode, or with a Complaining Protector or with a Defiant Child . Another common blended mode is found in those who seek to ward off abandonment by pleasing the other person ( Compliant Surrender ) and making things perfect for them ( Perfectionist Overcontroller ).

I introduce the term mode suites as an extension of the concept of blended modes, to refer to a set of modes with similar or overlapping features which may blend and/or sequence quite smoothly. As I suggest below, the Healthy Adult is not a single mode but a suite of modes in which individuals act maturely. However, there is also a suite of modes associated with narcissism, where the individual seamlessly sequences between and/or blends, for example, Self-Aggrandizer , Scolding Overcontroller , Bully and attack , Paranoid Overcontroller , and Complaining Protector in a single stream of interaction. The range of modes and characteristics that may sequence or blend in this way is illustrated by Day et al.’s (2020 ) qualitative study of the experiences of individuals with a narcissistic relative.

Backstage and frontstage: Roediger et al. (2018) and Roediger and Archonti (2020) use the metaphor of a theater in which some modes are “frontstage,” clear and visible, while others are less easy to see and can be thought of “backstage” or even “offstage.” A coping mode (frontstage), for example, blocks out a Child mode that is being coped with (backstage or offstage). Nevertheless, as Behary and Conway (2021) observe, clinicians may be able to detect the message from the backstage Child mode that is “hidden behind a wall of survival” and “got lost in delivery.”

Thus, the primary emotions of a Child mode can be channeled through a coping mode. This can happen through externalizing , or internalizing . In externalizing, for example, anger, with its source in a Child mode ( Angry Child, Defiant Child , or Enraged Child ), is channeled instrumentally toward others in a blaming and/or coercive manner through modes in which the aggression is a secondary emotion and is maladaptive ( Edwards, 2021 ). These Externalizing Overcompensators will be described later. The primary anger can also take an internalizing, route. It may be directed into self-attacking (see the Flagellating Overcontroller ). However, when combined with helplessness it becomes a muted embitterment that can be redirected toward the self, providing justification for the self-pity of the Self-Pity Victim mode, from where it may be further externalized in Complaining Protector . Or it may be redirected to keeping others out and resisting coercion, as in the Passive Resistor , or (with further externalizing added) in the Angry Protector .

A Comprehensive List of Schema Modes

The recognition that modes may blend or sequence, points to the importance of recognizing a range of experiential states. Identifying and naming modes alerts clinicians to schema perpetuation processes, and failure to recognize them weakens the power of the case conceptualization. It is pragmatic to focus on a small number of prominent modes for therapists early in training, when therapists share the case conceptualization with clients, or for psychoeducational and experiential work with groups. However, with greater experience, particularly when working with long term clients, therapists’ development of a more differentiated capacity for recognizing modes sensitizes them to the range and complexity of modes and will enhance their ability to identify obstacles to progress and, as Lazarus et al. (2020) put it, “arrive at fruitful tailored formulations of their clients’ experiences.” The differentiation of modes is, as Lazarus and Rafaeli (in press) observe, at once “pragmatic” and “clinical” since it allows therapist and client to identify and communicate about a range of “experiential or agentic states.”

This is the rationale for the present categorization which includes over eighty different modes. It draws on several sources within the schema therapy literature (e.g., Young et al., 2003 ; Lobbestael et al., 2007 ; Bernstein and van den Broek, 2009 ; Flanagan, 2014 ; Dadomo et al., 2016 ) but identifies others that are described outside it. They are presented here under the familiar headings. After some reflection, I listed separately an important set of coping modes in the category Repetitive Unproductive Thinking (RUT) . Many of these are hard to classify under the headings of Detached/Avoidant, Surrender and Overcompensator for reasons that will be elaborated below.

I have largely used names already in widespread use. When working with clients, of course, therapists should use names that are meaningful to the client, rather than the formal names used here.

Healthy Adult

The Healthy Adult is not a single mode but a suite of modes that can be identified in answer to the question, “How would a mature, compassionate and psychologically minded person think, feel and act in this situation?” Historically, we find conceptualization of mature functioning in Adler’s “community feeling” ( Kałużna-Wielobób et al., 2020 ), Rogers’ (1961) “fully functioning person,” Maslow’s (1971) “self-actualization” and “self-transcendence,” and the traditional concept of “wisdom” ( Baltes and Staudinger, 2000 ). Considerable attention has also been given to the dimensions of healthy functioning in the most recent editions of the DSM and ICD diagnostic systems and Bach and Bernstein (2019) have examined how these are consistent with, and help to elaborate, the concept of the Healthy Adult within schema therapy. Bernstein’s (2018) iModes cards draw on this vision of maturity. They pictorially represent 16 qualities of the Healthy Adult , under four headings: self-directedness, self-regulation, connection and transcendence. Roediger et al. (2018) present a similarly expanded view. Against the background of this emerging consensus, these qualities are summarized here under seven headings which are intended to be practical with respect to assessing the degree of Healthy Adult qualities in a client as well as pointing to the kind of work needed to build or strengthen them 1 .

Meta-Awareness: Capacity for Stepping Back and Reflection

Most therapy approaches recognize the importance of the capacity to step back and reflect on one’s own experience and that of others. Metacognitive capacity, referred to as “distancing” in Beck’s cognitive therapy, provides the basis for role-taking or perspective taking, an important capacity that emerges at the Piaget’s concrete operational stage as a result of what he called “decentring” ( Beck et al., 1979 ). Deficits in the development of role-taking result in behavioral problems associated with impulsiveness and lack of reciprocity and training in role taking is included in many cognitive behavioral programs (e.g., Lochman et al., 2003 ). In psychodynamic approaches to problems arising from poor self-regulation, metacognitive capacity is called “mentalization” ( Fonagy et al., 2004 ). In Acceptance and Commitment therapy, “defusion” ( Roediger et al., 2018 ) literally means breaking the fusion between rational, reality-based cognition and irrational or distorted thinking patterns based in Child, Parent or Coping modes. In Transactional Analysis, Berne used the metaphor of “contamination” of the Adult, and emphasized the importance of undoing that contamination ( Woollams et al., 1977 ).

The main focus in metacognitive therapy is on training clients to step back and note their own thoughts and reactions, to develop “detached mindfulness” ( Wells, 2009 ). Training in mindfulness meditation also increases such metacognitive capacity. This promotes disidentification, the ability to step back from a part of the self and recognize it is “not me” or at least “not the whole of me.” This can lead to “deautomatization,” the gaining of self-control over previously automatic responses ( Deikman, 1982 ). The term “disidentification” was also used in Psychosynthesis, a holistic psychotherapy developed by Assagioli who died in 1974. Teasdale (1999) , a pioneer of mindfulness-based cognitive therapy, also refers to “decentering” and “disidentification.” van Vreeswijk et al. (2014 , p.18) describe the integration of mindfulness with schema therapy, and point out its value in “turning off the ‘automatic pilot’,” and fostering “meta-awareness.” Metacognitive capacity provides the basis for clients to recognize and differentiate their schema modes, to view them self-compassionately and non-judgmentally, to reflect on their nature and function, and to deautomatize them. Without this, clients are “self-immersed” ( Lazarus and Rafaeli, in press ) and cannot usually experience any significant schema change.

Reality Orientation

The Healthy Adult is oriented toward the realities of the world and has the capacity to make accurate, informed appraisals of everyday situations that are not distorted by simplistic thinking or jumping to conclusions that are not adequately based on information and evidence. This includes facing painful aspects of reality and not denying or distracting from them through coping modes. Associated with this is the ability to use information obtained to provide the basis for engaging in rational, and practical problem-orientated behavior, and responsibly performing the practical tasks that are part of effective living in all important life areas. This involves recognizing and identifying problems of all kinds, and taking steps so solve them in a mature way. This requires the skills of searching for and obtaining information relevant to understanding a problem, evaluating sources of information, evaluating options for action, and planning and evaluating the chosen actions ( d’Zurilla and Nezu, 1999 ).

Agency and Capacity for Taking Responsibility

Healthy Adult maturity includes taking responsibility for one’s actions. This is associated with a sense of agency, feeling motivated and able to act in one’s own interests or according to one’s own values. This includes the capacity to make and keep commitments ( Rogers, 1961 ). These are all aspects of integrity – being consistent and trustworthy, and acting with a clear moral compass that is grounded in an authentic sense of self. This is founded on metacognitive capacity because when individuals behave impulsively or automatically without reflection, they may have difficulty accepting responsibility for their actions. Flipping from one mode to another creates inconsistency. Individuals in a default coping mode such as an overcompensator are not fully in touch with their own needs and experience and the needs and experience of others; they may act consistently but usually in a manner that is inflexible and lacks integrity.

Emotional Connection and Tolerance

The capacity to be humanly (emotionally) present and intelligently engaged with what has meaning and feels authentic is based on “openness to experience” ( Rogers, 1961 , p. 115). This means being in touch with one’s personal needs and emotional responses to situations and being able to tolerate the emotions experienced. Coping modes interfere with this, causing what Conway (2005 , p. 606) calls “episodic inhibition,” that is inhibition of the part of autobiographical memory system that is connected to emotions and early schemas. The Healthy Adult has access to these emotions, but can exercise discrimination and self-control with respect to how needs, emotions and concerns are expressed. Openness to emotions also includes positive emotions, which get shut down by episodic inhibition, and allows in experiences such as gratitude and personal meaning.

Reciprocity, Congruent Communication, and Democratic Values

The reciprocity principle is the basis for being able to engage in mature relationships in which there is mutual respect. This is at once a value and capacity. As a value, it means a commitment to having the same level of respect for the needs, perspectives, and experience of oneself and of others. As a capacity, it means being able act consistently on that basis. Combined with emotional connection and tolerance, this allows for congruent communication of experiences and needs, and mature reciprocity in interpersonal interactions and the ability to make respectful compromises in conflict situations. This is the foundation of assertiveness training, a well-established approach in CBT (e.g., Alberti and Emmons, 2008 ). The reciprocity principle is also the basis of democratic values toward the broader society in which one lives, with a capacity for acceptance and absence of prejudice toward others on the basis of ethnicity, culture, religious affiliation, political affiliation, sexual orientation etc.

A Coherent Sense of Identity

An important Healthy Adult function is as an executive that integrates the functioning of the other modes ( Young et al., 2003 ). This takes place as part of the normal, healthy development of executive functions. If that development is appropriately supported and not disrupted by unmet needs, trauma and neglect, individuals develop the capacity to sustain a coherent sense of who one is, with respect to personal beliefs, values, attitudes and motivations and feel a grounded sense of self that is consistent over time and through all significant life areas. This is accompanied by the capacity to accommodate a range of emotions and states, even when they are conflicting. Other people are experienced as separate and independent centers of their own experience. There is an absence of abrupt transitions between self-states or modes and an absence of dysfunctional modes in which the individual experiences extreme states, for example, of chaos, fragmentation or merger with another. Memory is largely accurate and consistent and not confabulated or combined with fantasy. The individual’s self-narrative (of who I am and what is important to me), is realistic and flexible and not marked by idealizations, oversimplifications, overcompensatory self-aggrandizement or self-identification as a victim ( Horowitz, 2016 ). Impairment on this dimension links to Bach and First’s (2018) recognition of the importance of including an appraisal of severity in assessing personality disorder.

Caring Beyond the Self: Compassion and Community Feeling

This refers to a sense of meaning and connection with life, a natural wisdom or spirituality that is not necessarily channeled through institutional religion, and which provides a sense of strength and direction in the face of loss and adversity. This engenders a sense of caring about and being motivated to strive for the common good, not just the good of oneself or one’s immediate family. Such individuals have self-worth based on what they have to offer, without needing to prove their worth and an attitude of kindness and compassion toward others, and spontaneous gratitude. They consider the effects of their actions not only from the immediate perspective, but also with respect to the effects for future generations. To this can be added the capacity for self-compassion ( Neff, 2013 ).

Dysfunctional Parent Modes

Dysfunctional parent modes are introjects, recordings, as it were, of the attitudes and behaviors of parents (or other authorities or caretakers) at times when they failed to meet the child’s core needs. Good parents who appropriately meet the needs of the growing child or adolescent are introjected as positive and functional, contributing to attachment security and adaptive adjustment. Dysfunctional introjects are reexperienced in the present as active voices (with for example punitive, shaming, demanding, guilt-inducing or anxiety-inducing messages), or as a felt sense of the parent figure and the implicit messages that s/he conveyed. Sometimes these introjects are projected on to the therapist, resulting in the client experiencing the therapist as likely to be, for example, unpredictable or punitive or making demands or disinterested.

The schema therapy literature mainly focuses on introjects that are experienced as explicit voices. These are now often called the Inner Critic modes. Roediger et al. (2018 , p. 40) explicitly say that they were “formerly called parent modes.” While they are called dysfunctional parent modes by Farrell et al. (2014) , Farrell and Shaw (2018) call them “dysfunctional critic modes” and point out that not calling them “parent” modes has the advantage that it does not trigger “defensiveness and family loyalty conflicts,” and does not complicate the inclusion of parents in the treatment of children and adolescents.

Here, they are still referred to as parent modes for several reasons:

(a) Introjection of the child’s experience of parents (or significant caretakers) is at the heart of these modes which correspond to what Bowlby called internal working models, which, as Roediger et al. (2018 , p. 40) remind us, can go back to infancy.

(b) They are not just experienced as voices. With somatic focusing the experience of being shut out by a parent, or a parent being absent physically or emotionally (depressed parent, abandoning parent) can come into focus as a clear experience that is not like a voice.

(c) Being critical is only one aspect of failing to meet important childhood needs. Other behaviors such as neglect, overprotectiveness and permissiveness, contribute to the development of early maladaptive schemas ( Peled, 2016 ).

(d) The term “parent” does not have to be used with the client. The term “critic” is appropriate where it captures the client’s experience of the mode. When, however, this is unmasked as originating from a particular parent, it may be useful to name it as a parent mode to bring the source of the introject into focus.

(e) Critical and demanding voices may not be introjects at all, as will be explained later.

Bowker (2021) recently listed 23 adjectives describing dysfunctional or toxic parents that can be introjected. In Table 1 , 16 parent modes are differentiated and described under five broad categories. In practice, blended Parent Modes combine several of these within and across the categories.

Table 1. Dysfunctional parent modes.

Child Modes

Child modes are working models of the self, based on memories from childhood (including early childhood and infancy). These are encoded in the cognitive system called “implicational” by Teasdale (1993) and “episodic” by Conway (2005) , which is directly connected to the brain’s emotional systems and is present at birth (and before). This is biologically separate from the language-based explicit system called “propositional” by Teasdale and “conceptual” by Conway.

Vulnerable Child Modes

In Vulnerable Child modes, individuals are, in effect, re-experiencing states of vulnerability related to experiences of unmet needs in childhood. This broad category can be differentiated into experiences related to specific primary maladaptive schemas, referred to in the descriptions below. These are variously differentiated in the literature. For example, Young et al. (2003) refer to four: Abandoned, Abused, Deprived, and Rejected. Lobbestael et al. (2007) list three: Lonely, Abandoned/Abused, and Dependent, but add a Humiliated and Inferior Child as a subtype of Abandoned/Abused, a mode that is also included by Dadomo et al. (2016) . Here eight distinct Vulnerable Child modes are identified, which can be combined into many blended Child modes.

Lonely Child (Neglected Child): Feels alone with no one to turn to when faced with confusing or distressing experiences or situations. Parents have not been available to help the child with difficult emotions, so that the person feels empty, alone, socially unacceptable, undeserving of love, unloved and unlovable. Emotional deprivation, social isolation, defectiveness/shame schemas .

Abandoned Child: An intense experience resulting from sudden traumatic separation from the mother or primary caretaker. This can result in and engulfing experience of being all alone in an endless dark place when occurring in the first few months of life. Abandonment schema .

Rejected Child : An experience of being emotionally cut off from a primary caretaker with an implicit or explicit message, “You are not wanted, I don’t care what you feel or what your experience is.” The child experiences invalidation of his/her needs and feelings. Defectiveness/Shame, Abandonment, Social isolation schemas .

Terrified Child: An experience of intense terror in response to one or more traumatic events including exposure to or witnessing angry exchanges, threats or assaults from parents. Vulnerability to harm schema .

Abused Child : Feels mistreated, abused, betrayed, and anticipates further abuse. There is usually a strong Punitive Parent voice. Mistrust/abuse schema

Humiliated/Shamed Child: Feels worthless and incapacitated by shame, anticipates further humiliation. Defectiveness/Shame schema .

Dependent Child: Feels incapable of making own decisions, and believes that s/he needs a strong person at his/her side to guide him/her to make the right decisions. This is usually the result of overprotective parents who failed to encourage the development of autonomy and self-reliance. Dependence/incompetence schema .

Desperate child: Feels desperate because of the intensity of the pain of basic needs not being met. May be related to any of the unmet needs so may blend several of the above. The pain is experienced as unbearable or close to unbearable and there is little or no expectation that those needs can be met or that the pain will end: often hidden behind a coping mode such as Helpless Surrenderer or an Overcompensator.

Angry/Unsocialized Child Modes

These modes have their source in intense experiences of impulse or emotion from childhood that, if expressed freely, appear as immature and are often destructive to self and relationships.

Angry Child: Experiences a deep sense of injustice, and feels anger about being unfairly treated, misunderstood, misrepresented, invalidated, dismissed or disregarded.

Defiant Child: Angry response to having one’s autonomy curtailed and being told what to do, as might be expressed in the sentence, “I don’t want to, and you can’t make me!”

Enraged Child: An experience of intense rage with an impulse to lash out and throw or smash objects in the environment or to retaliate against and hurt people, including physically assaulting and killing them (‘murderous rage’).

Impulsive Child: Acts impulsively without the capacity for self-control or delay of gratification or regard for the possible consequences for self or others: “I want it and I want it now!” This mode is called the Impulsive/Undisciplined Child by Young et al. (2003) . However, Lobbestael et al. (2007) and Roediger et al. (2018) separate out the Undisciplined Child which is a Coping child, as explained below.

Spoiled/Entitled Child: Expects and feels entitled to have what s/he wants and not to have to exercise self-control or be concerned about the needs and reactions of others; often the consequence of a Permissive Parent . Entitlement schema .

Healthy Child Modes

These modes are healthy states which follow from the Child’s needs being met.

Authentic Child: Experiences being in touch with and expressing one’s true self and a sense of authentic engagement with life. This is referred to as the True Self by Winnicott (1965/2016) who wrote, “Only the True Self can be creative and only the True Self can feel real.” An important goal of schema therapy is to restore and/or strengthen the individual’s access to this mode. Thus, Oldershaw et al. (2019) emphasize the importance of recovering a “lost emotional self,” without which an individual is like an orchestra without a conductor. Other writers use the metaphor of a compass ( Rivera et al., 2019 ). This is the central Healthy Child mode: the terms below represent different elements within this broader experience.

Contented Child: Experiences being at peace and satisfied because core emotional needs are currently met. Feels loved, contented, connected, fulfilled, valued, protected and safe. Although this is conflated with the Happy Child by Young et al. (2003) and Lobbestael et al. (2007) , it seems appropriate to separate out this relatively passive contented state from more active energized ones.

Happy Child: Experiences self-confidence, optimism, spontaneity and joy, a positive affectivity that is increasingly recognized as a feature of healthy well-being ( Rivera et al., 2019 ; Harpøth et al., 2020 ).

Playful Child: Experiences spontaneous playfulness and fun.

Creative Child: Experiences a natural curiosity and creativity.

Maladaptive Coping Modes

These modes are ways of coping with the emotional distress in the Child resulting from unmet needs due to toxic or neglectful parents, other caretakers, siblings and peers, or other traumatic and emotionally overwhelming events. Coping modes attenuate that distress, channel it (as when the Angry Child is expressed through an Externalizing Overcompensator, or block it out altogether). They result from a decision about how to cope that is usually implicit and not consciously planned ( Edwards, 2019 ). Coping modes usually begin in early childhood, though they generally become elaborated in later childhood and adolescence. While most coping modes fit comfortably within the surrender, detached/avoidant and overcompensatory categories, some do not and I have separated out a fourth class of coping modes under the heading Repetitive Unproductive Thinking.

Surrender Modes

The term “surrender” has three related meanings. First, it can refer to the way an individual surrenders to the underlying maladaptive schema, accepting the truth of schema beliefs such as “I am defective and unlovable” or “I cannot cope on own,” or “I will be let down and betrayed.” Coping involves acting in ways that seek to maintain connection with others in spite of these. Second, surrender can refer to submitting to the dominance of another person. In Compliant Surrender mode, both of these two meanings apply. Third, Young originally used the term schema “surrender” for states in which individuals behave as if they are like the child, with the same beliefs, emotions and behaviors as when the childhood pattern was set up. However, this is better conceptualized as a Vulnerable Child or an Angry/Unsocialized Child , or a blend of these with a coping mode.

Compliant Surrender: Acts from underlying subjugation, focusing on meeting the needs of others without attention to one’s own needs. Is subservient, self-deprecating, submissive, placating, and pleasing, toward others out of fear of conflict or rejection. Is likely to feel exploited and build resentment which may or may not be expressed ( Lobbestael et al., 2007 ).

Helpless Surrenderer: Feels helpless, dependent on others for help and in need of rescue ( Simpson et al., 2018 ; Simpson, 2020 ). Passive, not expressing needs and not present in a vulnerable way. This seems to be coping by freezing with its origin in childhood experiences of coping with being overwhelmed by fear or other overwhelming emotions. As discussed above, other features that Simpson (2020) includes in this mode are better seen as other modes that sequence or blend with this mode.

Self-Sacrificer/Rescuer: Focuses excessively on meeting the needs of others, with little attention to own needs. May be directed toward individuals or groups to whom one feels loyalty (family, a social organization, those that seem to be weak or in trouble or victimized (which may include animals as well as humans). This mode is often more satisfying and rewarding, at least in the short term, than Compliant Surrender, especially when blended with a Self-Aggrandizer , but in the long term it can lead to burnout, and chronic fatigue. Many authors do not differentiate this from Compliant Surrender but phenomenologically it has several distinctive features and is part of the Drama Triangle, discussed below.

Rolling Stone (passive): There is a lack of agency or capacity for commitment. It is named from the adage, “A rolling stone gathers no moss” (not from the music group) and is tapped by items in the Young Compensation Inventory: “I have trouble limiting myself to one job or career; I like to keep my options open,” “I like to be a ‘free agent’, to have the freedom to do what I want,” “I have trouble committing to one person or settling down.” It is constructed round an implicit acknowledgment of “I don’t really know what I want” and an underlying helplessness about that. In an overcompensatory version (described later), the individual takes pride in the freedom this provides and constructs it into an identity which belies the underlying helplessness and confusion.

Passive-resistor : Uncooperative and disinclined to take steps to engage in activities that would appear to others to be adaptive. There is likely a backstage Defiant Child expressed passively as opposed to actively (as in the overcompensatory Rebel mode). It is referred to as Stubborn Child by Dadomo et al. (2016) , but is a coping mode not a child mode.

Reassurance seeker : Though often grouped as part of Compliant Surrender mode, reassurance seeking is an important behavior, in its own right, long recognized as significant in maintaining psychological problems such as OCD ( Salkovskis and Westbrook, 1989 ), Health Anxiety ( Salkovskis and Warwick, 1986 ) and other anxiety disorders. A scale has been developed to measure it ( Rector et al., 2011 ). Reassurance-seeking can be a form of surrender to an underlying Dependence-Incompetence schema, and can sequence with Obsessive–Compulsive Overcontoller behaviors and various forms of rumination [thus Flanagan (2014) includes it under a “Worrywart” mode].

Self-pity/Victim: Experiences self as a victim, whether of mistreatment by others or of circumstances, and responds with self-pity, expressed as “poor me” ( Wessler et al., 2001 ; Edwards, 2020 ). Feels, helpless and passively awaits rescue while rejecting suggestions or help. There is often embitterment and resignation, coping with a Desperate child backstage. The individual appears distressed and even childlike, but there is no vulnerability ( Edwards, 2015 ). See also Flanagan’s (2014) Victim . This mode is particularly intractable when blended with a Care-seeking Overcompensator (see below) to create a Covert Martyr with an investment in the Victim role as a means of seeking validation for their sense of injustice about the way they have been mistreated (usually be their parents).

Detached/Avoidant Modes

In these modes, individuals disconnect from the emotional distress associated with schema activation by avoidance. This can involve: (1) Emotional avoidance: automatic disconnecting from emotions (for example by shutting down the attachment system), (2) Behavioral avoidance: avoiding places, people, activities or conversation topics that might be triggering, or (3) Cognitive Avoidance: engaging in distracting activities that prevent distressing thoughts and emotions from coming to awareness.

Detached protector: Withdraws psychologically from the pain of the EMSs by shutting off emotions, disconnecting from others, and functioning robotically. May remain quite functional in many practical areas of life. Usually has its origin in an early avoidant attachment to the mother ( Young et al., 2003 ).

Spaced out Protector: Shuts off emotions by spacing out or feeling sleepy. This can give rise to experiences of fogginess or unreality, and dysfunctional states of cognitive slowing and depersonalization.

Avoidant Protector: Avoids triggering by behavioral avoidance of situations or cues that may trigger distress ( Lobbestael et al., 2007 ).

Deceptive Protector: Avoids telling the truth or tells half-truths (“white lies”) to avoid attracting blame or shame ( Edwards, 2017 ). This is different from Conning and manipulative where the deceit is deliberate and strategic.

Detached Self-Soother: Engages in activities that soothe, stimulate or distract from emotional distress. There are several categories of these behaviors that are often addictive or compulsive ( Young et al., 2003 ).

(a) Excessive focus on adaptive behaviors such as working (workaholism) – occupational or domestic.

(b) Excessive time spent on unproductive activities that shut out unpleasant feelings; e.g., computer gaming, watching television, fantasizing, overeating (comfort eating), watching pornography, masturbating, taking ‘recreational’ drugs (self-medicating).

(c) Neutralizing: The compulsive behaviors found in OCD which are designed to neutralize disturbing intrusive images, impulses or thoughts ( Salkovskis and Westbrook, 1989 ).

(d) Wanting to die (coping with a Desperate Child ) either passively or actively planning suicide.

Two other modes that can also be conceptualized as self-soothing are listed in other categories below. The Overcompensatory daydreamer is categorized below under Repetitive Unproductive Thinking . The Detached Self-Stimulator , with its focus on risky and exciting behaviors is classified with the Overcompensators.

Overcompensation Modes

In these modes, individuals act in ways that are opposite to the underlying schema they are coping with. These modes are misleading because they convey messages such as, “I am happy,” “Everything is fine.” “I am a warm and balanced individual,” “I am an interesting valuable person,” “I am capable and self-sufficient,” etc. that belie the underlying Emotional Deprivation, Social Isolation, Defectiveness/Shame, Failure, Dependence/Incompetence, etc. ( Young et al., 2003 ). These modes often have an accompanying explicit narrative that supports the overcompensatory messages together with extensive rationalizations as to why they are true. On closer inspection, these narratives are delusional. The 48 items of the Young Compensation Inventory (YCI: Young, 1999 ) described a range of overcompensatory behaviors, and since then many more have been identified. Several of these features may combine to form blended overcompensator modes .

Strong and Independent Overcompensator : Individuals present a front of being strong, independent and capable and not needing support or assistance in any task they are engaged with or any problem they encounter. YCI item 20 reads, “I don’t like being dependent on anyone.” This mode often develops in childhood, where the child has to develop a premature independence, overcompensating for Dependence/Incompetence and Defectiveness/Unlovability and Emotional Deprivation schemas (a “parentified child”).

Social Overcompensator : Individuals present themselves as friendly and even warm, cheerful and happy. YCI item 44 reads, “I believe it’s important to “put on a happy face” regardless of what I feel inside.” But this is “fake happy,” a social façade that hides genuine feeling and experience, denies or minimizes problems and does not allow authentic engagement.

Pollyanna Overcompensator : Identified in people with eating disorders ( Simpson, 2020 ), but by no means confined to them, this mode is optimistic, idealizing of family members who are, objectively, neglectful or abusive, and dismissive of the distress occasioned by events and conflicts that most people find painful. YCI item 43 reads, “I try to be optimistic at all times; I don’t let myself focus on the negative.” This is often achieved by means of platitudes like, ‘Everything happens for a reason,’ or ‘It was meant to be.” In this mode, individuals unwittingly invalidate their own or others’ struggles and difficulties.

Comic Protector : Makes jokes, or smiles and laughs as a way of avoiding sensitive topics entirely, or to distract and steer away from the emotions they activate when they arise in conversation.

Rolling Stone: In contrast to the Surrender version [ Rolling Stone (passive) ], the individual takes pride in the freedom provided by failure to commit and constructs it into a positive identity which belies the underlying helplessness and confusion. This is captured to some extent by the YCI item, “I like to be a ‘free agent,’ to have the freedom to do what I want,” which is likely accompanied by rationalizing self-justification about why this is a healthy choice. Can be blended with the Rebel mode (see below).

Attachment-seeking Overcompensators: Modes through which individuals seek to gain or maintain connection with another in a manner that is coercive and sometimes entitled.

(a) Attention and Admiration Seeker: Engages in inappropriately extravagant, dramatic and exaggerated behavior (including sexually seductive behavior) to impress others and receive attention and admiration: called Attention and approval seeker by Lobbestael et al. (2007) .

(b) Hypervigilant Clinger: Attempts to prolong contact, refuses to leave, clings, or even begs in response to impending separation ( Behary, 2014 ). May blend with Scolding Overcontroller .

(c) Care-seeking Overcompensator: Individuals act disarmingly, with appealing charm, helplessness or present as sick, in a manner that coerces others to provide care ( Wilkinson, 2003 ). Despite the apparent helplessness, in the interests of secondary gain, they exert pressure on others who experience them as coercive and frustrating and the care may include being admitted to hospital or some other place where they will be attended to.

Detached Self-Stimulator: Excessive engagement in activities that are risky and exciting such as gambling, dangerous sports, promiscuous sex. This thrill-seeking is classified as an overcompensator since the overt behavior belies the underlying emptiness.

Overcontrollers: These protect from perceived or real threat by focusing attention on detail, and exercising extreme control (see Bamelis et al.’s 2014 Controller mode).

(a) Perfectionistic Overcontroller: focuses on getting things perfect to attain a sense of control and safety and ward off misfortune and criticism ( Lobbestael et al., 2007 ). YCI item 8 reads, “I work hard to be among the best or most successful.” The significance of unhealthy or “clinical perfectionism” has long been recognized in CBT and there are several existing measures of it ( Shafran et al., 2016 ).

(b) Eating Disordered Overcontroller, or Anorexic Overcontroller: an elaboration of the Perfectionistic Overcontroller with a focus on controlling body mass and becoming/remaining thin. Relentlessly applies perfectionistic and usually unrealistic about goal weight and foods that must be avoided ( Edwards, 2017 , 2020 ; Simpson, 2020 ).

(c) Invincible Overcontroller ( Simpson, 2020 ): Individuals believe and act as if they are omnipotent and can achieve anything they want by sheer determination and force of will ( American Psychological Association [APA], 2021 ; Kernberg, 1995 ). This can blend with a Self-aggrandizer , but may, by itself, lack the competitiveness and disdain of that mode and rather blend with a Strong and Independent Overcompensator .

(d) Obsessive–Compulsive Overcontroller: suppresses uncomfortable feelings by giving attention to detail or neutralizing them with repetitive ritualistic behaviors which may be overt (repetitive washing or checking or tidying and cleaning the house) ( Bernstein and van den Broek, 2009 ). This is tapped by YCI item 8, “I put a lot of emphasis on having order in my life (e.g., organization, structure, planning, routine).” Covert neutralizing (such as repeating words or phrases) is classified below under Repetitive Unproductive Thinking.

(e) Suspicious Overcontroller (or Paranoid Overcontroller ): anticipates that others will be malevolent, betray, and want to harm him/her, and is overly sensitized to seeing evidence for these things and vigilantly scans for them ( Lobbestael et al., 2007 ). This is typically a way of coping with an Abused Child with a Mistrust/abuse schema.

Externalizing overcompensators: These modes overlap to some extent and the features may blend or sequence.

(a) Self-aggrandizer: Behaves in an entitled, competitive, grandiose, or status-seeking way ( Young et al., 2003 ; Lobbestael et al., 2007 ; Behary, 2013 ). This is reflected in several YCI items including 17: “I like being in positions where I have control or authority over the people around me.” The individual is self-righteous, boastful, self-absorbed, lacks empathy, does not believe s/he should have to follow rules that apply to others and expects to be treated as special.

(b) Angry Protector: Uses a displays of anger to keep others at a distance and protect him/herself from others who are perceived as threatening ( Lobbestael et al., 2007 ). The anger may be muted or partially suppressed, but the mode may sequence with other externalizing overcompensators such as Bully and Attack or Complaining Protector.

(c) Scolding Overcontroller issues orders to others in a domineering way and makes belittling remarks as a way of controlling their behavior ( Edwards, 2013 , 2015 ); usually in a suite with a Self-Aggrandizer.

(d) Bully and Attack: The individual actively attacks and seeks to hurt others, demeaning and humiliating them in a controlled, strategic and sadistic way. Called the Bully by Flanagan (2014) , it can involve verbal and physical abuse or threats, sexual coercion and antisocial and even criminal acts ( Lobbestael et al., 2007 ; Bernstein and van den Broek, 2009 ).

(e) Complaining Protector: Individuals feel victimized and embittered, and vent their anger in a constant stream of complaints, directed at other people or institutions or the world in general, or at the person they are talking to. This is an externalizing version of the Self-pity/Victim mode, sometimes called the Help-rejecting complainer ( Edwards, 2015 ) because any attempt to offer advice or help is ignored or dismissed ( Bernstein and van den Broek, 2009 ). When blended with a Self-aggrandizer individuals boast about the degree to which they have suffered and feel entitled to be listened to and sympathized with ( Behary and Conway, 2021 ). When blended with a Self-sacrificer/Rescuer , the individual induces guilt (“after all I have done for you”) to create a Martyr mode ( Behary, 2021 ) which we might call an Overt Martyr to distinguish it from the Covert Martyr described above.

(f) Rebel: This is tapped by several YCI items such as “I dislike rules and can get satisfaction from breaking them,” “I think of myself as a rebel; I often go against the established authority,” and “I enjoy being unconventional, even if it’s unpopular or I don’t fit in.” This mode externalizes a backstage Defiant Child , and incorporates a narrative that portrays it as a valuable identity. Expression may range from being more passive-aggressive to being actively, even militantly rebellious. Flanagan (2014) names a Rebel mode but does not fully differentiate it from the Defiant Child .

(g) Conning and Manipulative: An extreme form of overcompensation that results in abusive and even criminal behavior in which the individual cons, lies, or manipulates in a manner designed to achieve a specific goal, which either involves victimizing others or escaping punishment ( Lobbestael et al., 2007 ; Bernstein and van den Broek, 2009 ).

(h) Predator: Another extreme form of overcompensation that results in abusive and even criminal behavior in which individuals focus on eliminating a threat, rival, obstacle, or enemy in a cold, ruthless, and calculating manner ( Lobbestael et al., 2007 ; Bernstein and van den Broek, 2009 ).

Repetitive Unproductive Thinking Modes

In these modes, individuals become caught up in repetitive rehearsal of thoughts and/or images in a manner that does not result in productive planning or problem-solving, and that perpetuates or even exacerbates problems. These modes all involve covert or largely covert processes that have a lot in common among themselves and have been extensively documented in the cognitive-behavioral literature where they are often referred to as repetitive negative thinking (RNT: Ehring and Watkins, 2008 ). I call them “unproductive” rather than “negative” because some of them, like the Overcompensatory daydreamer , are less obviously “negative” in the moment even though they contribute to perpetuating problems.

Like all coping modes, they shut out access to authentic feeling in the Child and the emotions associated with them are secondary, rather than primary ( Elliott and Greenberg, 2007 ). Many of these modes do not fall neatly under the categories of Surrender, Avoidance and Overcompensation, because they involve sequences of submodes. For example, depressive rumination or worrying may start with triggering of a primary schema such as Defectiveness, Abandonment or Vulnerability to Harm. The theme of the schema is then projected into a present situation and elaborated with cognitive distortions which are repeatedly rehearsed. This rehearsal keeps activating the schema which maintains the brooding on painful scenarios and this may alternate with futile attempts at problem-solving. These latter activities block access to the Vulnerable Child .

In the schema therapy literature, Edwards (2013) referred to a Worrying Overcontroller , in a case study, adapting the insights of Borkovec et al. (1998) into the language of schema modes. Brockman and Stavropoulos (2020) and Stavropoulos et al. (2020) examine many of these modes and refer to them as Overanalyzers . This term captures the phenomenology of only some of these modes and is included in the categorization below. Effective treatment needs to include a focus on developing meta-awareness ( Wells, 2009 ; Montgomery-Graham, 2016 ; Watkins, 2016 ; Topper et al., 2017 ; Hvenegaard et al., 2020 ), and for the schema therapist, the challenge is to use meta-awareness to unmask and by-pass the RUT coping to connect to the primary vulnerability.

I categorize them under five broad categories that focus on, respectively, (1) self-doubt, (2) denial of reality, (3) anticipating that one will not have the resources to cope with threat, (4) brooding on defectiveness, abandonment and loss, and (5) anger. More specific forms of rumination that have been described in the literature can be classified within these broad categories. However, some may contribute to more than one. For example, some of these listed under Worrying Overcontroller can exacerbate depression too.

(1) Overanalyzer: This mode is characterized by rehearsal of thoughts that focus on self-doubt, self-questioning and questioning the motivation of others or broader “Why?” questions about life and its meaning. This is often referred to as “second-guessing.” There may also be repeated attempts to mentally reassure oneself and attain certainty in an uncertain world. This is done by repeatedly reviewing and checking some aspect of one’s behavior to see whether it meets a standard or whether it was well received by another person. We know that reassurance-seeking as an external behavior does not work: the person seeks reassurance about something from another person and when they receive the reassurance they feel better but only briefly. Soon the self-doubt and self-questioning return. The same applies for reassurance-seeking that is entirely covert. Even if the person gets to the point of feeling reassured, it does not last, and the rumination continues.

(2) Denial Ruminator: In contrast to most other forms of rumination, these forms are particularly effective in damping down or shutting out the painful emotion they are coping with.

(a) Counterfactual Ruminator engages in repetitive regretful thinking about what would have happened “if only” one had acted differently, or some other condition had been different. It is counterfactual in that the individual is imagining what it would be like if the facts were different ( Tanner et al., 2013 ; Mitchell et al., 2016 ). This “if only …” thinking, with a focus on how a traumatic event might have been prevented, is a significant factor in preventing emotional processing of a traumatic event, and in perpetuating PTSD ( Clark and Ehlers, 2005 ; Michael et al., 2007 ; Turliuc et al., 2015 ). When the event is the death of a loved one it is often called Grief Rumination ( Smith and Ehlers, 2020 ). Traditionally this is called “undoing,” because the individual is trying to undo a reality that cannot be undone.

(b) Overcompensatory daydreamer: Spends time on overcompensatory daydreaming about, for example, finding the man/woman of one’s dreams, experiencing ecstatic sex or becoming successful, wealthy or famous, in the absence of any realistic plan likely to lead to achieving such goals. Although an overcompensation, individuals in this mode are passive and the mode can also be considered a form of Detached Self-Soother .

(3) Worrying Overcontroller: In this mode, individuals ruminate on their inability to cope with a variety of situations and what is likely to go wrong as a result. Over 30 years ago, Borkovec recognized this as a form of coping that “functions as a type of cognitive avoidance, and inhibits emotional processing” ( Borkovec et al., 1998 , p. 561). Anxiety is a common response to facing a situation which one does not believe one has the resources to cope. Consequently, repetitive thinking, with the focus on not being able to cope, generates chronic anxiety and contributes to Generalized Anxiety Disorder. Some people with this mode believe that worrying helps them cope better and that they need to do it to protect themselves. Others, by contrast, are concerned about not being able to control the worrying and worry further about that.

(c) Event Post-Mortem Ruminator : Following a social interaction, individuals repeatedly review aspects of their own behavior focusing on evidence that they did not perform well, made a poor impression on others or were humiliated. This mode has been described and targeted in cognitive therapy for social anxiety (e.g., Clark and Wells, 1995 ; Hackmann, 1997 ).

(d) Catastrophiser: Individuals ruminate on, and may actively visualize, the worst possible outcomes that might occur. This follows triggering of a Vulnerability to Harm schema and the worrying repeatedly reactivates it.

(e) Covert Obsessive–Compulsive Overcontroller : The individual repeatedly (and sometimes desperately) rehearses images or thoughts in an attempt to neutralize other distressing images or thoughts: for example, ritualistic counting or praying or “thinking a good thought to get rid of a bad thought.” Like overt behavioral compulsions, these activities are overcompensatory.

(f) Body checker: A largely covert form of obsessive–compulsive behavior in which individuals spend many hours a day checking their appearance. A common means is a mirror or another reflective surface. Using a car mirror can result in being late for work or social events or cause traffic accidents. Those with Body Dysmorphic Disorder focus on body parts whose appearance they are concerned about – “hot spots,” a behavior that maintains preoccupation with and shame about one’s appearance ( Veale and Riley, 2001 ). In Anorexia Nervosa and other eating disorders, body checking can involve pinching the skin at the abdomen to check for body fat, pressing the skin to feel one’s bones, mirror checking in which body parts are scrutinized to check if they are thin enough. This is often sequenced with a Flagellating Overcontroller (see below) self-talk – “look at those disgusting scars,” “my nose is just gross,” “look at those fat rolls,” that focus on perceived defects ( Simpson, 2020 ).

(g) Threat image ruminator: The individual is preoccupied with spontaneous threat-related images (visual, verbal, somatic) that are fear related and arise from the Terrified Child (or Terrified Adult if related to a more recent trauma). Such images are a feature of PTSD where, in addition to flashbacks to traumatic moments, images linked to cues at the time of a traumatic event can be taken as warning signals that something threatening is about to recur ( Ehlers et al., 2002 ). Examples would be, for someone involved in a vehicle collision at night, seeing headlights of a car rapidly approaching, or, for an abuse or torture survivor, hearing footsteps that preceded the arrival of the abuser. Other images may be “linked to preoccupations with appraisals of the trauma and its sequelae, rather than representing trauma memories ” ( Ehlers et al., 2002 , p. 1000). Such images are also common in eating disorders where the fear of becoming fat is portrayed in images of parts of the body covered in folds of fat. Simpson (2020) attributes these images to a Punitive Parent mode, but, whatever the source, they become a focus of preoccupation and rumination.

(4) Pessimistic or Depressive Ruminator: Focuses on repetitive thoughts related to defeat, despair and hopelessness about ever being able to address schema-based experiences such as a sense of unworthiness ( Defectiveness/Shame schema), rejection and abandonment ( Abandonment schema), social unacceptability ( Social isolation schema), failure ( Failure schema), or incompetence ( Incompetence/Dependence schema). Considerable attention has been given to this by Papageorgiou and Wells (2004) and Watkins (2016) .

(h) Social Comparison Ruminator engages in repetitive comparisons of oneself with others with respect to such aspects as appearance, body mass, practical, professional or social skills. This may be associated with a form of Counterfactual Rumination that focuses on, “If only I was thinner… had shinier hair … had these skills. had gone on a course about … etc.” This amplifies beliefs and feelings related to schemas such as defectiveness, failure and incompetence.

(5) Angry Ruminator : In this mode individuals ruminate angrily with a focus on having been mistreated in various ways: let down, neglected, abandoned, scorned, betrayed ( Karantzas, 2021 ). Rather than immediately channeling the anger through an Externalizing Overcompensator , they repeatedly rehearse thoughts about the mistreatment, the unfairness of it, and the speculate on the motives of the person they perceive as having mistreated them ( Sukhodolsky et al., 2001 ). Two specialized Angry Ruminators are:

(i) Vengeful Ruminator : Individuals rehearse vengeful thoughts and fantasies toward individuals they believe have harmed or traumatized them. This perpetuates many psychological problems including PTSD ( Gäbler and Maercker, 2011 ; Rowe et al., 2018 ).

(j) Flagellating Overcontroller: This is a voice that is self-attacking and shaming ( Simpson, 2020 , p. 51). It is also self-motivating, but in a harsh and cruel manner. It is a harmful and often intractable form of rumination. For a measure related to this, see Smart et al. (2016) . As Simpson points out, it is not a Punitive Parent (not an introjected recording of a Parent), but is the individual’s own Angry Child – or Enraged Child - that is internalized, attacking the self instead of those who the child is really angry with (e.g., neglectful or abusive parents). As Simpson states, “The anger is re-directed inwardly to protect the stability of the wider family system.” For further discussion of the differentiation of this mode, see the section below on Sources of Critical and Demanding Modes.

Mode Differentiation: Some Further Challenges

In conclusion, seven other concepts and processes will be examined that complicate the process of differentiating and working with modes.

(1) The Coping Child: Most coping modes have their origins in childhood, some in very early childhood or infancy. A Coping Child refers to a child who is in a coping mode. It is important to recognize this when working with imagery because, when the client has an image of a child, it may be a Coping child ( Edwards, 2019 ) or a Protector Child ( Edwards, 2020 , p. 270), rather than a Vulnerable or Angry Child . Since Child modes are the site of primary emotions while coping modes are the site of secondary emotions, a coping mode that presents as childlike is not, technically a Child mode, but a coping mode, developed in childhood to cope with intense experiences of unmet needs. In deep experiential work, we often find that current coping modes have been there since early childhood and incorporate quite simplistic and childlike beliefs and perspectives. When they appear in adults, it is easy to lose sight of their developmental origins, as these modes become elaborated with resources from later developmental periods. Most coping modes may have an underlying Coping child origin. Two examples are given here.

• Parentified Child : This is a child who, in response to a Guilt-inducing Parent or Victim Parent (see above) feels over-responsible for the well-being of the other, focuses on the needs of other, feels guilty if s/he fails to keep the other happy, and behaves in a prematurely independent way. This Coping Child is coping with the deprivation and guilt by subjugating his/her own needs ( Compliant Surrender ) and switching into a Self-Sacrificer/Rescuer mode, often blended with a Strong and Independent Overcompensator and a Perfectionist Overcontroller . This mode, which may be evident in children (the context in which the term originated), can also be recognized when bridging back to childhood memories in someone with the coping modes just referred to.

• Undisciplined Child : Although sometimes conflated with the Impulsive Child (e.g., by Young et al., 2003 ), the Undisciplined Child and Impulsive Child are different. The Impulsive Child is a genuine child mode, while the Undisciplined Child is a coping mode or a sequence of coping modes. In this mode, the individual “cannot force him/herself to finish routine or boring tasks, gets quickly frustrated and soon gives up” ( Lobbestael et al., 2007 , p. 84; see also the Stubborn Child of Dadomo et al., 2016 ). This can contribute to procrastination, beginning, for example, with a primary experience of frustration or defiance, followed by an experience of Helpless Surrender and end with a coping mode such as Detached Protector , Avoidant Protector , Detached Self-soother , Passive-Resistor or, Complaining Protector .

(2) Simple and composite modes: We can distinguish between simple modes that have few distinctive elements and composite modes that have many. In Detached Protector , for example, individuals are emotionally disconnected and robotic in a manner that is simple, consistent and recognizable. However, in some modes, several elements work together, some of which can themselves be identified as modes. These function as sub-modes within the larger system of a composite mode. For example, Edwards (2017) showed how an Eating Disordered Overcontroller included the following elements: (a) a decision to lose weight and get thin in order to feel in control and to become more attractive, popular and lovable; (b) a set of rules or standards to be followed with respect to diet and how parts of the body should appear, (c) a vigilant focusing of attention on situations where those rules or standards are to be applied, and behaving in a manner that follows from that; (d) motivational activity in the form of self-instructions and self-criticism that encourage the individual to maintain the standards, and punish the individual if the standards are not met (a Flagellating Overcontroller ); (e) a threat-warning mode that generates images of the body with large deposits of fat in various areas, to deter her from breaking the food rules; (f) a Rumination mode that is preoccupied with repeatedly checking her body and her diet with respect to whether they comply with the standards set. The way these various elements work together to implement the decision that created the mode in the first place show how a composite mode is more than just a habitual mode sequence.

(3) Parent–Child mode dyads: There is a dyadic relationship between a maladaptive Parent mode and a Vulnerable , or Angry Child mode. When a trigger situation activates a Child mode, the Parent mode with which it is dyadically connected is activated too ( Edwards, 2017 , 2019 ). The working models of Child and Parent are not independent of each other and form a Parent–Child mode dyad . This follows from Bowlby’s account of how attachment patterns involve working models of self and other in relationship. Four decades ago, Kernberg called these dyads “units” which are “constellations of affective memory” which combine an experience of self, and experience of other, and an affective charge ( Christopher et al., 2001 , p. 691; Clarkin et al., 2007 ). In schema therapy, this is recognized by Rafaeli et al. (2011 , p. 64) and by Dadomo et al. (2016) , who observe that, “the Punitive/Critical parent mode and the Vulnerable Child mode exist in a victim-abuser relationship to one another, with the critical, punitive voices triggering painful feelings of worthlessness and depression.” However, phenomenologically, it is difficult to ascertain a temporal sequence. If someone, hearing an angry remark, is triggered into a Defective Child mode, the introjected Blaming or Shaming Parent is activated simultaneously.

(4) Mode cycles: These are sequences that take place between two individuals where the behavior of the one triggers the other, who in turn behaves in a manner that triggers the first and this leads to a self-perpetuating cycle that creates chronic disconnection. This concept is central to emotionally focused therapy for couples ( Johnson, 2004 ), where the members of the couple are invited to step back and see the cycle and recognize that the enemy is the cycle, not the partner. This is incorporated into schema therapy for couples ( Simeone-DiFrancesco et al., 2015 ), where attention is given to the identification and naming of modes that contribute to the cycle.

(5) Drama Triangle: In what Karpman (1968) called the Drama Triangle (see also Liotti, 2004 ), dysregulated individuals with disturbed early attachment, become caught up in mode cycles in which they flip between three coping modes: Victim, Rescuer and Perpetrator. These correspond to Self-Pity/Victim , Self-Sacrificer/Rescuer , and Bully and Attack/Scolding Overcontroller modes. This results in a relationship in which the two parties A and B flip roles chaotically between complementary roles, for example from (1) A: Persecutor with B: Victim, to (2) A: Rescuer with B: Victim, to (3) B: Persecutor with A: Victim, to (4) B: Rescuer with A: Victim. In order to extract themselves from these cycles, individuals need to find a Healthy Adult that can step out of them.

(6) Sources of the Inner Critic: It is important to recognize that self-critical or demanding voices can have different sources. Initially it is pragmatic to use the term Inner Critic for them. However, in due course, it can be important to identify the source because this has implications for treatment. When the source is an introjected Parent voice, we work to identify the source in one or more parent or authority figures and help the child separate from the toxic parent, often by sending the parent away, and initiating a reparenting relationship with the therapist. However, self-critical messages may have their source in the Angry Child which is directed back at the self, resulting in a Flagellating Overcontroller as discussed above. In this case we need to validate the experience of the Angry Child and work with self-compassion ( Neff, 2013 ). A third process involves self-critical messages being recruited by an Overcontroller mode, particularly a Perfectionist or Eating Disordered Overcontroller , with the function of motivating individuals to meet the rules or standards built into that mode. In this case the therapeutic task is to change the decision to cope in that way ( Edwards, 2017 , 2019 ). This can complement working to send away an introjected parent, or support the Angry Child in redirecting his/her anger toward its proper target.

(7) Same behavior, different mode: A particular behavior may have its source in different modes depending on the underlying motivation. Consider, for example, self-harming ( Abbas et al., 2018 ). Consider how a suicide attempt might arise from several modes, including (1) a Detached Self-Soother with a desire to end overwhelming distress and find peace; (2) a Care-seeking Overcompensator , a “cry for help,” a way to show people how desperate one feels; (3) an Enraged Child channeled through Bully and Attack intending to punish someone, to make them sorry for their behavior, or (4) Flagellating Overcontroller as a way to punish oneself.

As indicated at the outset, the aim of this article has been to present a list of schema modes that draws on the existing literature within and beyond schema therapy and is phenomenologically grounded and clinically useful. Experienced schema therapists may have further modes to add, or be able to elaborate on some of the modes listed here that are only briefly described. As it stands, however, the present list provides a comprehensive resource that can alert clinicians to the differentiation of processes that are important for case conceptualization, especially for difficult cases where some of the less familiar modes described here play a role. An additional aim has been to present a number of concepts and accounts of processes that are relevant to differentiating and working with modes in clinical practice. Grounded in the literature but focused on clinical practice and, in particular, the challenges posed by case conceptualization, this article is intended to be a practical resource for clinicians working within the schema therapy model. As a comprehensive review, it is also intended to catalyze further debate and promote research that will contribute to the further differentiation and understanding of schema modes and the dynamic psychological processes that give rise to them.

Author Contributions

The author confirms being the sole contributor of this work and has approved it for publication.

This research and its publication were supported by Rhodes University.

Conflict of Interest

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

^ The author expresses gratitude to Poul Perris, Vartouhi Ohanian, and Jeff Conway for contributing to discussions which led to this approach.

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Keywords : schema therapy, schema mode, case conceptualization, schema perpetuation, mode sequences, blended modes, default modes

Citation: Edwards DJA (2022) Using Schema Modes for Case Conceptualization in Schema Therapy: An Applied Clinical Approach. Front. Psychol. 12:763670. doi: 10.3389/fpsyg.2021.763670

Received: 24 August 2021; Accepted: 28 December 2021; Published: 20 January 2022.

Reviewed by:

Copyright © 2022 Edwards. 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: David John Arthur Edwards, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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If I asked you to imagine a brunch, what would you see? Perhaps you would picture a big plate of scrambled eggs, fried bacon, sausage, with a side of toast and a big glass of orange juice to wash it all down.

What if I asked how you would go about introducing yourself to a new person? You would probably respond with: ‘Hi, my name is (insert your name here), it’s nice to meet you’? Maybe you would continue by asking what their name was, and where they’re from.

Why do so many of us have similar concepts of brunch and similar scripts of introductions if we all lived through unique experiences? These generalizations occur because our world is too complex for our minds to process all the available information in our environment. Instead, our brains use shortcuts and frameworks, called schemas, to make it easier to organize knowledge and understand new information. Schemas allow us to simplify and allocate our limited mental capacities efficiently. 1

Intelligence is not only the ability to reason; it is also the ability to find relevant material in memory and to deploy attention when needed. – Daniel Kahneman

Schema: the mental framework stored in memory containing basic knowledge about the concepts we know, used to guide perception, interpretation, problem solving, imagination and day-to-day interactions. 2

Assimilation: when new information is modified to fit into pre-existing schemas. 3

Accommodation: the process by which new information changes an old schema. 3

Cognition: the mental processes associated with memory, problem-solving, decision-making, comprehension, thinking, imagination, perception, and planning. 4

Stereotyping: a generalization about the personal attributes or characteristics of a specific group of people. 5

The first recorded mention of a schema was seen in German Philosopher Immanuel Kant’s The Critique of Pure Reason, published in 1781. 6 No further development was seen until 1923, when Swiss psychologist Jean Piaget picked up the idea from where Kant left off. Piaget was credited with the early development of the concept of schemas, which he used to explain a stage theory of cognitive development, particularly in children. According to Piaget, as a child begins to learn about the world around them, they create representations in their mind which progressively develop as they continue to learn new things. When you learn how to use a fork to eat, you have developed a schema for eating with a fork. This schema can then be applied to other things, such as eating with a spoon. 3

According to Piaget, the processes by which children adjust or change schemas are called assimilation and accommodation. For example, imagine a child’s concept of animals only includes dogs, and they come across a horse for the first time. The child may recognize it to have the same qualities as a dog: it’s furry, has a tail, and stands on four legs. Assimilation would say that the child believes the horse is a new type of dog. Accommodation, however, would say that the child believes that the horse is not a dog and thus needs to include a new schema within their concept of animals.

The concept of schemas was later popularized in 1932 by British psychologist Sir Frederic Charles Bartlett. He conducted experimental research on how schemas influence memory. Bartlett found that memory storage in our brains is not localized, but instead involves cognitive constructs, influenced by previous experiences, cultural and social norms, as well as personal attitudes. Information that fits into existing schemas will be interpreted based on the framework, while information that does not fit into an existing schema will be forgotten. However, modern schema theory states that once we encounter conflicting information enough times, our schema will become modified. He also found that alongside memory storage, our subjective understanding of the world is formed by the same network of cognitive structures. 7, 8, 9

According to the American Psychological Association, there are five types of schemas that everyone tends to possess:

Object Schemas: help us understand inanimate objects, primarily in differentiating different objects and knowing how they each work.
Person Schemas: created to understand individuals. For example, one’s schema about their parents might include the way they look, the way they act, their likes and dislikes, and personality traits.
Social Schemas: general knowledge about how people tend to behave in social situations. If someone is going to a restaurant for dinner, their restaurant schema will provide them with a general understanding of what social situation to expect.
Self-Schemas: help us understand ourselves. This can include our idea of who we are now, our past self, and who we could end up being in the future.
Event Schemas: also called scripts, help us know what to expect during a given event, particularly the sequence of behaviors and actions. When someone goes to the grocery store, they expect to grab a cart, walk through the aisles picking what they would like to buy, go to the checkout aisle, pay for their groceries, and leave.

Though there are is an endless number of different types of schemas, these are just the basic ones we use the most throughout our day-to-day lives. 9, 10

Jean Piaget

Jean Piaget was a Swiss psychologist and self-identified genetic epistemologist, primarily recognized for this theory of cognitive development which explains how children develop intellectually. Piaget received his PhD in zoology from the University of Neuchâtel in 1918. He later fostered an interest in psychoanalysis, which made him transition towards psychology work in the 1920s. While previous research in cognitive development suggested that children were simply small adults, Piaget’s research was the main catalyst for this change in perspective. His theories are widely accepted and studied today, by students and academics alike. 11

Frederic Bartlett

Sir Frederic Charles Bartlett was a British psychologist, recognized for his memory research. In 1924, he became an editor of the British Journal of Psychology, a position he maintained for 24 years. In 1931, Bartlett was elected to be the first full-time professor of experimental psychology at the University of Cambridge. During his time there, Cambridge became the center of experimental psychology, expanding exponentially in size. Bartlett Was one of the forerunners of cognitive psychology, publishing much research on cognition and memory throughout the 1920s and 1930s. 8

Consequences

Think back to when you were little, and just learned how to speak. Maybe it was English or a different mother tongue. Either way, the toddler version of you was speaking away with near perfect grammar, but without a drop of education on sentence structure, how to use adjectives or conjugate verbs.

This is an example of how useful schemas are to people. We are able to conduct ourselves accordingly even when we are unaware of all the specific details surrounding what we are saying, doing, and thinking. Schemas affect everything we perceive and help us interact with the world around us efficiently. They help us think and learn new information quickly, with minimal cognitive effort, by helping us categorize and organize new information from existing schemas. 9

Some schemas change over time. Maybe when you were younger your ‘teacher’ schema included the idea that you could ask them to zip up your coat before you left school for the day. As an adult you no longer hold that idea in your teacher schema and recognize it is your own responsibility to zip up your coat. 3

While schemas can be beneficial for improving our cognitive efficiency, there are possible negative consequences which can prove to be very dangerous. Sometimes existing schemas can hinder our ability to learn new information. One reason for this is that schemas lead us to pay attention to information that fits into our current schemas. So anything that appears to contradict our current knowledge tends to be rejected or ignored. This is also recognized in psychology as confirmation bias .

When it comes to our ‘Person’ schemas, this can lead to prejudice and stereotyping. Imagine a farmer from a rural town, who doesn’t get the opportunity to meet people of different ethnicities. Imagine this farmer also relies on TV and social media to hear about what is happening around the world. Since violence is more reported than positive acts, it is possible that the farmer will only experience other ethnic groups in the context of committing crimes. The farmer can then form a schema that all people of this ethnic group are dangerous crime-committers. This is also known as an illusory correlation bias , which describes a scenario where one believes there is an association between two variables that aren’t actually associated. When this farmer eventually comes across an individual of this ethnic group, they may choose to ignore all their good qualities and search for information that confirms what they saw on the news. This stereotyping can lead the farmer to fear this individual and perhaps act in a way that can be harmful to both parties involved.

Although this is only a hypothetical situation, we often hear from the news how prejudice and stereotyping can lead to racism and blatant hate crimes. It is important to acknowledge the fact that this happens so that we can avoid placing people in boxes with attributes that they haven’t had the chance to earn or dispel.

Controversies

Schema theory tends to be universally agreed upon and held in high regard by psychologists today. Though there are many negative consequences to the use of schemas, the concept itself tends to face little criticism. However, a paper published by the Reading Research Quarterly in 1991 evaluated schema theory and presented dual-coding theory as a theoretical alternative. Dual-coding theory proposes that our minds represent and remember everything in our environment using two systems: verbal and nonverbal/visual. 12 The authors found that schemas lacked a consistent definition and had mixed empirical support. They then discussed the results from a study on the effects of imagery on reading, and explained that dual coding theory offered a better explanation to the results than schema theory. 13

Schemas versus Guilt Assessment

A study published in 2010 investigated how criminal schemas would affect the guilt assessments from simulated jurors. 140 participants were placed either in the ‘no evidence’ or ‘evidence’ condition. In both conditions jurors were provided knowledge that the defendant had been charged with either one, two, three, or four offenses. Jurors in the evidence condition were given evidence from either one or two charges. They found that guilt evaluations, defendant character ratings, and measures of memory were influenced more by the number of charges judged than by the number of charges filed. In other words, the actual number of previous charges on the defendant were less influential than the jurors’ character and guilt evaluations on the number of charges judged during the study. 14 What this case study implies is that in the real world, the charges that jurors are assigning are being influenced by what they think of the defendant rather than the actual evidence at hand. This can have detrimental effects to the lives of the defendants if jurors are not aware that their evaluations may be swayed by their criminal schemas.

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> Journals
> American Political Science Review
> Volume 67 Issue 4
> Schema Theory: An Information Processing Model of Perception...

Article contents

Schema theory: an information processing model of perception and cognition *.

Published online by Cambridge University Press: 01 August 2014

The world is complex, and yet people are able to make some sense out of it. This paper offers an information-processing model to describe this aspect of perception and cognition. The model assumes that a person receives information which is less than perfect in terms of its completeness, its accuracy, and its reliability. The model provides a dynamic description of how a person evaluates this kind of information about a case, how he selects one of his pre-existing patterns (called schemata) with which to interpret the case, and how he uses the interpretation to modify and extend his beliefs about the case. It also describes how this process allows the person to make the internal adjustments which will serve as feedback for the interpretation of future information. A wide variety of evidence from experimental and social psychology is cited to support the decisions which went into constructing the separate parts of the schema theory, and further evidence is cited supporting the theory's system-level predictions. Since the schema theory allows for (but does not assume) the optimization of its parameters, it is also used as a framework for a normative analysis of the selection of schemata. Finally, a few illustrations from international relations and especially foreign-policy formation show that this model of how people make sense out of a complex world can be directly relevant to the study of important political processes.

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For their help I wish to thank Helga Novotny of Cambridge University; A. K. Sen of the London School of Economics; Brian Barry of Oxford University; Barry R. Schlenker of the State University of New York at Albany; Ian Budge, Michael Bloxam, Norman Schofield and Michael Taylor of the University of Essex; Ole Holsti of the University of British Columbia; Ernst Haas and Jeffrey Hart of the University of California at Berkeley; Cedric Smith of the University of London; Zolton Domotor of the University of Pennsylvania; and my research assistants Jacob Bercovitch, Ditsa Kafry, and William Strawn. Parts of this paper have been presented at research seminars at Tel Aviv University, Hebrew University (Jerusalem), Technion (Haifa), the London School of Economics, and the University of Essex. I am grateful to the discussants at all these places. For their generous financial support I wish to thank the Institute of International Studies of the University of California at Berkeley, the Fellowship Program of the Council on Foreign Relations, and the NATO Postdoctoral Fellowship Program of the National Science Foundation. Of course the author is solely responsible for the views presented in this paper.

In reviewing the psychological literature I have relied heavily on Gardner Lindzey and Elliot Aronson, eds., The Handbook of Social Psychology , second edition (Reading, Mass.: Addison-Wesley, 1968, 1969), especially the chapters by Berger and Lambert “Stimulus-Response Theory in Contemporary Social Psychology,” I, 81–178; Seymour Rosenberg, “Mathematical Models of Social Behavior,” I, 179–244; Robert B. Zajonc, “Cognitive Theories in Social Psychology,” I, 320–411; Leonard Berkowitz, “Social Motivation,” III, 50–135; Henri Tajfel, “Social and Cultural Factors in Perception,” III, 315–394; and George A. Miller and David McNeill, “Psycholinguistics,” III, 666–794.

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90 Attneave, “Multistability in Perception.”

91 Concept formation experiments provide further indirect evidence. See, for example, Bruner , Jerome S. , Goodnow , Jacqueline J. and Austin , George A. , A Study of Thinking ( New York : Wiley , 1956 ) Google Scholar .

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93 For example, DeSoto and Kuethe, “Perception of Mathematical Properties”; DeSoto and Kuethe, “Subective Probabilities;” and DeSoto, “Learning a Social Structure.”

94 Henley, Horsfall and DeSoto, “Goodness of Figure,” Axelrod, “Psycho-Algebra.”

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106 For a formal model with a similar tradeoff, see Amari , Shun-ichi , “ Theory of Learning Decision Systems ,” in Unifying Study of Basic Problems in Engineering and Physical Sciences by Means of Geometry , ed. Kondo , Kazoo (Division 1), ( Tokyo : Gakujutsu Bunken Fukyu-kai , 1969 ), pp. 33 – 42 (which is RAAG Memoirs, 4, [1969], 567–576) Google Scholar .

107 With the assumption that each instance of a schema has equal subjective probability, size determines redundancy. The assumption is based on the principle that if some instances have a higher subjective probability than others, they should be treated by the model as belonging to different schemata. For applications of redundancy to psychology see Garner, Uncertainty and Structure ; and Garner , Wendell R. and Clement , David E. , “ Goodness of Pattern and Pattern Uncertainty ,” Journal of Verbal Learning and Verbal Behavior , 2 (December, 1963 ), 446 – 452 CrossRef Google Scholar . For a recent critical review see Corcoran , D. W. J. , Pattern Recognition ( Harmondsworth, England : Penguin Books , 1971 ) Google Scholar .

108 For schemata of infinite size (e.g., with continuous rather than discrete parameters), the appropriate measure of size uses degrees of freedom. For example, a linear equation has two degrees of freedom (namely a and b in y = ax + b ), and a quadratic equation has three degrees of freedom (namely a, b and c in y = ax 3 + bx + c ).

109 Kogan and Tagiuri, “Interpersonal Preference and Cognitive Organization.”

110 To carry the analysis further one could do the type of indifference curve analysis used in microeconomics. Negatively sloped indifference curves could be drawn in Figure 4 to represent the tradeoffs between smallness and veridicality. Then the schemata should be given accessibility in order of their intersection with the ordered set of indifference curves. If there are enough alternative schemata to allow for a continuous approximation of the frontier of knowledge, then the schema which should be given the highest accessibility is represented by the point at which one of the indifference curves is tangent to the frontier of knowledge.

111 A metric function has the following properties: d(x,y) = d(y,x); d(x,y) ≥ 0; d(x,y) = 0 if and only if x = y , and d(x,y) + d(y,z) ≥ d(x,z) .

112 Although the distance between points is a metric function as defined in the previous footnote, the distance between sets is not.

113 Abelson and Rosenberg, “Symbolic Psycho-logic.”

114 Wiest, “A Quantitative Extension.”

115 Signal detectability theory treats the situation in which there is only one accessible schema. See Coombs, Dawes, and Tversky, Mathematical Psychology .

116 Geometric analysis of this section can be extended to yield a number of suggestive theorems about some of the more subtle consequences of the present information processing model. Here are four such results.

(1) Potential Completeness . If Q is a continuous space, then under a weak set of assumptions the modified and extended specification of a case will be a complete specification of the case. This corresponds to the situation in which the person can make an estimate about every feature of the case (e.g., every friendship relationship). For example, in Figure 5 the set of points in S 2 which are minimally distant from X is a single point, x ′, and is therefore a complete specification.

(2) Potential Enlargement . Under certain circumstances the modified and extended specification can actually be larger than the initial partial specification. This occurs when there are few points in the partial specification, but more points in the selected schema which are at the minimum distance from the initial partial specification than there were in the initial partial specification itself. In such a situation the person has a schema which he can use to interpret the case, but he does not end up with a single unique specification of the case (even if he started with one). He believes something is wrong with the initial information, but he can not pin down what it is, even though he has selected a schema with which to interpret the case.

(3) Cancellation Effect . Under a wide range of conditions, an initial partial specification with continuous parameters will be modified to achieve a fit to the selected schema by leaving most of the parameters unchanged and by giving the rest neutral values. This can be called the cancellation effect since the only changes in the modification are neutralizations. The cancellation effect is a consequence of the principle that the modification is made in such a way as to move the least distance to the selected schema.

(4) Seriatim Effect . Under a wide range of circumstances, the sequential presentation of the same information can reduce the amount of attitude change compared to a simultaneous presentation. The seriatim effect is due to the principle that a message is first evaluated for how well it fits into a previous interpretation of the case. Presenting discrepant information a little at a time can result in each message being blamed as it is received, whereas if the discrepant information were presented all at once, the blame might be affixed to the old interpretation.

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121 Masterman, The Double-Cross System .

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123 Solomon, Kamm and Wynne, “Traumatic Avoidance Learning.”

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Volume 67, Issue 4
Robert Axelrod (a1)
DOI: https://doi.org/10.2307/1956546

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DOI: 10.35678/2539-5645.5(36).2022.83-93
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LEARNING MANAGEMENT USING SCHEMA THEORY FOR ENGLISH LISTENING SKILL: A CASE STUDY OF CHINESE VOCATIONAL HIGH SCHOOL STUDENTS IN ZHEJIANG PROVINCE

Chenjie Li , Nipaporn Sakulwongs
Published in The EUrASEANs: journal on… 1 September 2022

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Optimising listening skills: analysing the effectiveness of a blended model with a top-down approach through cognitive load theory, 8 references, on the use of content specialists in the assessment of criterion-referenced test item validity., research design: qualitative, quantitative, and mixed methods approaches, the theory of the estimation of test reliability.

Highly Influential

Attitude and Motivation in Second Language Learning: Course Related Changes.

The case study approach

Sarah crowe.

1 Division of Primary Care, The University of Nottingham, Nottingham, UK

Kathrin Cresswell

2 Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK

Ann Robertson

3 School of Health in Social Science, The University of Edinburgh, Edinburgh, UK

Anthony Avery

Aziz sheikh.

The case study approach allows in-depth, multi-faceted explorations of complex issues in their real-life settings. The value of the case study approach is well recognised in the fields of business, law and policy, but somewhat less so in health services research. Based on our experiences of conducting several health-related case studies, we reflect on the different types of case study design, the specific research questions this approach can help answer, the data sources that tend to be used, and the particular advantages and disadvantages of employing this methodological approach. The paper concludes with key pointers to aid those designing and appraising proposals for conducting case study research, and a checklist to help readers assess the quality of case study reports.

Introduction

The case study approach is particularly useful to employ when there is a need to obtain an in-depth appreciation of an issue, event or phenomenon of interest, in its natural real-life context. Our aim in writing this piece is to provide insights into when to consider employing this approach and an overview of key methodological considerations in relation to the design, planning, analysis, interpretation and reporting of case studies.

The illustrative 'grand round', 'case report' and 'case series' have a long tradition in clinical practice and research. Presenting detailed critiques, typically of one or more patients, aims to provide insights into aspects of the clinical case and, in doing so, illustrate broader lessons that may be learnt. In research, the conceptually-related case study approach can be used, for example, to describe in detail a patient's episode of care, explore professional attitudes to and experiences of a new policy initiative or service development or more generally to 'investigate contemporary phenomena within its real-life context' [ 1 ]. Based on our experiences of conducting a range of case studies, we reflect on when to consider using this approach, discuss the key steps involved and illustrate, with examples, some of the practical challenges of attaining an in-depth understanding of a 'case' as an integrated whole. In keeping with previously published work, we acknowledge the importance of theory to underpin the design, selection, conduct and interpretation of case studies[ 2 ]. In so doing, we make passing reference to the different epistemological approaches used in case study research by key theoreticians and methodologists in this field of enquiry.

This paper is structured around the following main questions: What is a case study? What are case studies used for? How are case studies conducted? What are the potential pitfalls and how can these be avoided? We draw in particular on four of our own recently published examples of case studies (see Tables Tables1, 1 , ,2, 2 , ,3 3 and and4) 4 ) and those of others to illustrate our discussion[ 3 - 7 ].

Example of a case study investigating the reasons for differences in recruitment rates of minority ethnic people in asthma research[ 3 ]

Minority ethnic people experience considerably greater morbidity from asthma than the White majority population. Research has shown however that these minority ethnic populations are likely to be under-represented in research undertaken in the UK; there is comparatively less marginalisation in the US.

To investigate approaches to bolster recruitment of South Asians into UK asthma studies through qualitative research with US and UK researchers, and UK community leaders.

Single intrinsic case study

Centred on the issue of recruitment of South Asian people with asthma.

In-depth interviews were conducted with asthma researchers from the UK and US. A supplementary questionnaire was also provided to researchers.

Framework approach.

Barriers to ethnic minority recruitment were found to centre around:

1. The attitudes of the researchers' towards inclusion: The majority of UK researchers interviewed were generally supportive of the idea of recruiting ethnically diverse participants but expressed major concerns about the practicalities of achieving this; in contrast, the US researchers appeared much more committed to the policy of inclusion.

2. Stereotypes and prejudices: We found that some of the UK researchers' perceptions of ethnic minorities may have influenced their decisions on whether to approach individuals from particular ethnic groups. These stereotypes centred on issues to do with, amongst others, language barriers and lack of altruism.

3. Demographic, political and socioeconomic contexts of the two countries: Researchers suggested that the demographic profile of ethnic minorities, their political engagement and the different configuration of the health services in the UK and the US may have contributed to differential rates.

4. Above all, however, it appeared that the overriding importance of the US National Institute of Health's policy to mandate the inclusion of minority ethnic people (and women) had a major impact on shaping the attitudes and in turn the experiences of US researchers'; the absence of any similar mandate in the UK meant that UK-based researchers had not been forced to challenge their existing practices and they were hence unable to overcome any stereotypical/prejudicial attitudes through experiential learning.

Example of a case study investigating the process of planning and implementing a service in Primary Care Organisations[ 4 ]

Health work forces globally are needing to reorganise and reconfigure in order to meet the challenges posed by the increased numbers of people living with long-term conditions in an efficient and sustainable manner. Through studying the introduction of General Practitioners with a Special Interest in respiratory disorders, this study aimed to provide insights into this important issue by focusing on community respiratory service development.

To understand and compare the process of workforce change in respiratory services and the impact on patient experience (specifically in relation to the role of general practitioners with special interests) in a theoretically selected sample of Primary Care Organisations (PCOs), in order to derive models of good practice in planning and the implementation of a broad range of workforce issues.

Multiple-case design of respiratory services in health regions in England and Wales.

Four PCOs.

Face-to-face and telephone interviews, e-mail discussions, local documents, patient diaries, news items identified from local and national websites, national workshop.

Reading, coding and comparison progressed iteratively.

1. In the screening phase of this study (which involved semi-structured telephone interviews with the person responsible for driving the reconfiguration of respiratory services in 30 PCOs), the barriers of financial deficit, organisational uncertainty, disengaged clinicians and contradictory policies proved insurmountable for many PCOs to developing sustainable services. A key rationale for PCO re-organisation in 2006 was to strengthen their commissioning function and those of clinicians through Practice-Based Commissioning. However, the turbulence, which surrounded reorganisation was found to have the opposite desired effect.

2. Implementing workforce reconfiguration was strongly influenced by the negotiation and contest among local clinicians and managers about "ownership" of work and income.

3. Despite the intention to make the commissioning system more transparent, personal relationships based on common professional interests, past work history, friendships and collegiality, remained as key drivers for sustainable innovation in service development.

It was only possible to undertake in-depth work in a selective number of PCOs and, even within these selected PCOs, it was not possible to interview all informants of potential interest and/or obtain all relevant documents. This work was conducted in the early stages of a major NHS reorganisation in England and Wales and thus, events are likely to have continued to evolve beyond the study period; we therefore cannot claim to have seen any of the stories through to their conclusion.

Example of a case study investigating the introduction of the electronic health records[ 5 ]

Healthcare systems globally are moving from paper-based record systems to electronic health record systems. In 2002, the NHS in England embarked on the most ambitious and expensive IT-based transformation in healthcare in history seeking to introduce electronic health records into all hospitals in England by 2010.

To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide formative feedback for local and national rollout of the NHS Care Records Service.

A mixed methods, longitudinal, multi-site, socio-technical collective case study.

Five NHS acute hospital and mental health Trusts that have been the focus of early implementation efforts.

Semi-structured interviews, documentary data and field notes, observations and quantitative data.

Qualitative data were analysed thematically using a socio-technical coding matrix, combined with additional themes that emerged from the data.

1. Hospital electronic health record systems have developed and been implemented far more slowly than was originally envisioned.

2. The top-down, government-led standardised approach needed to evolve to admit more variation and greater local choice for hospitals in order to support local service delivery.

3. A range of adverse consequences were associated with the centrally negotiated contracts, which excluded the hospitals in question.

4. The unrealistic, politically driven, timeline (implementation over 10 years) was found to be a major source of frustration for developers, implementers and healthcare managers and professionals alike.

We were unable to access details of the contracts between government departments and the Local Service Providers responsible for delivering and implementing the software systems. This, in turn, made it difficult to develop a holistic understanding of some key issues impacting on the overall slow roll-out of the NHS Care Record Service. Early adopters may also have differed in important ways from NHS hospitals that planned to join the National Programme for Information Technology and implement the NHS Care Records Service at a later point in time.

Example of a case study investigating the formal and informal ways students learn about patient safety[ 6 ]

There is a need to reduce the disease burden associated with iatrogenic harm and considering that healthcare education represents perhaps the most sustained patient safety initiative ever undertaken, it is important to develop a better appreciation of the ways in which undergraduate and newly qualified professionals receive and make sense of the education they receive.
To investigate the formal and informal ways pre-registration students from a range of healthcare professions (medicine, nursing, physiotherapy and pharmacy) learn about patient safety in order to become safe practitioners.
Multi-site, mixed method collective case study.
: Eight case studies (two for each professional group) were carried out in educational provider sites considering different programmes, practice environments and models of teaching and learning.
Structured in phases relevant to the three knowledge contexts:
	Documentary evidence (including undergraduate curricula, handbooks and module outlines), complemented with a range of views (from course leads, tutors and students) and observations in a range of academic settings.

	Policy and management views of patient safety and influences on patient safety education and practice. NHS policies included, for example, implementation of the National Patient Safety Agency's , which encourages organisations to develop an organisational safety culture in which staff members feel comfortable identifying dangers and reporting hazards.

	The cultures to which students are exposed i.e. patient safety in relation to day-to-day working. NHS initiatives included, for example, a hand washing initiative or introduction of infection control measures.


1. Practical, informal, learning opportunities were valued by students. On the whole, however, students were not exposed to nor engaged with important NHS initiatives such as risk management activities and incident reporting schemes.
2. NHS policy appeared to have been taken seriously by course leaders. Patient safety materials were incorporated into both formal and informal curricula, albeit largely implicit rather than explicit.
3. Resource issues and peer pressure were found to influence safe practice. Variations were also found to exist in students' experiences and the quality of the supervision available.
The curriculum and organisational documents collected differed between sites, which possibly reflected gatekeeper influences at each site. The recruitment of participants for focus group discussions proved difficult, so interviews or paired discussions were used as a substitute.

What is a case study?

A case study is a research approach that is used to generate an in-depth, multi-faceted understanding of a complex issue in its real-life context. It is an established research design that is used extensively in a wide variety of disciplines, particularly in the social sciences. A case study can be defined in a variety of ways (Table (Table5), 5 ), the central tenet being the need to explore an event or phenomenon in depth and in its natural context. It is for this reason sometimes referred to as a "naturalistic" design; this is in contrast to an "experimental" design (such as a randomised controlled trial) in which the investigator seeks to exert control over and manipulate the variable(s) of interest.

Definitions of a case study

Author	Definition
Stake[ ]	(p.237)
Yin[ , , ]	(Yin 1999 p. 1211, Yin 1994 p. 13)

	•
	• (Yin 2009 p18)
Miles and Huberman[ ]	(p. 25)
Green and Thorogood[ ]	(p. 284)
George and Bennett[ ]	(p. 17)"

Stake's work has been particularly influential in defining the case study approach to scientific enquiry. He has helpfully characterised three main types of case study: intrinsic , instrumental and collective [ 8 ]. An intrinsic case study is typically undertaken to learn about a unique phenomenon. The researcher should define the uniqueness of the phenomenon, which distinguishes it from all others. In contrast, the instrumental case study uses a particular case (some of which may be better than others) to gain a broader appreciation of an issue or phenomenon. The collective case study involves studying multiple cases simultaneously or sequentially in an attempt to generate a still broader appreciation of a particular issue.

These are however not necessarily mutually exclusive categories. In the first of our examples (Table (Table1), 1 ), we undertook an intrinsic case study to investigate the issue of recruitment of minority ethnic people into the specific context of asthma research studies, but it developed into a instrumental case study through seeking to understand the issue of recruitment of these marginalised populations more generally, generating a number of the findings that are potentially transferable to other disease contexts[ 3 ]. In contrast, the other three examples (see Tables Tables2, 2 , ,3 3 and and4) 4 ) employed collective case study designs to study the introduction of workforce reconfiguration in primary care, the implementation of electronic health records into hospitals, and to understand the ways in which healthcare students learn about patient safety considerations[ 4 - 6 ]. Although our study focusing on the introduction of General Practitioners with Specialist Interests (Table (Table2) 2 ) was explicitly collective in design (four contrasting primary care organisations were studied), is was also instrumental in that this particular professional group was studied as an exemplar of the more general phenomenon of workforce redesign[ 4 ].

What are case studies used for?

According to Yin, case studies can be used to explain, describe or explore events or phenomena in the everyday contexts in which they occur[ 1 ]. These can, for example, help to understand and explain causal links and pathways resulting from a new policy initiative or service development (see Tables Tables2 2 and and3, 3 , for example)[ 1 ]. In contrast to experimental designs, which seek to test a specific hypothesis through deliberately manipulating the environment (like, for example, in a randomised controlled trial giving a new drug to randomly selected individuals and then comparing outcomes with controls),[ 9 ] the case study approach lends itself well to capturing information on more explanatory ' how ', 'what' and ' why ' questions, such as ' how is the intervention being implemented and received on the ground?'. The case study approach can offer additional insights into what gaps exist in its delivery or why one implementation strategy might be chosen over another. This in turn can help develop or refine theory, as shown in our study of the teaching of patient safety in undergraduate curricula (Table (Table4 4 )[ 6 , 10 ]. Key questions to consider when selecting the most appropriate study design are whether it is desirable or indeed possible to undertake a formal experimental investigation in which individuals and/or organisations are allocated to an intervention or control arm? Or whether the wish is to obtain a more naturalistic understanding of an issue? The former is ideally studied using a controlled experimental design, whereas the latter is more appropriately studied using a case study design.

Case studies may be approached in different ways depending on the epistemological standpoint of the researcher, that is, whether they take a critical (questioning one's own and others' assumptions), interpretivist (trying to understand individual and shared social meanings) or positivist approach (orientating towards the criteria of natural sciences, such as focusing on generalisability considerations) (Table (Table6). 6 ). Whilst such a schema can be conceptually helpful, it may be appropriate to draw on more than one approach in any case study, particularly in the context of conducting health services research. Doolin has, for example, noted that in the context of undertaking interpretative case studies, researchers can usefully draw on a critical, reflective perspective which seeks to take into account the wider social and political environment that has shaped the case[ 11 ].

Example of epistemological approaches that may be used in case study research

Characteristics	Criticisms	Key references
Involves questioning one's own assumptions taking into account the wider political and social environment.	It can possibly neglect other factors by focussing only on power relationships and may give the researcher a position that is too privileged.	Howcroft and Trauth[ ] Blakie[ ] Doolin[ , ]
Interprets the limiting conditions in relation to power and control that are thought to influence behaviour.		Bloomfield and Best[ ]
Involves understanding meanings/contexts and processes as perceived from different perspectives, trying to understand individual and shared social meanings. Focus is on theory building.	Often difficult to explain unintended consequences and for neglecting surrounding historical contexts	Stake[ ] Doolin[ ]
Involves establishing which variables one wishes to study in advance and seeing whether they fit in with the findings. Focus is often on testing and refining theory on the basis of case study findings.	It does not take into account the role of the researcher in influencing findings.	Yin[ , , ] Shanks and Parr[ ]

How are case studies conducted?

Here, we focus on the main stages of research activity when planning and undertaking a case study; the crucial stages are: defining the case; selecting the case(s); collecting and analysing the data; interpreting data; and reporting the findings.

Defining the case

Carefully formulated research question(s), informed by the existing literature and a prior appreciation of the theoretical issues and setting(s), are all important in appropriately and succinctly defining the case[ 8 , 12 ]. Crucially, each case should have a pre-defined boundary which clarifies the nature and time period covered by the case study (i.e. its scope, beginning and end), the relevant social group, organisation or geographical area of interest to the investigator, the types of evidence to be collected, and the priorities for data collection and analysis (see Table Table7 7 )[ 1 ]. A theory driven approach to defining the case may help generate knowledge that is potentially transferable to a range of clinical contexts and behaviours; using theory is also likely to result in a more informed appreciation of, for example, how and why interventions have succeeded or failed[ 13 ].

Example of a checklist for rating a case study proposal[ 8 ]

	Clarity: Does the proposal read well?
	Integrity: Do its pieces fit together?
	Attractiveness: Does it pique the reader's interest?
	The case: Is the case adequately defined?
	The issues: Are major research questions identified?
	Data Resource: Are sufficient data sources identified?
	Case Selection: Is the selection plan reasonable?
	Data Gathering: Are data-gathering activities outlined?
	Validation: Is the need and opportunity for triangulation indicated?
	Access: Are arrangements for start-up anticipated?
	Confidentiality: Is there sensitivity to the protection of people?
	Cost: Are time and resource estimates reasonable?

For example, in our evaluation of the introduction of electronic health records in English hospitals (Table (Table3), 3 ), we defined our cases as the NHS Trusts that were receiving the new technology[ 5 ]. Our focus was on how the technology was being implemented. However, if the primary research interest had been on the social and organisational dimensions of implementation, we might have defined our case differently as a grouping of healthcare professionals (e.g. doctors and/or nurses). The precise beginning and end of the case may however prove difficult to define. Pursuing this same example, when does the process of implementation and adoption of an electronic health record system really begin or end? Such judgements will inevitably be influenced by a range of factors, including the research question, theory of interest, the scope and richness of the gathered data and the resources available to the research team.

Selecting the case(s)

The decision on how to select the case(s) to study is a very important one that merits some reflection. In an intrinsic case study, the case is selected on its own merits[ 8 ]. The case is selected not because it is representative of other cases, but because of its uniqueness, which is of genuine interest to the researchers. This was, for example, the case in our study of the recruitment of minority ethnic participants into asthma research (Table (Table1) 1 ) as our earlier work had demonstrated the marginalisation of minority ethnic people with asthma, despite evidence of disproportionate asthma morbidity[ 14 , 15 ]. In another example of an intrinsic case study, Hellstrom et al.[ 16 ] studied an elderly married couple living with dementia to explore how dementia had impacted on their understanding of home, their everyday life and their relationships.

For an instrumental case study, selecting a "typical" case can work well[ 8 ]. In contrast to the intrinsic case study, the particular case which is chosen is of less importance than selecting a case that allows the researcher to investigate an issue or phenomenon. For example, in order to gain an understanding of doctors' responses to health policy initiatives, Som undertook an instrumental case study interviewing clinicians who had a range of responsibilities for clinical governance in one NHS acute hospital trust[ 17 ]. Sampling a "deviant" or "atypical" case may however prove even more informative, potentially enabling the researcher to identify causal processes, generate hypotheses and develop theory.

In collective or multiple case studies, a number of cases are carefully selected. This offers the advantage of allowing comparisons to be made across several cases and/or replication. Choosing a "typical" case may enable the findings to be generalised to theory (i.e. analytical generalisation) or to test theory by replicating the findings in a second or even a third case (i.e. replication logic)[ 1 ]. Yin suggests two or three literal replications (i.e. predicting similar results) if the theory is straightforward and five or more if the theory is more subtle. However, critics might argue that selecting 'cases' in this way is insufficiently reflexive and ill-suited to the complexities of contemporary healthcare organisations.

The selected case study site(s) should allow the research team access to the group of individuals, the organisation, the processes or whatever else constitutes the chosen unit of analysis for the study. Access is therefore a central consideration; the researcher needs to come to know the case study site(s) well and to work cooperatively with them. Selected cases need to be not only interesting but also hospitable to the inquiry [ 8 ] if they are to be informative and answer the research question(s). Case study sites may also be pre-selected for the researcher, with decisions being influenced by key stakeholders. For example, our selection of case study sites in the evaluation of the implementation and adoption of electronic health record systems (see Table Table3) 3 ) was heavily influenced by NHS Connecting for Health, the government agency that was responsible for overseeing the National Programme for Information Technology (NPfIT)[ 5 ]. This prominent stakeholder had already selected the NHS sites (through a competitive bidding process) to be early adopters of the electronic health record systems and had negotiated contracts that detailed the deployment timelines.

It is also important to consider in advance the likely burden and risks associated with participation for those who (or the site(s) which) comprise the case study. Of particular importance is the obligation for the researcher to think through the ethical implications of the study (e.g. the risk of inadvertently breaching anonymity or confidentiality) and to ensure that potential participants/participating sites are provided with sufficient information to make an informed choice about joining the study. The outcome of providing this information might be that the emotive burden associated with participation, or the organisational disruption associated with supporting the fieldwork, is considered so high that the individuals or sites decide against participation.

In our example of evaluating implementations of electronic health record systems, given the restricted number of early adopter sites available to us, we sought purposively to select a diverse range of implementation cases among those that were available[ 5 ]. We chose a mixture of teaching, non-teaching and Foundation Trust hospitals, and examples of each of the three electronic health record systems procured centrally by the NPfIT. At one recruited site, it quickly became apparent that access was problematic because of competing demands on that organisation. Recognising the importance of full access and co-operative working for generating rich data, the research team decided not to pursue work at that site and instead to focus on other recruited sites.

Collecting the data

In order to develop a thorough understanding of the case, the case study approach usually involves the collection of multiple sources of evidence, using a range of quantitative (e.g. questionnaires, audits and analysis of routinely collected healthcare data) and more commonly qualitative techniques (e.g. interviews, focus groups and observations). The use of multiple sources of data (data triangulation) has been advocated as a way of increasing the internal validity of a study (i.e. the extent to which the method is appropriate to answer the research question)[ 8 , 18 - 21 ]. An underlying assumption is that data collected in different ways should lead to similar conclusions, and approaching the same issue from different angles can help develop a holistic picture of the phenomenon (Table (Table2 2 )[ 4 ].

Brazier and colleagues used a mixed-methods case study approach to investigate the impact of a cancer care programme[ 22 ]. Here, quantitative measures were collected with questionnaires before, and five months after, the start of the intervention which did not yield any statistically significant results. Qualitative interviews with patients however helped provide an insight into potentially beneficial process-related aspects of the programme, such as greater, perceived patient involvement in care. The authors reported how this case study approach provided a number of contextual factors likely to influence the effectiveness of the intervention and which were not likely to have been obtained from quantitative methods alone.

In collective or multiple case studies, data collection needs to be flexible enough to allow a detailed description of each individual case to be developed (e.g. the nature of different cancer care programmes), before considering the emerging similarities and differences in cross-case comparisons (e.g. to explore why one programme is more effective than another). It is important that data sources from different cases are, where possible, broadly comparable for this purpose even though they may vary in nature and depth.

Analysing, interpreting and reporting case studies

Making sense and offering a coherent interpretation of the typically disparate sources of data (whether qualitative alone or together with quantitative) is far from straightforward. Repeated reviewing and sorting of the voluminous and detail-rich data are integral to the process of analysis. In collective case studies, it is helpful to analyse data relating to the individual component cases first, before making comparisons across cases. Attention needs to be paid to variations within each case and, where relevant, the relationship between different causes, effects and outcomes[ 23 ]. Data will need to be organised and coded to allow the key issues, both derived from the literature and emerging from the dataset, to be easily retrieved at a later stage. An initial coding frame can help capture these issues and can be applied systematically to the whole dataset with the aid of a qualitative data analysis software package.

The Framework approach is a practical approach, comprising of five stages (familiarisation; identifying a thematic framework; indexing; charting; mapping and interpretation) , to managing and analysing large datasets particularly if time is limited, as was the case in our study of recruitment of South Asians into asthma research (Table (Table1 1 )[ 3 , 24 ]. Theoretical frameworks may also play an important role in integrating different sources of data and examining emerging themes. For example, we drew on a socio-technical framework to help explain the connections between different elements - technology; people; and the organisational settings within which they worked - in our study of the introduction of electronic health record systems (Table (Table3 3 )[ 5 ]. Our study of patient safety in undergraduate curricula drew on an evaluation-based approach to design and analysis, which emphasised the importance of the academic, organisational and practice contexts through which students learn (Table (Table4 4 )[ 6 ].

Case study findings can have implications both for theory development and theory testing. They may establish, strengthen or weaken historical explanations of a case and, in certain circumstances, allow theoretical (as opposed to statistical) generalisation beyond the particular cases studied[ 12 ]. These theoretical lenses should not, however, constitute a strait-jacket and the cases should not be "forced to fit" the particular theoretical framework that is being employed.

When reporting findings, it is important to provide the reader with enough contextual information to understand the processes that were followed and how the conclusions were reached. In a collective case study, researchers may choose to present the findings from individual cases separately before amalgamating across cases. Care must be taken to ensure the anonymity of both case sites and individual participants (if agreed in advance) by allocating appropriate codes or withholding descriptors. In the example given in Table Table3, 3 , we decided against providing detailed information on the NHS sites and individual participants in order to avoid the risk of inadvertent disclosure of identities[ 5 , 25 ].

What are the potential pitfalls and how can these be avoided?

The case study approach is, as with all research, not without its limitations. When investigating the formal and informal ways undergraduate students learn about patient safety (Table (Table4), 4 ), for example, we rapidly accumulated a large quantity of data. The volume of data, together with the time restrictions in place, impacted on the depth of analysis that was possible within the available resources. This highlights a more general point of the importance of avoiding the temptation to collect as much data as possible; adequate time also needs to be set aside for data analysis and interpretation of what are often highly complex datasets.

Case study research has sometimes been criticised for lacking scientific rigour and providing little basis for generalisation (i.e. producing findings that may be transferable to other settings)[ 1 ]. There are several ways to address these concerns, including: the use of theoretical sampling (i.e. drawing on a particular conceptual framework); respondent validation (i.e. participants checking emerging findings and the researcher's interpretation, and providing an opinion as to whether they feel these are accurate); and transparency throughout the research process (see Table Table8 8 )[ 8 , 18 - 21 , 23 , 26 ]. Transparency can be achieved by describing in detail the steps involved in case selection, data collection, the reasons for the particular methods chosen, and the researcher's background and level of involvement (i.e. being explicit about how the researcher has influenced data collection and interpretation). Seeking potential, alternative explanations, and being explicit about how interpretations and conclusions were reached, help readers to judge the trustworthiness of the case study report. Stake provides a critique checklist for a case study report (Table (Table9 9 )[ 8 ].

Potential pitfalls and mitigating actions when undertaking case study research

Potential pitfall	Mitigating action
Selecting/conceptualising the wrong case(s) resulting in lack of theoretical generalisations	Developing in-depth knowledge of theoretical and empirical literature, justifying choices made
Collecting large volumes of data that are not relevant to the case or too little to be of any value	Focus data collection in line with research questions, whilst being flexible and allowing different paths to be explored
Defining/bounding the case	Focus on related components (either by time and/or space), be clear what is outside the scope of the case
Lack of rigour	Triangulation, respondent validation, the use of theoretical sampling, transparency throughout the research process
Ethical issues	Anonymise appropriately as cases are often easily identifiable to insiders, informed consent of participants
Integration with theoretical framework	Allow for unexpected issues to emerge and do not force fit, test out preliminary explanations, be clear about epistemological positions in advance

Stake's checklist for assessing the quality of a case study report[ 8 ]

1. Is this report easy to read?

2. Does it fit together, each sentence contributing to the whole?

3. Does this report have a conceptual structure (i.e. themes or issues)?

4. Are its issues developed in a series and scholarly way?

5. Is the case adequately defined?

6. Is there a sense of story to the presentation?

7. Is the reader provided some vicarious experience?

8. Have quotations been used effectively?

9. Are headings, figures, artefacts, appendices, indexes effectively used?

10. Was it edited well, then again with a last minute polish?

11. Has the writer made sound assertions, neither over- or under-interpreting?

12. Has adequate attention been paid to various contexts?

13. Were sufficient raw data presented?

14. Were data sources well chosen and in sufficient number?

15. Do observations and interpretations appear to have been triangulated?

16. Is the role and point of view of the researcher nicely apparent?

17. Is the nature of the intended audience apparent?

18. Is empathy shown for all sides?

19. Are personal intentions examined?

20. Does it appear individuals were put at risk?

Conclusions

The case study approach allows, amongst other things, critical events, interventions, policy developments and programme-based service reforms to be studied in detail in a real-life context. It should therefore be considered when an experimental design is either inappropriate to answer the research questions posed or impossible to undertake. Considering the frequency with which implementations of innovations are now taking place in healthcare settings and how well the case study approach lends itself to in-depth, complex health service research, we believe this approach should be more widely considered by researchers. Though inherently challenging, the research case study can, if carefully conceptualised and thoughtfully undertaken and reported, yield powerful insights into many important aspects of health and healthcare delivery.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

AS conceived this article. SC, KC and AR wrote this paper with GH, AA and AS all commenting on various drafts. SC and AS are guarantors.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2288/11/100/prepub

Acknowledgements

We are grateful to the participants and colleagues who contributed to the individual case studies that we have drawn on. This work received no direct funding, but it has been informed by projects funded by Asthma UK, the NHS Service Delivery Organisation, NHS Connecting for Health Evaluation Programme, and Patient Safety Research Portfolio. We would also like to thank the expert reviewers for their insightful and constructive feedback. Our thanks are also due to Dr. Allison Worth who commented on an earlier draft of this manuscript.

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Case of Silvia: A Schema-Focused Approach

Published: June 2001
Volume 11 , pages 217–229, ( 2001 )

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John J. Cecero 1 &
Jeffrey E. Young 2

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This case study systematically addresses the components and sequence of a Schema-Focused cognitive therapy approach to the assessment, formulation, and treatment of Silvia's anxious and depressive symptoms and enduring life problems. Following a description of the major tools and procedures involved in collecting the evidence that is required to generate a Schema-Focused case conceptualization, a comprehensive formulation of this case is presented as a guide for treatment intervention. A Schema-Focused Therapy approach is then applied to this case, highlighting the four essential strategies—cognitive, experiential, behavioral, and the therapy relationship—used to change Silvia's maladaptive schemas. Adjunctive interventions and potential problems with this therapy approach are also proposed for consideration.

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A case study comparing both stochastic and worst-case robust control co-design under different control structures

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As uncertainty considerations become increasingly important aspects of concurrent plant and control optimization, it is imperative to identify and compare the impact of uncertain control co-design (UCCD) formulations on their associated solutions. While previous work developed the theory for various UCCD formulations, their implementation, along with an in-depth discussion of the structure of UCCD problems, implicit assumptions, method-dependent considerations, and practical insights, is currently missing from the literature. Therefore, in this study, we address some of these limitations by focusing on UCCD formulations, with an emphasis on optimal control structures, and uncertainty propagation techniques. Specifically, we propose three optimal control structures for UCCD problems: (i) open-loop multiple-control (OLMC), (ii) multi-stage control (MSC), and (iii) open-loop single-control (OLSC). Stochastic in expectation UCCD (SE-UCCD) and worst-case robust UCCD (WCR-UCCD) formulations, which are motivated by probabilistic and crisp representations of uncertainties, respectively, are implemented for a simplified strain-actuated solar array case study. Solutions to the OLMC SE-UCCD problem are obtained using two uncertainty propagation techniques: generalized Polynomial Chaos expansion (gPC) and Monte Carlo simulation (MCS). The OLMC and MSC WCR-UCCD problems are solved by leveraging the structure of the linear program, leading to polytopic uncertainties. To highlight the importance of uncertainty in early-stage design, the closed-loop reference-tracking response of the systems is also investigated. Insights from such studies underscore the role of the control structure in managing the trade-offs between risk and performance, as well as meeting problem requirements. The results also emphasize the benefits of efficient uncertainty propagation techniques for dynamic optimization problems.

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Human risk assessments are a precondition for virtually all industrial action or environmental regulation, all the more essential in a world where chemical and environmental hazards are becoming more abundant. These documents catalog potential environmental, toxicological, ecological, or other harms resulting from a particular hazard, from chemical spills to construction projects to dangerous workplaces. They turn on a number of variables, of which the most significant is the degree of human exposure to the hazardous agent or process.

Human and Ecological Risk Assessment combines the virtues of a textbook and reference work to introduce and analyze these vital documents. Beginning with the foundational theory of human health risk assessment, it then supplies case studies and detailed analysis illustrating the practice of producing risk assessment documents. Fully updated and authored by leading authorities in the field, the result is an indispensable work.

Readers of the second edition of Human and Ecological Risk Assessment will also find:

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This case study systematically addresses the components and sequence of a Schema-Focused cognitive therapy approach to the assessment, formulation, and treatment of Silvia's anxious and depressive symptoms and enduring life problems. Following a description of the major tools and procedures involved in collecting the evidence that is required to generate a Schema-Focused case conceptualization ...
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The cognitive level of analysis

The sociocultural level of analysis

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