Schema therapy and parenting with mental illness

1. Introduction

1.1 Background

In Australia, approximately one in 5 families have at least one parent who has (or has had) a mental illness (Maybery et al., 2009). Although many of these parents adaptively cope in their parenting role (Falkov et al., 2012), for others, mental illness may adversely impact parenting, leading to negative outcomes for children, especially if there is limited appropriate support for the family (Reupert et al., 2015). Parents may find it difficult to balance the demands of parenting while simultaneously looking after their own mental health and recovery needs (Carpenter-Song et al., 2014; Tabak et al., 2016). Fluctuations of severe mental illness can periodically reduce parenting capability (Venkataraman & Ackerson, 2008), making it difficult to consistently attend to the physical and emotional needs of children (Marston et al., 2016; Tabak et al., 2016). Parents report experiencing self-blame and shame, and some may be fearful of the involvement of child protective services (Halsa, 2018). Accordingly, many parents are reluctant to seek help for parenting issues (Halsa, 2018) and may conceal challenges.

Without adequate support, children of parents with a mental illness have an increased risk of developing their own psychological difficulties (Leijdesdorff et al., 2017). To illustrate, children of parents with a Severe Mental Illness (SMI, mostly defined as schizophrenia, major depressive disorder, bipolar disorder or severe borderline personality disorder) have a 50% chance of developing any mental illness (Rasic et al., 2014). Additionally, children of parents with an SMI have a 32% chance of developing an SMI themselves (Rasic et al., 2014). Both environmental and genetic factors play a role in this heightened risk (Reupert & Maybery, 2016; Yung, 2007).

There are limited therapeutic treatments that target both parenting and mental illness simultaneously (Phelan et al., 2012; Zimmer-Gembeck et al., 2021). Nonetheless, parents with a mental illness want their parenting role recognised and supported (Jones et al., 2016). Providing psychological treatment for parents that incorporates support for their parenting roles and responsibilities plays a preventative role for children (Reiss, 2008; Solantaus et al., 2010). Research into the Let’s Talk about Children program, a family-focused intervention that promotes parent, family and child wellbeing (Solantaus & Toikka, 2006), highlights how working with parents can decrease negative outcomes and increase protective factors in children (Allchin & Solantaus, 2022). Therefore, as transgenerational mental illness may be prevented through supporting clients’ parenting roles (Allchin & Solantaus, 2022; Reiss, 2008; Solantaus et al., 2010), there is arguably a need for additional therapeutic interventions that address clients’ parenting skills as well as provide them with mental health support.

Schema therapy is one therapeutic approach that may be beneficial for attending to parental mental illness. It is a developmentally oriented therapy that emphasises the importance of meeting core emotional needs during childhood (Young et al., 2003). Within this therapy, psychological problems are conceptualised as maladaptive responses to not having emotional needs met in childhood that continue into adulthood (Farrell et al., 2014). The aim is to teach people how to identify their underlying emotional needs and care for themselves when these needs are not being met, as an attuned or ‘good’ parent would. Thus, schema therapy develops skills that are necessary for being an engaged and responsive parent figure for oneself. These self-parenting skills are promoted in the context of self-growth and not the context of direct parenting of children (Young et al., 2003). Research is needed to examine whether this therapeutic approach may also assist parents with a mental illness to meet the emotional needs of their children.

Early maladaptive schemas (EMSs) can be defined as the beliefs we hold about ourselves, others and the world that result from interactions of unmet core childhood needs, early environment and innate temperament (Farrell et al., 2014; Young et al., 2003). EMSs help children make sense of their early life experiences; however, when EMSs are carried into adulthood, they can become problematic, inaccurate and limiting. When EMSs are activated, intense emotional, cognitive and behavioural states, which are referred to as modes, can be triggered (Farrell et al., 2014; Young et al., 2003). Schema therapists may use drawings to depict a client’s modes associated with a current problem or situation in session, in a technique called mode mapping (Simeone-DiFrancesco, 2015).

The 4 basic categories of schema modes are:

• innate child modes

• dysfunctional critic modes

• maladaptive coping modes

• healthy modes (Farrell et al., 2014).

Innate child modes are characterised by intense negative emotions and urges that were felt in childhood or early adolescence and are activated by schemas (Young et al., 2003). Dysfunctional critic modes encompass a negative internalised parental ‘voice’ and reflect aspects of inattentive or critical attachment figures (e.g. parents, teachers, etc.) during childhood and adolescence (Young et al., 2003). Maladaptive coping modes refer to parts of the self that overuse unhealthy coping styles to dampen the felt distress of innate child modes (Young et al., 2003). Healthy modes can help regulate and counter the effects of other modes (Young et al., 2003) and are broken down into the healthy adult mode and happy child mode. The healthy adult mode is characterised by functional thoughts and behaviours and is the part of the self that is capable, strong and well-functioning in adult life (Young et al., 2003).

The researchers of this study were curious about whether strengthening the healthy adult mode would have a positive influence on parenting.

Schema therapy is driven by an overarching principle of limited reparenting (Young et al., 2010). Limited reparenting involves the therapist taking on a ‘parental role’ with the client, to help meet unmet core needs (Farrell et al., 2014). In providing limiting reparenting, the therapist starts by providing co-regulation support to the client, while demonstrating the healthy adult mode, until the client has developed their own healthy adult enough to take on this role for themselves (Young et al., 2003).

Studies have investigated the benefits of schema therapy with diagnostic groups such as personality disorders, obsessive-compulsive disorder, chronic depression and anxiety and post-traumatic stress disorder (Khasho et al., 2019; Legra & Verhey, 2017; Videler et al., 2018). However, there is a paucity of research related to the use of schema therapy across other demographic groups such as cross-cultural groups, populations with diverse genders and sexualities and parents with a mental illness. Given the focus that schema therapy has on developing self-parenting skills and addressing unmet childhood core emotional needs, it is valuable to examine its use with parents who have a mental illness.

1.2 Research objectives

Given the current lack of evidence in this area, this study was exploratory and sought to examine the views and experiences of practitioners who practise schema therapy with parents. Specifically, the study aimed to explore schema therapists’ views regarding how schema therapy did and did not meet the needs of parents, as well as any adaptations they had made to the therapy when working with parents (if at all).

2.Methods

Ethics approval was first obtained from [redacted for peer review] Human Ethics Committee (Project Number: 34615).

2.1 Participants

Participants (n = 13) were all schema therapists practising in Australia (advanced certification = 4, currently undergoing standard certification = 7, not certified = 2). Participants were recruited via emails sent to Australian members of the International Society of Schema Therapy and a post made on the Schema Therapy Institute Australia Facebook page. To be included in the study, therapists had to be practising schema therapy with clients who were parents. One participant did not specify their age. The mean age of the other 12 participants was 43.75 (SD = 9.69, range = 32). The mean years of experience practising schema therapy was 4.69 years (SD = 3.01, range = 9 years). With the exception of one occupational therapist, the participants were all psychologists. They were located in urban/suburban areas of ACT, Victoria and Queensland.

Table I

Participants’ self-reported demographic information

2.2 Procedure

The recruitment email and Facebook post directed potential participants to an online survey where they were provided with information about the study, indicated their consent and provided their demographic and contact details. Sixteen responses were received. Respondents were then contacted by email to arrange an interview time; however, 3 respondents did not reply.

Semi-structured interviews were conducted via the Zoom video conferencing platform. Interview lengths ranged from 19 minutes to 53 minutes, averaging 32 minutes. With permission from participants, all interviews were recorded and subsequently transcribed using Otter transcribing software. The accuracy of the transcriptions was checked, and personal information was removed from participants’ transcripts. These were then emailed to the participants, who were given the opportunity to add or remove incorrect or potentially identifiable information. No participants requested changes to their transcripts.

2.3 Interview

The semi-structured interview schedule was created by the researchers specifically for this study. It consisted of 5 open-ended questions designed to examine schema therapists’ experiences when working with parents. Open-ended questions were followed up with additional probing questions, as needed, to obtain more detail. For example, participants were asked: ‘What have your experiences been like of using schema therapy with parents with a mental illness?’ and ‘Do you think that the schema therapy model is relevant to the experiences of clients who are parents? Why/Why not?’ The interview schedule, which can be found in Appendix A, was reviewed by 2 practising schema therapists, who approved it without suggesting any changes.

2.4 Analysis

Interview data were analysed using interpretative phenomenological analysis (IPA). This methodology, which examines participants’ experiences and perspectives of phenomena (Smith et al., 2009), was aligned with the aim of the study, which was to explore schema therapists’ experiences when working with parents with a mental illness. Following IPA guidelines, each transcript was coded by identifying and highlighting key words or short phrases that captured salient information relevant to the research questions (Saldaña, 2015). The codes were revised multiple times and then used to identify key themes relating to the research aim. Double coding of each transcript also occurred, with all transcripts analysed by the first author, in addition to a separate analysis of 4 transcripts undertaken by the second author. The remaining 9 transcripts were double coded by the third author. Differences in coding were discussed and managed by further reviewing the transcripts. Throughout the study, the first 3 authors also engaged in reflective conversations about possible interpretations of the interview data and themes.

2.5 Reflexivity statement

The first author has lived experience of growing up with a parent who suffered from mental illness. She has also practised as a provisional psychologist in a Master of Educational and Developmental Psychology degree in Australia. The author drew on these experiences to understand and interpret the interview data. However, in accordance with IPA practices of intersubjective reflexivity (Eatough & Smith, 2008), this author regularly clarified her understanding of participants’ meanings throughout the interviews and engaged in interrogative self-reflection after each interview, taking notes of thoughts and emotions that might have influenced the research process.

The second author is a qualified psychologist, an experienced schema therapist and experienced researcher into mental health clinicians’ experiences and families where parents have mental illness. The third author, also a qualified psychologist, is an academic professor with specialist research experience in families where parents experience mental illness. The fourth author is a social worker and an experienced mental health clinician and academic with clinical and research experience in families with parental mental illness.

3. Results

The analysis resulted in 3 findings being identified: schema therapy can be used to increase understanding of one’s parenting behaviour; there are parallels between meeting parents’ needs and meeting their children’s needs; and there is a need for a systemic focus that encompasses family dynamics. These findings are described below with exemplars from interviews. Participants are tagged using codes from Table I (e.g. P1, P2).

3.1 Schema therapy can be used to increase understanding of one’s parenting behaviour

Participants indicated that schema therapy helped their clients develop understanding in a range of areas relating to their parenting. These included ‘what mode their child [was] in … why they’re clashing with their children’ (P1), how ‘coping styles shaped [their] parenting practices’ (P5) and ‘the core needs’ of their children. P5 observed, ‘Building that historical contextual perspective has really helped people understand how they relate to their own kids.’

Seven participants commented that schema therapy helped clients recognise transgenerational parenting patterns and ‘to relate [these to] their own parenting style’. In particular, schema therapy ‘[brought] to mind [clients’] own experiences of being parented’ and helped them realise that their ‘critical voices’ were often ‘echoes of their parents’, which were then negatively impacting their own parenting (P10). According to P8, schema therapy also ‘help[ed] them see the pattern’ of negative parenting styles and mental illness that extended across previous generations, rather than originating with them. Six participants suggested that a recognition of this history offered ‘the opportunity for [parents] to actually be able to correct intergenerational trauma’ (P13). It provided an opportunity to do ‘the opposite’ (P8), ‘parent differently’ (P3) ‘so that they don’t “monkey see, monkey do” and continue the cycle’ (P12).

While many of the participants did not give clear details about how schema therapy in its standardised form achieved this increased understanding of intergenerational and parenting issues, 3 participants described adaptations they used to emphasise family systems and build intergenerational understanding within their schema therapy practice. P7 worked with clients to identify schemas held by their parents and what it ‘would look like for their children’ if the same schemas were passed on to them. P4 created mode maps with clients that also included modes of their children. P9 regularly referred to the ‘healthy adult mode’ of a client’s partner to emphasise that this mode was ‘her ally’ and that she was not parenting alone, and even included the partner’s healthy adult mode on the client’s mode map.

Participants noted that an increased understanding of the transgenerational nature of schemas and modes was painful for many parents. Three participants commented that many parents felt ‘guilt … or the shame’ (P2) when they ‘realise[d] that [they] [hadn’t] been meeting [their] child’s needs’ (P13) and that their maladaptive modes and schemas were being passed on to them. P2 reflected on sessions where parents had ‘that “aha” moment of “I’m doing this aspect of parenting that didn’t work, that hurt me. And now I’m putting it on my kids”.’ Similarly, P7 described parents ‘feeling a sense of guilt for the way that their modes or schemas ... impact their kids’. Alternatively, P13 suggested that an understanding of intergenerational patterns also ‘gives you clear targets for what to hope to address as a parent’ and can be used to prompt hope for change.

When awareness of these intergenerational and parenting issues was framed as an opportunity for change, parents developed greater ‘empathy for themselves’ (P1) and ‘self-compassion’ (P3). P2 reflected that self-compassionate understanding reduces parents’ stress and high expectations of themselves, so that they are more able to attend to what their child needs and are also more compassionate towards their child (P2). Additionally, schema therapy was seen as an opportunity to ‘change ... what happens for [the clients’] own children’ (P3) as parents recognised transgenerational schemas and modes.

3.2 There are parallels between meeting parents’ needs and meeting their children’s needs

Five participants highlighted how schema therapy can provide a dual focus for parents, on meeting both the needs of their child and their own needs, by accessing their own vulnerable child mode. P2 highlighted this when she said, ‘There is this beautiful parallel process of meeting those unmet needs … growing up your own healthy adult, which then enables that parent to have an embodied experience about how to meet their own child’s needs.’

Participants described techniques to achieve this. P3 prompted clients to reconsider their relationship with their vulnerable child mode by making comparisons to how they respond to their child if they are upset. She described using ‘an example of “if this was a biological child at age 7 … how would we respond to them?”’ This helped address issues when a client ‘[could] see the vulnerability in the biological child, but they [couldn’t] necessarily see it in themselves’. Similarly, P5 asked parents to identify criticisms that they regularly made of themselves and then direct those criticisms to photographs of their children. This helped clients recognise that these criticisms were inappropriate and harmful to their vulnerable child mode.

An adaptation of limited reparenting was discussed by 2 participants, which was referred to as ‘limited re-grandparenting’ (P1). This was when participants assisted parents to develop their healthy adult mode in order to attend to the needs of their vulnerable child mode so that they could be available to meet the emotional needs of their children. Importantly, this method of working with parents had been informed by participants’ previous training and experience in systemic practices, rather than purely from the schema therapy framework.

Six participants echoed the importance of strengthening clients’ healthy adult mode to promote good parenting of themselves and their children. P4 noted that when working with parents, schema therapists want to ‘build up … the healthy adult’, who ‘can take a step back and deal with’ challenging situations with children. Likewise, P10 described how growing one’s healthy adult mode through schema therapy helps parents to ‘learn how to handle [confrontation] better’ with their children. P8 summarised the importance of the healthy adult mode by stating ‘good parenting comes from healthy adult space’, while P9 stated ‘to be an effective parent needs strong, healthy adult modes’.

3.3 There is a need for a systemic focus that encompasses family dynamics

Despite their varying descriptions of how schema therapy was used to meet the specific needs of parents and their children, participants commonly explained how they applied standard schema therapy techniques, without acknowledging parenting-specific considerations. Four participants described that they were ‘not sure’ how to adapt aspects of schema therapy to meet the needs of parents, in addition to P13, who said that they ‘[didn’t] think schema therapy would need to be adapted’. These 4 participants did not distinguish between their clients who were and were not parents. Conversely, the 9 other participants noted that they adapted their practice when working with parents, such as emphasising the role of family members in techniques and drawing on ‘other therapy modalities’ (P2) to add to schema therapy, including cognitive behavioural therapy, emotion-focused coaching and parenting programs.

Participants expressed a need for additional training and resources for using schema therapy with parents. Five participants said that they wanted formalised schema therapy models and protocols for working with parents and additional training, including ‘specific information as to what schemas and modes make parenting difficult’ (P9). Three participants expressed a desire for resources on schema therapy for parents with a mental illness, including ‘books or literature around how schema therapy might interact with parenting’ (P3). P1 described how the lack of parent-specific schema therapy resources meant that they drew on resources for couples, and children and adolescents, when working with parents. Meanwhile, P2 noted that they had drawn on resources from non-schema therapy ‘parenting programs’ to extend their schema therapy with parents.

4. Discussion

The purpose of this study was to explore schema therapists’ experiences in using schema therapy with parents, their views on its impact on parenting, and how they adapted schema therapy when working with parents, if at all. Three key findings were identified:

• Schema therapy can be used to increase an understanding of one’s behaviour relating to parenting and builds self-compassion.

• There are parallels between meeting parents ‘needs and meeting their children’s needs.

• There is a need for a systemic focus that encompasses family dynamics.

All 3 findings speak to the utility for therapists of using schema therapy to raise and explore the topic of parenting when proving mental health treatment to clients who are parents. Recognising clients’ identity as a parent is important for mental health practice and promotes client recovery (Hine et al., 2019).

Parenting demands can be difficult for all parents, let alone those who are balancing these demands and their own mental health needs (Carpenter-Song et al., 2014; Marston et al., 2016; Tabak et al., 2016). Some participants described how schema therapy can provide a dual focus on educating clients about the needs of their internal vulnerable child mode as well as the needs of their real-life child. This dual focus in schema therapy could potentially help parents address their own mental health, while concurrently learning about the needs of their children. Further, some viewed the schema therapy model as a framework to develop self-parenting abilities by strengthening clients’ healthy adult mode which they described as having a flow-on effect to the parenting of their children.

Participants also noted that they were able to use schema therapy to promote client insight into their parenting. Some described using different aspects of the schema therapy model, including modes and experiential techniques, to help clients recognise and discuss behaviours related to parenting. Further, others commented on their use of the schema therapy model to discuss transgenerational parenting patterns. Hence, schema therapy could be used as a therapeutic tool to introduce and facilitate discussions about clients’ roles as parents, parenting behaviours and any potential difficulties therein.

However, some participants did not distinguish between clients who were parents and clients who were not parents. This finding is consistent with research in other adult mental health services (psychiatric services) where the parenting status of clients is not routinely identified (Dean & Macmillan, 2001; Maybery & Reupert, 2009). By failing to identify and conceptualise the parenting role of clients, therapists may subsequently not respond to clients’ parenting and family needs, missing an opportunity to support their clients’ recovery.

Further, there appeared to be a dichotomy between schema therapists who saw a need to adapt the model when working with parents and those who did not do this or were unsure how to. The differing ways schema therapists delivered the model to parents (through delivering it as standard or adapting it in consideration of the parenting role) suggests different levels of comfort with the model, experience working with families or parents, and understanding of parents’ needs. There is a need for further professional development among some schema therapists on how they might apply the schema therapy model as a tool to discuss parenting. Additional training and resources designed for practising schema therapy in relation to parenting, and to being a parent with mental health challenges, might be beneficial.

4.1 Limitations and future directions

The voluntary sampling method used is a limitation of this study as it may have attracted participants with a strong interest in working with clients who are parents. Survey-based methods or additional qualitative studies with large sample sizes are required to generalise and extend on these findings across the schema therapy workforce. Further research might investigate parents’ perspectives and experiences of undergoing schema therapy within the context of their parenting needs and role. The insights gained from parents who undergo schema therapy could be used to inform and develop iterations of the schema therapy model that incorporate family dynamics. Formalised adaptations of the model to encompass a systemic focus and family dynamics could enhance therapists’ practice framework when working with parents.

5. Conclusion

The findings of this study indicate that some schema therapists found the schema therapy model to be a useful tool to introduce and speak to clients’ roles as parents. However, not all schema therapists recognised or addressed clients’ unique parenting roles. Looking forward, professional development that recognises the role of parenting might be developed and provided to schema therapists. This study also highlighted scope for further iterations of the schema therapy model that explicitly encompass parenting and family dynamics.

ADVERTISEMENT