TYPE O iginal Resea ch
PUBLISHED 02 June 2023
DOI 10.3389/ psy .2023.1180839
OPEN ACCESS
EDITED BY
Da id John A hu Edwa ds,
Rhodes Uni e si y, Sou h A ica
REVIEWED BY
Anna Vic o ia Olde shaw,
Can e bu y Ch is Chu ch Uni e si y,
Uni ed Kingdom
Ma hew Pugh,
Cen al and No h Wes London NHS
Founda ion T us , Uni ed Kingdom
*CORRESPONDENCE
Anna Ka ha ina Josek
[email p o ec ed]
†These au ho s sha e fi s au ho ship
‡Deceased
RECEIVED 06 Ma ch 2023
ACCEPTED 12 May 2023
PUBLISHED 02 June 2023
CITATION
Josek AK, Schaich A, B aakmann D, Assmann N,
Jauch-Cha a K, A n z A, Schweige U and
Fassbinde E (2023) Chai wo k in schema
he apy o pa ien s wi h bo de line pe sonali y
diso de —A quali a i e s udy o pa ien s’
pe cep ions. F on . Psychia y 14:1180839.
doi: 10.3389/ psy .2023.1180839
COPYRIGHT
©2023 Josek, Schaich, B aakmann, Assmann,
Jauch-Cha a, A n z, Schweige and Fassbinde .
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e ms.
Chai wo k in schema he apy o
pa ien s wi h bo de line
pe sonali y diso de —A quali a i e
s udy o pa ien s’ pe cep ions
Anna Ka ha ina Josek1,2*†, Anja Schaich1,2†, Diana B aakmann1,
Nele Assmann1, Kamila Jauch-Cha a2, A noud A n z3,
Ul ich Schweige 4‡ and E a Fassbinde 1,2
1Depa men o Psychia y and Psycho he apy, Uni e si y o Lübeck, Lübeck, Ge many, 2Depa men o
Psychia y and Psycho he apy, Ch is ian-Alb ech s Uni e si ä Kiel, Kiel, Ge many, 3Depa men o
Clinical Psychology, Uni e si y o Ams e dam, Ams e dam, Ne he lands, 4Depa men o Psychia y,
Psychosoma ics and Psycho he apy, Uni e si y o Lübeck, Lübeck, Ge many
Objec i e: Chai wo k is one o he co e expe ien ial echniques o Schema
The apy (ST) which is used in he ea men o pa ien s wi h bo de line pe sonali y
diso de (BPD). Howe e , li le is known abou how people wi h BPD expe ience
chai wo k. The aim o his s udy was o explo e he expe iences o pa ien s wi h
BPD wi h chai wo k in ST.
Me hod: Quali a i e da a we e collec ed h ough semi-s uc u ed in e iews wi h
29 pa icipan s wi h a p ima y diagnosis o BPD who expe ienced chai wo k as
pa o hei ST ea men . The in e iew da a we e analyzed using quali a i e
con en analysis.
Findings: Many pa icipan s epo ed ini ial skep icism, and di icul ies wi h
engaging in chai wo k. Specific he apis beha io s as well as some ex e nal
(e.g., es ic ed acili ies, noise) and in e nal ac o s (especially eeling ashamed
o idiculous) we e named as hinde ing ac o s. Pa icipan s desc ibed se e al
he apis beha io s acili a ing chai wo k such as p o iding sa e y, clea guidance
h ough he p ocess as well as flexible applica ion o he echnique acco ding o
hei needs, and su icien ime o deb iefing. Pa icipan s expe ienced emo ional
pain and exhaus ion as sho - e m e ec s o he echnique. All pa icipan s
epo ed posi i e long- e m e ec s including an imp o ed unde s anding o hei
mode model as well as posi i e mode changes (e.g., less Puni i e Pa en and
mo e Heal hy Adul Mode), g ea e sel -accep ance, imp o emen s in coping wi h
emo ions and needs as well as imp o emen s in in e pe sonal ela ionships.
Conclusions: Chai wo k is expe ienced as an emo ionally demanding bu aluable
echnique. Based on he pa icipan s’ s a emen s, he deli e y o chai wo k can be
op imized which can help o imp o e ea men ou come.
KEYWORDS
bo de line pe sonali y diso de , chai wo k, quali a i e esea ch, schema he apy,
pe spec i e, expe ien ial echniques, psycho he apy
1. In oduc ion
Schema The apy (ST) has been ound o be an e ec i e ea men o pa ien s wi h
bo de line pe sonali y diso de (BPD) (1–3) as well as o indi iduals wi h o he pe sonali y
diso de s (PD) (4). Quali a i e s udies also show ha pa ien s wi h BPD and o he PDs alue
ST and i s echniques as well as he bene i s gained h ough ea men (5,6). Howe e ,
F on ie s in Psychia y 01 on ie sin.o g
Josek e al. 10.3389/ psy .2023.1180839
hese s udies we e b oad in scope and asked abou pa ien s’
expe iences wi h ST in gene al. Ye , ST is a complex ea men wi h
mul iple ea men echniques and a ious po en ial mechanisms
ha migh lead o he apeu ic gains. De ailed in o ma ion
abou pa ien s’ expe iences wi h speci ic ST echniques and
hei ela ionship o he change o mode p ocesses is limi ed.
Ne e heless, p e ious quali a i e esea ch sugges ha expe ien ial
echniques a e named by pa ien s as among he mos aluable
echniques (6).
The e o e, we decided o use mo e speci ic ques ioning and
conduc ed a esea ch se ies ocusing on expe ien ial echniques
which a e co e ea u es o ST. Imagina y Resc ip ing (IR) was i s
in es iga ed in he se ies (7) and we ound a ious long- e m e ec s
o IR epo ed by pa icipan s, including a be e unde s anding o
schema modes and an imp o emen ega ding emo ion egula ion,
iden i ying, and dealing wi h schema modes and in e pe sonal
ela ionships. We could iden i y hinde ing and acili a ing ac o s
o he implemen a ion o IR based on which we we e able o de i e
clinical implica ions o he apis s o op imizing IR. The ollowing
a icle ocusses on pa icipan s’ expe iences wi h chai wo k, he
o he impo an expe ien ial echnique o ST, which has no ye
been in es iga ed in de ail.
In ST, chai wo k plays an impo an ole in wo king wi h so-
called “schema modes.” Mos o en hese di e en sides o he
pa ien a e placed on di e en chai s and dialogues be ween hem
a e ini ia ed (8). Kellogg and Ga cia To es (9) desc ibe The Fou
Dialogues as a amewo k o be used o ca ego ize chai wo k in a 2
x 2 ma ix including in e nal/ex e nal and one chai /many chai s.
Especially an in e nal o ien a ion is widely used in ST, o example
“in e iewing” one schema mode (one chai ) and mode dialogues
(mul iple chai s).
The ollowing “schema modes” a e cha ac e is ic o BPD: he
Abandoned/Abused Child Mode (associa ed wi h s ong emo ions,
such as sadness, loneliness, and ea s o abandonmen ); he Ang y,
Impulsi e Child Mode ( e lec ed in ang y ou bu s s, hos ili y o
impulsi e beha io s); he Puni i e Pa en Mode (cha ac e ized
by sel -ha ed, shame, sel -de alua ion, and sel -punishmen ); he
De ached P o ec o Mode (associa ed wi h a emp o de ach
om emo ional pain by main aining dis ance om o he people
and a oiding o dis ac ing om emo ions wi h e.g., sel -ha m,
dissocia ion, subs ance abuse, binge ea ing, o social wi hd awal);
and he Heal hy Adul Mode ( ela ed o heal hy unc ioning and
ela ionships), which is o en only ba ely p esen a he beginning
o he apy. In ea men , speci ic asks a e pu sued o e e y mode:
ca e o he Vulne able Child Modes o mee us a ed needs, help
he Ang y Child Modes deal wi h ange , comba he Puni i e Pa en
and eassu e he De ached P o ec o Mode, so ha he pa ien s
can educe hei a oidance s a egies and lea n heal hie s a egies
o managing emo ions and ela ionships. Ul ima ely, he mos
impo an goal is o s eng hen he Heal hy Adul Mode.
Chai wo k is assumed o be one o he co e echniques o
p omo e hese changes on an expe ien ial le el. I can be used
o be e unde s and pa ien s’ p oblems in he ligh o he mode
model and should help pa ien s o expe ience emo ions and needs
in a sa e way. Chai wo k also aims o enable he pa ien o c ea e
new emo ional expe iences and o achie e changes in dys unc ional
schemas and modes. To accomplish his, he he apis o he
Heal hy Adul Mode in e ac s wi h he o he modes o adap
hei s a emen s and hei ac ions o he abo e-named mode-
speci ic goals o ST (e.g., com o ing he Vulne able Child, igh ing
he Puni i e Pa en Mode). This app oach allows he pa ien o
expe ience in a highly emo ional way ha hei needs and eelings
a e impo an and ha he sel -de alua ion ypical o he Puni i e
Pa en Mode can be educed (8). No ably, all quali a i e s udies
in ST ha e shown ha pa ien s expe ience expe ien ial echniques
as emo ionally pain ul and demanding, ye impo an o hei
he apeu ic gains (5–7). De ailed quali a i e insigh s in o pa ien s’
expe iences wi h chai wo k may help o op imize he applica ion
and o enhance pa ien s’ accep ance o his cen al ST echnique as
well as o be e unde s and i s e ec s.
The e o e, his s udy used con en analysis o quali a i e
in e iews wi h BPD pa ien s diagnosed wi h BPD ecei ing
chai wo k in he con ex o ST o explo e he ollowing
esea ch ques ions:
1. Wha a e BPD pa ien s’ expe iences wi h chai wo k in ST?
2. Which ac o s do BPD pa ien s pe cei e as help ul o hinde ing
ega ding chai wo k?
3. Which long- and sho - e m e ec s do he pa ien s expe ience
a e ecei ing chai wo k in ST?
2. Ma e ials and me hods
Fo he desc ip ion o ou esea ch design, app oach o da a
acquisi ion and analysis as well as he p esen a ion o ou indings,
we ollow he epo ing s anda ds o jou nal a icles o quali a i e
esea ch (10).
2.1. Rec ui men and pa icipan s
Da a we e collec ed by in e iewing 29 pa ien s wi h BPD.
Pa ien s we e ec ui ed om he ST condi ion o he PRO∗BPD-
ial, a andomized ial compa ing he e ec i eness o ST and
Dialec ical Beha io The apy (DBT) o ou pa ien s wi h BPD
(11). This s udy was conduc ed a he ou pa ien clinic o
he Depa men o Psychia y and Psycho he apy, Uni e si y o
Lübeck, Ge many. Main inclusion c i e ia o he PRO∗BPD ial
we e a p ima y diagnosis o BPD and age be ween 18 and 65
yea s. Exclusion c i e ia we e li e ime psycho ic diso de , an IQ
unde 85, and acu e se e e subs ance dependence needing clinical
de oxi ica ion ea men . Addi ional in o ma ion on ec ui men
and p ocedu es o he PRO∗BPD s udy can be ound in he s udy
p o ocol (12).
Pa ien s pa icipa ing in PRO∗BPD we e con ac ed o ake pa
in he quali a i e s udy i hey had ecei ed a leas 5 mon hs o ST,
we e willing o pa icipa e in he quali a i e s udy and ga e hei
in o med consen . A he ime o he in e iew 26 pa icipan s had
ecei ed a leas 6 mon hs o he apy, one had al eady comple ed
he apy (ea ly success) and wo had d opped ou .
Table 1 gi es demog aphic and clinical cha ac e is ics o his
s udy’s sample.
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Josek e al. 10.3389/ psy .2023.1180839
TABLE 1 Demog aphic and clinical cha ac e is ics o he sample (N=29).
n%
Gende
Male 6 20.7
Female 23 79.3
Highes educa ion le el
Elemen a y school (4 yea s) 1 3.4
Seconda y school (9 yea s) 2 6.9
Seconda y school (10 yea s) 13 44.8
Seconda y school (12 yea s) 5 17.2
Seconda y school (13 yea s) 4 13.8
P o essional school 1 3.4
Uni e si y deg ee 3 10.3
Employmen s a us
S uden 5 17.2
Hommake 1 3.4
Employed 6 20.7
Unemployed 1 3.4
Incapaci a ed o wo k 16 55.2
Como bid diso de s (DSM-IV)
Axis I
A ec i e diso de s 19 65.5
Subs ance diso de s 7 24.1
Anxie y diso de s 25 86.2
Soma oo o m diso de s 3 10.3
Ea ing diso de s 15 51.7
Axis II
A oidan pe sonali y diso de 11 37.9
Obsessi e compulsi e pe sonali y diso de 13 44.8
Dependen pe sonali y diso de 4 13.8
Pa anoid pe sonali y diso de 4 13.8
Schizo ypal pe sonali y diso de 2 6.9
His ionic pe sonali y diso de 2 6.9
Na cissis ic pe sonali y diso de 3 10.3
2.2. P ocedu e and da a collec ion
A e ecei ing e bal and w i en explana ion o he s udy all
subjec s p o ided w i en in o med consen . The E hics Commi ee
o he Uni e si y o Lübeck app o ed o he esea ch p o ocol
and amendmen s.
We used in-dep h semi-s uc u ed in e iews (“Quali a i e
In e iew o echniques in schema he apy pa 1 (Image y
Resc ip ing) and pa 2 (Chai wo k)“) de eloped by h ee o he
au ho s (EF, AA, US) who ha e ex ensi e expe ience in BPD
esea ch and ea men . The pa o he in e iew ele an o he
TABLE 2 Quali a i e in e iew on componen s o
schema he apy—Chai wo k.
Now, we a e going o ocus on Chai wo k
Wha a e you expe iences wi h Chai wo k?
•Posi i e and nega i e expe iences
•Wha did you ind pa icula ly easy o di icul ?
•Cos s and bene i s o Chai wo k
Wha did you ind help ul o less help ul abou he beha io o you he apis
du ing he pe o mance o he echnique? I no add essed du ing ee speech:
•In oduc ion o he echnique
•Pe o mance o he echnique
•Deb ie ing
•Time managemen
•Emo ional suppo by he he apis
We e he e o he ac o s ha you ound help ul o hinde ing ega ding he
pe o mance o he echnique? Fo example, ex e nal o in e nal ac o s such as
hough s o emo ions?
•Rega ding you modes?
Which e ec s did you no ice a e he pe o mance o he echnique?
•I no add essed du ing ee speech:
•Sho - e m, long- e m?
•Rega ding you in e pe sonal ela ionships?
•Rega ding he way you look a you sel ?
•Emo ional? Cogni i e? Physical? Rega ding you beha io ?
•Rega ding you modes?
Is he e any hing impo an you would like o say o he apis s who wo k wi h
his echnique in he con ex o Schema he apy?
p esen s udy (pa 2 Chai wo k) can be ound in Table 2. The
in e iews began wi h an open ques ion ega ding he pa icipan s’
gene al expe iences wi h chai wo k. Follow up ques ions (compa e
i alics in Table 2) helped he pa icipan s o elabo a e on he
ques ion and o add ess speci ic issues. The in e iews we e
conduc ed by ou g adua e s uden s in psychology who we e no
in ol ed in he ea men deli e y and had no in o ma ion abou
he s udy ou come. Two ques ions we e added la e (compa e
unde lined i ems in Table 2) and assessed by elephone o he
in e iews al eady conduc ed.
The in e iews las ed 36 o 148 min and we e conduc ed ace-
o- ace. The added ques ions we e assessed ia elephone o ele en
o ou pa icipan s. The elephone in e iews las ed be ween 2:34
and 24:04 min. Fo he i e pa icipan s who could no be eached
we used only he exis ing da a.
The in e iews we e audio- eco ded and ansc ibed using
he p o ocol o D esing and Pehl (13), a sys em o ules o he
sys ema ic ansc ip ion o audio o ideo da a.
2.3. Da a analysis
In e iew da a we e analyzed ollowing he p ocedu es o
quali a i e con en analysis (QCA) (14,15) using MAXQDA
so wa e (16). The goal o QCA is o ob ain meaning ul da a ha
sys ema ically desc ibes he ma e ial (e.g., in e iews) in o de o
answe a speci ic esea ch ques ion. I can be used especially when
he meaning o he da a is no ob ious. We chose QCA because
i is o ien ed o he esea ch ques ions, and i is able o p ocess he
amoun s o da a p oduced by quali a i e in e iews and educes he
in o ma ion he in e iews con ain o hei co e. We ook a mixed
app oach consis ing o induc i e elemen s (no o ming a p io i
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Josek e al. 10.3389/ psy .2023.1180839
ca ego ies) and deduc i e elemen s ( amewo k se by he in e iew
ques ions) o c ea e a sys em o ca ego ies and subca ego ies. We
s a ed he p ocess o da a analysis by choosing six in e iews wi h
pa icipan s wi h di e en age and ea men du a ion, and which
we e conduc ed by di e en in e iewe s. These in e iews we e
independen ly analyzed by he i s au ho and a Mas e ’s s uden
in psychology. Reading he in e iews helped o gain amilia i y
wi h he ma e ial, no coding ca ego ies we e de eloped a p io i.
In he nex s eps all passages which we e conside ed ele an
o answe ing he esea ch ques ions we e ma ked in MAXQDA
using di e en colo s. The six in e iews we e p ocessed sepa a ely
o he di e en esea ch ques ions. Fo he anspa ency and
aceabili y o he p ocess, a coding amewo k was de eloped. In
he nex s ep o da a educ ion, he ma ked ex passages we e
pa aph ased and hen gene alized wi h a low abs ac ion le el.
Meaningless pa aph ases we e dele ed, pa aph ases wi h he same
meaning we e combined, and pa aph ases wi h simila meanings
we e exp essed by a new s a emen . In he nex s ep a p elimina y
ca ego y sys em was es ablished, a ibu ing codes o he ele an
ex passages. Uni s o analysis we e de ined as ollows: Code uni :
any con ex ual u e ance o he pa icipan , including non- e bal
u e ances; con ex uni : a passage un il he change o speake ; uni
o analysis: all a ailable in e iews. A he same ime, i was e i ied
ha he ac ual s a emen s o he pa icipan s we e cap u ed, and
he ex passages we e o ele ance o he esea ch ques ion. The
de eloped ca ego ies we e so ed u he , summa ized, o di ided i
necessa y and a anged hie a chically.
The ca ego y sys em was hen p esen ed and discussed in an
expe g oup (including DB, AS, NA and EF) wi h he aim o
con ibu e u he expe ise o he o ma ion o he ca ego ies,
checking hem o plausibili y and ag eeing on he ca ego ies by
discou se. A e adap ing sugges ions o he expe g oup, wo
au ho s (AJ, AS) each coded i e ansc ip s, chosen o ep esen
pa icipan s wi h di e ences in gende , age and symp om se e i y.
Subsequen ly he wo da ase s we e expo ed and me ged on
MAXQDA o calcula e he in e - a e ag eemen , o Cohen’s Kappa
(17), and ound i o be κ=0.84 which indica es a good in e - a e
eliabili y (17).
In he nex s ep he emaining 24 in e iews we e analyzed.
Las ly, in consul a ion wi h he expe g oup, one o he au ho s
(AJ) compiled a inal adap ion o he ca ego y sys em in which
ca ego ies we e summa ized and new ca ego ies we e in eg a ed
i adequa e.
3. Resul s
A con en analysis o pa ien ’s epo ed expe iences esul ed
in i e key domains, showing a ch onological p ocess, beginning
wi h he ini ial engagemen in chai wo k (Domain A), o e he
applica ion, including help ul and hinde ing aspec s (Domain
B), o he deb ie ing o he chai dialogue in he same session
(Domain C) and sho - e m e ec s o chai wo k (Domain D) as
well as long e m e ec s o chai wo k (Domain E). This pape
con ains he phenomenological desc ip ion o he da a based on he
s a emen s o he in e iewed pa icipan s. Fo he sake o cla i y
and eadabili y we decided no he epo all sub(sub) hemes, bu a
comple e o e iew o he ca ego y sys em can be ound in Table 3.
TABLE 3 Ca ego y sys em.
Domains/ hemes/sub hemes/sub hemes N(%)
A. Ini ial engagemen in chai wo k 23 (79%)
A 1. Ini ial engagemen in chai wo k is di icul 19 (66%)
A 1.1. P oblems o ake he echnique se iously a i s 4 (14%)
A 1.2. Fea ha emo ions would come up hinde ing engagemen
in chai wo k a i s
5 (17%)
A 1.3. Di icul ies aking on he pe spec i e o speci ic modes 7 (24%)
A 1.4 I akes ime o unde s and and us he echnique 11 (38%)
A 1.5 Unable o engage in chai wo k o easons ha couldn’ be
speci ied
3 (10%)
A 2. The engagemen in chai wo k was acili a ed by a sho
explana ion o he echnique
13 (45%)
A 2.1. An explana ion ahead o he echnique is help ul 8 (28%)
A 2.2. A sho p epa a ion phase was help ul 6 (21%)
B. Applica ion o chai wo k 29
(100%)
B1 Fac o s ha hinde ed chai wo k 20 (69%)
B1.1. Hinde ing he apis beha io s 10 (35%)
B1.1.1. Too much p essu e o engage in chai wo k
B1.1.2. The apis does no p o ide enough emo ional suppo
du ing chai wo k
3 (10%) 3
(10%)
B1.1.3. Technique is used oo o en o oo seldom o bene i om
i
5 (17%)
B1.2. Hinde ing ex e nal ac o s 5 (17%)
B1.2.1. Noise o In e up ions 3 (10%)
B1.2.2. Res ic ed acili ies 2 (7%)
B1.3. Hinde ing in e nal ac o s 13 (45%)
B1.3.1. Feeling emba assed o ashamed 11 (38%)
B1.3.2. Puni i e Pa en mode hinde ed chai wo k 3 (10%)
B1.3.3. Ha d o accep how he apis ea s Vulne able Child
mode
3 (10%)
B1.3.4. No need o swi ch chai s 3 (10%)
B2. Speci ic he apis beha io s acili a e chai wo k 27 (93%)
B2.1. The apis clea ly guides h ough he p ocess 15 (52%)
B2.1.1. The apis es ic s lood o wo ds 3 (10%)
B2.1.2. The apis s uc u es p ocess 8 (28%)
B2.1.3. The apis s ays pe sis en 4 (14%)
B2.1.4. The apis p o ides assis ance in isualizing he Vulne able
Child mode
5 (17%)
B2.2. The apis is lexible in applying he echnique 8 (28%)
B2.2.1. The apis is lexible in applying he echnique acco ding o
needs and wishes
5 (17%)
B2.2.2. The apis gi es enough ime 2 (7%)
B2.2.3. The apis s esses olun a iness 3 (10%)
B2.3. The apis p o ides sa e y, wa m h, and encou agemen 26 (90%)
B2.3.1. The apis is empa hic and dedica ed 19 (66%)
B2.3.2. The apis sugges s help ul mode messages 14 (48%)
(Con inued)
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TABLE 3 (Con inued)
Domains/ hemes/sub hemes/sub hemes N(%)
B2.3.3. The apis p o ides eelings o sa e y and suppo 11 (38%)
B2.3.4. The apis es ic s Puni i e Pa en mode 4 (14%)
B2.3.5. The apis ea s modes se iously 3 (10%)
B2.3.6. The apis is physically close du ing chai wo k 3 (10%)
C. Pos -p ocessing is impo an 24 (83%)
C 1. The apis akes enough ime o pos -p ocessing 18 (62%)
C 2. Summing up esul s o chai wo k is essen ial 7 (24%)
C 3. Planning an ac i i y a e session helps o educe dis ess 3 (10%)
D. Pa ien s expe ienced a ious sho - e m e ec s 20 (69%)
D 1. Emo ional pain igh a e chai wo k 15 (52%)
D 2. Relie ed igh a e chai wo k 9 (31%)
D 3. Be e sel unde s anding 4 (14%)
E. Pa ien s expe ienced many posi i e long- e m e ec s 29
(100%)
E 1. Emo ional expe iences changed in o a posi i e di ec ion 15 (52%)
E 1.1. Imp o ed awa eness o emo ions 8 (28%)
E 1.2. Emo ions pe cei ed as less o e whelming 11 (38%)
E 1.3. Less guil and shame 2 (7%)
E 2. Dealing di e en ly wi h needs 7 (24%)
E2.1 Mo e awa eness o needs 6 (21%)
E2.2 Be e ul illmen o needs 4 (14%)
E 3. Imp o ed social skills 23 (79%)
E 3.1 Mo e openness in ela ionships, and imp o ed exp ession o
eelings and needs
16 (55%)
E 3.2. I ’s easie o ake o he ’s pe spec i e 10 (35%)
E 3.3. Imp o ed se ing bounda ies 4 (14%)
E 3.4. Less agg essi e in ela ionships 11 (38%)
E 4. Though p ocesses changed 19 (66%)
E 4.1. Less chaos in head, mo e cla i y ega ding hough s
E 4.2. Reduced in luence o dys unc ional hough s
E 4.3. Able o hink be o e ac ing
16 (55%)
•11
(38%)
•4 (14%)
E 5. Wa me owa d onesel 9 (31%)
E 5.1. Mo e sel -compassion 7 (24%)
E 5.2. Be e sel -accep ance 4 (14%)
E 6. Changes in expe iencing he mode model 27 (93%)
E 6.1. Mo e awa eness o modes 17 (59%)
E 6.2. Chai wo k helps o be e unde s and and expe ience he
schema mode model
7 (24%)
E 6.3. Imp o ed pe spec i e aking o he modes 11 (38%)
E 6.4. Mo e o en in Heal hy Adul mode 7 (24%)
E 6.5. Reduced coping modes o coping beha io 11 (38%)
E 6.6. Less o en in he Puni i e Pa en mode 8 (28%)
E 6.7. Di e en beha io owa d he Vulne able Child mode 15 (52%)
(Con inued)
TABLE 3 (Con inued)
Domains/ hemes/sub hemes/sub hemes N(%)
E 7. O he posi i e e ec s 15 (52%)
E 7.1. Be e physical wellbeing 10 (35%)
E 7.2. Mo e elaxed in di icul si ua ions 10 (35%)
E 7.3. Mo e posi i e in gene al 3 (10%)
3.1. Domain A Ini ial engagemen in
chai wo k
Twen y- h ee pa icipan s (79%) epo ed abou hei ini ial
engagemen in chai wo k. They desc ibed bo h di icul ies and
help ul ac o s, as he hemes in his sec ion show:
Theme A.1: Ini ial engagemen in chai wo k is di icul
Sub heme A1.1 p oblems o ake he echnique se iously
a i s .
Sub heme A1.1 P oblems o ake he echnique se iously a
i s : Fou pa icipan s (14%) epo ed ini ial di icul ies in
aking he chai wo k se iously. They ound ha i “sounds
qui e s ange” (P11). “A i s , I hough his is possibly nonsense
and i was di icul o make sense o i ” (P15).
Sub heme A1.2 Fea ha emo ions would come up hinde ing
engagemen in chai wo k a i s : Fi e pa icipan s (17%)
s a ed ha hey we e a aid o emo ions which made hem
hesi a e o ge in o chai wo k:
“Bu a he e y beginning he e was also [...] ea , [...].
And I was so a aid and I wan ed o p o ec mysel om ge ing
in ol ed as we did a chai dialogue” (P8).
Sub heme A1.3 Di icul ies aking on he pe spec i e o speci ic
modes: Se en pa icipan s (24%) desc ibed ha di icul ies wi h
de eloping an awa eness o hei modes and aking o e he
modes’ pe spec i e was a ba ie in he beginning. Di icul ies
included “ge ing in o i [ he mode]” (P12), “ o s ay in he mode
and no swi ch [be ween modes]” (P18) and o consciously “swi ch
[be ween he modes] i you a e old o do i [by he he apis ]” (P4).
Sub heme A1.4 I akes ime o unde s and and us he
echnique: Fu he mo e, ele en pa icipan s (38%) desc ibed ha
hey had ouble belie ing in he echnique and we e impa ien
a i s :
“The ini ial pe iod was e y di icul . I always hough : ‘Why
am I doing his?’ and ‘Why do I need his? No hing changes
anyway’. [...] So, [I was] impa ien , well, i jus akes ime o
de ec any changes a all. I jus doesn’ happen o e nigh ” (P1).
The pa icipan s desc ibed how he he apis helped hem o
o e come he ini ial ba ie :
“Well, in he in oduc ion I didn’ unde s and a all wha he
wan ed om me. Tha was one o he o ma i e e en s. I s ood
in on o i and hough o mysel : ‘Wha is his now?’ So, i
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ook him a li le bi o ime and pa ience o kind o explain and
illus a e he whole hing o me, and ha was kind o he bigges
hu dle in he beginning” (P23).
Theme A.2: The engagemen in chai wo k was acili a ed by
a sho explana ion o he echnique
Thi een pa icipan s (45%) desc ibed ha hey bene i ed om
a b ie in oduc o y explana ion and hen ge ing s a ed wi h
chai wo k quickly:
“I was help ul ha she [ he he apis ] explained e y sho ly
wha I had o expec [in chai wo k] and hen said: ‘Don’ le us
alk abou i a leng h, le ’s y i ”’ (P23).
3.2. Domain B Applica ion o chai wo k
All pa icipan s desc ibed help ul and hinde ing ac o s du ing
he applica ion o chai wo k:
Theme B.1: Fac o s ha hinde ed chai wo k
Sub heme B1.1 Hinde ing he apis beha io s:
Subsub heme B.1.1.1 Too much p essu e o engage in
chai wo k: Th ee pa icipan s (10%) desc ibed ha hey el
p essu ed o con inue wi h chai wo k agains hei will:
“I some imes had he eeling ha when I had eached my
b eaking poin and said, ’No, no mo e,’ my he apis would say,
’We s ill ha e 5 min, we can go on.”’ (P23).
“Less help ul was [ ha ] I had he eeling, ha my he apis
wan ed o go h ough wi h i by hook o by c ook” (P28).
Subsub heme B.1.1.2 The apis does no p o ide enough
emo ional suppo du ing chai wo k: Th ee pa icipan s (10%) el
“ oo li le emo ional suppo ” (P13) du ing chai wo k and wished
hei he apis would ha e been “a bi mo e empa he ic” (P1).
Sub heme B1.2 Hinde ing ex e nal ac o s (e.g., noise,
in e up ions o es ic ed acili ies):
Fi e pa icipan s (17%) epo ed ha hey el dis up ed by
noise o o he in e up ions, like phone calls, cons uc ion noise o
people s epping in o he he apy oom and es ic ed acili ies:
“Noise is always a ac o . [...] I you can’ concen a e
p ope ly, you’ e ou o i e y quickly” (P3).
“A some poin he e we e simply no enough chai s, o i
was all he same chai s” (P9).
Sub heme B1.3 Hinde ing in e nal ac o s:
Subsub heme B.1.3.1 Feeling emba assed o ashamed:
Ele en pa icipan s (38%) epo ed ha a eeling o
emba assmen o shame hinde ed hem du ing chai wo k:
“A he ou se I always hough i was a li le bi
emba assing” (P8).
Se en pa icipan s desc ibed “s ong eelings o shame” (P19)
and se en pa icipan s desc ibed expe iencing de alua ing
hough s abou chai wo k e.g.,:
“I [chai wo k] is e y silly” (P20).
“I don’ wan o alk o chai s. I don’ wan my he apis o
alk o chai s. I simply jus can’ ake i se iously” (P13).
In e es ingly, wo pa icipan s desc ibed bo h.
Subsub heme B.1.3.2 Puni i e Pa en Mode hinde ed
chai wo k: Th ee pa icipan s (10%) explici ly desc ibed ha
he ac i a ion o he Puni i e Pa en Mode hinde ed hem
du ing chai wo k: “Mainly he Puni i e Pa en Mode kep
in e e ing again and again. And hen I couldn’ qui e pu mysel
in he o he s’ [modes] shoes” (P11).
Subsub heme B.1.3.3 Ha d o accep how he apis ea s
Vulne able Child Mode: Th ee pa icipan s (10%) desc ibed ha
he so way he he apis ea ed he Vulne able Child Mode was
di icul o accep o hem:
“Now don’ be sad, li le [pa icipan s gi en name], o
some hing. And ha is o cou se some hing ha can be bo h good
i you ge in ol ed in i , bu which can also seem a bi silly [...] I
s ill can’ qui e accep i , I ha e o say” (P29).
Theme B.2: Speci ic he apis beha io s acili a e chai wo k
Sub heme B2.1 The apis clea ly guides h ough he p ocess:
Subsub heme B.2.1.1 The apis es ic s lood o wo ds:
Th ee pa icipan s (10%) said ha i was help ul o hem ha
he he apis s es ic ed hei speech on some occasions:
“Ac ually, hey always did ha qui e well... wi h my o en
o wo ds. They ha e limi ed i well” (P25).
“Ac ually, hey always did ha qui e well... wi h my o en
o wo ds. They ha e limi ed i well” (P25).
And u he s a ed ha hey go be e a accep ing
being s opped:
“Since [I’ e] lea ned why hey [ he he apis s] say ha . I
always emembe ha when he eelings o hu come and i ’s
help ul o accep ha ” (P25).
Subsub heme B.2.1.2 The apis s uc u es p ocess: Eigh
pa icipan s (28%) desc ibed i as help ul ha he he apis
clea ly s uc u ed he p ocess o chai wo k:
“Well, ha hey [ he he apis s] a e p ac ically like ha . Yes
always di ec ing [ he p ocess was help ul]” (P3).
“And o me i was good [...] ha she asked me many
ques ions and hen somehow helped me ge o he poin ” (P19).
“We always had limi ed ime in he sessions, and i was
always he case ha my he apis was e y good, made su e ha
he whole hing [ he chai wo k] was gi en a easonable ime
ame” (P23).
Subsub heme B.2.1.3 The apis s ays pe sis en : Fou
pa icipan s (14%) s a ed ha i helped hem o engage in
chai wo k when hei he apis insis ed o use chai wo k:
“I hink his insis ence was help ul” (P10).
Subsub heme B.2.1.4 The apis p o ides assis ance in isualizing
he Vulne able Child Mode: Fi e pa icipan s (17%) s a ed ha hei
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he apis helped hem o isualize hei Vulne able Child Mode by
using plushies o childhood pic u es o example:
“My he apis always had a li le lion si ing on a chai . Tha
is de ini ely help ul in any case, so ha you know, aha, he e’s
li le [pa icipan ’s gi en name]” (P23).
Sub heme B2.2 The apis is lexible in applying he echnique
acco ding o needs and wishes:
Eigh pa icipan s (28%) epo ed ha he
he apis ’s lexible handling o chai wo k was
help ul o hem, o example using cu en
si ua ions o chai wo k ins ead o ollowing a
p e ab ica ed plan:
“Yes, i was o en he case ha my he apis didn’ say we’ e
going o do his somehow s ubbo nly bu did i acco ding o he
si ua ion. When I came wi h a cu en si ua ion, he would b ing
in a chai ” (P26), o scheduling enough ime o he conduc
o chai wo k:
“[The he apis ] ga e me ime, so I didn’ eel s essed
ou , bu had always enough ime, o ge in o he oles
emo ionally” (P15).
Sub heme B2.3 The apis p o ides sa e y, wa m h,
and encou agemen :
Subsub heme B.2.3.1 The apis is empa he ic and dedica ed:
Nine een pa icipan s (66%) highligh ed he empa he ic and
commi ed a i ude o hei he apis s o be help ul o hem:
“[The he apis ] had a g ea unde s anding and was hen
able o help me o engage wi h i (chai wo k) be e ” (P15).
“They we e bene olen owa d us. Sympa he ic. Yes, e y
empa he ic” (P2).
Some exp essed elie ha hei he apis s did no expec hem
o “do i [chai wo k] pe ec ly igh away” (P29).
Subsub heme B.2.3.2. The apis sugges s help ul mode messages:
Fou een pa icipan s (48%) said ha i helped hem wi h
chai wo k when hei he apis s’ sugges ed messages o he
di e en modes when hey we e s uck. Pa icipan s s a ed ha he
he apis s “helped ou ” when hey “didn’ know wha o say in he
Heal hy Adul chai “ (P12):
“So, when I didn’ know wha o say o ei he he Demanding
Pa en Mode o he Child Mode, she so o jumped in and made
sugges ions abou wha I could say” (P23).
Subsub heme B.2.3.3 The apis p o ides eelings o sa e y and
suppo : Ele en pa icipan s (38%) s a ed ha hei he apis s
suppo ed hem and made hem eel sa e du ing chai wo k e.g., by
gi ing encou agemen and p aise:
“Well, o con ey a sense o sa e y, so you a e eally able o
engage [in chai wo k] wi hou wo ies“ (P22).
“Maybe o ge some p aise du ing he dialogue: ’Hey, you’ e
done ha well now and you’ e o e come you sel ”’ (P18).
Subsub heme B.2.3.4 The apis es ic s Puni i e Pa en Mode:
Fou pa icipan s (14%) epo ed ha hey ound i help ul ha he
he apis s “pu he b akes” (P23) on he Puni i e Pa en Mode, only
gi ing i “li le space” (P24) and allowing i o be he e “only e y
b ie ly” (P24).
Subsub heme B.2.3.5 The apis ea s modes se iously: Th ee
pa icipan s (10%) desc ibed ha i helped hem ha he apis s
ea ed he modes se iously:
“The absolu e se iousness was help ul. The apis s a e eally
good a i e en ually. Al hough I ac ually hough , ‘wha is she
doing he e’, she alked se iously wi h he chai s and was o ally
au hen ic” (P13).
Subsub heme B.2.3.6. The apis is physically close du ing
chai wo k: Th ee pa icipan s (10%) s a ed ha i helped hem
du ing chai wo k ha he he apis s ayed physically close o hem,
kneeling, o si ing close o hei chai in gene al, especially when
wo king wi h he Vulne able Child Mode:
“She was always c ouched a my side du ing he chai
dialogues” (P23).
“And ha he he apis , was always by my side. [...] so you
didn’ eel alone, because when you’ e a li le child you’ e also
a aid, and she always ga e you. .. always s ood by you” (P29).
3.3. Domain C Pos -p ocessing is impo an
Twen y- ou pa icipan s (83%) epo ed ha pos -p ocessing
was impo an o hem, as shown in he ollowing hemes:
Theme C.1: The apis akes enough ime o pos -p ocessing
Eigh een (62%) pa icipan s epo ed ha s uc u ing he
session in such a way ha enough ime o pos -p ocessing emains
a i s end, was an impo an and help ul aspec :
“Well, o me i was always impo an , ha we alked abou
he chai wo k a e wa ds” (P22).
Theme C.2: Summing up esul s o chai wo k is essen ial
To sum up and analyze he indings and implica ions o he
chai wo k was desc ibed as impo an by almos one qua e o he
pa icipan s (24%):
“Du ing he pos -p ocessing [...] she summed up he esul s,
wha jus occu ed [...] Tha was good o me” (P23).
Theme C.3: Planning an ac i i y a e he session helps o
educe dis ess
Th ee pa icipan s (10%) s a ed ha planning some hing
pleasan a e he session was a help ul ac o o hem:
“My he apis has always made su e a e a di icul session
ha we discussed oge he wha I can do a e he he apy. Well,
ha I don’ lie unde he blanke a home, bu o unde ake
some hing, isi ing iends, d inking co ee [...]” (P29).
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3.4. Domain D Pa ien s expe ienced a ious
sho - e m e ec s
Twen y pa icipan s (69%) expe ienced sho - e m e ec s
di ec ly a e chai wo k, as desc ibed in he ollowing hemes:
Theme D.1: Emo ional pain igh a e chai wo k
Fi een pa icipan s (52%) s essed ha chai wo k “in
he sho e m” (P18) le hem eeling “agi a ed” (P18) and
“ex emely dis essed” (P21).
“A e wa ds you a e e y emo ional and agi a ed and you
ind i di icul a e his [chai ] dialogue o le i sink in a bi and
o ake his in ensi y ou o i ” (P15).
Theme D.2: Relie ed igh a e chai wo k
On he o he side, almos one hi d o he pa icipan s (31%)
desc ibed expe iencing “a bi o elie ” (P23) igh a e he p ocess
and a posi i e “change o emo ions” (P12), e.g.:
“When I was sad be o e, hen mos o he imes I wasn’ so
sad a e wa ds o whiche e eeling [...]” (P12).
Theme D.3: Be e sel unde s anding
Fou pa icipan s (14%) also s a ed ha hey had a clea e iew
o hemsel es di ec ly a e he echnique:
“Fo me, he esul was ha I was able o unde s and mysel
be e ” (P8).
3.5. Domain E Pa ien s expe ienced many
posi i e long- e m e ec s
All pa icipan s epo ed posi i e long- e m e ec s. The
obse ed e ec s we e wide- anging, as can be seen in he hemes
o his domain:
Theme E.1: Emo ional expe iences changed in o a
posi i e di ec ion
Sub heme E1.1 Imp o ed awa eness o emo ions: Eigh
pa icipan s (28%) epo ed an imp o ed abili y o eel and name
hei emo ions:
“Yes, i jus helped me o pe cei e emo ions” (P22).
“Now I know which emo ions I ha e his minu e, i i is
sadness, u y, o any hing else. Yes, i helped me o pe cei e
emo ions” (P29).
Sub heme E1.2 Emo ions pe cei ed as less o e whelming:
Ele en pa icipan s (38%) epo ed eeling less o e whelmed by
hei emo ions in gene al:
“This alone helps a li le bi by he p ocessing [o emo ions],
well i is no so o e whelming” (P23).
O he s epo ed a educ ion o speci ic emo ions:
“I am a li le mo e balanced. No so ang y anymo e” (P10).
Sub heme E1.3 Less guil and shame: Two pa icipan s (7%)
a ibu ed expe iencing less “ eelings o guil ” (P25) and “shame”
(P25) o a long- e m e ec o chai wo k:
“I becomes clea o me, ha i is no my aul ” (P23).
Theme E.2: Dealing di e en ly wi h needs
Sub heme E.2.1 Mo e awa eness o needs: Six pa icipan s
(21%) s a ed ha hei awa eness o hei needs has g own due
o chai wo k:
“I unde s ood wha I needed a ha momen . O simply
wha I was missing” (P5).
He e, a be e awa eness o he modes hey we e in and
linking hese modes o he speci ic need o he momen played an
impo an ole o some pa icipan s:
“I ge a clea e pic u e o which pa s eel neglec ed a he
momen , yes, o ha e some need a he momen ha is no
ul illed. O [which modes] a e c ying ou o some hing, and I
ha e a be e idea o wha i is eally abou o me” (P18).
Sub heme E.2.2 Be e ul illmen o needs: Fou pa icipan s
(14%) said ha hei abili y o mee hei needs imp o ed
h ough chai wo k:
“I mysel can also ul il mo e o my own needs” (P26).
Theme E.3: Imp o ed social skills
Sub heme E3.1 Mo e openness in ela ionships,
and imp o ed exp ession o eelings and needs: Mo e
han hal o he pa icipan s (55%) ealized ha hey
could be e open up o o he s, especially ha hey
imp o ed hei abili y o exp ess hei own needs, wishes
and emo ions:
“Yes, I am able o exp ess clea e wha I wan and wha I
eel” (P12).
“And he e a e also si ua ions whe e I can’ cope on my own,
and hen I can also say, oh, swee ie, look, I need you igh now,
o gi e me a hug. I can exp ess mysel and say ha , and I don’
need o be ashamed, because i ’s some hing qui e no mal” (P26).
Sub heme E3.2 I ’s easie o ake o he ’s pe spec i e:
Ten pa icipan s (35%) desc ibed ha hey we e able o ake he
iew o o he people, e.g., pa en s, pa ne s, o iends, mo e easily:
“[The change is] mainly ela ed o my pa en s. [...] some
hings ha I accused hem o . I go a be e unde s anding o
hem h ough he chai wo k” (P22).
They said ha hey we e “ i ually being able o unde s and
o he s’ decisions be e ” (P22).
Sub heme E3.3 Imp o ed se ing o bounda ies:
Fou pa icipan s (14%) epo ed o be able
o se bounda ies in in e pe sonal ela ionships
mo e easily:
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“I ha e lea ned o say no on some occasions. To hink o
mysel and say: ‘No, I’m no going o do ha oday. I wan o
do some hing o mysel .’ And ha has changed a lo ” (P1).
“Tha one no longe allows onesel o be exploi ed” (P26).
Sub heme E3.4 Less agg essi e in ela ionships: Mo eo e ,
almos 40% o he pa icipan s obse ed being less agg essi e in
hei ela ionships, ha hey no longe “des oy ela ionships” (P29)
o “s a igh s” (P29) all he ime:
“When I am in a Coping Mode ha is immedia ely
associa ed wi h a challenge, wi h ha ed, ange and agg ession
and by now I am hinking abou deescala ing he si ua ion, so I
am less agg essi e, less ang y, eeling less ha ed” (P27).
Theme E.4: Though p ocesses changed
Two hi ds o pa icipan s (66%) epo ed changes in he way
hey deal wi h hei hough s. These imp o emen s could be linked
o h ee sub hemes:
Sub heme E4.1 Less chaos in head, mo e cla i y o hough s:
Six een pa icipan s (55%) s a ed expe iencing hei hough
p ocesses we e less chao ic and somehow “clea e ”:
“A li le awakening, [...] a cla i y [ ega ding my hough s] a
eal cla i y, ac ually, ha you suddenly had” (P7).
“And I was also clea e in wha I hink o wha I wan o
say” (P12).
Sub heme E4.2 Reduced in luence o dys unc ional hough s:
Ele en pa icipan s (38%) desc ibed ha hey we e able o
ee alua e hei hough s and do a “ eali y check” (P21):
“So, I don’ lis en o punishing hough s so much anymo e.
I can block ou no -so-sensible hough s be e . And, yeah. They
don’ in luence me as much anymo e” (P4).
Sub heme E4.3 Able o hink be o e ac ing: Fou pa icipan s
(14%) we e able o hink be o e hey ac ed:
“Well, in he long e m i ’s always ha I no longe o e shoo
he ma k like ha , bu ha I eally hink hings h ough ca e ully.
And hen also weigh he si ua ion wi h p os and cons” (P3).
Theme E.5: Wa me owa d onesel
Sub heme E5.1 Mo e sel -compassion: Se en pa icipan s
(24%) desc ibed being mo e sel -compassiona e due o chai wo k:
“[I de eloped a] much mo e lo ing in e ac ion and also, an
unde s anding o mysel ” (P7).
“I’m lea ning o lo e mysel ” (P1).
Sub heme E5.2 Be e sel -accep ance: Fou pa icipan s (14%)
s a ed ha hey we e able o be mo e accep ing owa d hemsel es:
“I jus [gained mo e] sel -accep ance” (P6).
“[I ealized ha ] I’m allowed o make mis akes” (P25).
Theme E.6: Changes in expe iencing he mode model
Almos all pa icipan s (93%) desc ibed expe iencing
changes in hei mode model anging om mo e awa eness
o hei modes and aking o e a mode’s pe spec i e
mo e easily o a deepe unde s anding and expe iencing
o he mode model h ough chai wo k. Fu he mo e, hey
desc ibed being able o spend mo e ime in he Heal hy Adul
Mode and less ime in he Puni i e Pa en and in Coping
Modes, as well as a changed a i ude owa d he Vulne able
Child Mode:
Sub heme E6.1 Mo e awa eness o modes: Se en een
pa icipan s (59%) s a ed ha chai wo k helped hem o sha pen
hei awa eness o he occu ence o di e en modes:
“To make [ he modes] a li le bi mo e isible and also o be
mo e awa e o he modes. I ound ha help ul” (P14).
“Exac ly, ha I ha e lea ned a lo h ough his [chai wo k],
o e lec mysel now. In which mode am I now eally, which I
didn’ know be o e” (P5).
Sub heme E6.2 Chai wo k helps o be e unde s and
and expe ience he schema mode model: Se en
pa icipan s (24%) desc ibed ha chai wo k helped hem
o unde s and and expe ience hei schema mode model
mo e ho oughly:
“[Chai wo k wo ked] be e han in he imagina ion.
Because ha ’s whe e I eally, el he mode changes in chai
he apy. While I was on one chai , I no iced ha I was al eady
changing o he nex one and hen I mo ed on my own” (P5).
“The echnique helped me no only o pe cei e i isually,
bu also o eel i , he mode model. And yes, ha helped me a
lo ” (P22).
Sub heme E6.3 Imp o ed pe spec i e aking o he modes:
Ele en pa icipan s (38%) s a ed ha chai wo k helped hem o
ake o e he pe spec i e o hei modes mo e easily:
“So, he ad an age [o chai wo k] was somehow his change
o pe spec i e” (P17).
“Yes, as I said, ha one has con e sa ions wi h onesel , wi h
one’s own modes, ha you can also see hem as pe sons, no as
enemies” (P25).
Sub heme E6.4 Mo e o en in Heal hy Adul Mode: Se en
pa icipan s (24%) no iced ha hey use hei Heal hy Adul Mode
mo e equen ly:
“And hen [a e he chai wo k I was] e y much in my
Adul , Heal hy Adul ” (P21).
“Yes, I also y o lis en o my Heal hy Adul mo e
o en” (P23).
Sub heme E6.5 Reduced Coping Modes o coping beha io :
Ele en pa icipan s (38%) epo ed expe iencing ewe Coping
Modes, o example hey desc ibed less dissocia ion: “I no longe
dissocia e e y o en” (P24), educed sel -ha m: “The e a e no
mo e [sel -in lic ed] inju ies; his mindse is gone oo” (P11), o
binge ea ing: “The binge ea ing has become less and is also less
ampan ” (P20).
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