Chairwork in schema therapy for patients with borderline personality disorder-A qualitative study of patients' perceptions

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 . This is an open-access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion License (CC BY). The use, dis ibu ion o ep oduc ion in o he o ums is pe mi ed, p o ided he o iginal au ho (s) and he copy igh owne (s) a e c edi ed and ha he o iginal publica ion in his jou nal is ci ed, in acco dance wi h accep ed academic p ac ice. No use, dis ibu ion o ep oduc ion is pe mi ed which does no comply wi h hese 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. F on ie s in Psychia y 02 on ie sin.o g 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 F on ie s in Psychia y 03 on ie sin.o g 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) F on ie s in Psychia y 04 on ie sin.o g Josek e al. 10.3389/ psy .2023.1180839 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 F on ie s in Psychia y 05 on ie sin.o g Josek e al. 10.3389/ psy .2023.1180839 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 F on ie s in Psychia y 06 on ie sin.o g Josek e al. 10.3389/ psy .2023.1180839 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). F on ie s in Psychia y 07 on ie sin.o g Josek e al. 10.3389/ psy .2023.1180839 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: F on ie s in Psychia y 08 on ie sin.o g Josek e al. 10.3389/ psy .2023.1180839 “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). F on ie s in Psychia y 09 on ie sin.o g Josek e al. 10.3389/ psy .2023.1180839 34. Bell T, Mon ague J, Elande J, Gilbe P. Mul iple emo ions, mul iple sel es: compassion ocused he apy chai wo k. Cogn Beha The . (2021) 14:180. doi: 10.1017/S1754470X210 00180 35. Chua N, Se pell L, Bu ne -S ua S, Pugh M. In e iewing ano exia: How do indi iduals gi en a diagnosis o ano exia ne osa expe ience Voice Dialogue wi h hei ea ing diso de oice? A quali a i e analysis. Clin Psychol Psycho he . (2022) 29:600–10. doi: 10.1002/cpp. 2652 36. Bell T, Mon ague J, Elande J, Gilbe P. Suddenly you a e king solomon”: mul iplici y, ans o ma ion and in eg a ion in compassion ocused he apy chai wo k. J Psycho he In eg . (2021) 31:223–37. doi: 10.1037/in 0000240 37. Siegel D. The De eloping Mind. New Yo k, NY: The Guil o d (1999). F on ie s in Psychia y 16 on ie sin.o g