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

TYPE Original Research PUBLISHED 02 June 2023 DOI 10.3389/fpsyt.2023.1180839 OPEN ACCESS EDITED BY David John Arthur Edwards, Rhodes University, South Africa REVIEWED BY Anna Victoria Oldershaw, Canterbury Christ Church University, United Kingdom Matthew Pugh, Central and North West London NHS Foundation Trust, United Kingdom *CORRESPONDENCE Anna Katharina Josek [email protected] †These authors share first authorship ‡Deceased RECEIVED 06 March 2023 ACCEPTED 12 May 2023 PUBLISHED 02 June 2023 CITATION Josek AK, Schaich A, Braakmann D, Assmann N, Jauch-Chara K, Arntz A, Schweiger U and Fassbinder E (2023) Chairwork in schema therapy for patients with borderline personality disorder—A qualitative study of patients’ perceptions. Front. Psychiatry 14:1180839. doi: 10.3389/fpsyt.2023.1180839 COPYRIGHT ©2023 Josek, Schaich, Braakmann, Assmann, Jauch-Chara, Arntz, Schweiger and Fassbinder. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Chairwork in schema therapy for patients with borderline personality disorder—A qualitative study of patients’ perceptions Anna Katharina Josek1,2*†, Anja Schaich1,2†, Diana Braakmann1, Nele Assmann1, Kamila Jauch-Chara2, Arnoud Arntz3, Ulrich Schweiger4‡ and Eva Fassbinder1,2 1Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany, 2Department of Psychiatry and Psychotherapy, Christian-Albrechts Universität Kiel, Kiel, Germany, 3Department of Clinical Psychology, University of Amsterdam, Amsterdam, Netherlands, 4Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck, Lübeck, Germany Objective: Chairwork is one of the core experiential techniques of Schema Therapy (ST) which is used in the treatment of patients with borderline personality disorder (BPD). However, little is known about how people with BPD experience chairwork. The aim of this study was to explore the experiences of patients with BPD with chairwork in ST. Method: Qualitative data were collected through semi-structured interviews with 29 participants with a primary diagnosis of BPD who experienced chairwork as part of their ST treatment. The interview data were analyzed using qualitative content analysis. Findings: Many participants reported initial skepticism, and difficulties with engaging in chairwork. Specific therapist behaviors as well as some external (e.g., restricted facilities, noise) and internal factors (especially feeling ashamed or ridiculous) were named as hindering factors. Participants described several therapist behaviors facilitating chairwork such as providing safety, clear guidance through the process as well as flexible application of the technique according to their needs, and sufficient time for debriefing. Participants experienced emotional pain and exhaustion as short-term effects of the technique. All participants reported positive long-term effects including an improved understanding of their mode model as well as positive mode changes (e.g., less Punitive Parent and more Healthy Adult Mode), greater self-acceptance, improvements in coping with emotions and needs as well as improvements in interpersonal relationships. Conclusions: Chairwork is experienced as an emotionally demanding but valuable technique. Based on the participants’ statements, the delivery of chairwork can be optimized which can help to improve treatment outcome. KEYWORDS borderline personality disorder, chairwork, qualitative research, schema therapy, perspective, experiential techniques, psychotherapy 1. Introduction Schema Therapy (ST) has been found to be an effective treatment for patients with borderline personality disorder (BPD) (1–3) as well as for individuals with other personality disorders (PD) (4). Qualitative studies also show that patients with BPD and other PDs value ST and its techniques as well as the benefits gained through treatment (5,6). However, Frontiers in Psychiatry 01 frontiersin.org Josek et al. 10.3389/fpsyt.2023.1180839 these studies were broad in scope and asked about patients’ experiences with ST in general. Yet, ST is a complex treatment with multiple treatment techniques and various potential mechanisms that might lead to therapeutic gains. Detailed information about patients’ experiences with specific ST techniques and their relationship to the change of mode processes is limited. Nevertheless, previous qualitative research suggest that experiential techniques are named by patients as among the most valuable techniques (6). Therefore, we decided to use more specific questioning and conducted a research series focusing on experiential techniques which are core features of ST. Imaginary Rescripting (IR) was first investigated in the series (7) and we found various long-term effects of IR reported by participants, including a better understanding of schema modes and an improvement regarding emotion regulation, identifying, and dealing with schema modes and interpersonal relationships. We could identify hindering and facilitating factors for the implementation of IR based on which we were able to derive clinical implications for therapists for optimizing IR. The following article focusses on participants’ experiences with chairwork, the other important experiential technique of ST, which has not yet been investigated in detail. In ST, chairwork plays an important role in working with socalled “schema modes.” Most often these different sides of the patient are placed on different chairs and dialogues between them are initiated (8). Kellogg and Garcia Torres (9) describe The Four Dialogues as a framework to be used to categorize chairwork in a 2 x 2 matrix including internal/external and one chair/many chairs. Especially an internal orientation is widely used in ST, for example “interviewing” one schema mode (one chair) and mode dialogues (multiple chairs). The following “schema modes” are characteristic of BPD: the Abandoned/Abused Child Mode (associated with strong emotions, such as sadness, loneliness, and fears of abandonment); the Angry, Impulsive Child Mode (reflected in angry outbursts, hostility or impulsive behaviors); the Punitive Parent Mode (characterized by self-hatred, shame, self-devaluation, and self-punishment); the Detached Protector Mode (associated with attempt to detach from emotional pain by maintaining distance from other people and avoiding or distracting from emotions with e.g., self-harm, dissociation, substance abuse, binge eating, or social withdrawal); and the Healthy Adult Mode (related to healthy functioning and relationships), which is often only barely present at the beginning of therapy. In treatment, specific tasks are pursued for every mode: care for the Vulnerable Child Modes to meet frustrated needs, help the Angry Child Modes deal with anger, combat the Punitive Parent and reassure the Detached Protector Mode, so that the patients can reduce their avoidance strategies and learn healthier strategies for managing emotions and relationships. Ultimately, the most important goal is to strengthen the Healthy Adult Mode. Chairwork is assumed to be one of the core techniques to promote these changes on an experiential level. It can be used to better understand patients’ problems in the light of the mode model and should help patients to experience emotions and needs in a safe way. Chairwork also aims to enable the patient to create new emotional experiences and to achieve changes in dysfunctional schemas and modes. To accomplish this, the therapist or the Healthy Adult Mode interacts with the other modes to adapt their statements and their actions to the above-named modespecific goals of ST (e.g., comforting the Vulnerable Child, fighting the Punitive Parent Mode). This approach allows the patient to experience in a highly emotional way that their needs and feelings are important and that the self-devaluation typical for the Punitive Parent Mode can be reduced (8). Notably, all qualitative studies in ST have shown that patients experience experiential techniques as emotionally painful and demanding, yet important for their therapeutic gains (5–7). Detailed qualitative insights into patients’ experiences with chairwork may help to optimize the application and to enhance patients’ acceptance of this central ST technique as well as to better understand its effects. Therefore, this study used content analysis of qualitative interviews with BPD patients diagnosed with BPD receiving chairwork in the context of ST to explore the following research questions: 1. What are BPD patients’ experiences with chairwork in ST? 2. Which factors do BPD patients perceive as helpful or hindering regarding chairwork? 3. Which longand short-term effects do the patients experience after receiving chairwork in ST? 2. Materials and methods For the description of our research design, approach to data acquisition and analysis as well as the presentation of our findings, we follow the reporting standards for journal articles for qualitative research (10). 2.1. Recruitment and participants Data were collected by interviewing 29 patients with BPD. Patients were recruited from the ST condition of the PRO∗BPDtrial, a randomized trial comparing the effectiveness of ST and Dialectical Behavior Therapy (DBT) for outpatients with BPD (11). This study was conducted at the outpatient clinic of the Department of Psychiatry and Psychotherapy, University of Lübeck, Germany. Main inclusion criteria for the PRO∗BPD trial were a primary diagnosis of BPD and age between 18 and 65 years. Exclusion criteria were lifetime psychotic disorder, an IQ under 85, and acute severe substance dependence needing clinical detoxification treatment. Additional information on recruitment and procedures of the PRO∗BPD study can be found in the study protocol (12). Patients participating in PRO∗BPD were contacted to take part in the qualitative study if they had received at least 5 months of ST, were willing to participate in the qualitative study and gave their informed consent. At the time of the interview 26 participants had received at least 6 months of therapy, one had already completed therapy (early success) and two had dropped out. Table 1 gives demographic and clinical characteristics of this study’s sample. Frontiers in Psychiatry 02 frontiersin.org Josek et al. 10.3389/fpsyt.2023.1180839 TABLE 1 Demographic and clinical characteristics of the sample (N=29). n% Gender Male 6 20.7 Female 23 79.3 Highest education level Elementary school (4 years) 1 3.4 Secondary school (9 years) 2 6.9 Secondary school (10 years) 13 44.8 Secondary school (12 years) 5 17.2 Secondary school (13 years) 4 13.8 Professional school 1 3.4 University degree 3 10.3 Employment status Student 5 17.2 Hommaker 1 3.4 Employed 6 20.7 Unemployed 1 3.4 Incapacitated for work 16 55.2 Comorbid disorders (DSM-IV) Axis I Affective disorders 19 65.5 Substance disorders 7 24.1 Anxiety disorders 25 86.2 Somatooform disorders 3 10.3 Eating disorders 15 51.7 Axis II Avoidant personality disorder 11 37.9 Obsessive compulsive personality disorder 13 44.8 Dependent personality disorder 4 13.8 Paranoid personality disorder 4 13.8 Schizotypal personality disorder 2 6.9 Histrionic personality disorder 2 6.9 Narcissistic personality disorder 3 10.3 2.2. Procedure and data collection After receiving verbal and written explanation of the study all subjects provided written informed consent. The Ethics Committee of the University of Lübeck approved of the research protocol and amendments. We used in-depth semi-structured interviews (“Qualitative Interview for techniques in schema therapy part 1 (Imagery Rescripting) and part 2 (Chairwork)“) developed by three of the authors (EF, AA, US) who have extensive experience in BPD research and treatment. The part of the interview relevant for the TABLE 2 Qualitative interview on components of schematherapy—Chairwork. Now, we are going to focus on Chairwork What are your experiences with Chairwork? •Positive and negative experiences •What did you find particularly easy or difficult? •Costs and benefits of Chairwork What did you find helpful or less helpful about the behavior of your therapist during the performance of the technique? If not addressed during free speech: •Introduction of the technique •Performance of the technique •Debriefing •Time management •Emotional support by the therapist Were there other factors that you found helpful or hindering regarding the performance of the technique? For example, external or internal factors such as thoughts or emotions? •Regarding your modes? Which effects did you notice after the performance of the technique? •If not addressed during free speech: •Short-term, long-term? •Regarding your interpersonal relationships? •Regarding the way you look at yourself? •Emotional? Cognitive? Physical? Regarding your behavior? •Regarding your modes? Is there anything important you would like to say to therapists who work with this technique in the context of Schema therapy? present study (part 2 Chairwork) can be found in Table 2. The interviews began with an open question regarding the participants’ general experiences with chairwork. Follow up questions (compare italics in Table 2) helped the participants to elaborate on the question and to address specific issues. The interviews were conducted by four graduate students in psychology who were not involved in the treatment delivery and had no information about the study outcome. Two questions were added later (compare underlined items in Table 2) and assessed by telephone for the interviews already conducted. The interviews lasted 36 to 148 min and were conducted faceto-face. The added questions were assessed via telephone for eleven of our participants. The telephone interviews lasted between 2:34 and 24:04 min. For the five participants who could not be reached we used only the existing data. The interviews were audio-recorded and transcribed using the protocol of Dresing and Pehl (13), a system of rules for the systematic transcription of audio or video data. 2.3. Data analysis Interview data were analyzed following the procedures of qualitative content analysis (QCA) (14,15) using MAXQDA software (16). The goal of QCA is to obtain meaningful data that systematically describes the material (e.g., interviews) in order to answer a specific research question. It can be used especially when the meaning of the data is not obvious. We chose QCA because it is oriented to the research questions, and it is able to process the amounts of data produced by qualitative interviews and reduces the information the interviews contain to their core. We took a mixed approach consisting of inductive elements (not forming a priori Frontiers in Psychiatry 03 frontiersin.org Josek et al. 10.3389/fpsyt.2023.1180839 categories) and deductive elements (framework set by the interview questions) to create a system of categories and subcategories. We started the process of data analysis by choosing six interviews with participants with different age and treatment duration, and which were conducted by different interviewers. These interviews were independently analyzed by the first author and a Master’s student in psychology. Reading the interviews helped to gain familiarity with the material, no coding categories were developed a priori. In the next steps all passages which were considered relevant for answering the research questions were marked in MAXQDA using different colors. The six interviews were processed separately for the different research questions. For the transparency and traceability of the process, a coding framework was developed. In the next step of data reduction, the marked text passages were paraphrased and then generalized with a low abstraction level. Meaningless paraphrases were deleted, paraphrases with the same meaning were combined, and paraphrases with similar meanings were expressed by a new statement. In the next step a preliminary category system was established, attributing codes to the relevant text passages. Units of analysis were defined as follows: Code unit: any contextual utterance of the participant, including non-verbal utterances; context unit: a passage until the change of speaker; unit of analysis: all available interviews. At the same time, it was verified that the actual statements of the participants were captured, and the text passages were of relevance to the research question. The developed categories were sorted further, summarized, or divided if necessary and arranged hierarchically. The category system was then presented and discussed in an expert group (including DB, AS, NA and EF) with the aim to contribute further expertise to the formation of the categories, checking them for plausibility and agreeing on the categories by discourse. After adapting suggestions of the expert group, two authors (AJ, AS) each coded five transcripts, chosen to represent participants with differences in gender, age and symptom severity. Subsequently the two datasets were exported and merged on MAXQDA to calculate the inter-rater agreement, or Cohen’s Kappa (17), and found it to be κ=0.84 which indicates a good inter-rater reliability (17). In the next step the remaining 24 interviews were analyzed. Lastly, in consultation with the expert group, one of the authors (AJ) compiled a final adaption of the category system in which categories were summarized and new categories were integrated if adequate. 3. Results A content analysis of patient’s reported experiences resulted in five key domains, showing a chronological process, beginning with the initial engagement in chairwork (Domain A), over the application, including helpful and hindering aspects (Domain B), to the debriefing of the chair dialogue in the same session (Domain C) and short-term effects of chairwork (Domain D) as well as long term effects of chairwork (Domain E). This paper contains the phenomenological description of the data based on the statements of the interviewed participants. For the sake of clarity and readability we decided not the report all sub(sub)themes, but a complete overview of the category system can be found in Table 3. TABLE 3 Category system. Domains/themes/subthemes/subthemes N(%) A. Initial engagement in chairwork 23 (79%) A 1. Initial engagement in chairwork is difficult 19 (66%) A 1.1. Problems to take the technique seriously at first 4 (14%) A 1.2. Fear that emotions would come up hindering engagement in chairwork at first 5 (17%) A 1.3. Difficulties taking on the perspective of specific modes 7 (24%) A 1.4 It takes time to understand and trust the technique 11 (38%) A 1.5 Unable to engage in chairwork for reasons that couldn’t be specified 3 (10%) A 2. The engagement in chairwork was facilitated by a short explanation of the technique 13 (45%) A 2.1. An explanation ahead of the technique is helpful 8 (28%) A 2.2. A short preparation phase was helpful 6 (21%) B. Application of chairwork 29 (100%) B1 Factors that hindered chairwork 20 (69%) B1.1. Hindering therapist behaviors 10 (35%) B1.1.1. Too much pressure to engage in chairwork B1.1.2. Therapist does not provide enough emotional support during chairwork 3 (10%) 3 (10%) B1.1.3. Technique is used too often or too seldom to benefit from it 5 (17%) B1.2. Hindering external factors 5 (17%) B1.2.1. Noise or Interruptions 3 (10%) B1.2.2. Restricted facilities 2 (7%) B1.3. Hindering internal factors 13 (45%) B1.3.1. Feeling embarrassed or ashamed 11 (38%) B1.3.2. Punitive Parent mode hindered chairwork 3 (10%) B1.3.3. Hard to accept how therapist treats Vulnerable Child mode 3 (10%) B1.3.4. No need to switch chairs 3 (10%) B2. Specific therapist behaviors facilitate chairwork 27 (93%) B2.1. Therapist clearly guides through the process 15 (52%) B2.1.1. Therapist restricts flood of words 3 (10%) B2.1.2. Therapist structures process 8 (28%) B2.1.3. Therapist stays persistent 4 (14%) B2.1.4. Therapist provides assistance in visualizing the Vulnerable Child mode 5 (17%) B2.2. Therapist is flexible in applying the technique 8 (28%) B2.2.1. Therapist is flexible in applying the technique according to needs and wishes 5 (17%) B2.2.2. Therapist gives enough time 2 (7%) B2.2.3. Therapist stresses voluntariness 3 (10%) B2.3. Therapist provides safety, warmth, and encouragement 26 (90%) B2.3.1. Therapist is empathic and dedicated 19 (66%) B2.3.2. Therapist suggests helpful mode messages 14 (48%) (Continued) Frontiers in Psychiatry 04 frontiersin.org Josek et al. 10.3389/fpsyt.2023.1180839 TABLE 3 (Continued) Domains/themes/subthemes/subthemes N(%) B2.3.3. Therapist provides feelings of safety and support 11 (38%) B2.3.4. Therapist restricts Punitive Parent mode 4 (14%) B2.3.5. Therapist treats modes seriously 3 (10%) B2.3.6. Therapist is physically close during chairwork 3 (10%) C. Post-processing is important 24 (83%) C 1. Therapist takes enough time for post-processing 18 (62%) C 2. Summing up results of chairwork is essential 7 (24%) C 3. Planning an activity after session helps to reduce distress 3 (10%) D. Patients experienced various short-term effects 20 (69%) D 1. Emotional pain right after chairwork 15 (52%) D 2. Relieved right after chairwork 9 (31%) D 3. Better self understanding 4 (14%) E. Patients experienced many positive long-term effects 29 (100%) E 1. Emotional experiences changed into a positive direction 15 (52%) E 1.1. Improved awareness of emotions 8 (28%) E 1.2. Emotions perceived as less overwhelming 11 (38%) E 1.3. Less guilt and shame 2 (7%) E 2. Dealing differently with needs 7 (24%) E2.1 More awareness of needs 6 (21%) E2.2 Better fulfillment of needs 4 (14%) E 3. Improved social skills 23 (79%) E 3.1 More openness in relationships, and improved expression of feelings and needs 16 (55%) E 3.2. It’s easier to take other’s perspective 10 (35%) E 3.3. Improved setting boundaries 4 (14%) E 3.4. Less aggressive in relationships 11 (38%) E 4. Thought processes changed 19 (66%) E 4.1. Less chaos in head, more clarity regarding thoughts E 4.2. Reduced influence of dysfunctional thoughts E 4.3. Able to think before acting 16 (55%) •11 (38%) •4 (14%) E 5. Warmer toward oneself 9 (31%) E 5.1. More self-compassion 7 (24%) E 5.2. Better self-acceptance 4 (14%) E 6. Changes in experiencing the mode model 27 (93%) E 6.1. More awareness of modes 17 (59%) E 6.2. Chairwork helps to better understand and experience the schema mode model 7 (24%) E 6.3. Improved perspective taking of the modes 11 (38%) E 6.4. More often in Healthy Adult mode 7 (24%) E 6.5. Reduced coping modes or coping behavior 11 (38%) E 6.6. Less often in the Punitive Parent mode 8 (28%) E 6.7. Different behavior toward the Vulnerable Child mode 15 (52%) (Continued) TABLE 3 (Continued) Domains/themes/subthemes/subthemes N(%) E 7. Other positive effects 15 (52%) E 7.1. Better physical wellbeing 10 (35%) E 7.2. More relaxed in difficult situations 10 (35%) E 7.3. More positive in general 3 (10%) 3.1. Domain A Initial engagement in chairwork Twenty-three participants (79%) reported about their initial engagement in chairwork. They described both difficulties and helpful factors, as the themes in this section show: Theme A.1: Initial engagement in chairwork is difficult Subtheme A1.1 problems to take the technique seriously at first. Subtheme A1.1 Problems to take the technique seriously at first: Four participants (14%) reported initial difficulties in taking the chairwork seriously. They found that it “sounds quite strange” (P11). “At first, I thought this is possibly nonsense and it was difficult to make sense of it” (P15). Subtheme A1.2 Fear that emotions would come up hindering engagement in chairwork at first: Five participants (17%) stated that they were afraid of emotions which made them hesitate to get into chairwork: “But at the very beginning there was also [...] fear, [...]. And I was so afraid and I wanted to protect myself from getting involved as we did a chair dialogue” (P8). Subtheme A1.3 Difficulties taking on the perspective of specific modes: Seven participants (24%) described that difficulties with developing an awareness for their modes and taking over the modes’ perspective was a barrier in the beginning. Difficulties included “getting into it [the mode]” (P12), “to stay in the mode and not switch [between modes]” (P18) and to consciously “switch [between the modes] if you are told to do it [by the therapist]” (P4). Subtheme A1.4 It takes time to understand and trust the technique: Furthermore, eleven participants (38%) described that they had trouble believing in the technique and were impatient at first: “The initial period was very difficult. I always thought: ‘Why am I doing this?’ and ‘Why do I need this? Nothing changes anyway’. [...] So, [I was] impatient, well, it just takes time to detect any changes at all. It just doesn’t happen overnight” (P1). The participants described how the therapist helped them to overcome the initial barrier: “Well, in the introduction I didn’t understand at all what he wanted from me. That was one of the formative events. I stood in front of it and thought to myself: ‘What is this now?’ So, it Frontiers in Psychiatry 05 frontiersin.org Josek et al. 10.3389/fpsyt.2023.1180839 took him a little bit of time and patience to kind of explain and illustrate the whole thing to me, and that was kind of the biggest hurdle in the beginning” (P23). Theme A.2: The engagement in chairwork was facilitated by a short explanation of the technique Thirteen participants (45%) described that they benefited from a brief introductory explanation and then getting started with chairwork quickly: “It was helpful that she [the therapist] explained very shortly what I had to expect [in chairwork] and then said: ‘Don’t let us talk about it at length, let’s try it”’ (P23). 3.2. Domain B Application of chairwork All participants described helpful and hindering factors during the application of chairwork: Theme B.1: Factors that hindered chairwork Subtheme B1.1 Hindering therapist behaviors: Subsubtheme B.1.1.1 Too much pressure to engage in chairwork: Three participants (10%) described that they felt pressured to continue with chairwork against their will: “I sometimes had the feeling that when I had reached my breaking point and said, ’No, no more,’ my therapist would say, ’We still have 5 min, we can go on.”’ (P23). “Less helpful was [that] I had the feeling, that my therapist wanted to go through with it by hook or by crook” (P28). Subsubtheme B.1.1.2 Therapist does not provide enough emotional support during chairwork: Three participants (10%) felt “too little emotional support” (P13) during chairwork and wished their therapist would have been “a bit more empathetic” (P1). Subtheme B1.2 Hindering external factors (e.g., noise, interruptions or restricted facilities): Five participants (17%) reported that they felt disrupted by noise or other interruptions, like phone calls, construction noise or people stepping into the therapy room and restricted facilities: “Noise is always a factor. [...] If you can’t concentrate properly, you’re out of it very quickly” (P3). “At some point there were simply not enough chairs, or it was all the same chairs” (P9). Subtheme B1.3 Hindering internal factors: Subsubtheme B.1.3.1 Feeling embarrassed or ashamed: Eleven participants (38%) reported that a feeling of embarrassment or shame hindered them during chairwork: “At the outset I always thought it was a little bit embarrassing” (P8). Seven participants described “strong feelings of shame” (P19) and seven participants described experiencing devaluating thoughts about chairwork e.g.,: “It [chairwork] is very silly” (P20). “I don’t want to talk to chairs. I don’t want my therapist to talk to chairs. I simply just can’t take it seriously” (P13). Interestingly, two participants described both. Subsubtheme B.1.3.2 Punitive Parent Mode hindered chairwork: Three participants (10%) explicitly described that the activation of the Punitive Parent Mode hindered them during chairwork: “Mainly the Punitive Parent Mode kept interfering again and again. And then I couldn’t quite put myself in the others’ [modes] shoes” (P11). Subsubtheme B.1.3.3 Hard to accept how therapist treats Vulnerable Child Mode: Three participants (10%) described that the soft way the therapist treated the Vulnerable Child Mode was difficult to accept for them: “Now don’t be sad, little [participants given name], or something. And that is of course something that can be both good if you get involved in it, but which can also seem a bit silly [...] I still can’t quite accept it, I have to say” (P29). Theme B.2: Specific therapist behaviors facilitate chairwork Subtheme B2.1 Therapist clearly guides through the process: Subsubtheme B.2.1.1 Therapist restricts flood of words: Three participants (10%) said that it was helpful for them that the therapists restricted their speech on some occasions: “Actually, they always did that quite well... with my torrent of words. They have limited it well” (P25). “Actually, they always did that quite well... with my torrent of words. They have limited it well” (P25). And further stated that they got better at accepting being stopped: “Since [I’ve] learned why they [the therapists] say that. I always remember that when the feelings of hurt come and it’s helpful to accept that” (P25). Subsubtheme B.2.1.2 Therapist structures process: Eight participants (28%) described it as helpful that the therapist clearly structured the process of chairwork: “Well, that they [the therapists] are practically like that. Yes always directing [the process was helpful]” (P3). “And for me it was good [...] that she asked me many questions and then somehow helped me get to the point” (P19). “We always had limited time in the sessions, and it was always the case that my therapist was very good, made sure that the whole thing [the chairwork] was given a reasonable time frame” (P23). Subsubtheme B.2.1.3 Therapist stays persistent: Four participants (14%) stated that it helped them to engage in chairwork when their therapist insisted to use chairwork: “I think his insistence was helpful” (P10). Subsubtheme B.2.1.4 Therapist provides assistance in visualizing the Vulnerable Child Mode: Five participants (17%) stated that their Frontiers in Psychiatry 06 frontiersin.org Josek et al. 10.3389/fpsyt.2023.1180839 therapist helped them to visualize their Vulnerable Child Mode by using plushies or childhood pictures for example: “My therapist always had a little lion sitting on a chair. That is definitely helpful in any case, so that you know, aha, there’s little [participant’s given name]” (P23). Subtheme B2.2 Therapist is flexible in applying the technique according to needs and wishes: Eight participants (28%) reported that the therapist’s flexible handling of chairwork was helpful to them, for example using current situations for chairwork instead of following a prefabricated plan: “Yes, it was often the case that my therapist didn’t say we’re going to do this somehow stubbornly but did it according to the situation. When I came with a current situation, he would bring in a chair” (P26), or scheduling enough time for the conduct of chairwork: “[The therapist] gave me time, so I didn’t feel stressed out, but had always enough time, to get into the roles emotionally” (P15). Subtheme B2.3 Therapist provides safety, warmth, and encouragement: Subsubtheme B.2.3.1 Therapist is empathetic and dedicated: Nineteen participants (66%) highlighted the empathetic and committed attitude of their therapists to be helpful for them: “[The therapist] had a great understanding and was then able to help me to engage with it (chairwork) better” (P15). “They were benevolent toward us. Sympathetic. Yes, very empathetic” (P2). Some expressed relief that their therapists did not expect them to “do it [chairwork] perfectly right away” (P29). Subsubtheme B.2.3.2. Therapist suggests helpful mode messages: Fourteen participants (48%) said that it helped them with chairwork when their therapists’ suggested messages for the different modes when they were stuck. Participants stated that the therapists “helped out” when they “didn’t know what to say in the Healthy Adult chair“ (P12): “So, when I didn’t know what to say to either the Demanding Parent Mode or the Child Mode, she sort of jumped in and made suggestions about what I could say” (P23). Subsubtheme B.2.3.3 Therapist provides feelings of safety and support: Eleven participants (38%) stated that their therapists supported them and made them feel safe during chairwork e.g., by giving encouragement and praise: “Well, to convey a sense of safety, so you are really able to engage [in chairwork] without worries“ (P22). “Maybe to get some praise during the dialogue: ’Hey, you’ve done that well now and you’ve overcome yourself”’ (P18). Subsubtheme B.2.3.4 Therapist restricts Punitive Parent Mode: Four participants (14%) reported that they found it helpful that the therapists “put the brakes” (P23) on the Punitive Parent Mode, only giving it “little space” (P24) and allowing it to be there “only very briefly” (P24). Subsubtheme B.2.3.5 Therapist treats modes seriously: Three participants (10%) described that it helped them that therapists treated the modes seriously: “The absolute seriousness was helpful. Therapists are really good at it eventually. Although I actually thought, ‘what is she doing there’, she talked seriously with the chairs and was totally authentic” (P13). Subsubtheme B.2.3.6. Therapist is physically close during chairwork: Three participants (10%) stated that it helped them during chairwork that the therapist stayed physically close to them, kneeling, or sitting close to their chair in general, especially when working with the Vulnerable Child Mode: “She was always crouched at my side during the chair dialogues” (P23). “And that the therapist, was always by my side. [...] so you didn’t feel alone, because when you’re a little child you’re also afraid, and she always gave you. .. always stood by you” (P29). 3.3. Domain C Post-processing is important Twenty-four participants (83%) reported that post-processing was important to them, as shown in the following themes: Theme C.1: Therapist takes enough time for post-processing Eighteen (62%) participants reported that structuring the session in such a way that enough time for post-processing remains at its end, was an important and helpful aspect: “Well, for me it was always important, that we talked about the chairwork afterwards” (P22). Theme C.2: Summing up results of chairwork is essential To sum up and analyze the findings and implications of the chairwork was described as important by almost one quarter of the participants (24%): “During the post-processing [...] she summed up the results, what just occurred [...] That was good for me” (P23). Theme C.3: Planning an activity after the session helps to reduce distress Three participants (10%) stated that planning something pleasant after the session was a helpful factor for them: “My therapist has always made sure after a difficult session that we discussed together what I can do after the therapy. Well, that I don’t lie under the blanket at home, but to undertake something, visiting friends, drinking coffee [...]” (P29). Frontiers in Psychiatry 07 frontiersin.org Josek et al. 10.3389/fpsyt.2023.1180839 3.4. Domain D Patients experienced various short-term effects Twenty participants (69%) experienced short-term effects directly after chairwork, as described in the following themes: Theme D.1: Emotional pain right after chairwork Fifteen participants (52%) stressed that chairwork “in the short term” (P18) left them feeling “agitated” (P18) and “extremely distressed” (P21). “Afterwards you are very emotional and agitated and you find it difficult after this [chair] dialogue to let it sink in a bit and to take this intensity out of it” (P15). Theme D.2: Relieved right after chairwork On the other side, almost one third of the participants (31%) described experiencing “a bit of relief ” (P23) right after the process and a positive “change of emotions” (P12), e.g.: “When I was sad before, then most of the times I wasn’t so sad afterwards or whichever feeling [...]” (P12). Theme D.3: Better self understanding Four participants (14%) also stated that they had a clearer view of themselves directly after the technique: “For me, the result was that I was able to understand myself better” (P8). 3.5. Domain E Patients experienced many positive long-term effects All participants reported positive long-term effects. The observed effects were wide-ranging, as can be seen in the themes of this domain: Theme E.1: Emotional experiences changed into a positive direction Subtheme E1.1 Improved awareness of emotions: Eight participants (28%) reported an improved ability to feel and name their emotions: “Yes, it just helped me to perceive emotions” (P22). “Now I know which emotions I have this minute, if it is sadness, fury, or anything else. Yes, it helped me to perceive emotions” (P29). Subtheme E1.2 Emotions perceived as less overwhelming: Eleven participants (38%) reported feeling less overwhelmed by their emotions in general: “This alone helps a little bit by the processing [of emotions], well it is not so overwhelming” (P23). Others reported a reduction of specific emotions: “I am a little more balanced. Not so angry anymore” (P10). Subtheme E1.3 Less guilt and shame: Two participants (7%) attributed experiencing less “feelings of guilt” (P25) and “shame” (P25) to a long-term effect of chairwork: “It becomes clear to me, that it is not my fault” (P23). Theme E.2: Dealing differently with needs Subtheme E.2.1 More awareness of needs: Six participants (21%) stated that their awareness for their needs has grown due to chairwork: “I understood what I needed at that moment. Or simply what I was missing” (P5). Here, a better awareness of the modes they were in and linking these modes to the specific need of the moment played an important role for some participants: “I get a clearer picture of which parts feel neglected at the moment, yes, or have some need at the moment that is not fulfilled. Or [which modes] are crying out for something, and I have a better idea of what it is really about for me” (P18). Subtheme E.2.2 Better fulfillment of needs: Four participants (14%) said that their ability to meet their needs improved through chairwork: “I myself can also fulfil more of my own needs” (P26). Theme E.3: Improved social skills Subtheme E3.1 More openness in relationships, and improved expression of feelings and needs: More than half of the participants (55%) realized that they could better open up to others, especially that they improved their ability to express their own needs, wishes and emotions: “Yes, I am able to express clearer what I want and what I feel” (P12). “And there are also situations where I can’t cope on my own, and then I can also say, oh, sweetie, look, I need you right now, or give me a hug. I can express myself and say that, and I don’t need to be ashamed, because it’s something quite normal” (P26). Subtheme E3.2 It’s easier to take other’s perspective: Ten participants (35%) described that they were able to take the view of other people, e.g., parents, partners, or friends, more easily: “[The change is] mainly related to my parents. [...] some things that I accused them of. I got a better understanding for them through the chairwork” (P22). They said that they were “virtually being able to understand others’ decisions better” (P22). Subtheme E3.3 Improved setting of boundaries: Four participants (14%) reported to be able to set boundaries in interpersonal relationships more easily: Frontiers in Psychiatry 08 frontiersin.org Josek et al. 10.3389/fpsyt.2023.1180839 “I have learned to say no on some occasions. To think of myself and say: ‘No, I’m not going to do that today. I want to do something for myself.’ And that has changed a lot” (P1). “That one no longer allows oneself to be exploited” (P26). Subtheme E3.4 Less aggressive in relationships: Moreover, almost 40% of the participants observed being less aggressive in their relationships, that they no longer “destroy relationships” (P29) or “start fights” (P29) all the time: “When I am in a Coping Mode that is immediately associated with a challenge, with hatred, anger and aggression and by now I am thinking about deescalating the situation, so I am less aggressive, less angry, feeling less hatred” (P27). Theme E.4: Thought processes changed Two thirds of participants (66%) reported changes in the way they deal with their thoughts. These improvements could be linked to three subthemes: Subtheme E4.1 Less chaos in head, more clarity of thoughts: Sixteen participants (55%) stated experiencing their thought processes were less chaotic and somehow “clearer”: “A little awakening, [...] a clarity [regarding my thoughts] a real clarity, actually, that you suddenly had” (P7). “And I was also clearer in what I think or what I want to say” (P12). Subtheme E4.2 Reduced influence of dysfunctional thoughts: Eleven participants (38%) described that they were able to reevaluate their thoughts and do a “reality check” (P21): “So, I don’t listen to punishing thoughts so much anymore. I can block out not-so-sensible thoughts better. And, yeah. They don’t influence me as much anymore” (P4). Subtheme E4.3 Able to think before acting: Four participants (14%) were able to think before they acted: “Well, in the long term it’s always that I no longer overshoot the mark like that, but that I really think things through carefully. And then also weigh the situation with pros and cons” (P3). Theme E.5: Warmer toward oneself Subtheme E5.1 More self-compassion: Seven participants (24%) described being more self-compassionate due to chairwork: “[I developed a] much more loving interaction and also, an understanding for myself” (P7). “I’m learning to love myself” (P1). Subtheme E5.2 Better self-acceptance: Four participants (14%) stated that they were able to be more accepting toward themselves: “I just [gained more] self-acceptance” (P6). “[I realized that] I’m allowed to make mistakes” (P25). Theme E.6: Changes in experiencing the mode model Almost all participants (93%) described experiencing changes in their mode model ranging from more awareness for their modes and taking over a mode’s perspective more easily to a deeper understanding and experiencing of the mode model through chairwork. Furthermore, they described being able to spend more time in the Healthy Adult Mode and less time in the Punitive Parent and in Coping Modes, as well as a changed attitude toward the Vulnerable Child Mode: Subtheme E6.1 More awareness of modes: Seventeen participants (59%) stated that chairwork helped them to sharpen their awareness for the occurrence of different modes: “To make [the modes] a little bit more visible and also to be more aware of the modes. I found that helpful” (P14). “Exactly, that I have learned a lot through this [chairwork], to reflect myself now. In which mode am I now really, which I didn’t know before” (P5). Subtheme E6.2 Chairwork helps to better understand and experience the schema mode model: Seven participants (24%) described that chairwork helped them to understand and experience their schema mode model more thoroughly: “[Chairwork worked] better than in the imagination. Because that’s where I really, felt the mode changes in chair therapy. While I was on one chair, I noticed that I was already changing to the next one and then I moved on my own” (P5). “The technique helped me not only to perceive it visually, but also to feel it, the mode model. And yes, that helped me a lot” (P22). Subtheme E6.3 Improved perspective taking of the modes: Eleven participants (38%) stated that chairwork helped them to take over the perspective of their modes more easily: “So, the advantage [of chairwork] was somehow this change of perspective” (P17). “Yes, as I said, that one has conversations with oneself, with one’s own modes, that you can also see them as persons, not as enemies” (P25). Subtheme E6.4 More often in Healthy Adult Mode: Seven participants (24%) noticed that they use their Healthy Adult Mode more frequently: “And then [after the chairwork I was] very much in my Adult, Healthy Adult” (P21). “Yes, I also try to listen to my Healthy Adult more often” (P23). Subtheme E6.5 Reduced Coping Modes or coping behavior: Eleven participants (38%) reported experiencing fewer Coping Modes, for example they described less dissociation: “I no longer dissociate very often” (P24), reduced self-harm: “There are no more [self-inflicted] injuries; this mindset is gone too” (P11), or binge eating: “The binge eating has become less and is also less rampant” (P20). Frontiers in Psychiatry 09 frontiersin.org Josek et al. 10.3389/fpsyt.2023.1180839 34. Bell T, Montague J, Elander J, Gilbert P. Multiple emotions, multiple selves: compassion focused therapy chairwork. Cogn Behav Ther. (2021) 14:180. doi: 10.1017/S1754470X210 00180 35. Chua N, Serpell L, Burnett-Stuart S, Pugh M. Interviewing anorexia: How do individuals given a diagnosis of anorexia nervosa experience Voice Dialogue with their eating disorder voice? A qualitative analysis. Clin Psychol Psychother. (2022) 29:600–10. doi: 10.1002/cpp. 2652 36. Bell T, Montague J, Elander J, Gilbert P. Suddenly you are king solomon”: multiplicity, transformation and integration in compassion focused therapy chairwork. J Psychother Integr. (2021) 31:223–37. doi: 10.1037/int0000240 37. Siegel D. The Developing Mind. New York, NY: The Guilford (1999). Frontiers in Psychiatry 16 frontiersin.org