Schema therapy is a flexible and transdiagnostic psychological treatment approach (1) which was initially developed for the formulation and treatment of pervasive emotional difficulties. In recent years, researchers and clinicians have been increasingly interested in its usefulness as a general psychotherapeutic formulation and treatment framework. As a “third-wave” cognitive behavioural therapy (CBT), schema therapy integrates cognitive-behavioural, emotion-focused and humanistic principles based on cognitive as well as psychodynamic theory. Unlike ‘traditional’ CBT, schema therapy adopts an explicit focus on patients’ emotions and pays particular attention to the therapeutic relationship as well as links between autobiographical experiences and dynamic patterns of thoughts, feelings, and behaviours in the here-and-now (2).

Schema therapy is built on two central concepts (1): (1) “early maladaptive schemas” - deeply rooted psychological “themes”, which are characterized by certain patterns of unmet childhood needs and early attachment experiences; and (2) “schema modes” - momentarily activated, dynamic state expressions of the more trait-like schema personality features.

The schema therapy framework subsumes schema modes under so-called “parent”, “child”, and “coping” domains. In addition, a “healthy adult” mode reflects individuals’ ability to integrate thoughts, feelings and behaviours in a context-appropriate, flexible, and adaptive manner (2, 3).

Schema modes can be thought of as cognitive-affective-behavioural “self-states” wherein, at a given point in time, individuals’ thoughts, feelings and behaviours are determined by “parent modes” (negative self-related beliefs related to internalized early relational objects), “child modes” (beliefs and primary emotions associated with unmeet childhood needs), or “coping modes” (secondary emotions and maladaptive coping behaviours; 4, 5).

“Parent modes” are learnt cognitive-affective systems, which lead people to experience themselves in a manner akin to how close attachment figures treated them. These systems were initially learned through implicit and model learning (6) and self-perpetuate via their interaction with maladaptive child and coping modes. In “punitive parent” mode, patients may feel intolerant, impatient and cruel towards themselves or others - or guilty and ashamed of their alleged shortcomings at the time (6). In “demanding parent” mode, individuals may emotionally experience high levels of pressure to fulfill rigid norms and values and feel obliged to act accordingly in order to protect their sense of self.

“Child modes” represent self-states that are characterized by unmet emotional needs. The “vulnerable child” mode encompasses ways of thinking and feeling that reflect unmet emotional core needs in childhood. Its quality may differ according to idiosyncratic experiences in peoples’ autobiographies. For example, having experienced unpredictable or frightening parental behaviours, the vulnerable child may take the form of high levels of anxiety (and anger) in close relationships; neglect and ignorance may lead to feelings of loneliness or isolation; and guilt-inducing or blaming behaviours may lead to pervasive feelings of shame or lack of self-worth. The “angry child” aims to protect the vulnerable child mode and presents as a tendency to show spontaneous angry reactions to unmet needs (6).

“Maladaptive coping modes” are learnt behavioural states that initially helped children to adapt to difficult, negligent or emotionally harmful environments. These attempts to ensure a sense of (emotional) safety map onto strategies akin to “fight” (overcompensating modes; e.g. “self-aggrandizer” or “bully-attack”), “flight” (avoidant modes; e.g. “detached protector” or “detached self-soother”) or “freeze” responses (e.g. “compliant surrenderer”; 1). Once established, coping modes can maintain emotional distress in adulthood by becoming too rigid and inflexible – thereby preventing corrective emotional learning (6).

Whilst schema modes exist in everyone, clinical populations differ in terms of the frequencies and intensities with which maladaptive modes occur (1). Therapeutically, schema therapy adopts a variety of cognitive, behavioural, emotion-focused/experiential and relational treatment techniques contingent on the moment-by-moment occurrence of schema modes or mode-shifts, respectively. The therapeutic process aims to decrease the intensity and rigidity of maladaptive parent and coping modes, support the experience and expression of the child modes, and strengthen the healthy adult mode (7). Figure 1 provides an illustration of the schema-mode-model as assessed in the present study.

Because both symptoms, broader psychological difficulties and problematic interpersonal patterns can be conceptualized as mode activations, mode interactions or mode 'flips', the schema-mode-model offers a highly flexible transdiagnostic framework for psychological formulation and treatment planning (2). Importantly, the model can be used both in a nomothetic and idiographic way – thereby offering a helpful tool to conceptualize psychological processes in a given patient population for clinical researchers – and in a single individual for psychological practitioners.

Schema mode expressions in patients with chronic tinnitus are unknown. Chronic tinnitus denotes a phantom perception of noise without an external sound source for a period of more than 3 months (8). Whilst acute tinnitus can be associated with a variety of factors, most importantly hearing loss (9), its chronic expression appears to denote an independent clinical entity – which is closely associated with psychological distress – primarily individual expressions of depression and anxiety (10–12). Research on personality predispositions that may increase an individual’s vulnerability to interpret the tinnitus symptom in a threatening manner is heterogeneous (13). This heterogeneity may be partly owed to a dissociation between individuals with or without identified inner-ear pathology one the one hand (where an underlying medical condition may explain initial symptom onset) – and idiosyncratic psychological vulnerability-stress profiles that influence the psychological ‘style’ in which the symptom is appraised on the other hand (14–17).

Initial research on the impact of coping styles in patients with chronic tinnitus also yielded mixed and somewhat contradictory results. For example, Budd and Pugh (18) identified that tinnitus-related distress was influenced by catastrophic thinking about the consequences of tinnitus – and associated avoidance behaviours. By contrast, embracing seemingly ‘adaptive’ coping styles (such as positive self-talk, distraction or attention switching techniques) did not predict lower levels of tinnitus-related distress. Postulating a warning against mechanistic ways of psychological thinking, the authors concluded that “the mere use of coping strategies does not necessarily mean that these strategies will be useful” (18, S. 334). This important conclusion was further corroborated by Beukes et al. (19), Dineen et al. (20), and Andersson and Willebrandt (21) all of whom emphasized that coping strategies “per se” do not effectively reduce tinnitus-related distress. Indeed, the mechanistic idea of “coping” in a standardisable matter without considering both context and individual psychological profiles appears rather unhelpful. Rather, research ought to focus on the role of behaviours’ context, meaning and function for individuals in order to understand psychological appraisal-emotion-reaction patterns.

This study is the first to examine schema modes, i.e. autobiographically shaped and situationally activated “self-states” (35) in patients with chronic tinnitus. Schema modes are part of a transdiagnostic psychological formulation and treatment framework that has been shown to be successful in ameliorating emotional distress across a broad variety of psychological difficulties (26, 36–38).

First, we compared the frequencies and intensities of schema mode activations of patients with chronic tinnitus to those of healthy controls from a German-speaking reference sample (23). We found that patients with chronic tinnitus showed frequent activation of the vulnerable and angry child modes, indicating high levels of latent emotional vulnerability and painful emotions, such as fear, sadness, shame, loss and anger in our sample.

To cope with these emotions, patients showed frequent activation of avoidant/detached coping modes, which involve affective numbing and avoidance of emotional themes, feelings, or thoughts. Consistent with clinical observation, chronic tinnitus patients in avoidant coping modes might either be unaware of their emotions - or reluctant to engage with them therapeutically. In clinical contact, patients might present with various subtle forms of emotional detachment, such as (1) intellectualization, (2) distant, superficial, or overly ‘cognitive’ reflections, (3) vagueness, (4) avoidance of meaningful or emotional topics and (5) a demand for concrete “solutions” rather than allowing for a focus on emotional topics and themes.

Interpersonally, the compliant surrenderer dominated patients' emotional coping styles. Correspondingly, patients did not commonly endorse the more overtly narcissistic self-aggrandizer. The compliant surrenderer mode reflects a tendency to please and conform to others’ expectations at the expense of one’s own needs - but also to experience or demonstrate heightened levels of anxiety, confusion or passive-aggression if others do not meet one’s expectations. In psychological therapy, patients in this mode may seem passive and submissive, but also undermine the therapist or the therapeutic process in subtle ways in order to indirectly express anger or assert a sense of control.

A less common but still frequently expressed coping mode was the bully-attack, which presents as patients demonstrating an aggressive demeanor with a goal to intimidate others in order to protect themselves from perceived threat. In this mode, patients may threaten third-parties including clinicians directly or indirectly in order to assert power or dominance. The mode can range from subtly menacing or threatening implications to overt attacks at the extreme end of the spectrum.

Surprisingly, patients with chronic tinnitus hardly ever endorsed statements linked to the punitive parent mode. Whilst this conspicuously low frequency of the punitive parent may reflect a “true” absence of respective beliefs, the finding is much more likely to reflect patients’ detached coping style indicating an emotional avoidance of key themes pertaining to vulnerability, anger, shame or stigma (39). This interpretation appears likely given that (1) the punitive parent and detached protector mode correlated highly, and (2) depression [which drives tinnitus chronification (11)] is also characterised by frequent expresisons of punitive parent, child, and avoidant coping modes (40, 41).

Correlational analyses revealed moderate-to-strong correlations between the vulnerable child and all psychological distress-related constructs; as well as the angry child and perceived stress, anxiety and worry. Beyond the helpful therapeutic focus this may offer, these findings are in keeping with previous research on “worry as avoidance” of underlying, harder-to-bear emotional states (42, 43).

Intrapersonally, patients with chronic tinnitus seem to cope primarily with emotional detachment – in particular the detached protector mode. Whilst emotional detachment may be useful in the short term, its highly negative correlation with ‘joy’ also emphasizes the emotional “price to pay” for this self-protection strategy, i.e. that feelings of joy are numbed alongside emotions that are perceived as more threatening (44). Because the detached protector involves ‘cognitive’ ways of dealing with emotional distress (e.g. being overly rational, intellectualizing or adopting a ‘somatic’ focus), cognitive interventions may maintain tinnitus-related distress. By contrast, emotion-focused techniques may offer a more helpful group of psychological treatment techniques to ameliorate distress (45). Overall, these findings are in keeping with evidence on associations between medically unexplained symptoms and difficulties in affect regulation (46) and suggest that an affective focus in psychological therapy may be well suited to ameliorate tinnitus-related distress (47).

Interpersonally, patients appeared to manage emotion-driven self-states most frequently in the compliant surrenderer mode. In this mode, patients may either act in seemingly passive, approval-seeking or self-deprecating ways or disempower themselves by showing inflexible self-pitying tendencies. This interaction style may lead to complex interpersonal dynamics in the multiprofessional team as well as patients’ lives that should be thoroughly assessed and addressed throughout psychological therapy (48, 49).

Overall, the results mirror previous findings on “emotional excitability” (potentially reflecting child modes) on the one hand and “aggression inhibition” on the other hand (potentially reflecting detached or avoidant coping modes) as personality-rooted drivers of tinnitus-related distress (50).

Cross-sectional mediation analyses suggested that tinnitus-related distress was driven by interactions of child and avoidant coping modes. Clinically, this finding suggests that psychological interventions should focus less on avoidance of “the tinnitus symptom” or “behaviours that are avoided because of tinnitus”, but on underlying emotional themes pertaining to feelings of vulnerability, shame or anger. The idea of emotional avoidance as a key transdiagnostic mediator of stress experiences and psychological difficulties has been well researched (51, 52); however, the present study is the first to demonstrate a comparable construct from the schema-mode-model in patients with chronic tinnitus.

The compliant surrender’s role in maintaining tinnitus-related distress reflects existing research on challenging interpersonal dynamics in patients presenting with functional syndromes or depression respectively (53, 54). The mode’s mediating role further suggests that a relational focus on patients’ emotion regulation strategies may further benefit psychological treatment outcome. This is in keeping with previous research that suggests an interplay of emotional detachment and seemingly pleasing (yet controlling) interpersonal coping styles in patients with functional somatic syndromes (55) - and a therapeutic need to adopt both intrapersonal and interpersonal perspectives regarding patients’ emotions and biographically influenced, dynamically applied regulation strategies.

Exploratory models that included the punitive and demanding parent modes resulted in broadly similar patterns emphasizing the crucial importance of underlying feelings of vulnerability and anger – and emotional detachment or interpersonal compliance as attempts to stabilize the self at high cost. Notably, one indirect effect suggested positive associations between the punitive parent, angry child, and bully-attack mode – and a negative association between the latter and tinnitus-related distress. For a subset of patients, it thus appears as if a coping style akin to “attacking others before they attack me” may protect them from feelings of vulnerability and increase senses of self-efficacy and control in the short-term (56).

The study features several methodological shortcomings. The absence of a “real” control group leaves the presented findings tentative: Whilst the healthy control reference sample was adequately powered, it was not representative of the general population (23) – and the interpretation of the here-reported between-group comparisons needs to be made with caution. Due to the cross-sectional nature of the data, the mediation analyses do not reflect “true” mediation – which requires temporal lags between the independent, mediating and outcome variables (57). Results can thus not be interpreted causally, and future prospective studies need to demonstrate the diagnostic usefulness and clinical relevance of the schema-mode-model for helping patients with chronic tinnitus-related distress.

In conclusion, schema therapy and its formulation and treatment framework offer a promising ‘modern’ clinical development in psychotherapy research and practice (58) with an ever-evolving empirical evidence base (5, 59). As a “third-wave” cognitive-behavioural therapy, it offers a broad, non-stigmatizing and holistic perspective on how to understand and ameliorate emotional suffering. Furthermore, its flexible conceptualization framework enables practitioners to use a wide range of emotion-focused, and humanistically informed experiential interventions in clinical practice. The present study is the first to demonstrate (1) the expression and interaction of maladaptive schema modes in patients with chronic tinnitus and (2) strong correlations between these self-states and more established psychological constructs. The findings (1) suggest that tinnitus-related distress can be expressed in schema mode terms – which may offer a helpful framework for clinical formulation and treatment planning, and (2) open up schema-therapy based psychotherapeutic interventions for empirical examination in in this population (26).

As per Charité Universitätsmedizin Berlin’s ethics committee, unfortunately, we cannot make the data public without restrictions because we did not obtain patients’ consent to do so at the time. Nevertheless, interested researchers can contact the directorate of the Tinnitus Center with data access requests (birgit.mazurek@charite.de). Alternatively, interested researchers may also contact the Charité's Open Data and Research Data Management Officer Dr. Evgeny Bobrov (evgeny.bobrov@charite.de).

The studies involving humans were approved by Charité Universitätsmedizin Berlin EA4/216/20. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

BB: Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Visualization, Writing – original draft, Writing – review & editing. ES: Formal analysis, Writing – review & editing. PB: Writing – review & editing. BM: Funding acquisition, Resources, Writing – review & editing.