Schema Triggering and Mode Analysis Logbook

Use the form below to capture schema triggers and schemas (modes) that were active during an upsetting event.

Describe in your own words the event that upset you: *

What were your feelings and emotions? *

What were your thoughts *

(align each to a feeling/emotion on the left)

What did you do? How did you behave? *

Which early maladaptive schemas were triggered, if known? *

What modes were active? Circle and describe them

Child *

Vulnerable *

Angry/impulsive *

Parent *

Demanding *

Punitive *

Coping *

Detached protector *

Detached self-soother *

Self-pity *

Compliant surrenderer *

Over-controller *

Other *

What was the effect of switching between the different modes? (copy) *

Healthy Adult Response: How could you have responded to the situation that may have led to a better outcome? *

How do you feel about the situation now, having been through this worksheet? *

Full Name *

First

Last

E-mail *