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Schema-focused Therapy : New Hope for Treatment of Personality Disorder Patients. Joan Farrell, Ph.D. Program Director, Center for Borderline Personality DisorderTreatment & Research Indiana University School of Medicine Larue Carter Hospital. WHAT IS A PERSONALITY DISORDER?.

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Schema focused therapy new hope for treatment of personality disorder patients l.jpg

Schema-focused Therapy: New Hope for Treatment of Personality Disorder Patients

Joan Farrell, Ph.D.

Program Director,

Center for Borderline Personality DisorderTreatment & Research

Indiana University School of Medicine

Larue Carter Hospital


What is a personality disorder l.jpg
WHAT IS A PERSONALITY DISORDER?

  • Ongoing ,rigid pattern of inner experience & behavior results in serious problems & impaired function

  • Symptoms longstanding and intense

  • Pervasive - occur in most relationships

  • Develop during childhood development even if diagnosed later


Borderline personality disorder l.jpg
BORDERLINE PERSONALITY DISORDER

  • Incidence 15% Out & 23% In

  • Prevalence 2-6% US

  • Suicidality & para-suicide

    in 69-80%

  • Successful suicide rate 10%

  • High utilizers of services & treatment dollars

  • History of sexual abuse or rape– 85%


Defining bpd dsmiv l.jpg
DEFINING BPD DSMIV:

Affect

  • Emotional reactivity

  • Difficulty with anger

    Behavior

  • Suicidal behavior, SIB

  • Impulsivity - potentially self-damaging

    Interpersonal

  • Abandonment fears

  • Stormy, idealize then devalue


Defining bpd dsmiv cont l.jpg
DEFINING BPD DSMIV: cont

Self

  • Unstable identity

  • Emptiness

    Reality testing

  • Transient, stress- related

    paranoid episodes, dissociation.

    Any combination of 5 symptoms earns a BPD diagnosis.


Hypothesized etiology person with bpd l.jpg

Emotional Sensitivity

Negative attentional bias

Biology? Genetics? Temperament?

+

Invalidating Environment

Emotional Awareness Deficits

Emotional Regulation Deficits

Cognitive Distortions

Maladaptive Core Schemas

HYPOTHESIZED ETIOLOGYPerson with BPD


Neurobiology of personality disorder bpd l.jpg
NEUROBIOLOGYOF PERSONALITY DISORDER BPD

Overactive Amygdala (the engine)

  • Intense emotional reactivity - persistent unhappy mood

  • dissociation & psychotic thinking

    Other areas of dysfunction

  • Right Hemisphere - difficulty with self-other boundaries

  • Orbital Frontal Cortex - impulsivity

  • Pre-frontal Cortex - planning (the brakes)

    Person w/BPD can have a faulty engine, or brakes, or both.

    Findings like these led to NAMI including BPD as area of interest


Pd challenge to cognitive therapy l.jpg
PD CHALLENGE TO COGNITIVE THERAPY

  • Cognitions & behaviors more rigid

  • The gap between cognitive & emotional change much greater

  • Intimate relationships more central to their problems

  • Homework is often not done


Background l.jpg
BACKGROUND

Schema Therapy was developed to Improve the Effectiveness of

Cognitive Therapy with

Personality Disorder patients

CT for MDD - Beck’s Studies

60% Success rate

30% relapse at 1 year


Schema therapy defined l.jpg
SCHEMA THERAPY DEFINED

  • Integrative, unifying theory & treatment

  • Designed to treat long standing emotional difficulties

  • Difficulties are presumed to have origins in childhood & adolescent development

  • Combines cognitive, behavioral, experiential, attachment &

    object relations approaches


Early maladaptive schemas l.jpg
EARLY MALADAPTIVE SCHEMAS

  • Pervasive theme or pattern

  • Memories, bodily sensations,

    emotions & cognitions

  • About oneself and relationships

  • Developed during childhood/adolescence & elaborated through lifetime

  • Dysfunctional to a significant degree


Maladaptive schemas l.jpg

Abandonment

Mistrust & Abuse

Emotional Deprivation

Defectiveness

Failure

Unrelenting Standards

Punitiveness

Dependence

Jeffrey Young

MALADAPTIVE SCHEMAS


More schemas l.jpg
MORE SCHEMAS

  • Self-Sacrifice

  • Approval Seeking

  • Negativity

  • Entitlement

  • Insufficient Self Control

  • Emotional Inhibition

  • Social Isolation

  • Vulnerability

  • Enmeshment


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Early Maladaptive Schemas

develop when specific

childhood needs

are not met.


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CORE CHILDHOOD NEEDS

  • Safety

  • Empathy

  • Acceptance & Praise

  • Guidance & Protection

  • “Stable Base”, Predictability

  • Love, Nurturing & Attention

  • Validation of Feelings & Needs


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SCHEMAS DEVELOP WHEN

  • Toxic frustration of needs

  • Traumatization, victimization, mistreatment

  • Over-indulgence

  • Selective internalization or identification

  • Temperament or neurobiology

    can play a role


Schemas lifetraps l.jpg
SCHEMAS = LIFETRAPS

They erupt when

triggered by

everyday events

related to the schema.

*

They may not “fit”

what is needed in

one’s adult life.


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BROAD GOAL OF SCHEMA THERAPY

To help patients get their core needs met

in an adaptive manner

through changing their maladaptive schemas and coping styles


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STEPS IN

SCHEMA THERAPY


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STEPS

  • Empathize with current problems & validate emotions

  • Life History

  • Outline Therapy Goals

  • ID Schemas – education & awareness

  • ID Maladaptive Coping Strategies

  • ID Schema Modes


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STEP ONE

  • Engage a relationship -avoidant patient in a healing therapeutic relationship.

  • Will transfer to improved interpersonal functioning outside of psychotherapy.


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SCHEMA HEALING

We are trying to create a healthy healing, reparenting environment so they can finish the steps in childhood development that they missed


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OUR ROLE IS TO RE-PARENT IN A LIMITED WAY

We must find ways to validate their feelings and needs—

While setting limits on and challenging their unhealthy behaviors.

HEAL HERE,

TO TAKE ON THE OUTSIDE WORLD


Limited reparenting means giving patients l.jpg
LIMITED REPARENTING MEANS GIVING PATIENTS

  • SAFETY

  • RESPECT

  • VALIDATION OF FEELINGS

  • SENSITIVITY TO TRIGGERS

  • PATIENCE

  • UNDERSTANDING

  • SUPPORT & COMFORT

  • CONSISTENCY

  • HEALTHY BOUNDARIES


Validation l.jpg
VALIDATION

  • Communicate understanding and acceptance of whatever emotion they express –e.g. crying, venting in an appropriate place

  • When necessary for safety, question their choice of action and suggest healthy alternatives


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THERAPIST STYLE

  • Empathic Confrontation

  • Relentless, but not blaming or critical

  • Stress consequences of not changing

  • Stress the advantages of changing

  • Active coaching, model Healthy Adult


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THERAPIST STYLE

  • Selective self-disclosure

  • Genuine, transparent and warm

  • When schema driven behavior occurs –point it out but don’t react negatively


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We can NUDGENegative Core Beliefs

  • By the way we treat patients in our interactions with them.:

    This is where our role is critical – our responses will either reinforce negative core beliefs or challenge them.


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STEP 2: LIFE HISTORY-

In contrast to CBT , SFT includes childhood


Joy social history l.jpg
JOY - SOCIAL HISTORY

  • Twin adopted as infant

  • Large family, varied parentage

  • Told adoptive parents tried to

    give her back

  • Ran away

  • Caretaker of other children


Joy psych history l.jpg
JOY – PSYCH. HISTORY

  • Adopted

  • First hospitalization- suicide attempt at 15

  • Sexual abuse neighborhood boys

  • Rape at 20

  • Married at 25 to unavailable man

  • Child at 26

  • Stormy marriage

  • In and out of college

  • Ongoing hospitalizations, suicide attempts

  • Ongoing cutting

  • Angry episodes with husband, violence

  • Suicide attempt, commitment


Joy diagnoses l.jpg
JOY - DIAGNOSES.

Axis I – MDD, PTSD, hx ED

Axis II BPD

  • Anger

  • Emotional reactivity

  • Suicide attempts

  • Impulsivity

  • Stormy relationships

  • Abandonment fears

  • Emptiness


Step 3 identify schemas l.jpg
STEP 3: IDENTIFY SCHEMAS

  • Disconnection and Rejection

    Abandonment, Emotional Deprivation, Defectiveness

  • Other-directedness:

    Subjugation of needs, self-sacrifice, approval seeking

  • Over vigilance and Inhibition:

    Unrelenting standards, Punitiveness


Slide35 l.jpg

Usually,

schemas & coping styles

are not in

conscious awareness….

But can be recognized

when pointed out to

a person.


Schema example defectiveness l.jpg
SCHEMA EXAMPLE: DEFECTIVENESS

Not just a belief that she is “bad”, but feelings of shame and memories of rejection.

Origin in bio. Parents abandonment & adoptive parents rejection

Triggered whenever she does not get unconditional acceptance from significant others


Core beliefs the cognitive part of schemas l.jpg
CORE BELIEFS - THECOGNITIVE PART OF SCHEMAS

  • I am Unworthy & Defective

    = I am “Bad” & I Deserve Punishment

  • Other people will abuse or reject me.

  • If I am Abandoned, I’ll die.

  • I am helpless and

    my situation is hopeless.


Schema perpetuation l.jpg
SCHEMA PERPETUATION

COGNITIVE DISTORTIONS

  • All or None thinking

  • Overgeneralization

  • Disqualifying the positive

  • Jumping to conclusions

  • Magnification

  • Should statements

  • Personalization


Any positive result must be written down l.jpg
ANY POSITIVE RESULT MUST BE WRITTEN DOWN

No memory file folders exist to store

the info that contradicts core beliefs in so,

Don’t expect them to remember getting a positive response from you until it has happened many times.

e.g., “Are you mad at me?”

Until a new positive belief forms they will keep testing.


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STEP 4: ID MALADAPTIVE COPING STRATEGIES

Childhood survival strategies

can recur when Schema Issues

are triggered.


Patients coping strategies are normal reactions to crisis l.jpg
PATIENTS’ COPING STRATEGIES ARE NORMAL REACTIONS TO CRISIS

  • OVERCOMPENSATION = FIGHT

  • WITHDRAWAL = FLIGHT

  • SURRENDER = FREEZE

    but they use them

    most of the time


Faulty coping defenses develop l.jpg
FAULTY COPING DEFENSES DEVELOP

  • Overcompensate – criticize others, drive people away

  • Surrender – accept

    abusive relationships

  • Avoidance - isolate


Surrender behaviors l.jpg
SURRENDER BEHAVIORS

  • Attempts to be a perfectionist

  • Focuses on the negative

  • Minimizes importance of desires

  • Treats self and others harshly

    and punitively


Avoidance behaviors l.jpg
AVOIDANCE BEHAVIORS

Avoids:

  • Relationships

  • Employment

  • Negative feelings

  • Social situations

    and groups

I’ve decided to quit my job, drop out

Of society, and wear live animals as hats.


Overcompensation behaviors l.jpg
OVERCOMPENSATION BEHAVIORS

  • Criticizes and rejects others while seeming to be perfect –we become “the enemy”

  • Acts recklessly w/out regard to danger

  • Attends excessively to the needs of others


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STEP 5: ID SCHEMA MODES

  • Schema Modes are intense emotional states that result when schemas are triggered.

  • They include a negative coping strategy.

  • Patients may not have memory of them.


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DETACHED PROTECTOR

  • E.g., Dissociation, flatness


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ANGRY CHILD

  • Stereotype of person with BPD


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VULNERABLE CHILD

  • Fear, regression e.g., fetal position


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PUNITIVE PARENT

  • Mode where self-injury & suicide attempts occur


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HEALTHY ADULT

  • The desired result of Schema Therapy


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SCHEMA THERAPY STAGES

  • Emotional bonding

  • Get around Detached Protector

  • Heal Abandoned Vulnerable Child

  • Banish Punitive Parent

  • Channel Angry Child effectively

  • Develop Healthy Adult


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TREATMENT STRATEGY

  • We teach them to understand their intense reactions to triggers so that they can learn to control the intense emotion, stop and think and make healthier choices.

  • This therapeutic learning occurs in small steps.


I m not a brat i have issues l.jpg
“I’M NOT A BRAT, I HAVE ISSUES”

  • WE BEGIN WITH DAMAGED CHILDREN WHO NEED EXTRA SENSITIVITY AND CARE FROM US

  • OUR GOAL IS TO END UP WITH HEALTHY ADULTS WHO HAVE LEARNED TO CARE FOR THEMSELVES


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HIGHLIGHTS

OFSCHEMA THERAPY TECHNIQUE


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EXPERIENTIAL SCHEMA WORK

Counter schema modes:

“I know in my head

that I am not evil,

but I feel evil”


Gestalt techniques l.jpg
GESTALT TECHNIQUES

“Empty Chair” Dialogues

Example: reduce the hold

of the Punitive Parent.




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COMPARED TO AXIS I TREATMENT

  • More emphasis on:

    • The therapy relationship

    • Lifelong coping styles

    • Childhood origins & developmental processes

  • Need to weaken schema before behavior change will take place

  • Emotion seen as valuable information

  • Longer treatment


Empirical validation bpd patients l.jpg
EMPIRICAL VALIDATION –BPD PATIENTS

  • RCT with 4 sites and 86 BPD patients

  • 2 years Individual SFT

    Arntz, et al.,

    Arch Gen Psychiatry June, 2006

    • “Cured” – 45% vs. 22% TFP

    • Significant improvements in quality of life


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The BASE Program

People with

Borderline pd

Awareness

Skills &

Empowerment


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BASE HAS 4 OVERLAPPING COMPONENTS

  • Psychoeducation about BPD

  • Emotional Awareness Training

  • Skills Training

  • Schema –focused Therapy


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BARRIERS TO APPLICATION

Schema issues kept them from using the healthy coping skills they learned

E.g., the beliefs that they are bad,

helpless or hopeless


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BASE VARIATIONS

OUTPATIENT

  • With/without individual therapy

  • 8 – 12 months

  • 90 minutes long

  • 1-2 sessions/week

  • 6 month & one year follow-up

INPATIENT

  • With weekly individual therapy

  • 90 -180 days

  • 60 minute session

  • 15 weekly sessions

  • 6 month & 1 year follow-up

1


Inpatient base program results l.jpg
Inpatient BASE Program Results

Borderline Syndrome Index Pre Treatment

BPD

% patients meeting diagnosis criteria

“Not” BPD


Slide67 l.jpg

“Not” BPD

Borderline Syndrome Index

Post Treatment

Clinical & Statistical Significance

BPD


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GAF Score Change

mean = 57.51, SD = 5.91

POST

Paired Sample t-test

t = -17.55(36), p< .01

PRE

mean = 28.16, SD = 10.70





Mean number hospitalizations l.jpg
Mean Number Hospitalizations

6.0

.24

One Year before

One Year After


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