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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

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
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
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
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
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
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
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
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
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
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
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
Abandonment

Mistrust & Abuse

Emotional Deprivation

Defectiveness

Failure

Unrelenting Standards

Punitiveness

Dependence

Jeffrey Young

MALADAPTIVE SCHEMAS
more schemas
MORE SCHEMAS
  • Self-Sacrifice
  • Approval Seeking
  • Negativity
  • Entitlement
  • Insufficient Self Control
  • Emotional Inhibition
  • Social Isolation
  • Vulnerability
  • Enmeshment
slide15
Early Maladaptive Schemas

develop when specific

childhood needs

are not met.

core childhood needs
CORE CHILDHOOD NEEDS
  • Safety
  • Empathy
  • Acceptance & Praise
  • Guidance & Protection
  • “Stable Base”, Predictability
  • Love, Nurturing & Attention
  • Validation of Feelings & Needs
schemas develop when
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
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.

broad goal of schema therapy
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

slide20
STEPS IN

SCHEMA THERAPY

steps
STEPS
  • Empathize with current problems & validate emotions
  • Life History
  • Outline Therapy Goals
  • ID Schemas – education & awareness
  • ID Maladaptive Coping Strategies
  • ID Schema Modes
step one
STEP ONE
  • Engage a relationship -avoidant patient in a healing therapeutic relationship.
  • Will transfer to improved interpersonal functioning outside of psychotherapy.
schema healing
SCHEMA HEALING

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

our role is to re parent in a limited way
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
LIMITED REPARENTING MEANS GIVING PATIENTS
  • SAFETY
  • RESPECT
  • VALIDATION OF FEELINGS
  • SENSITIVITY TO TRIGGERS
  • PATIENCE
  • UNDERSTANDING
  • SUPPORT & COMFORT
  • CONSISTENCY
  • HEALTHY BOUNDARIES
validation
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
therapist style
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
therapist style28
THERAPIST STYLE
  • Selective self-disclosure
  • Genuine, transparent and warm
  • When schema driven behavior occurs –point it out but don’t react negatively
we can nudge negative core beliefs
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.

step 2 life history
STEP 2: LIFE HISTORY-

In contrast to CBT , SFT includes childhood

joy social history
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
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
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
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
Usually,

schemas & coping styles

are not in

conscious awareness….

But can be recognized

when pointed out to

a person.

schema example defectiveness
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
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
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
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.

step 4 id maladaptive coping strategies
STEP 4: ID MALADAPTIVE COPING STRATEGIES

Childhood survival strategies

can recur when Schema Issues

are triggered.

patients coping strategies are normal reactions to crisis
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
FAULTY COPING DEFENSES DEVELOP
  • Overcompensate – criticize others, drive people away
  • Surrender – accept

abusive relationships

  • Avoidance - isolate
surrender behaviors
SURRENDER BEHAVIORS
  • Attempts to be a perfectionist
  • Focuses on the negative
  • Minimizes importance of desires
  • Treats self and others harshly

and punitively

avoidance behaviors
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
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
step 5 id schema modes
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.
detached protector
DETACHED PROTECTOR
  • E.g., Dissociation, flatness
angry child
ANGRY CHILD
  • Stereotype of person with BPD
vulnerable child
VULNERABLE CHILD
  • Fear, regression e.g., fetal position
punitive parent
PUNITIVE PARENT
  • Mode where self-injury & suicide attempts occur
healthy adult
HEALTHY ADULT
  • The desired result of Schema Therapy
schema therapy stages
SCHEMA THERAPY STAGES
  • Emotional bonding
  • Get around Detached Protector
  • Heal Abandoned Vulnerable Child
  • Banish Punitive Parent
  • Channel Angry Child effectively
  • Develop Healthy Adult
treatment strategy
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
“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
slide55
HIGHLIGHTS

OFSCHEMA THERAPY TECHNIQUE

experiential schema work
EXPERIENTIAL SCHEMA WORK

Counter schema modes:

“I know in my head

that I am not evil,

but I feel evil”

gestalt techniques
GESTALT TECHNIQUES

“Empty Chair” Dialogues

Example: reduce the hold

of the Punitive Parent.

compared to axis i treatment
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
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
the base program
The BASE Program

People with

Borderline pd

Awareness

Skills &

Empowerment

base has 4 overlapping components
BASE HAS 4 OVERLAPPING COMPONENTS
  • Psychoeducation about BPD
  • Emotional Awareness Training
  • Skills Training
  • Schema –focused Therapy
barriers to application
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

base variations
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
Inpatient BASE Program Results

Borderline Syndrome Index Pre Treatment

BPD

% patients meeting diagnosis criteria

“Not” BPD

slide67
“Not” BPD

Borderline Syndrome Index

Post Treatment

Clinical & Statistical Significance

BPD

gaf score change
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
Mean Number Hospitalizations

6.0

.24

One Year before

One Year After

ad