Schema Therapy: An Introduction to Basic and Mode Model

1. Schema Therapy:An Introduction to Basic and Mode Model Diomidis Psomas, Chartered Counselling Psychologist HPC Registered

2. Schema Therapy • Designed to treat a variety of long-standing emotional difficulties • It is an integrative, unifying theory and treatment • EMSs presumed to have significant origins in childhood& adolescent development(interaction of temperament and dysfunctional interpersonal experiences + trauma) Combines cognitive, behavioral, attachment, objectrelations, and experiential approaches

3. Goals of Schema Therapy • Help patients get their core emotional needs met (everything must lead towards this main goal) • Identify and change Schemas and coping styles • Indentify and 'integrate' the different modes

4. Core emotional needs we all had and still have 1.     secure attachments to others, safety, stability 2.     autonomy, competence, sense of identity 3.     freedom to express needs and emotions 4.     spontaneity and play 5.     realistic limits and self-control

5. “Early Maladaptive Schemas are pervasive and enduring themes or patterns that have their origins in early adverse experiences, are elaborated over the course of a lifetime, and are dysfunctional to a significant degree”Bernstein, 2002: 619 5 Schema Domains 1.    Disconnection and rejection 2.    Impaired Autonomy and performance 3.    Impaired Limits 4.    Other directedness 5.    Overvigilance and Inhibition 18 Early Maladaptive Schemas i.e. Disconnection and Rejection domain Abandonment/Instability Mistrust/Abuse Emotional Deprivation Defectiveness/Shame Social Isolation/Alienation Young, 1999; Young et. al., 2003

6. Unhelpful strategies of coping with Schemas Surrendering (giving in) Compliant and dependent Avoidance (running away) Substance misuse Social/emotional detachment Stimulation/workaholic Overcompensation (fighting back) Aggression Excessive Self-Reliance Manipulation Perfectionism Demandingness

7. Presentations suitable for ST • Long term mental health problems (i.e. long standing depression, anxiety and personality disorders) • Client already been through a course of therapy before (or a number of different therapies), but did not appear to be particularly helpful • Clients have ended up stuck with other types of treatment • Addresses the deeper roots of problems, contributing to making more lasting changes • Addresses all levels of a problem; cognitive, emotional, behavioural (for past and present problems), relational as well as the origins • Helps people ‘create’ or strengthen an inner Healthy Adult that is kind, compassionate, caring, and helps them with emotional as well as practical difficulties

8. ST: Treatment Phase one: Assessment and Education 1. Identify problems and therapy goals 2. Assess suitability 3. Identify life patterns, link schema eruptions to present probs 4. Identify coping styles 5. Identify modes 6. Educate; about Core Needs, Schema Development, clarify links between schemas and current probs Phase two: Change Discredit Schemas; Cognitive, Experiential techniques and Behavioural pattern breaking

9. Cognitive Interventions • Evidence for and against a schema (past and present) • Reframing past, re-attribution (discredit evidence 'for') • Alternative explanations • Schema and Healthy side dialogues • Schema Flashcards • Schema diary

10. Experiential Techniques Imagery Chair work Role plays

11. Behavioural Pattern Breaking Identify maladaptive coping styles and rehearse alternative coping behaviours (role plays, imagery) Assign homework targeting specific behaviours that perpetuate the schema

12. Schema Modes “The moment to moment emotional states and coping responses – adaptive and maladaptive – that we all experience” (Young, et al., 2003: 37) • We all have them, the more extreme though the more problems they create • Modes are triggered by life situations that have similarities to past events and incidents • Specifically PD clients may shift rapidly from one mode to another

13. The Modes • Child Modes (vulnerable/abandoned/abused child,angry/impulsive child) • Dysfunctional Parent modes (critical/punitive parent, demanding parent) • Detached Protector Modes (angry protector) • Healthy Adult mode

14. Critical Parent Detached Protector HA Angry/impulsive Child ____________ Vulnerable Child

15. Abandoned Child Function: Helpless, in despair to get needs met or find protection and feel safe and protected Symptoms: Lonely, isolated, defective, unlovable, lost, worried, worthless, weak, excluded, pessimistic etc

16. Angry/Impulsive Child Function: Acts impulsively, expresses anger inappropriately and often intensely Symptoms: Anger/rage,impulsivity, demandingness, manipulative, controlling, abusive, suicidal threats, promiscuity

17. Punitive Parent Function: Punishes child for expressing needs and feelings, for making mistakes, for feeling vulnerable or even playful Symptoms: Abusive towards self, punitive (self-mutilation), self-critical, anger at self for feeling needy (or anything really)

18. Vulnerable Child / Critical Parent

19. Child and Parent

20. Detached Protector Function: Cuts off needs and feelings; detaches from others, does not want to feel or even think Symptoms: Does not want to talk, misses appointments, feeling empty, bored, numb, self-mutilating, may dissociate, is compliant

21. Healthy Adult Aim of therapy is to strengthen this mode Function: Nurtures, protects vulnerable/abandoned child Sets limits for angry child Fights Punitive Parent Has healthy attitudes towards emotions, needs, makes healthy decisions (therapist essentially is the role model for Healthy Adult)

22. Imagery mode work/Rescripting (intervention) 3 phases • Scene as experienced by patient as child • Rescripting: scene viewed by patient as adult (Health Adult); HA intervening • Rescripting: patient as child experiencing HAs interventions (Arntz & Weertman, 1999) * For distressing scenes/incidents start from step 1, for traumatic incidents start from ‘safe place’ imagery

23. Research Evidence - SFT vs. TFP (2006) BPD; 3 yrs, 2 sessions per week Dropouts ST: 27% TFP: 50% At completion 'Full Recovery' ST:46% TFP: 24% At 1yr Follow up ST:52% TFP:28% At completion 'reliable and significant change' ST: 66% TFP:43% ST cost effective: Dutch Society net gain of 4,500 euros per patient

24. Further Evidence - Farrell, J.M. et al (2009) Group Schema Therapy 30 sessions for BPD patients Compared TAU vs. GST-TAU. Dropout TAU: 25% GST-TAU: 0% At completion 'Full Recovery' TAU: 16% GST-TAU: 94% - Johnston, C et al (2009) Modes, Childhood Trauma and Dissociation in BPD 'Angry and Impulsive Child' + 'Abandoned and Abused Child' Predicted dissociation. Supported emphasis on identification and integration of dysfunctional personality modes in BPD - Wang et al (2010) 9 year follow up of depressed patients YSQ scales promising as vulnerability markers for depression Highlighted necessity to identify and tackle long-term vulnerability factors

25. Further Evidence II - Gude & Hofart (2008);study suggesting that agoraphobic patients with Cluster C traits could benefit more from schema-focused programs rather than in treatment as usual programs in order to reduce their level of interpersonal problems. Studies supporting imagery rescripting - Smucker et al (1995); Imagery Rescripting: A new treatment for survivors of childhood sexual abuse suffering posttraumatic stress - Arntz & Weertman (1999); treatment of childhood memories: theory and practice

26. References • Arntz., A & Weertman, A. (1999). Treatment of childhood memories: theory and practice. Behaviour Research and Therapy, 37, 715-740 • Bernstein, D. (2002). Cognitive Therapy of personality disorders in patients with Histories of emotional abuse or neglect. Psychiatric Annals, 32(10), 618-628 • Cloitre, M., Cohen, L.R. & Koenen, K.C. (2006). Treating Survivors of Childhood Abuse: Psychotherapy for the interrupted life. New York: The Guilford Press • Farrell, J.M., Shaw, I.A., & Webber, M.A. (2009). A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder: A randomized controlled trial. Journal of Behavior Therapy and Experimental Psychiatry, 40, 317-328. • Giesen-Bloo, J., van Dyck,R., Spinhoven,P., Tilburg, W., Dirksen, C., van Asselt, T., Kremers, I., Nadort,M., Arntz, A. (2006). Outpatient Psychotherapy for Borderline Personality Disorder; Randomized trial of Schema-Focused Therapy vs Transference-Focused Psychotherapy. Archives of General Psychiatry, 63, 649-658. • Gude, T., & Hoffart, A. (2008). Change in interpersonal problems after cognitive agoraphobia and schema-focused therapy versus psychodynamic treatment as usual of inpatients with agoraphobia and Cluster C personality disorders: health and disability. Scandinavian Journal of Psychology, 49, 195-199.

27. References - Johnston, C., Dorahy, M.J., Courtney, D., Bayles, T., & O’Kane, M. (2009). Dysfunctional schema modes, childhood trauma and dissociation in borderline personality disorder. Journal of Behavior Therapy and Experimental Psychiatry, 40, 248-255. - Millon, T., Millon, C.M., Meagher, S., Grossman S. & Ramnath, R. (2004). Personality Disorders in Modern Life. New Jersey: John Wiley & Sons, Inc - Young, J.E. (1999). Cognitive therapy for personality disorders: A schema-focused approach (3rd ed.). USA: Professional Resource Exchange, Inc - Young, J.E., Klosko, J.S. & Weishaar, M.E. (2003). Schema therapy: A practitioner’s guide. New York: The Guilford Press