Transcript Working with Adult Survivors of Childhood Abuse

Schema Therapy:
An Introduction to
Basic and Mode Model
Diomidis Psomas,
Chartered Counselling Psychologist
HPC Registered
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, object
relations, and experiential approaches
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
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.
5.
spontaneity and play
realistic limits and self-control
“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
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
Presentations suitable for ST
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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
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
Cognitive Interventions
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Evidence for and against a schema (past
and present)
Reframing past, re-attribution (discredit
evidence 'for')
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Alternative explanations
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Schema and Healthy side dialogues
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Schema Flashcards
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Schema diary
Experiential Techniques
Imagery
Chair work
Role plays
Behavioural Pattern Breaking
Identify maladaptive coping styles and rehearse
alternative coping behaviours (role plays, imagery)
Assign homework targeting specific behaviours that
perpetuate the schema
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
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
Critical
Parent
Detached
Protector
HA
Angry/impulsive
Child
____________
Vulnerable
Child
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
Angry/Impulsive Child
Function:
Acts impulsively, expresses anger inappropriately and often
intensely
Symptoms:
Anger/rage,impulsivity, demandingness, manipulative,
controlling, abusive, suicidal threats, promiscuity
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)
Vulnerable Child / Critical Parent
Child and Parent
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
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)
Imagery mode work/Rescripting
(intervention)
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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
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
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
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
References
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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 TransferenceFocused 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.
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