11 Schema focused therapies Flashcards
Art
Schema Therapy for Borderline Personality Disorder
Disconnection and rejection
- Expectation that they cannot rely on security or predictability of their surroundings
- Assuming a lack of reliability, support, empathy & respect from others
(1) Abandonment/instability
- Belief that they will soon lose anyone
- Belief that all intimate relationships will end eventually
- Important others seen as unreliable & unpredictable in their ability to support the patients or in their devotion to the patients
- They will end up alone
(2) Mistrust/abuse
Convinced that others will take advantage of them
(3) Emotional deprivation
-Thinking that primary emotional needs are not/inadequately met by others
-Most common forms:
Deprivation of nurturance: no attention, warmth or companionship, Deprivation of empathy: no one listens to you, understands you or can share your feelings, Deprivation of protection: no on gives you advice or direction
(4) Defectiveness/shame
- Feeling of intrinsic incompleteness & badness
- Others will discover how bad patient is -> no longer want to do something with patient
- Overly concerned with judgement of others
- Very conscious of themselves & their inadequacies
- Strong feelings of shame
(5) Social isolation/alienation
- Feeling of isolation from rest of the world
- Feeling different from everyone else & not belonging into this world
Art
Schema Therapy for Borderline Personality Disorder
Impaired autonomy and performance
Expecting that they are incapable of functioning & performing on their own
(6) Dependence/incompetence
- Not capable of taking on daily responsibilities
- Extremely dependent on others
(7) Vulnerability to harm or illness
- Convinced that something terrible could happen at any moment
- Not able to do anything about disaster
- Taking extraordinary precautions to avoid disasters
(8) Enmeshment/undeveloped self
- Overly involved with & connected to one or more caregivers
- Unable to develop own identity due to over-involvement
- Feeling of non-existence without other person
(9) Failure
- Convinced about not being able to perform at same level as peers
- Feeling stupid, foolish, talentless & ignorant
- Not trying to succeed at things
Art
Schema Therapy for Borderline Personality Disorder
Impaired limits
o Inadequate boundaries, feelings of responsibility & frustration tolerance
o Not good at setting realistic long-term goals
o Difficulty working together with others
o Family history of offering little direction or giving feeling of being superior to rest of the world
-Parents set few limitations
-Parents did not encourage patient to preserve during difficult times and/or take others into consideration
(10) Entitlement/grandiosity
- Cannot tolerate any frustration in achieving goals
- Not capable of suppressing feelings or impulses
- Avoiding unpleasantness or being uncomfortable
Art
Schema Therapy for Borderline Personality Disorder
Other-directedness
o Elevated need for love & approval of others
-Taking needs of other into consideration while suppressing own needs
o Family history of only accepting them given certain conditions
(12) Subjugation
- Avoiding negative consequences by giving themselves over
- Suppressing all of their needs & emotions
- Thinking that their desires, opinions & feelings are not cared for by others
- > Pent-up rage expressed in an inadequate manner (e.g. passive-aggressive or psychosomatic symptoms)
(13) Self-sacrifice
- Voluntarily & regularly sacrificing own needs for others viewed as weaker
- Feeling guilty when attending their own needs
- Overly sensitive to pain of others
(14) Approval-seeking/recognition-seeking
-Searching for approval, appreciation & acknowledgement in an exaggerated manner
• At cost of own development & needs
-Excessive desire for status, beauty & social approval
Art
Schema Therapy for Borderline Personality Disorder
Overvigilance and inhibition
o Suppressing spontaneous feelings & needs strict rules & values
o Family history of emphasizing achievement, perfectionism & repression of feelings and emotions
(15) Negativity/pessimism
- Always seeing negative side of things
- Ignoring/minimizing positive sides
- Constantly worried & hyper-alert
(16) Emotional inhibition
-Holding emotions & impulses
• Believing that expression will damage others or lead to feelings of shame, abandonment or loss of self-worth
(17) Unrelenting standards/hypercriticalness
- Believing to never be good enough
- Believing to always need to try harder
- Trying to satisfy unusually high set of personal standards to avoid criticism
- Critical of themselves & others around them
- Perfectionism, rigid rules & preoccupation with time and efficiency
(18) Punitiveness
- Feeling that they should be punished severely for their mistakes
- Aggressive, intolerant & impatient
- Completely unforgiving of their mistakes
Art
Schema Therapy for Personality Disorders
Intro
o Study examined the effectiveness of schema therapy among different personality disorders
- Cluster C: avoidant, dependent & obsessive-compulsive
- Histrionic
- Narcissistic
- Paranoid personality disorder
o Previous research
- Lower drop-out rates in schema therapy
- More cost-efficient
- Superiority over treatment usual for BPD
Art
Schema Therapy for Personality Disorders
Discussion
o Superiority of schema therapy
o Greater improvement on Global Assessment of Functioning Scale & Social and Occupational Functioning Assessment Scale
o Lower depressive disorder rates at follow-up
o Lower dropout rate linked to higher acceptability & greater improvement in recovery from personality disorders
Based on Social and Occupational Assessment Scale
This could not be found when using Global Assessment of Functioning Scale
o Lowest number of patients in therapy after 3 years compared to other treatments -> Better results in less time
o Schema therapy model highly appreciated by patients & therapist
It guides therapist in choosing best techniques
It helps patients to better understand their own behaviours & feelings
o Schema therapy’s effectiveness
Use of multiple channels to achieve structural personality change (behavioural techniques, CBT techniques,…)
Extensive processing of traumatic & adverse childhood experiences
• They are a core factor in the development of personality disorders
o Differences between schema therapy & clarification-oriented psychotherapy
(1) Higher directiveness of schema therapy
(2) Therapeutic relationship in which schema therapists attempt to meet childhood needs of patients
(3) Extensive processing of childhood trauma
(4) Behavioural pattern breaking
Art
Schema Therapy for Personality Disorders
Pt.2
Introduction
o Schema therapy (ST) was developed by Young in 1980s to treat patients with chronic personality problems who did not benefit from CBT
o Collaboration of different therapeutic schools & (bio)psychological theories
o Aim of study: what is the perspective of patients and therapists about ST?
Art
Schema Therapy for Personality Disorders
Pt.2
Discussion
oHigh emphasis on therapeutic relationship
oPatients & therapists consider schema mode model as valuable framework for understanding patient’s problems
oPatients did not find focus of ST too narrow (in contrast with previous literature)
oST has broader focus than other treatments for personality disorders meets more needs of patients
oTherapist recommend providing an active ST training to gain experience
-Influence of training method on treatment outcome
oPatient felt like needing more information
Especially if information relates to possible fears
Lack of information about possibility of strong emotions in session
Connection between present & past within imagery not clear enough
Too much time-pressure within imagery
Lack of information about possibility of telephone contact outside session -> Patients might need to be given information on multiple occassions
o Therapist recommend flexibility in protocol for patients where personality change is not possible (more sessions, longer sessions,…)
Art 2
Principles and Clinical Application of Schema Therapy for Patients with BPD
Introduction
o Among most frequent single personality disorder diagnosis
o 70 – 77% are female
o 1 – 2% prevalence rate (more inpatients than outpatients)
o Pattern of labile emotions, impulsivity, unstable interpersonal behaviour & identity since childhood
o Important features: impulsivity, moodiness, fear of abandonment
- Fear of abandonment can trigger emotional outbursts provocations or disappointments -> Vicious circles of conflicts & rejection
o History of labile of difficult temperament
Many have been victims of physical or sexual abuse
Art 2
Principles and Clinical Application of Schema Therapy for Patients with BPD
Introduction 2
o Highest suicide rate (9 – 10%) & high levels of self-mutilations
o Commonly abuse drugs or alcohol
o Highest dropout rate of treatment
o Standardized forms of treatments: individual psychotherapy, group therapy, psychopharmacological treatments & clinical management
Pharmacological treatment facilitates treatment compliance & temperament modification
o Short-term therapy has limitations - often ineffective
o Cognitive approaches to BPD
- Cognitive Coping therapy
- Dialectical Behaviour Therapy (DBT)
Art2
Dialectical Behaviour Therapy (DBT)
Dialectical Behaviour Therapy (DBT) =
variety of cognitive & behavioral techniques
-evidence-based psychotherapy with efforts to treat borderline personality disorder
-evidence that DBT can be useful in treating mood disorders, suicidal ideation, and for change in behavioral patterns such as self-harm, and substance abuse
-type of talking therapy
-based on cognitive behavioural therapy (CBT), but it’s specially adapted for people who feel emotions very intensely
The aim of DBT =
• understand and accept your difficult feelings
• learn skills to manage them
• become able to make positive changes in your life
‘Dialectical’ means trying to understand how two things that seem opposite could both be true. For example, accepting yourself and changing your behaviour might feel contradictory.
- Adoption of dialectical, philosophical perspective with CBT
- Rational Emotive therapy
- Cognitive therapy
- Cognitive Evolutionary therapy
- Schema therapy
Art2
Model of Schema Therapy
o Short-term cognitive therapies require cognitive flexibility & free access to thoughts and feelings not possible in BPD patients
o Rigid dysfunctional belief systems were developed early in life & used as template for self-concept and conception of environment
o Early maladaptive schema (EMS): subset of schemas that are limited & deeply rooted in rigid, self-perpetuating schemas originating in childhood
Stable & enduring themes that developed during childhood
Elaborated throughout individual’s lifetime
Significantly dysfunctional
Product of developmental needs in childhood that have not been met
• Adverse family relationships initiate & reinforce child’s EMS and maladaptive coping style
Used in present for processing & activating thoughts, feelings and interpersonal behaviours
18 different EMSs
• Most strongly apparent in BPD patients
o Abandonment (AB)
o Defectiveness (DE)
o Emotional Deprivation (ED)
o Insufficient Self-Control (IS)
o Mistrust/Abuse (MA)
o Punitiveness (PU)
o Subjugation (SU)
Art2
Model of Schema Therapy
Schema Mode
BPD patients have frequent rapid emotional changes this is a problem in doing schema work
• Solution: understanding rapid emotional changes as an expression of alternation between clusters of schemas & coping strategies conceptualized as modes or aspects of self
Schema mode: facet of person’s self-involving a natural grouping of early maladaptive schemas, distinct mood states & coping styles
• Part of self developed early in life in response to pain & frustrations due to unmet basic needs
• Has not been completely integrated with other facets into integrated self
• Mode is detached from person’s self fragmented or disintegrated self-system
• Each mode represents different coping strategies & emotions tied to specific social settings
• Activated when particular schemas or coping responses have erupted into strong emotions or rigid coping styles that take over and control an individual’s functioning
Art2
Model of Schema Therapy
Schema Modes in BPD
(1) The abandoned child mode: state of being helpless child who is prevented from getting its need for protection & love met
• Feeling depressed, frightened, worthless or unloved
• Making frantic efforts to avoid abandonment
• Having an idealized view of nurtures
(2) The angry and impulsive child mood: person acts impulsively to get needs met or to ventilate feelings, often in an inappropriate way
• Intense anger, impulsive, demanding, devaluating or abusive behaviour
• Sometimes suicide threats
(3) The punitive parents mode: child punished themselves for expressing normal needs and feelings & for making mistakes or not fulfilling own expectations
• Intense self-hatred or self-criticism for being needy self-denial or self-mutilation
(4) Detached protector mode: helps to cut off or suppress needs & reduce painful feelings
• Detaches from own feelings & people
• Behaving obediently or avoiding in order to stabilize own psyche
• Pushed into dysphoric state (depression, feelings of emptiness & boredom)
• Common coping responses: substance abuse, self-mutilation, depersonalization, psychosomatic complaints, compliant or avoidant behaviour
(5) Healthy adult mode: serves as an executive function in relation to other modes
• Moderates or inhibits any maladaptive coping & dysfunctional modes
• Enhances affirm basic emotional needs
• Recognizable modes will be mild, flexible & adaptive
• Able to recognize & experience different modes simultaneously without losing sense of having unified self
• Heavily underdeveloped in BPD patients (Shifts between other modes are abrupt & intense)
Art2
Model of Schema Therapy
Basic principles in the treatment
o Collaborative working relationship between patient & therapist
o Extreme sensitivity & fear of being abandoned or rejected -> Should be addressed in the early phase of the treatment
o Coping with various schema modes through encouragement, learning of self-help techniques & by modelling the therapist
o More frequent sessions in early phase of therapy & later reduced
Art2
Model of Schema Therapy
Main objective: coping with the schema modes
o Learning skills to control behaviour & increase control of impulses
o Healthy adult mode: helping patient incorporate healthy adult mode
o Abandoned child: learning to empathize with & protect them -> Helping abandoned child to be able to give & receive love and support
o Punitive parent: encouraging patient to fight, talk back & expunge
o Angry and impulsive child: setting limits -> Finding ways of expressing mode’s needs & emotions in more adaptive and appropriate ways
Art2
Model of Schema Therapy
Main objective: coping with the schema modes 2
o Dealing with detached protector first & gradually replacing it with healthy adaptive adult
o Training of new social skills
o Adjunct treatment often required (e.g. couples’ therapy)
o Bypassing the detached protector
o Limited re-parenting of the abandoned child
o Re-channel the angry child through the therapy relationship
o Combating punitive parent through cognitive restructuring
o Dealing with suicidal threats and crisis
o Termination of therapy and relapse prevention strategies
Art2
Model of Schema Therapy
Dealing with suicidal threats and crisis
Important to establish motive behind them =
(1) Self-punishment for not fulfilling own expectations or standards
(2) Distraction form psychological pain & distress
(3) Getting attention & care
Specific procedures
•Motivation of suicidal threats & crisis
o Punitive parent: motivated by internalized self-criticism for being disloyal against abusive parent, for making mistakes or by anger at oneself for expressing needs & feelings
o Angry and impulsive child: explosive & impulsive outbursts of anger and range in order to get needs met or to vent feelings in an inappropriate way
o Detached protector mode: breaking out of detached protector mode; wanting to feel “alive”
o Abandoned child mode: strong feelings of hopelessness,p abandonment or worthlessness -> Distraction from emotional pain
• Suicide attempt
o Increasing frequency of contact with patient
o Assessing risk of suicide
o Considering psychopharmacological & other adjunctive treatments
o Strengthening relationship with patient & emphasizing with them
o Beck Hopelessness Scale as predictor of suicidal incidents
Art2
Model of Schema Therapy
Termination of therapy and relapse prevention strategies
- Termination can trigger person’s abandonment schema
- Preparing patient for relapse of symptoms & interpersonal difficulties
- Developing plan for how to meet adversities & difficulties
- Knowing which kind of interpersonal triggers patients should be aware of in daily life
- Developing a plan for harsh situations
- Gradually shifting towards patient’s life outside of therapy
- Giving patient opportunity to adjust to gradual reduction in contact
Art2
Model of Schema Therapy
Assessment in schema therapy
Instruments and inventories in schema therapy
- Young Schema Questionnaire (YSQ)
- Young Parenting Inventory (YPI)
- > Both used to identify schemas & core problems
• Matched to assess family information from different angles (to avoid feelings of guilt in patient)
- Young-Rygh Avoidance Inventory (YRAI)
- Young Compensation Inventory (YCI)
- > Both used to identify schema driven behaviour
- Schema Mode Questionnaire (YAMI-PM) (Used to assess different modes)
Lec
Schema
• ‘An extremely stable, enduring negative pattern of thoughts, feelings and (interpersonal) behaviour that develops during childhood or adolescence and is elaborated throughout an individual’s life.
Lec
Schema therapy
Applied for personality disorders- Jeffery Young
Lec
Clusters of Personality disorder
Cluster A: the ‘bizar’ Schizotypic, schizoid, paranoid
Cluster B: the ‘dramatic’ Narcisistic, borderline, antisocial, histerionic
Cluster C: the ‘scared’ Avoidant, obsessive-compulsive, dependent
