L12: Schema Therapy Flashcards
core emotional needs of ST
- Stability, nurturance, safety, acceptance
- Autonomy, competence, sense of identity
- Freedom to express needs and emotions
- Spontaneity and play
- Realistic limits and self control
(proposed: fairness & self-coherence/comprehensible world)
need for fairness/justice
- Fundamental need already present in childhood
- Experiments with animals indicate a need for fairness in specific species. This need serves constructive collaboration between individuals in groups (survival value)
ST theory
unmet core needs/trauma -> maladaptive schema’s -> coping with schema activation (influenced by temperament) -> schema modes
ST basic emotional needs -> schema domain -> schemas
- Secure attachment, stability and care -> Disconnection and rejection
* Abandonment/instability
* Mistrust/abuse
* Emotional deprivation
* Defectiveness/shame
* Social isolation/alienation - Autonomy, competence, identity -> Impaired autonomy and achievement
* Dependency/incompetence
* Vulnerability to harm and illness
* Enmeshment/undeveloped self
* Failure - Play and spontaneity -> Overvigilance and inhibition
* Negativity/pessimism
* Emotional inhibition
* Unrelenting standards
* Punitiveness - Expression and validation of emotions, needs and opinions -> Other-directedness
* Subjugation
* Self sacrifice
* Approval seeking - Realistic limits -> Impaired limits
* Entitlement/grandiosity
* Insufficient self-control - Fairness -> Unfairness/Injustice
* Unfairness - Self-coherence/coherence of the world -> Lack of coherence
* Lack of self-coherence
* Incomprehensible worl
schema modes =
emotional-cognitive-behavioral state
- a combination of activated schema and coping with this
- Modes vary from functional (flexible, adaptive) to dysfunctional (inflexible, nonadaptive)
verschil schema and mode
- Schema = ‘trait’; mode = ‘state’
- Explains extreme switches and opposites within 1 person (e.g., states of superiority and inferiority)
3 types of dysfunctional coping with an activated schema
- surrender: give in to schema activation (believe it is true) -> vulnerable child, punitive parent
- avoidance: avoid (full) schema activation -> detached protector, self-soother
- overcompensation: believe the opposite is true -> self-aggrandizer
basic schema mode model
healthy adult
detached protector
punitive/demanding mode
angry child
vulnerable child
voor wie is schematherapie
Schematherapie is een vorm van psychotherapie voor mensen met terugkerende psychische klachten waarvan de oorzaak in de persoonlijkheid ligt. Denk hierbij aan identiteitsproblemen, hechtingsproblematiek, onzekerheid, perfectionisme en een zich herhalende depressie.
There are four categories of
modes in the basic approach of the mode model:
- Dysfunctional child modes
- Dysfunctional parent modes
- Dysfunctional coping modes
- Healthy modes
dysfunctional child modes
Dysfunctional child modes are developed when basic emotional needs were frustrated in childhood. These modes are accompanied by intense emotions like fear, loneliness, helplessness, sadness, or mistrust in the vulnerable child modes. Other child modes include the angry child, enraged child, impulsive child, and undisciplined child modes. Dysfunctional child modes result from surrendering to an EMS.
dysfunctional parent modes
The dysfunctional parent modes include internalized negative beliefs about oneself that are developed during childhood due to behavior and reactions of significant others like parents, teachers, or peers. There are punitive parent and demanding parent modes.
Dysfunctional parent modes are associated with high standards, self-devaluations, self-hatred, guilt, or shame. Dysfunctional parent modes result from surrendering to two specific EMSs: punitiveness and unrelenting standards
3 dingen die volgens schema therapie leiden tot problemen als volwassene
- maladaptive schemas
- schema modes
- associated coping strategies
wat is de rol van de therapeutische relatie hierin
The therapeutic relationship has an essential role in revealing and modifying dysfunctional interpersonal relationships and the patient’s relationships in the outside world.
The therapeutic relationship is built using …
empathic confrontation and limited reparenting
interventions in ST
cognitive-behavioral interventions; behavioral techniques (e.g., role-play, behavioral experiments, skills training, problem-solving, behavioral activation, or relaxation techniques); and experiential techniques such as chair dialogues and imagery rescripting.
when an EMS gets activated, this leads to…
emotional distress -> coping strategies to reduce this pain -> but these coping strategies block access to primary feelings and needs, and result in unmet needs and problems that persist into adult life
is ST transdiagnostic?
ST can be seen as a transdiagnostic approach, but there are disorder-specific case conceptualizations for most of the PDs.
ST effectiveness study for BPD
ST was successful in reducing BPD symptom
severity and general psychopathology as well improving the quality of life.
group schema therapy (GST) effectiveness
GST alone + combined individual and group therapy were all effective compared to TAU.
why did Young develop ST
As Young tried to understand why these patients did not profit from CBT, he discovered that they seemed to have developed coping strategies as a response to adverse experiences in their past. These led to difficulties in the therapeutic relationship and the therapeutic process for multiple reasons; some learned to suppress or avoid their emotions or thoughts and were therefore not able or willing to follow CBT protocol on observing, recording, and sharing their thoughts and feelings. Due to coping strategies developed as a response to adverse interpersonal experiences such as mistrust, dependency, hostility, or controlling behavior, patients had trouble engaging in a collaborative relationship with their therapists. Young encountered other difficulties: patients’ complaints were vague and hard to capture, which made it difficult to fit them in traditional CBT treatment targets. A lack of psychological flexibility, inherent to PDs, also made them less responsive to CBT techniques and prevented changes in the short treatment period characteristic for CBT. In order to meet the needs of these patients, Young developed ST.
dus waar is ST een combinatie van
CBT, attachment, interpersonal and object-relation theories. also some gestalt and emotion-focused therapy
EMSs=
dysfunctional knowledge structures acquired early in life, that govern cognitive processes such as attention, interpretation, or memory consolidation
what do schemas do
schema’s tend to act as filters for information by processing information in a way that fits the schema, which makes them self-sustaining and very resistant to change. schemas can be triggered by external or internal stimuli (especially if they show similarities to when the schema was developed)
coping styles functie
These coping styles are typically developed during childhood as an adaptive way to
help the child survive and endure distressing situations and emotions (e.g., dissociation
during an abusive experience). In adulthood, however, these former “survival strategies”
have become rigid, inflexible, and automatically activated behaviors that prevent
healthy interpersonal relationships, functional emotion regulation, and satisfaction of
emotional core needs.
In patients with PDs, usually, multiple schemas and coping strategies are active at the same time, and patients tend to switch between schemas quickly.
Daarom heeft Young dit gemaakt:
schema modes -> combi van activated schema and a coping strategy. describes the moment-to-moment emotional-cognitive-behavioural state of the patient
- dysfunctional child mode
- dysfunctional parent mode
- dysfunctional coping mode
- healthy mode
dysfunctional child mode
Dysfunctional child modes are developed when basic emotional needs were frustrated in childhood.
- vulnerable child (depressie-achtig, alone, unloved, pessimism, unworthiness, soms narcissism)
- angry child (victimization, bitterness, jealousy, rage, anxious, self-doubt)
- impulsive/undisciplined child (rechless, sud, suicide, rage)
- happy child (feels safe, loved and content)
Dysfunctional child modes result from surrendering to an EMS.
dysfunctional parent modes
The dysfunctional parent modes include internalized negative beliefs about oneself that are developed during childhood due to behavior and reactions of significant others like parents, teachers, or peers. There are punitive parent and demanding parent modes. Dysfunctional parent modes are associated with high standards, self-devaluations, selfhatred, guilt, or shame. Dysfunctional parent modes result from surrendering to two specific EMSs: punitiveness and unrelenting standards.
dus kort overzichtje van wat elke mode is
dysfunctional child modes: when basic emotional needs were frustrated
dysfunctional parent modes: internalized negative beliefs about oneself, developed due to parents/teachers/peers
dysfunctional coping modes:
dysfunctional coping modes
The dysfunctional coping modes result when the coping strategy with the EMS activation is an avoidance or overcompensation type. These coping strategies, when strong enough, overshadow the EMS, and the experience and behavior of the person is dominated by the coping strategy rather than by the EMS. These coping strategies are usually developed during childhood and serve as “survival strategies:’ In adulthood, they aim to prevent, numb or invert the intense emotions activated by child modes and parent modes.
dus wat gebeurt er bij elk van de drie dysfunctional coping techniques bij een geactiveerde EMS
surrender -> dysfunctional child mode & dysfunctional parent mode
avoidance & overcompensation -> dysfunctional coping modes
hoe kan een vulnerable child narcissism laten zien
Rarely, a patient’s self-perceived flaws may be intentionally withheld on the inside; when this occurs, instead of showing one’s true self, the patient may appear to others as “egotistical”, “attention-seeking”, selfish, distant, and may exhibit behaviors unlike their true nature. The patient might create a narcissistic alter-ego/persona in order to escape or hide the insecurity from others. Due to fear of rejection, of feeling disconnected from their true self and poor self-image, these patients, who truly desire companionship/affection, may instead end up pushing others away
compliant surrender
is a coping mode where one experiences the schema that triggered it as true. This in turn leads to feelings such as helplessness, sadness, guilt, or anger about the situation. People in this mode often believe it is pointless to challenge their schema, and that it must simply be accepted. They also often adopt an interpersonally passive and dependent style, seeking to please people in their lives, to minimize conflict, and therefore avoid further harm or abuse.
detached protector/avoidance
is based in escape. Patients in Detached Protector schema mode withdraw, dissociate, alienate, or hide in some way. This may be triggered by numerous stress factors or feelings of being overwhelmed. When a patient with insufficient skills is in a situation involving excessive demands, it can trigger a Detached Protector response mode. Stated simply, patients become numb in order to protect themselves from the harm or stress of what they fear is to come, or to protect themselves from fear of the unknown in general
overcompensator
is marked by attempts to fight off schemas in a way that is rigid and extreme. It often involves aggressiveness, rebelliousness, violating the rights of other people, and an attempt to dominate them. In this mode, a person who feels emotionally deprived demands affection from others, while a person who believes others cannot be trusted will try to preemptively hurt them before they do. It may also involve obsessiveness in an excessive attempt to control the environment, or forced behaviors, such as extreme forgiveness for someone with a Punitiveness schema.
punitive parent=
beliefs of a patient that they should be harshly punished, perhaps due to feeling “defective”, or making a simple mistake. The patient may feel that they should be punished for even existing. Sadness, anger, impatience, and judgment are directed to the patient and from the patient. The Punitive Parent has great difficulty in forgiving themself even under average circumstances in which anyone could fall short of their standards. The Punitive Parent does not wish to allow for human error or imperfection, thus punishment is what this mode seeks.
demanding parent=
is associated with a strong sense of pressure to achieve. When experiencing this mode, people often feel like their performance is inadequate, no matter how well they do or how much effort they make. Common beliefs also involve the idea that rest, fun, and relaxation are not acceptable and that one’s attention should remain focused on achieving more. It is important to note that while this mode is often accompanied by Punitive Parent, this is not always the case. Clients with the Demanding Parent mode feel pressure and dissatisfaction with their achievements, but not necessarily guilt, shame or feelings of worthlessness.
kijken in schrift naar schema mode model
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avoidance soorten protectors
- Detached protector: Tries to achieve distance from emotions by withdrawing from
relationships and dysfunctional emotion control strategies ( e.g., substance use, dissociation, distraction). - Avoidant protector: Avoids social interaction, challenging situations, and conflicts, as well as intensive sensations or activities.
- Angry protector: Tries to keep others at distance by angry and aggressive behavior.
- Detached self-soother: Tries to avoid emotions by engaging in activities that soothe, stimulate, or distract ( e.g., addictive or compulsive behaviors like gambling, sports, eating, TV, fantasies, sex).
self-aggrendizer=
van overcompensation coping mode.
grandiose, arrogant, self-confident.
soorten overcompensation
- self-aggrandizer (grandiose, self-confident, lack empathy)
- attention and approval seeking (extravagant, inappropriate, exaggerated to get attention)
- perfectionistic over-controller (prevent misfortune, criticism, mistakes or guilt by rumination, perfectionism, planning and control)
- suspicious over-controller (prevent threat by vigilance, suspiciousness)
- bully and attack (prevent loss of control by being aggressive to others)
wat moet je doen met healthy mode
strengthen
wat moet je doen met de coping modes
validate, confront empathically, review pros and cons, reduce, encourage to try alternative techniques
the more the child modes are processed, the less these coping modes are needed
wat moet je doen met maladaptive parent modes
question, limit, fight, reduce -> to develop self-compassion and healthy self-concept to replace the dysfunctional parent mode
wat moet je doen met maladaptive child modes: vulnerable
sooth and comfort, help feel and fulfill needs, process childhood experiences
wat moet je doen met vulnerable child modes: impulsive/angry/undisciplined
let ventilate, set limits, develop ways to deal with anger and desires, get in touch with vulnerability
but most importantly: reach and soothe the vulnerable child mode underneath these externalising modes
indicaties en contraindicaties voor schematherapie
indications: personality disorders, persistent maladaptive emotional and interpersonal problems, complex and chronic course of problems (eg. trauma)
contraindications: states that prevent emotional learning (SUD, low body weight, severe medical diseases), severe ongoing psychological stressors (unstable living, house insecurity, contact with violence)
welke modes worden vaak als eerste aangepast
In most cases, the coping modes are addressed first, as they block the access to the vulnerable child mode. As these coping modes have been protecting patients for many years, they are often reluctant to lower their “shield”.
As soon as the patients reduce their coping
modes, therapists can get access to the vulnerable child mode.
schema therapy approach
- Development and socialization to individual mode model
- Derive treatment aims from mode model
- Validate, question, reduce coping modes
- Soothe and comfort child modes
- Reduce parent modes
- Strengthen healthy modes
typical schema modes in HPD
- abandoned/abused child
- impulsive and undisciplined child
- attention and approval seeking
typical schema modes in NPD
- lonely child mode
- demanding parent mode
coping:
- self-aggrandizer
- detached self-soother (gambling, sud, sex, work, sports etc)
typical schema modes in BPD
- abandoned, abused child
- angry child
- impulsive child mode
- punitive parent mode
coping
- detached protector mode (avoidance)
typical schema modes in DPD
- abandoned/abused or dependent child mode
- demanding parent
- punitive parent
coping:
- compliant surrender mode
typical schema modes for AVPD
- lonely child
- abandoned/abused child
- punitive parent mode
coping:
- avoidant protector mode
- compliant surrender mode (adapt to ideas of others)
typical modes in OCPD
- lonely child mode
- demanding parent mode
coping:
- perfectionistic over-controller mode
- detached self-soother
- self-aggrandizer mode
typical schema modes in PPD
- abandoned/abused child
- angry child
- punitive parent modes
coping:
- suspicious over-controller
- avoidant protector mode
most important techniques in therapeutic relationship
- limited reparenting (of behaving as a good parental figure toward patients throughout the treatment, while at the same time respecting the limits of a professional therapist-patient relationship. -> support, empathy, praise, and providing secure attachment, but also setting adequate limits and encouraging autonomy)
- empathic confrontation (Therapists show understanding and validate the patients’ feelings and needs that led to the problematic behavior, linking them to their early life history and schema mode model. At the same time, therapists also confront patients with the consequences of their behavior in a friendly but explicit way; therapists reveal to patients their own reactions and feelings concerning the patients’ behavior, after checking that their reactions are not connected with their own dysfunctional schemas)
2 experiential techniques in ST
- chair dialogues (the chairs represent different modes, by letting patients switch chairs they can experience and express the modes that are relevant to a certain problem)
- imagery exercises: diagnostic imagery (to explore origin of situations, imagine it and describe in detail in first-person language to get emotions and explore these), imagery rescripting (to reprocess aversive childhood memories, to a better ending)
3 channels are
- feeling (experiential)
- thinking (cognitive)
- doing (behavioural)
3 focus are
- therapeutic relationship
- past (childhood)
- present (in/outside therapy)
ST techniques: feeling
- TR: limited reparenting
- past: imagery rescripting, drama techniques, writing exercises
- present: imagery rescripting of future scenarios, empty chair technique
ST techniques: thinking
- TR: challenging negative beliefs about therapist
- past: psychoeducation, reattribution
- present: understand problems with current mode model, cognitive challenging
ST techniques: doing
- TR: trying out new behaviour towards therapist, empathic confrontation
- past: assertiveness towards caregivers
- present: assertiveness, exposure in vivo, new behaviours, new choices
exp; ST vs. Transference-Focused Psychotherapy for Borderline Personality Disorder Giesen-Bloo et al (2006).
survival analyses: meer mensen leefden/successful completion na 1000 dagen schema therapie dan transferance focused therapy
welke therapieen hadden de minste dropout
ST & MBT
laagste was CTBe
en waar hoogste therapie retention & percentage recovered van cluster c,, par, his en nar
ook schema therapie (tov. clarification oriented psychotherapy and treatment as usual)
Forensic PDs (high security hospitals):
Treatment retention (per year)
- Retention high in both groups
- Significant treatment by time interaction (p < .05).
- ST > TAU during second year of treatment.
- also lower SNAP PD scale scores
BPD severity bij TFP vs ST
ST meer afname in symptomen
welke twee psychotherapieen meest effectief voor borderline
- ST
- MBT (mentalization based treatment)
treatment retention: Combined individual-group ST superior to Group-ST and Specialized-TAU. op alle dimensies. QOL ook hoger. vooral ST-B. ook minder EMSs, modes, meer functional modes.
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- ST integrative model
– Integrates insights and techniques from different schools in a cognitive (schema) model - ST highly acceptable (low dropout) & effective in wide range of PDs
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