Transcript Schema Therapy: An Effective Approach to Personality

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?
 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
 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:
Affect
1. Emotional reactivity
2. Difficulty with anger
Behavior
3. Suicidal behavior, SIB
4. Impulsivity - potentially self-damaging
Interpersonal
5. Abandonment fears
6. Stormy, idealize then devalue
DEFINING BPD DSMIV: cont
Self
7. Unstable identity
8. Emptiness
Reality testing
9. 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
NEUROBIOLOGY
OF PERSONALITY
DISORDER BPD
Overactive Amygdala (the engine)
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Intense emotional reactivity - persistent unhappy mood
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dissociation & psychotic thinking
Other areas of dysfunction
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Right Hemisphere - difficulty with self-other boundaries
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Orbital Frontal Cortex - impulsivity
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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
• 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
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
 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
 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
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Abandonment
Mistrust & Abuse
Emotional Deprivation
Defectiveness
Failure
Unrelenting Standards
Punitiveness
Dependence
Jeffrey Young
MORE SCHEMAS
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Self-Sacrifice
Approval Seeking
Negativity
Entitlement
Insufficient Self Control
Emotional Inhibition
Social Isolation
Vulnerability
Enmeshment
Early Maladaptive Schemas
develop when specific
childhood needs
are not met.
CORE CHILDHOOD NEEDS
 Safety
 Empathy
 Acceptance & Praise
 Guidance & Protection
 “Stable Base”, Predictability
 Love, Nurturing & Attention
 Validation of Feelings & Needs
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
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
To help patients get their
core needs met
in an adaptive manner
through changing their
maladaptive schemas and
coping styles
STEPS IN
SCHEMA
THERAPY
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
 Engage a relationship -avoidant patient in
a healing therapeutic relationship.
 Will transfer to improved interpersonal
functioning outside of psychotherapy.
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
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
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SAFETY
RESPECT
VALIDATION OF FEELINGS
SENSITIVITY TO TRIGGERS
PATIENCE
UNDERSTANDING
SUPPORT & COMFORT
CONSISTENCY
HEALTHY BOUNDARIES
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
 Empathic Confrontation
 Relentless, but not blaming or critical
 Stress consequences of not
changing
 Stress the advantages of changing
 Active coaching, model Healthy Adult
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
 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 HISTORYIn contrast to CBT , SFT includes childhood
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
 Adopted
 First hospitalizationsuicide 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
. PTSD, hx ED
Axis I – MDD,
Axis II BPD
• Anger
• Emotional reactivity
• Suicide attempts
• Impulsivity
• Stormy relationships
• Abandonment fears
• Emptiness
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
Usually,
schemas & coping styles
are not in
conscious awareness….
But can be recognized
when pointed out to
a person.
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
• 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
COGNITIVE DISTORTIONS
• All or None thinking
• Overgeneralization
• Disqualifying the positive
• Jumping to conclusions
• Magnification
• Should statements
• Personalization
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
Childhood survival strategies
can recur when Schema Issues
are triggered.
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
 Overcompensate – criticize
others, drive people away
 Surrender – accept
abusive relationships
 Avoidance - isolate
SURRENDER BEHAVIORS
• Attempts to be a perfectionist
• Focuses on the negative
• Minimizes importance of
•
desires
Treats self and others harshly
and punitively
AVOIDANCE BEHAVIORS
Avoids:
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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
• 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
 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
 E.g., Dissociation, flatness
ANGRY CHILD
 Stereotype of
person with
BPD
VULNERABLE CHILD
 Fear, regression e.g., fetal
position
PUNITIVE PARENT
 Mode where self-injury
& suicide attempts
occur
HEALTHY ADULT
 The desired result of Schema
Therapy
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
 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”
 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
HIGHLIGHTS
OF SCHEMA
THERAPY
TECHNIQUE
EXPERIENTIAL SCHEMA WORK
Counter schema modes:
“I know in my head
that I am not evil,
but I feel evil”
GESTALT TECHNIQUES
“Empty Chair” Dialogues
Example: reduce the hold
of the Punitive Parent.
SAFE PLACE IMAGE
SCHEMA
ORIGINS
WORK
COMPARED TO AXIS I
TREATMENT
 More emphasis on:
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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
• RCT with 4 sites and 86
BPD patients
• 2 years Individual SFT
Arntz, et al.,
Arch Gen Psychiatry June, 2006
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“Cured” – 45% vs. 22% TFP
Significant improvements
in quality of life
The BASE Program
People with
Borderline pd
Awareness
Skills &
Empowerment
BASE HAS 4
OVERLAPPING
COMPONENTS
 Psychoeducation about BPD
 Emotional Awareness Training
 Skills Training
 Schema –focused Therapy
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
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
80
Percent
60
40
20
Inpatient
BASE
Program
Results
Borderline Syndrome Index Pre Treatment
% patients meeting diagnosis criteria
100
BPD
85.71%
“Not” BPD
14.29%
0
1.00
2.00
BS1Clin
BS2Clin
100
“Not” BPD
80
Percent
60
Borderline Syndrome Index
Post Treatment
Clinical & Statistical
Significance
40
20
0
BPD
GAF Score Change
mean = 57.51, SD = 5.91
Paired Sample t-test
t = -17.55(36), p< .01
PRE
mean = 28.16, SD = 10.70
POST
Self-Injurious Behavior
100
90
80
70
60
50
40
30
20
10
0
Pre-treat
Post
6 mos.
1 year
Suicide Attempts
100
90
80
70
60
50
40
30
20
10
0
Pre-treat
Post
6 mos.
1 year
Percent of Patients Hospitalized
100
90
80
70
60
50
40
30
20
10
0
Year Before
6 mos. Post
1 year post
Mean Number Hospitalizations
6
5
6.0
4
3
2
1
.24
0
Pre-Treatment
One
Year before
Post-treatment
One
Year After