Schema Therapy

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Schema Therapy was developed by Dr. Jeffrey E. Young for use in treatment of personality disorders and chronic DSM Axis I disorders, such as when patients fail to respond or relapse after having been through other therapies (for example, traditional cognitive behavioral therapy). Schema Therapy is an integrative psychotherapy[1] combining theory and techniques from previously existing therapies, including cognitive behavioral therapy, psychoanalytic object relations theory, attachment theory, and Gestalt therapy.[2]

Introduction[edit]

Four main theoretical concepts in Schema Therapy are early maladaptive schemas (or simply schemas), coping styles, modes, and basic emotional needs:[3]

  1. In cognitive psychology, a schema is an organized pattern of thought and behavior. It can also be described as a mental structure of preconceived ideas, a framework representing some aspect of the world, or a system of organizing and perceiving new information. In Schema Therapy, schemas specifically refer to early maladaptive schemas, defined as "self-defeating life patterns of perception, emotion, and physical sensation".[4] For instance, a person with an Abandonment schema could be hypersensitive (have an "emotional button" or "trigger") about her perceived value to others, which in turn could make her feel sad and panicky in her interpersonal relationships.
  2. Coping styles are a person's behavioral responses to schemas. Maladaptive coping styles (such as overcompensation, avoidance, or surrender) very often wind up reinforcing the schemas.[5] Continuing the Abandonment example: Having imagined a threat of abandonment in a relationship and feeling sad and panicky, a person using an avoidance coping style might then behave in ways to limit the closeness in the relationship to try to protect herself from being abandoned. The resulting loneliness or even actual loss of the relationship could easily reinforce the person's Abandonment schema.
  3. Modes are mind states that cluster schemas and coping styles into a temporary "way of being" that a person can shift into occasionally or more frequently.[6] For example, a Vulnerable Child mode might be a state of mind encompassing schemas of Abandonment, Defectiveness, Mistrust/Abuse and a coping style of surrendering (to the schemas).
  4. If a patient's basic emotional needs are not met in childhood, then schemas, coping styles, and modes can develop.[7] Some basic needs that have been identified are: connection, mutuality, reciprocity, flow, and autonomy.[7] For example, a child with unmet needs around connection—perhaps due to parental loss to death, divorce, or addiction—might develop an Abandonment schema.

The goal of Schema Therapy is to help patients meet their basic emotional needs by helping the patient learn how to:

  • heal schemas by diminishing the intensity of emotional memories comprising the schema and the intensity of bodily sensations, and by changing the cognitive patterns connected to the schema, and
  • replace maladaptive coping styles and responses with adaptive patterns of behavior.[8]

Techniques used in Schema Therapy including limited reparenting and Gestalt therapy psychodrama techniques such as imagery re-scripting and empty chair dialogues. (See the Techniques section below.)

There is a growing literature of outcome studies on Schema Therapy, where Schema Therapy has shown impressive results. (See the Outcomes studies section below.)

Early maladaptive schemas[edit]

Early maladaptive schemas are self-defeating emotional and cognitive patterns established from childhood and repeated throughout life.[4] They may be made up of emotional memories of past hurt, tragedy, fear, abuse, neglect, unmet safety needs, abandonment, or lack of normal human affection in general. Early maladaptive schemas can also include bodily sensations associated with such emotional memories. Early maladaptive schemas can have different levels of severity and pervasiveness: the more severe the schema, the more intense the negative emotion when the schema is triggered and the longer it lasts; the more pervasive the schema, the greater the number of situations that trigger it.

Schema domains[edit]

Schema domains are five broad categories of unmet needs into which are grouped 18 early maladaptive schemas identified by Young, Klosko & Weishaar (2003):[3]

  1. Disconnection/Rejection includes 5 schemas: Abandonment/Instability, Mistrust/Abuse, Emotional Deprivation, Defectiveness/Shame, Social Isolation/Alienation
  2. Impaired Autonomy/Performance includes 4 schemas: Dependence/Incompetence, Vulnerability to Harm or Illness, Enmeshment/Undeveloped Self, Failure
  3. Impaired Limits includes 2 schemas: Entitlement/Grandiosity, Insufficient Self-Control/Self-Discipline
  4. Other-Directedness includes 3 schemas: Subjugation, Self-Sacrifice, Approval-Seeking/Recognition-Seeking
  5. Overvigilance/Inhibition includes 4 schemas: Negativity/Pessimism, Emotional Inhibition, Unrelenting Standards/Hypercriticalness, Punitiveness

Schema modes[edit]

Schema modes are momentary mind states which every human being experiences at one time or another.[6] A schema mode consists of a cluster of schemas and coping styles. Life situations that a person finds disturbing or offensive, or arouse bad memories, are referred to as "triggers" that tend to activate schema modes. In psychologically healthy persons, schema modes are mild, flexible mind states that are easily pacified by the rest of their personality. In patients with personality disorders, schema modes are more severe, rigid mind states that may seem split off from the rest of their personality.

Identified schema modes[edit]

Young, Klosko & Weishaar (2003) identified 10 schema modes grouped into four categories. The four categories are: Child modes, Dysfunctional Coping modes, Dysfunctional Parent modes, and the Healthy Adult mode. The four Child modes are: Vulnerable Child, Angry Child, Impulsive/Undisciplined Child, and Happy Child. The three Dysfunctional Coping modes are: Compliant Surrenderer, Detached Protector, and Overcompensator. The two Dysfunctional Parent modes are: Punitive Parent and Demanding Parent.

  • Angry Child is fueled mainly by feelings of victimization or bitterness, leading towards negativity, pessimism, jealousy, and rage. While experiencing this schema mode, a patient may have urges to yell, scream, throw/break things, or possibly even injure herself or harm others. The Angry Child schema mode is enraged, anxious, frustrated, self-doubting, feels unsupported in ideas, and vulnerable.
  • Impulsive Child is the mode where anything goes. Behaviors of the Impulsive Child schema mode may include: reckless driving, substance abuse, cutting oneself, suicidal thoughts, gambling, or fits of rage, such as punching a wall when "triggered" or laying blame of circumstantial difficulties upon innocent people. Unsafe sex, rash decisions to run away from a situation without resolution, tantrums perceived by peers as infantile, and so forth are a mere few of the behaviors which a patient in this schema mode might display. Impulsive Child is the rebellious and careless schema mode.
  • Detached Protector 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 Detached Protector. 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.
  • Abandoned Child is the mode in which a patient may feel defective in some way, thrown aside, unloved, obviously alone, or may be in a "me against the world" mindset. The patient may feel as though peers, friends, family, and even the entire world have abandoned her. Behaviors of patients in Abandoned Child include, but are not limited to: falling into major depression, pessimism, feeling unwanted, feeling unworthy of love, and personality traits perceived as irredeemable flaws. 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.
  • Punitive Parent is identified by beliefs of a patient that she should be harshly punished, perhaps due to feeling "defective", or making a simple mistake. She may feel that she 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 herself even under average circumstances in which anyone could fall short of her standards. The Punitive Parent does not wish to allow for human error or imperfection, thus punishment is what this mode seeks.
  • Healthy Adult is the mode that Schema Therapy aims to help a patient achieve as the long-lasting state of well-being. The Healthy Adult is comfortable making decisions, is a problem-solver, thinks before acting, is appropriately ambitious, sets limits and boundaries, nurtures self and others, forms healthy relationships, takes on all responsibility, sees things through, and enjoys/partakes in enjoyable adult activities and interests with boundaries enforced, takes care of his/her physical health, and values herself. In this schema mode the patient focuses on the present day with hope and strives toward the best tomorrow possible. The Healthy Adult forgives the past, no longer sees herself as a victim (but as a survivor), and expresses all emotions in ways which are healthy and cause no harm.

Techniques in Schema Therapy[edit]

Treatment plans in Schema Therapy generally encompass three basic classes of techniques: cognitive, experiential, and behavioral (in addition to the basic healing components of the therapist–patient relationship).[9] Cognitive strategies expand on standard cognitive behavioral therapy techniques such as listing pros and cons of a schema, testing the validity of a schema, or conducting a dialogue between the "schema side" and the "healthy side".[10] Experiential and emotion focused strategies expand on standard Gestalt therapy psychodrama and imagery techniques.[11] Behavioral pattern-breaking strategies expand on standard behavior therapy techniques, such as role playing an interaction and then assigning the interaction as homework.[12] One of the most central techniques in Schema Therapy is the use of the therapist–patient relationship, specifically through a process called "limited reparenting".[13]

From an integrative psychotherapy perspective, limited reparenting and the experiential techniques, particularly around changing modes, could be seen as actively changing what psychoanalysis has described as object relations, or what psychoanalyst Thomas Ogden called internal object relations.[14] Historically, mainstream psychoanalysis tended to reject active techniques—such as Fritz Perls' Gestalt therapy work or Franz Alexander's "corrective emotional experience"—but contemporary relational psychoanalysis (led by analysts such as Lewis Aron, and building on the ideas of earlier unorthodox analysts such as Sándor Ferenczi) is more open to active techniques. It is notable that in a head to head comparison of a psychoanalytic object relations treatment (Otto F. Kernberg's transference focused psychotherapy) and Schema Therapy, Schema Therapy had significantly better outcomes.[15]

Limited reparenting[edit]

The process of limited reparenting[16] is the heart of treatment in Schema Therapy. It has been gaining strong empirical support through the results of two randomized controlled trials of Schema Therapy. These outcome studies have found that a large percentage of patients with borderline personality disorder can achieve full recovery across the complete range of symptoms.[15][17] The dropout rate in these studies was notably extremely low. The patients in these studies attributed a great deal of the effectiveness of the treatment and the low dropout rate to limited reparenting.

Meeting needs and establishing a secure attachment: Limited reparenting flows directly from Schema Therapy's assumption that early maladaptive schemas and modes arise when core needs are not met. Schema Therapy's aim is to meet these needs by helping the patient find the experiences that were missed in early childhood that will serve as an antidote to the damaging experiences that led to maladaptive schemas and modes. Limited reparenting, paralleling healthy parenting, involves the establishment of a secure attachment with the therapist, within the bounds of a professional relationship, doing what he/she can to meet these needs. Research spanning a wide range of disciplines[citation needed] supports the notion that secure attachment is at the root of adaptive functioning, well-being and flourishing.

The broad range of limited reparenting: The focus of limited reparenting spans a broad range of needs including early connection, joy, adequate limits, and autonomy. Just as the process of parenting takes widely different forms, limited reparenting may involve warmth and nurturance, firmness, self-disclosure, confrontation, playfulness, and setting limits amongst other things. It takes the form of simultaneous tenderness and firmness through what is called "empathic confrontation". It will also vary depending upon the phase of treatment. For this reason, Schema Therapy cannot be typified by a particular stance such as neutrality, firmness or nurturance. It is best typified by the broad range of responses and inclinations on the part of the therapist it incorporates, its flexibility, and the organization of these responses around the core needs of the patient.

Limited reparenting and trusting needs: The process of limited reparenting involves welcoming and encouraging the patient's dependency on the therapist (the minimal amount of dependency necessary to keep the patient in therapy). The therapist's responses to the patient's affect becomes internalized by the patient and supports the patient's Healthy Adult mode. This Healthy Adult mode becomes a strong foundation for the establishment of autonomy. In this way limited reparenting is based upon trust of the patient's dependency needs and a belief that is more effective to meet them than fight them.

The key steps in limited reparenting: Limited reparenting involves reaching the Vulnerable Child mode and reassuring, being firm with or setting limits on the avoidant and compensatory coping styles. In the midst of this, the therapist helps to provide constructive outlets for what is called the Angry Child mode. In addition, it often requires that the therapist help the patient confront punitive, demanding, or subjugating parent modes or schemas. These steps are usually facilitated by the use of guided imagery, an experiential technique that allows the therapist to establish more direct contact with the various modes and schemas.

Imagery[edit]

Guided imagery is an experiential technique often used early in Schema Therapy to more clearly and deeply understand schemas and modes.[18] This is accomplished by:

  1. eliciting upsetting childhood memories in the form of images of experiences with mother, father, or other significant people;
  2. asking the patient to carry on dialogues with these people;
  3. asking the patient what she needs from significant others and understanding these needs in terms of the associated schema; and
  4. asking the patient to identify which current situations have the same emotions as the images from early childhood and, thus, clarifying the links between early memories and current triggers of schemas and modes.

Imagery is also often an important element of the change phase. This involves a process called "imagery rescripting" through which painful memories are revised in ways that allow for the patient to meet their needs. In instances where parents or significant others were, and remain, unable to meet the patient's needs, this involves the therapist entering into an image and serving as a transitional source of healthy parenting. This leads to a secure attachment developing between the patient and therapist, a form of attachment that is known to lead growth and integration.[citation needed]

Imagery during the change phase also involves encouraging the patient to express emotions. This will occur within an image or role-play during a session and not necessarily with significant others. Imagery is also used to help patients grieve for the losses in their life and to overcome psychological trauma. In the case of trauma, imagery rescripting involves a reworking of the emotional memories in the direction of meeting needs such as safety.

Flash cards[edit]

Flash cards contain written statements that are read by the patient in-between sessions.[19] They are developed by the therapist or collaboratively by therapist and patient. The statements are similar to those made by a parent to a child at the developmental age that the patient currently experiences their Vulnerable Child mode. They serve as links to the therapist and, as such, as transitional objects, especially in the early phases of treatment of work on problems rooted in early attachment. The messages and sentiments expressed in the cards are gradually internalized and help develop the Healthy Adult mode.

Flash cards are often developed for each type of challenging situation and phase of treatment. They can take various forms such notes or poems, depending of the creativity of the therapist and the developmental level of the Vulnerable Child mode, and may be carefully thought-out or spontaneous gestures. Patients who suffer from problems such as borderline personality disorder often find flash cards to be especially powerful.[citation needed]

Chair work[edit]

Chair work involves the patient moving between two chairs as she dialogues between different parts of herself such as a "schema side" and "healthy side" or a Detached Protector mode and the Healthy Adult mode.[20] Dialogues can also take place between the patient and imagined significant others for such purposes as reaching closure or practicing assertiveness. Imagery work and chair work are frequently blended with one another.

Schema Diary[edit]

A Schema Diary is a form that the patient fills out in-between sessions that provides a guide for the patient to organize her experience in terms of what she has been learning in the therapy.[21] The patient describes her schema driven reactions in terms of thoughts, feelings, behaviors, underlying schemas, healthy perspectives and realistic concerns, overreactions, and healthy behavior. It is a summary of all the major elements and stages of the therapy process and, as such, provides an important template. For some patients and therapists the Schema Diary is internalized and not used explicitly, especially at later stages in the therapy. For other therapist–patient pairs it becomes an important tool to further the internalization of Healthy Adult processes.

Outcome studies on Schema Therapy[edit]

Schema Therapy vs transference focused psychotherapy outcomes (Archives of General Psychiatry 2006)[edit]

Dutch investigators, including Dr. Josephine Giesen-Bloo and Dr. Arnoud Arntz (the project leader), compared Schema Therapy (also known as schema focused therapy or SFT) with transference focused psychotherapy (TFP) in the treatment of borderline personality disorder. 86 patients were recruited from four mental health institutes in the Netherlands. Patients in the study received two sessions per week of SFT or TFP for three years. After three years, full recovery was achieved in 45% of the patients in the SFT condition, and in 24% of those receiving TFP. One year later, the percentage fully recovered increased to 52% in the SFT condition and 29% in the TFP condition, with 70% of the patients in the SFT group achieving "clinically significant and relevant improvement". Moreover, the dropout rate was only 27% for SFT, compared with 50% for TFP.

Patients began to feel and function significantly better after the first year, with improvement occurring more rapidly in the SFT group. There was continuing improvement in subsequent years. Thus investigators concluded that both treatments had positive effects, with Schema Therapy clearly more successful.[15]

Less intensive outpatient, individual schema therapy (Behaviour Research and Therapy 2009)[edit]

Dutch investigators, including Dr. Marjon Nadort and Dr. Arnoud Arntz, assessed the effectiveness of Schema Therapy in the treatment of borderline personality disorder when utilized in regular mental health care settings. A total of 62 patients were treated in eight mental health centers located in the Netherlands. The treatment was less intensive along a number of dimensions including a shift from twice weekly to once weekly sessions during the second year. Despite this, there was no lessening of effectiveness with recovery rates that were at least as high and similarly low dropout rates.[17]

Pilot study of group Schema Therapy for BPD (Journal of Behavior Therapy and Experimental Psychiatry 2009)[edit]

Investigators Dr. Joan Farrell, Ida Shaw and Dr. Michael Webber at the Indiana University School of Medicine Center for BPD Treatment & Research tested the effectiveness of adding an eight-month, 30-session Schema Therapy group to treatment-as-usual (TAU) for borderline personality disorder (BPD) with 32 patients. The dropout rate was 0% for those patients who received group Schema Therapy in addition to TAU and 25% for those who received TAU alone. At the end of treatment, 94% of the patients who received group Schema Therapy in addition to TAU compared to 16% of the patients receiving TAU alone no longer met BPD diagnostic criteria. The Schema Therapy group treatment led to significant reductions in symptoms and global improvement in functioning. The large positive treatment effects found in the group Schema Therapy study suggest that the group modality may augment or catalyze the active ingredients of the treatment for BPD patients.[22] As of 2014, a collaborative randomized controlled trial is under way at 14 sites in six countries to further explore this interaction between groups and Schema Therapy.[23]

Cost effectiveness of Schema Therapy[edit]

Even the most intensive version of Schema Therapy mentioned in the first study was found to be cost effective. An economic analysis conducted by the authors of the study indicated that, for each year Schema Therapy patients were in the study, Dutch society benefited from a net gain of €4,500 Euros per patient (the equivalent of about $5,700 US dollars), despite the cost-intensive treatment.[24]

Notes[edit]

References[edit]

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