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 needswe 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.     spontaneity and play

5.     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 Domains1.    Disconnection and rejection

2.    Impaired Autonomy and performance3.    Impaired Limits

4.    Other directedness5.    Overvigilance and Inhibition

18 Early Maladaptive Schemasi.e. Disconnection and Rejection domain

Abandonment/InstabilityMistrust/Abuse

Emotional DeprivationDefectiveness/Shame

Social Isolation/AlienationYoung, 1999; Young et. al., 2003

Unhelpful strategies of coping with Schemas

Surrendering (giving in)Compliant and dependent

Avoidance (running away)Substance misuse

Social/emotional detachmentStimulation/workaholic

Overcompensation (fighting back)Aggression

Excessive Self-RelianceManipulationPerfectionism

Demandingness

Presentations suitable for ST 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 Education1. Identify problems and therapy goals2. Assess suitability3. Identify life patterns, link schema eruptions to present probs4. Identify coping styles5. Identify modes6. Educate; about Core Needs, Schema Development, clarify links

between schemas and current probs

Phase two: ChangeDiscredit Schemas; Cognitive, Experiential techniques and

Behavioural pattern breaking

Cognitive Interventions

Evidence for and against a schema (past and present)

Reframing past, re-attribution (discredit evidence 'for')

Alternative explanations Schema and Healthy side dialogues Schema Flashcards 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

CriticalParent

HA

Angry/impulsive Child

____________ Vulnerable

Child

DetachedProtector

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)

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

• 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 Transference-Focused 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