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Schema Therapy: An Effective Approach to Personality Disorder Patients

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* Schema Therapy provides a plan for how to integrate into cognitive therapy in an empirically validated way - the experiential techniques of other therapy systems. – PowerPoint PPT presentation

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Title: Schema Therapy: An Effective Approach to Personality Disorder Patients


1
(No Transcript)
2
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

3
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

4
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

5
DEFINING BPD DSMIV
  • Affect
  • Emotional reactivity
  • Difficulty with anger
  • Behavior
  • Suicidal behavior, SIB
  • Impulsivity - potentially self-damaging
  • Interpersonal
  • Abandonment fears
  • Stormy, idealize then devalue

6
DEFINING BPD DSMIV cont
  • Self
  • Unstable identity
  • Emptiness
  • Reality testing
  • Transient, stress- related
  • paranoid episodes, dissociation.
  • Any combination of 5 symptoms earns a BPD
    diagnosis.

7
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

8
NEUROBIOLOGY OF PERSONALITY DISORDER BPD
  • Overactive Amygdala (the engine)
  • Intense emotional reactivity - persistent unhappy
    mood
  • dissociation psychotic thinking
  • Other areas of dysfunction
  • Right Hemisphere - difficulty with self-other
    boundaries
  • Orbital Frontal Cortex - impulsivity
  • 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

9
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

10
BACKGROUND
  • Schema Therapy was developed to Improve the
    Effectiveness of
  • Cognitive Therapy with
  • Personality Disorder patients
  • CT for MDD - Becks Studies
  • 60 Success rate
  • 30 relapse at 1 year

11
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

12
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

13
MALADAPTIVE SCHEMAS
  • Abandonment
  • Mistrust Abuse
  • Emotional Deprivation
  • Defectiveness
  • Failure
  • Unrelenting Standards
  • Punitiveness
  • Dependence
  • Jeffrey Young

14
MORE SCHEMAS
  • Self-Sacrifice
  • Approval Seeking
  • Negativity
  • Entitlement
  • Insufficient Self Control
  • Emotional Inhibition
  • Social Isolation
  • Vulnerability
  • Enmeshment

15
  • Early Maladaptive Schemas
  • develop when specific
  • childhood needs
  • are not met.

16
CORE CHILDHOOD NEEDS
  • Safety
  • Empathy
  • Acceptance Praise
  • Guidance Protection
  • Stable Base, Predictability
  • Love, Nurturing Attention
  • Validation of Feelings Needs

17
SCHEMAS DEVELOP WHEN
  • Toxic frustration of needs
  • Traumatization, victimization, mistreatment
  • Over-indulgence
  • Selective internalization or identification
  • Temperament or neurobiology
  • can play a role

18
SCHEMAS LIFETRAPS
  • They erupt when
  • triggered by
  • everyday events
  • related to the schema.
  • They may not fit
  • what is needed in
  • ones adult life.

19
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

20
  • STEPS IN
  • SCHEMA THERAPY

21
STEPS
  • Empathize with current problems validate
    emotions
  • Life History
  • Outline Therapy Goals
  • ID Schemas education awareness
  • ID Maladaptive Coping Strategies
  • ID Schema Modes

22
STEP ONE
  • Engage a relationship -avoidant patient in a
    healing therapeutic relationship.
  • Will transfer to improved interpersonal
    functioning outside of psychotherapy.

23
SCHEMA HEALING
  • We are trying to create a healthy healing,
    reparenting environment so they can finish the
    steps in childhood development that they missed

24
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

25
LIMITED REPARENTING MEANS GIVING PATIENTS
  • SAFETY
  • RESPECT
  • VALIDATION OF FEELINGS
  • SENSITIVITY TO TRIGGERS
  • PATIENCE
  • UNDERSTANDING
  • SUPPORT COMFORT
  • CONSISTENCY
  • HEALTHY BOUNDARIES

26
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

27
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

28
THERAPIST STYLE
  • Selective self-disclosure
  • Genuine, transparent and warm
  • When schema driven behavior occurs point it out
    but dont react negatively

29
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.

30
STEP 2 LIFE HISTORY-
  • In contrast to CBT , SFT includes childhood

31
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

32
JOY PSYCH. HISTORY
  • Adopted
  • First hospitalization- suicide 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

33
JOY - DIAGNOSES .
  • Axis I MDD, PTSD, hx ED
  • Axis II BPD
  • Anger
  • Emotional reactivity
  • Suicide attempts
  • Impulsivity
  • Stormy relationships
  • Abandonment fears
  • Emptiness

34
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

35
  • Usually,
  • schemas coping styles
  • are not in
  • conscious awareness.
  • But can be recognized
  • when pointed out to
  • a person.

36
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

37
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, Ill die.
  • I am helpless and
  • my situation is hopeless.

38
SCHEMA PERPETUATION
  • COGNITIVE DISTORTIONS
  • All or None thinking
  • Overgeneralization
  • Disqualifying the positive
  • Jumping to conclusions
  • Magnification
  • Should statements
  • Personalization

39
ANY POSITIVE RESULT MUST BE
WRITTEN DOWN
  • No memory file folders exist to store
  • the info that contradicts core beliefs in so,
  • Dont 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.

40
STEP 4 ID MALADAPTIVE COPING STRATEGIES
  • Childhood survival strategies
  • can recur when Schema Issues
  • are triggered.

41
PATIENTS COPING STRATEGIES ARE NORMAL REACTIONS
TO CRISIS
  • OVERCOMPENSATION FIGHT
  • WITHDRAWAL FLIGHT
  • SURRENDER FREEZE
  • but they use them
  • most of the time

42
FAULTY COPING DEFENSES DEVELOP
  • Overcompensate criticize others, drive people
    away
  • Surrender accept
  • abusive relationships
  • Avoidance - isolate

43
SURRENDER BEHAVIORS
  • Attempts to be a perfectionist
  • Focuses on the negative
  • Minimizes importance of desires
  • Treats self and others harshly
  • and punitively

44
AVOIDANCE BEHAVIORS
  • Avoids
  • Relationships
  • Employment
  • Negative feelings
  • Social situations
  • and groups

Ive decided to quit my job, drop out Of society,
and wear live animals as hats.
45
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

46
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.

47
DETACHED PROTECTOR
  • E.g., Dissociation, flatness

48
ANGRY CHILD
  • Stereotype of person with BPD

49
VULNERABLE CHILD
  • Fear, regression e.g., fetal position

50
PUNITIVE PARENT
  • Mode where self-injury suicide attempts occur

51
HEALTHY ADULT
  • The desired result of Schema Therapy

52
SCHEMA THERAPY STAGES
  • Emotional bonding
  • Get around Detached Protector
  • Heal Abandoned Vulnerable Child
  • Banish Punitive Parent
  • Channel Angry Child effectively
  • Develop Healthy Adult

53
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.

54
IM 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

55
  • HIGHLIGHTS
  • OF SCHEMA THERAPY TECHNIQUE

56
EXPERIENTIAL SCHEMA WORK
  • Counter schema modes
  • I know in my head
  • that I am not evil,
  • but I feel evil

57
GESTALT TECHNIQUES
  • Empty Chair Dialogues
  • Example reduce the hold
  • of the Punitive Parent.

58
SAFE PLACE IMAGE
59
SCHEMA ORIGINS WORK
60
COMPARED TO AXIS I TREATMENT
  • More emphasis on
  • 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

61
EMPIRICAL VALIDATION BPD PATIENTS
  • RCT with 4 sites and 86 BPD patients
  • 2 years Individual SFT
  • Arntz, et al.,
  • Arch Gen Psychiatry June, 2006
  • Cured 45 vs. 22 TFP
  • Significant improvements in quality of life

62
The BASE Program
  • People with
  • Borderline pd
  • Awareness
  • Skills
  • Empowerment

63
BASE HAS 4 OVERLAPPING COMPONENTS
  • Psychoeducation about BPD
  • Emotional Awareness Training
  • Skills Training
  • Schema focused Therapy

64
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

65
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

66
Inpatient BASE Program Results
Borderline Syndrome Index Pre Treatment
BPD
patients meeting diagnosis criteria
Not BPD
67
Not BPD
Borderline Syndrome Index Post Treatment
Clinical Statistical Significance
BPD
68
GAF Score Change
mean 57.51, SD 5.91
POST
Paired Sample t-test t -17.55(36), plt .01
PRE
mean 28.16, SD 10.70
69
Self-Injurious Behavior
70
Suicide Attempts
71
Percent of Patients Hospitalized
72
Mean Number Hospitalizations
6.0
.24
One Year before
One Year After
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