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 WHAT IS A PERSONALITY DISORDER?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 Affect 1.1. Emotional reactivityEmotional reactivity2.2. Difficulty with angerDifficulty with anger
BehaviorBehavior3.3. Suicidal behavior, SIBSuicidal behavior, SIB4.4. Impulsivity - potentially self-damagingImpulsivity - potentially self-damaging
Interpersonal Interpersonal 5.5. Abandonment fearsAbandonment fears6.6. Stormy, idealize then devalueStormy, idealize then devalue
DEFINING BPD DSMIV: cont: cont
Self7. Unstable identity
8. Emptiness
Reality testing9. Transient, stress- related
paranoid episodes, dissociation.
Any combination of 5 symptoms earns a BPD diagnosis.
HYPOTHESIZED ETIOLOGY
Person with BPDPerson with BPD
Emotional Sensitivity Negative attentional biasBiology? Genetics? Temperament?
+
Invalidating Environment
Emotional Awareness Deficits Emotional Regulation Deficits Cognitive Distortions Maladaptive Core Schemas
NEUROBIOLOGYOF PERSONALITY
DISORDER BPDOveractive 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
PD CHALLENGE TO TO COGNITIVE THERAPYCOGNITIVE 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 SCHEMASMALADAPTIVE SCHEMAS
Abandonment Mistrust & Abuse Emotional Deprivation Defectiveness Failure Unrelenting Standards Punitiveness Dependence Jeffrey Young
MORE SCHEMAS
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 SCHEMAS DEVELOP WHENDEVELOP WHEN
Toxic frustration of needs
Traumatization, victimization, mistreatment
Over-indulgence
Selective internalization or identification
Temperament or neurobiology
can play a role
SCHEMAS = LIFETRAPSThey 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 STEPS IN
SCHEMA SCHEMA THERAPYTHERAPY
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 HEALINGSCHEMA HEALING
We are trying to create a healthy healing, reparenting environment so they can finish the steps in childhood development that they missed
We must find ways to validate their feelings We must find ways to validate their feelings and needs—and needs—
While setting limits on and challenging While setting limits on and challenging their unhealthy behaviors.their unhealthy behaviors.
HEAL HERE, HEAL HERE,
TO TAKE ON THE OUTSIDE WORLDTO TAKE ON THE OUTSIDE WORLD
OUR ROLE IS TO OUR ROLE IS TO RE-PARENTRE-PARENT IN A LIMITED WAY IN A LIMITED WAY
LIMITED REPARENTING MEANS LIMITED REPARENTING MEANS GIVING PATIENTSGIVING PATIENTS
SAFETYSAFETY RESPECTRESPECT VALIDATION OF FEELINGSVALIDATION OF FEELINGS SENSITIVITY TO TRIGGERSSENSITIVITY TO TRIGGERS PATIENCEPATIENCE UNDERSTANDINGUNDERSTANDING SUPPORT & COMFORTSUPPORT & COMFORT CONSISTENCYCONSISTENCY HEALTHY BOUNDARIESHEALTHY BOUNDARIES
VALIDATIONVALIDATION
Communicate understanding and Communicate understanding and acceptance of whatever emotion they acceptance of whatever emotion they express –e.g. crying, venting in an express –e.g. crying, venting in an appropriate placeappropriate place
When necessary for safety, question their When necessary for safety, question their choice of action and suggest healthy choice of action and suggest healthy alternativesalternatives
THERAPIST STYLE
Empathic Confrontation Empathic Confrontation
Relentless, but not blaming or criticalRelentless, but not blaming or critical
Stress consequences of not Stress consequences of not changingchanging
Stress the advantages of changingStress the advantages of changing Active coaching, model Healthy AdultActive 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 NUDGENegative Core Beliefs
By the way we treat patients in our By the way we treat patients in our interactions with them.:interactions with them.:
This is where our role is critical – our This is where our role is critical – our responses will either reinforce negative responses will either reinforce negative core beliefs or challenge them. core beliefs or challenge them.
STEP 2: LIFE HISTORY-
In 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 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
JOY - DIAGNOSES.Axis I – MDD, PTSD, hx ED
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
• 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.
CORE BELIEFS - THECOGNITIVE PART OF SCHEMAS
SCHEMA PERPETUATION
COGNITIVE DISTORTIONS
• All or None thinking
• Overgeneralization
• Disqualifying the positive
• Jumping to conclusions
• Magnification
• Should statements
• Personalization
ANY POSITIVE RESULT ANY POSITIVE RESULT
MUST BE WRITTEN DOWNMUST BE WRITTEN DOWN
No memory file folders exist to store No memory file folders exist to store the info that contradicts core beliefs in so,the info that contradicts core beliefs in so,
Don’t expect them to remember getting a Don’t expect them to remember getting a positive response from you until it has positive response from you until it has happened many times. happened many times.
e.g., “Are you mad at me?”e.g., “Are you mad at me?”
Until a new positive belief forms they will Until a new positive belief forms they will keep testing. 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 FAULTY COPING DEFENSES DEVELOPDEFENSES DEVELOP
Overcompensate – Overcompensate – criticize criticize others, drive people awayothers, drive people away
Surrender – Surrender – accept accept
abusive relationshipsabusive relationships
Avoidance - Avoidance - isolateisolate
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: • Relationships
• Employment
• Negative feelings
• Social situations
and groups
I’ve decided to quit my I’ve decided to quit my job, drop outjob, drop outOf society, and wear Of society, and wear live animals as hats.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 STRATEGYTREATMENT STRATEGY
We teach them to understand their intense We teach them to understand their intense reactions to triggers so that they can learn reactions to triggers so that they can learn to control the intense emotion, stop and to control the intense emotion, stop and think and make healthier choices.think and make healthier choices.
This therapeutic learning occurs in small This therapeutic learning occurs in small steps.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 HIGHLIGHTS
OFOF SCHEMA SCHEMA THERAPY THERAPY TECHNIQUETECHNIQUE
EXPERIENTIAL SCHEMA WORK
Counter schema modes:Counter schema modes:
““I know in my headI know in my head
that I am not evil,that I am not evil,
but I feel 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 COMPARED TO AXIS I TREATMENTTREATMENT
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
EMPIRICAL VALIDATION EMPIRICAL VALIDATION –– BPD PATIENTSBPD PATIENTS
• RCT with 4 sites and 86 BPD patients
• 2 years Individual SFTArntz, et al.,
Arch Gen Psychiatry June, 2006
“Cured” – 45% vs. 22% TFP
Significant improvements in quality of life
The BASE Program
People with
Borderline pdAwareness 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-up11
Inpatient BASE Program ResultsInpatient BASE Program Results
2.001.00
BS1Clin
100
80
60
40
20
0
Per
cent
85.71%
14.29%
BS1Clin
Borderline Syndrome Index Pre Treatment
“Not” BPD
BPD
% p
atie
nts
mee
ting
diag
nosi
s cr
iteria
2.001.00
BS2Clin
100
80
60
40
20
0
Per
cent
BS2Clin
“Not” BPD
BPD
Borderline Syndrome IndexPost Treatment
Clinical & Statistical Significance
GAF Score Change
PRE
POST
Paired Sample t-testt = -17.55(36), p< .01
mean = 28.16, SD = 10.70
mean = 57.51, SD = 5.91
Self-Injurious Behavior
0
10
20
30
40
50
60
70
80
90
100
Pre-treat Post 6 mos. 1 year
Suicide Attempts
0
10
20
30
40
50
60
70
80
90
100
Pre-treat Post 6 mos. 1 year
Percent of Patients Hospitalized
0
10
20
30
40
50
60
70
80
90
100
Year Before 6 mos. Post 1 year post
Mean Number Hospitalizations
0
1
2
3
4
5
6
Pre-Treatment Post-treatmentOne Year before One Year After
.24
6.0