Schema-focused Therapy : New Hope for Treatment of Personality Disorder Patients

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. Emotional Sensitivity Negative attentional bias Biology? Genetics? Temperament? + Invalidating Environment Emotional Awareness Deficits Emotional Regulation Deficits Cognitive Distortions Maladaptive Core Schemas HYPOTHESIZED ETIOLOGYPerson with BPD

8. NEUROBIOLOGYOF 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 - Beck’s 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. Abandonment Mistrust & Abuse Emotional Deprivation Defectiveness Failure Unrelenting Standards Punitiveness Dependence Jeffrey Young MALADAPTIVE SCHEMAS

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 one’s 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 don’t react negatively

29. We can NUDGENegative 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 - THECOGNITIVE 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.

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, 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.

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 I’ve 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