Group Schema Therapy Borderline Personality Disorder Joan Farrell, Ph.D. Ida Shaw, M.A. Indiana University School of Medicine Center for BPD Treatment & Research BASE Consulting Group Schema Therapy Institute Midwest .

THE ALL BPD GROUP: ORDEAL OR OPPORTUNITY? Prevalence is high Few willing therapists We like challenges & believed in the benefits of group therapy for trauma Bpd patients tended to leave mixed groups unexpectedly & feel more odd afterward Owever, the results of our first RCT influenced us on the opportunity side. We began with the group from hell and eventually found that the ST group produced very large statistically and clinically effective treatment effects. !988 – THE GROUP FROM HELL

GOALS OF BASE: GROUP SCHEMA THERAPY 1 Positive, trusting therapeutic alliance with therapists & group Increased awareness of feelings and needs Increased ability to regulate emotion Free enough of maladaptive schemas to take healthy action that matches present situation. environment

RCT OUTPATIENT GROUP SCHEMA THERAPY 32 women patients were randomly assigned to two conditions: TAU Individual psychotherapy (not ST) TAU plus weekly Schema Therapy group

STUDY DESIGN Inclusion Criteria Exclusion Criteria Women >18 years old Met cut-off for BPD diagnosis on DIB-R IQ > 89 In individual TAU psychotherapy for at least 6 months and agree to continue that treatment Able to commit to 14 month study period Antisocial PD Lifetime dx of schizophrenia, schizo-affective disorder, bipolar 1 DID Referred by their individual psychotherapists University Hospital /State Psychiatric hospital joint outpatient clinic

PATIENT DEMOGRAPHICS BY GROUP Treatment group Control Group AGE MEAN (sd) 35.3 (9.3) 35.9 (8.1) EDUCATION - HS 13% 33% COLLEGE GRAD 31% 42% EMPLOYMENT 69% 50% STUDENT 6% 17% HOUSEWIFE 12.5% DISABILITY 8% PSYCHOTROPIC MED AT BASELINE 100% RECENT SUI RECENT SIB

SCHEMA THERAPY GROUP Outpatient 30 sessions over 8 months Sessions were 90 minutes long 1 session per week 6 patients, 2 therapists No outside group therapeutic contact with group therapists – referred to individual therapist

OUTCOME MEASURES BORDERLINE SYMPTOMS DIB-R – Structured interview (Gunderosn) Borderline syndrome index – self report (Conte, Plutchik) GLOBAL SEVERITY PSYCH.SYMPTOMS SCL-90 GLOBAL SEVERITY SCORE (DEROGATIS) GLOBAL ASSESSMENT FUNCTIONING RATING BY INDIVIDUAL THERAPIST BLIND ASSESSMENT PRE, POST, 6 MONTH FOLLOW-UP

RESULTS: Improved Global Functioning Decreased Global Symptom Severity Symptom Checklist 90 Global Severity Score GAF Scores By individual therapists

RESULTS: Reductions in BPD Symptoms Diagnostic Interview for Borderlines - Revised Borderline Syndrome Index

LARGE TREATMENT EFFECT SIZES RESULTS: LARGE TREATMENT EFFECT SIZES BSI DIB-R SCL-90 GAF Treatment Group ST TAU Post-test 2.48 .09 4.29 .49 .72 -.25 1.80 .14 Six Month Follow-up 2.96 .04 4.45 .35 1.17 -.13 2.67 -.14 Effect sizes using pooled SDs at baseline and mean change scores per condition (a positive sign indicates improvement).

RECOVERY FROM BPD IS POSSIBLE Outpatient results Schema Therapy TAU TIME Post 6 month Recovered based on DIB-R score 94% 100% 25% 17% GAF > 60 56% 88% 8%  p< .001 2 PATIENT RETENTION: ST GROUP 100%, TAU 75% Farrell, Shaw et al, J of Behavior therapy & Experimental Psychiatry, 2009

PATIENTS REPORT AS MOST HELPFUL: “The feeling of belonging” “I felt understood for the first time” “There are people like me, so there is hope!” “Therapists were patient & consistent” “Therapists did not give up on me” “Learning effective coping skills” Yalom’s universality effect seems particularly meaningful for this group of people. Nan learned about self through monitoring – learned that way that she wasn’t “wrong” just different from her family. Being in a group of people like me helped me feel not alone (most frequent) I felt understood for the first time Having patient staff Being on a separate unit The consistency of the BPD team Learning effective coping skills 13

WHY SUCH LARGE EFFECT SIZES? The Curative Factors of groups directly address the main schema issues of patients with BPD (and many PDs). Group Catalyzes or Augments Schema Therapy’s active ingredients – attachment, emotional learning, schema mode change, generalization and transition to Healthy Adult function

Group Curative Factors Schemas of BPD Universality Group cohesiveness Altruism Installation of hope Corrective recapitulation of the primary family Development of socializing techniques Existential factors Catharsis Imitative behavior Interpersonal learning Imparting of information Yalom, The Theory and Practice of Group Therapy Abandonment Mistrust /abuse Emotional deprivation Defectiveness/shame Social Isolation/alienation Undeveloped self Emotional Inhibition Unrelenting standards Punitiveness

GROUP CATALYZES ST COMPONENTS Limited Re-parenting Experiences with peers feel more “real”. Closer analogue of the family may intensify Autonomy Group can act as a tangible “bridge” to life outside therapy Schema Mode Change More options for experiential work Vicarious learning gets around detachment The experience of belonging to a peer group is powerfully healing Multiple person mode role-play vs chair-work

IF THE GROUP CURATIVE FACTORS ARE ACTIVATED Don’t do Individual therapy while a group merely watches Individual patient focus limited Focus weaves between individual, common schemas and group One therapist is always attending to group connections Cognitive focus is suspended when opportunities for emotional learning occur

SCHEMA THERAPY MODEL of BPD Schemas = Trait-like, ongoing, are triggered Modes = Moment-to-Moment States MODES of BPD hypothesized by Young, empirically validated by Arntz & Loebestal: Child Modes=innate response to unmet needs Maladaptive Coping Modes = overused survival responses to trauma or unmet core needs Dysfunctional Parent modes = internalized critic Under-developed Happy Joyful Child and Healthy Adult Modes

MODES ACCOUNT FOR CLINICAL PRESENTATION & SYMPTOMS OF BPD Vulnerable child Angry Child Impulsive Child MODE FLIPPING Abandonment Fears EXPLAINS THE CLINICAL PRESENTATION OF PATIENTS WITH BPD Emotional Reactivity Unstable relationships Unstable self Intense anger poor control THE MODE MODEL PROVIDES YOU WITH THE FOCI OF TREATMENT TO FOLLOW Impulsive behavior SIB, SI Punitive or Demanding Parent Reality connection - Dissociation Psychotic symptoms Emptiness Detached Protector

MODE CHANGE IN GROUP ST GOOD QUALITY OF LIFE THERAPIST ANGRY – IMPULSIVE CHILD MODES MODE CHANGE IN GROUP ST THERAPIST P A R E N T PUNITIVE DEMANDING M O D S DETACHED PROTECTOR ANGRY CHILD CHANNELED VULNERABLE CHILD IMPULSIVE CHILD LIMITED THE GROUP GOOD QUALITY OF LIFE PUNITIVE & DEMANDING PARENTS BANISHED THAT WAS FOR THE EXPERIENTIAL PEOPLE AND VISUAL LEARNERS HAPPY CHILD DEVELOPS HEALTHY ADULT

MAIN COMPONENTS OF SCHEMA THERAPY LIMITED REPARENTING AN INTEGRATIVE MODEL EXPERIENTIAL WORK IMAGERY RESCRIPTING MODE ROLE PLAYS COGNITIVE PROCESSING BEHAVIORAL PATTERN BREAKING THE LAST TWO COMPONENTS DISTINGUISHES ST FROM EXPERIENTIAL THERAPY

Limited Re-parenting meets core unmet childhood needs Safety Stability, predictability Validation Guidance Caring Support for exploration Needs being met allows the Vulnerable Child to be present and experiential work can be done Reaching and healing the VC is one of STs major goals

Step One: Secure Attachment Establish Therapist - Patient Bonds Be genuine Eye contact Soft tones Convey that they matter Friendly facial expressions Validation of feelings Active listening Meet needs -be nurturing and supportive Bond first with the Vulnerable Child Mode

TWO “PARENTS” FOR THE BPD GROUP Alternate taking the lead or focusing on maintaining connections with the group Equal partners share the tasks and attend to the “children” Use signals – when you want help, another idea, etc. Support each other Point out therapist schema and mode activation One can take a patient out of group when necessary

LIMITED RE-PARENTING FOR A GROUP Build a healthy “family”, the optimal setting for treating PD A closer analogue to family of origin and “real life” Group has more options for positive connections that can extend to “real life”

BUILDING A HEALTHY “FAMILY” FACILITATE COHESIVENESS Point out similarities – symptoms, problems, developmental history Differences are OK too – acceptance Respect Validation ALL Mutual support Shared emotional experiences, group memory, language Conflict managed by therapists at first

ONE PRIMARY NEED IS SAFETY Therapist Tasks include: Be in charge – like a symphony conductor– amplify, quiet or control as needed Impart competence & confidence Teach Safe-place imagery Group support can add safety if a “healthy family” has been created Use empathic confrontation & limit setting when needed Group can feel more or less safe depending upon the culture that is developed by the therapist. Group ST is designed to be a particular kind of group experience – a healthy family.

GROUP ST IS INTEGRATIVE Combines structure and flexibility – homework provides a shared focus, but may be collected rather than discussed, to “seize the experiential moment”. Therapists direct & set limits at first and as the “family” forms, let the “kids” take over, while maintaining involvement and availability – “do what they cannot”

MODE CHANGE WORK Get through/around coping modes Heal Vulnerable child mode Eliminate Punitive/demanding modes Channel Angry Child mode Healthy limits for Impulsive/Undisciplined Child mode

To do experiential work BYPASS DETACHED PROTECTOR Experiential Focusing Exercise Awareness work Vicarious learning Observing consequences of remaining in DP in peers Empathic confrontation has increased salience when peers confront, sometimes too scary & therapist must

HEALING THE VULNERABLE CHILD Group provides the new experience of belonging Opportunities for receiving nurturing & caring from a larger “family unit” group Discovery that sadness does not destroy the self

GROUP IMAGERY WORK Safety Images Good Parent Images Building Healthy Adult Strength Images Imagery Re-scripting Individual focus is broadened to the group Whole group re-scripting Individual to group can include the group in many different ways: e.g. Michael, group planned the re-scripting with him and supported him during it. Or KG

MODE ROLE PLAY: Group provides many options Good parent for Vulnerable Child Fight the Dysfunctional “Parent” Mode Support the VC doing this comes later Comfort and soothe the frightened VC Self-soothing comes later Good Parent for Angry or Impulsive Child Listen and validate Set limits and Guide

CONTAIN & CHANNEL ANGRY/ IMPULSIVE CHILD MODE Containment & limits from therapists & group Safety in numbers Role play options with “good parent” or peers Assertiveness Negotiation Conflict resolution Learning that anger can be positive & channeled safely

GROUP CONFLICT RESOLUTION Conflict is an important learning opportunity Properly managed by therapists can increase group cohesiveness Set limits on “Bully” mode As last resort, leave wēi and jī “We got through it, resolved it and no one was hurt or kicked out”

BANISH the “PUNITIVE PARENT” “Villains” are clear to peers Group consensus on what is “reasonable” vs. “punitive” Group as an “army of defenders” – role plays Creepy PP anthem Destroy in effigy Role plays & psychodrama Re-scripting with “Good Parent”, later Healthy Adult HEALTHY ADULT - BANISHES PUNITIVE PARENT THERAPIST BANISHES PUNITIVE PARENT GROUP JOINS IN AND/OR ESCORTS PP OUT

MULTIPLE MODE ROLE-PLAYS POSSIBLE Banish Punitive Parent: played by Therapist, peers, patient then reverse roles Healthy Adult Mode of pt. - banishes Punitive Parent Group joins in to help and/or escorts PP out Therapist and group play all roles this allows vicarious learning, avoids further detachment

STRENGTHEN THE HEALTHY ADULT MODE Identify strengths & accomplishments Support for claiming their voices Reinforce competence Praise Share celebrations Peers can reframe “mistakes” effectively Group provides a controlled experience of competence and value -- with therapists there to help assign meaning to the event and the cognitive anchor of a label.

In conclusion Group can be the place where: The Abandoned Child: finds security and healing The Punitive Parent: is banished Angry/Impulsive Child/Teen: transformed into strong and competent Healthy Adult The all BPD “group from Hell” became a powerful medium for effectively treating BPD symptoms and improving the quality of life of this troubled group of patients

FOR MORE INFORMATION: www.bpd-home-base.org Joan Farrell, Ph.D. & Ida Shaw, MA ijinindy@sbcglobal.net (317) 941-4331 Indianapolis, IN USA Group Schema Therapy training, supervision and research www.bpd-home-base.org