Schema Therapy A Very Brief Introduction Thomas Irelan, Ph.D. Department of Clinical & Counselling Psychology NHS Grampian 9 June 2011

Schema Therapy is: An integrative theory and treatment that combines cognitive, behavioural, interpersonal, and experiential techniques Designed to treat the chronic, characterological aspects of disorders that have their origins in childhood and adolescence

Origins of Schema Therapy An expansion of cognitive therapy for complex patients (severity, duration, and co-morbidity) and personality disorders These patients have more rigid cognitions and behaviours The gap between cognitive and emotive change is much greater Intimate relationships are more central to their problems Often will not engage with traditional CBT techniques

Schema Therapy vs Cognitive Therapy Greater emphasis on the therapeutic relationship More emphasis on affect and mood states More discussion of childhood origins and developmental processes More emphasis on lifelong coping styles More emphasis on core themes

Young’s Early Maladaptive Schemas (EMS) A broad, pervasive theme or pattern regarding oneself and one’s relationships with others and the world

General Definition of a Schema Schemas continue to be elaborated over time through assimilation and accommodation Schemas may be adaptive or maladaptive A script is a schema for an event

Young’s Early Maladaptive Schemas (EMS) Developed during childhood or adolescence as a result of core emotional needs not being met adequately Elaborated throughout one’s lifetime Dysfunctional to a significant degree

Characteristics of EMSs A theme or understanding, not just a belief Drives behaviours (rather than behaviours being a part of the schema) Dimensionality: i.e. variation in degree of intensity, pervasiveness, and frequency Many are pre-verbal and associated with the amygdala

Characteristics of EMSs Capable of generating high levels of disruptive affect, self-defeating, and can be harmful to others Capable of interfering significantly with getting core needs met Deeply entrenched patterns central to one’s sense of self Triggered by everyday events

The 18 Early Maladaptive Schemas Disconnection & Rejection Emotional Deprivation Abandonment Mistrust/Abuse Social Isolation Defectiveness Impaired Autonomy Failure Dependence Vulnerability Impaired Limits Entitlement Insufficient Self-Control Other-Directedness Subjugation Self-Sacrifice Approval Seeking Overvigilence & Inhibition Emotional Inhibition Unrelenting Standards Negativity/Pessimism Punitiveness

Origins of EMS: Temperament EMS form through the interaction of temperament and early life experiences (including cultural factors) Dimensions of temperament: Shy ↔ Outgoing Non-Emotional ↔ Emotional Calm ↔ Anxious Pessimistic ↔ Optimistic Passive ↔ Active Result is variance in levels of resiliency

Origins of EMS: Early Life Experiences Core emotional needs of the individual are not met through: Toxic frustration of needs (deprivation) Traumatisation and victimisation Over-indulgence Selective internalisation or identification with significant others

Core Emotional Needs Safety Predictability Love, nurturance, and attention Acceptance and praise Empathy Guidance and protection Validation of emotions and needs The goal of Schema Therapy is to help patients find adaptive ways to meet their core emotional needs (by changing maladaptive schemas, coping responses, and modes)

Schema Coping Styles Surrender (freeze) Avoidance (flight) Compliance Avoidance (flight) Substance abuse Detachment Social isolation, avoidance Stimulation/workaholism Overcompensation (fight) Aggression, hostility Excessive self-reliance Manipulation Demandingness Perfectionism Overcontrol

Schema Perpetuation Cognitive distortions and coping styles produce behaviour that leads to self-fulfilling prophecies; either results are assimilated into the schema or selectively processed if they do not fit the schema Repetition results in self-defeating life patterns and schemas are perpetuated Do exercise here.

Schema Therapy The goal of Schema Therapy is schema healing, i.e. reducing the intensity of memories and bodily sensations associated with a schema, the emotional charge of the schema, and the restructuring of maladaptive cognitions

Schema Therapy Phase 1: Assessment and Education Determine suitability for Schema Therapy Introduce model Go through questionnaires (Young Schema Questionnaire and/or Schema Mode Inventory and Young Parenting Inventory Imagery for assessment Develop shared formulation and goals for treatment

Schema Therapy Phase 2: Change Cognitive Strategies Experiential Strategies (imagery, two-chair work, etc.) Behavioural Pattern-Breaking Use of the Therapeutic Relationship Mode Work

Future Solutions Schemas Past Origins Present Problems

The Therapy Relationship Schema Therapists are: • personal • objective and compassionate • open and direct • flexible • focussed on meeting the emotional needs of their patient

The Therapy Relationship Assessment • watch for schema triggering during sessions and point out to the patient • identify and discuss schemas that were activated • link schema activation in the session with experiences outside of therapy Self-disclosure • judiciously based upon the needs of the patient • can be especially helpful with Social Isolation schema

The Therapy Relationship Limited Reparenting • meeting the unmet emotional needs of their patients in healthy ways within the bounds of a therapeutic relationship Empathic Confrontation • by validating schemas coping styles based on their origins • gently and firmly pointing out the problems they create in the present (including in the therapeutic relationship) • how they prevent the patient from getting his or her emotional needs met (including the therapeutic relationship)

Schema Mode Work: History Developed for more severe clients (BPD, NPD, ASPD) Places more focus on here-and-now mood states Provides more effective strategies for overcoming avoidance and overcompensation

What is a Mode? The specific schemas that are currently activated for any individual The predominant state we are in at any given time Schemas= traits, modes= states An aspect, side, or part of a person or his/her personality

Schema Modes Child Modes Maladaptive Coping Modes Adult Modes Vulnerable Child Angry/Enraged Child Impulsive/Undisciplined Child Contented Child Adult Modes Punitive Parent Demanding Parent Healthy Adult Maladaptive Coping Modes Compliant Surrenderer Detached Protector Overcompensator

Current Uses of Schema Therapy Used with BPD, NPD, ASPD, Cluster C PDs Eating Disorders Forensic settings Substance abuse Couples therapy

Current Developments (International) Research being done in all areas on previous slide Group models being developed, with research trials beginning for group ST with Borderline Personality Disorder

Current Developments (Scotland) First cohort being trained to accreditation in Schema Therapy Introductory trainings Development of supervision networks

For Further Information Thom Irelan tirelan@nhs.net 01224 557475 www.isst-online.com www.schematherapy.com