1. Schema Therapy with addictive patients Eckhard Roediger M.D. IST-F rankfurt Institut für Schematherapie - Frankfurt www.schematherapie-roediger.de kontakt@eroediger.de ACBS Conference in Berlin July 2015

2. Comorbidity PD and Substance Abuse BPS: 57 % Substance Abuse (Linehan, 1999) 36 % Alcohol, 40 % Drogen (Schmahl, 2005) Substance  17,7 % BPD (Verheul, 2001) Abuse: 5,2 - 32 % BPD (Linehan, 1999)  6.0 % Avoidant (Verheul, 2001) Pure substance abuse treatment doesn´t improve the PD (Verheul, 2001) A dual treatment focus is required Comorbidity leads to severe pathology and worse outcome

3. ACT DBT ST Cognition Behavior Emotion Contextual Self Wise mind Healthy Adult Mindfulness Contingency Management Diary cards Skills training Biological Model Developmental Model Limited Reparenting Experiential Techniques Re-appraisal Values Core Needs Cognitve Diffusion Acceptance Strategies Relational Frame Theory Dialectical Balance

4. The „Principles“ of Schema Therapy Specific Relationship (Limited Reparenting) (active, directive, flexible, modelling, self-disclosure) Consistant Therapy Model all Techniques rely to (as „bedrock“ for the Case Conceptualization) (Framework to relate current Schema activations to) Intensive use of Experiental Techniques (in almost every session, instead of „talking about it“)

5. Schematherapy vs. TFP RCT with 86 BL-Patients Arnoud Arntz, Maastricht (NL) *Intention-to-treat-Analysis Giesen-Bloo, J. et al., Arch Gen Psychiatry, 2006;63:649-658 Naturalistic Multicenter Studie with 62 BL-Patients Marjon Nadort, Maastricht (NL), appr. 69 Sessions in 1,5 Years Nadort, M. et al., Behavior Research and Therapy 2009 ; 47:961-973 Naturalistic BL-Study 19% (1,5 Ys) 42% 56,8% 1.55

6. “Cluster-C”-Study (conducted by A. Arntz) RCT mit 323 Pat. with 6 Personality Disorders (no BPD) Follow-up:STCOPTAU recovery from PD81,4 %51,2%51.8% Cohen´s d1,761,271,1 Dropout16% (28%/5%) ST: 1. Year: 40 Sessions (weekly), 2. Jahr 10 Sessions (monthly) Follow-up after 3 years Bamelis et al (2014). Am J Psychiatry (online) (ST: 147; TAU: 135; Client Oriented PT (R. Sachse): 41)

7. What does Dual-Focus-Schema-Therapy mean? What does Dual-Focus-Schema-Therapy mean? DFST means the conjoint treatment of addicitve behavior together with the underlying personality disorder. Axis-I-symptoms are driven by automatic behavior and need specific treatment on a behavioral level. This is the basement of treatment and has priority. Maladaptive coping styles contribute to the persistence of axis-I-symptoms, keep the level of emotional activation high, cause relapses and counteract treatment attempts. The might be treated with Schema therapy strategies.

8. Healthy Adult Mode Activated Core Beliefs (towards self and others) Basic Emotions (Fear  Anger) Inconsistency Coping Modes (Behavior and Social Emotions) Perceive and fulfill Re-appraise and impeach ? Internalized Representations of sign. Others Frustrated Core Needs SurenderAvoidanceDominance Clinical Symptoms AttachmentAssertiveness

9. Demanding Parent: „You have to be the best in your job“ Vulnerable Child: „I need approval at any price!“ Angry Child: „They don´t recognize at all how much I do for the company!“ Submission (excessive working) Self Aggrandizer (reward drinking) Auto-agressive Self Soother (heavy drinking) Punitive Parent: „You´re a failure! You will loose Betty!“ High level of inconsistency Undisciplined Child: „You deserve this little reward if they don´t acknowledge you!“ Inconsis- tency Vulnerable Child: „I feel very sad and need support from Betty

10. State of the implementation Samuel Ball outlined DFST already in 1998 (24 week program) Ball´s aproach was based on a combination of Marlatt´s relapse prevention strategies and the old Schema model Ball did not make intensive use of the experiential techniques that probably contribute a lot to the result of the Arntz trials (Giesen-Bloo et al. 2006; Bamelis et al. 2014) DFST is currently in implementation in an inpatient treatment program in southern Germany (AHG Wilhelmsheim). Initial studies showed a decrease in substance intake days and a better therapy relationship with DFST compared to a 12-step programm (Ball 2004)

11. Readings Simeone-DiFrancesco C., Roediger, E., Stevens, B. (2015). Healing Relationships: Schema Therapy for Couples, Oxford, UK: Wiley-Blackwell (includes a chapter on substance abuse) Roediger, E. (2012). Why are mindfulness and acceptance central elements for therapeutic change? An integrative perspective. In: van Vreeswijk M, Broersen J, Nadort M (eds). Handbook of Schema Therapy. Theory, Research and Practice. New York: Wiley Thank you for your attention!