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