Alexander RobertsonSupervisor - Associate Prof. Stephen Theiler

Why is this topic important?One of the challenges facing mental health services is developing effective treatments for chronic, difficult-to-treat clients such as dual diagnosis clients

Schema therapy demonstrating clinically effective outcomes

Limited research

Apparent need –number of dual diagnosis clients referred to Banyule Community Health Service (BCHS)

What is schema therapy?

Young et al. Schema Focused Cognitive Therapy

Newer, integrative psychotherapy combining theory and techniques from existing therapies including:

Cognitive Behavioural Therapy Emotion Focused Attachment Theory Gestalt Therapy

Maladaptive Schemas“Maladaptive schemas are seen as enduring, unconditional, negative beliefs about oneself, others and the world that organize one’s experiences and subsequent behaviours” (Ball, 2004, p402).

…and what is dual diagnosis? Dual diagnosis is comorbidity of mental illness and substance

use Dual diagnosis can mean an increase in challenging

behaviours:• self-harm and aggression;• avoidance of services and;• resistance to or non-compliance with treatment and

recovery programs.

Schema therapy & Dual Diagnosis Core beliefs such as mistrust, failure, social isolation,

insufficient self control could affect treatment goals and are often found in dual diagnosis clients

Schema therapy focuses on these central issues and beliefs that are often at the very heart of challenging behaviours

Thus one of the aims for counsellors is to target specific maladaptive schemasand implement treatment strategies that identify and then change these schemas

Therapeutic Alliance

Used in research methodology as a measure of outcome Research has found that improving the therapeutic alliance

between client and therapist is a key factor in seeing positive outcomes in treatment

In the current study Investigated particular aspects of schema therapy

such as EMS identification and feedback (using Young’s Schema Questionnaire short form) and how this affected the therapeutic alliance (using WAI)

Whether there was a profile of certain maladaptive schemas that tend to be associated with dual diagnosis group

Sample size of 55 clients with a dual diagnosis attending Banyule Community Health Service (34 males, 21 females; M=41.91 years, SD= 11.43years) Treatment group = 31 Control group = 24

Treatment group: WAI > YSQ > YSQ results >WAI

Control group: WAI > normal session > WAI

One-on-one consultations with Counsellors & clients

Method

Depression and anxiety are one of the highest co-occurring mental illnesses with people with substance use.

Alcohol was the highest co-occurring drug followed by cannabis and amphetamines

Results- Dual Diagnosis

Results also indicate that dual diagnosis clients reported an overall high level of Unrelenting Standards, Self-Sacrifice, Social Isolation and Mistrust and Abuse.

Results- Dual Diagnosis

The results suggest that doing EMS identification and feedback significantly improved the therapeutic alliance.

The results show there was no significant difference within the WAI scores of the control group. Suggesting that the therapeutic alliance remained the same between the two counselling sessions.

Results in Therapeutic Alliance as a measure of outcome in therapy

Qualitative ResultsDual Diagnosis clients “Some of the schemas discussed describe me perfectly and

makes me feel that they are real and not just in my head” “This goes into the heart of some of my issues, it feels a bit

scary at first but I think it’s very important for me.”

Counsellors “I felt the questionnaire and the feedback given helped speed

up the counselling process.” “Some clients felt that the EMS identification and feedback

helped them clarify some of their underlying issues and concerns.”

Exploring information about the clients past and their early maladaptive schemas, helps develop a strong and fairly quick alliance between the client and the therapist.

Awareness & preparedness of AOD Counsellors of particular schemas being triggered; helping in the treatment of those core emotional needs such as trust and self-care.

Implications for Theory & Clinical Practice

Educating Dual Diagnosis clients about maladaptive schemas and helping them gain a deeper understanding of themselves may give relief from psychological symptoms

Implications for Theory and Clinical Practice

Method- EMS identification and feedback may not constitute different treatment intervention

Not empirically validated that schema work is a superior treatment to other types of interventions.

Longitudinal study needed Small sample size and difference in control group Limits to the generalizability of the findings

Limitations

Future Research Tease out the specific dual diagnosis elements that

may be influencing therapeutic alliance How schema therapy work influences clients with

different dual diagnoses. To generalise the relationship between EMS

identification & feedback with dual diagnosis clients beyond community health setting

Provide greater support for the theorised link between EMS identification and feedback and therapeutic alliance

Overall, the study findings extend previous maladaptive schema and substance use research

Demonstrate high scores in Young’s Schema Questionnaires overall and in particular with high scores in the Mistrust/Abuse, Self-Sacrifice, Social Isolation and Unrelenting Standards schemas.

The study findings add to research by demonstrating that exploring early maladaptive schemas can improve therapeutic alliance.

However, future research is required to further elucidate this relationship.

Conclusion

References Ball, Samuel A. (2007)Cognitive-Behavioral and Schema-Based Models for

the Treatment of Substance Use Disorders.; In: Cognitive schemas and core beliefs in psychological problems: A scientist-practitioner guide. Riso, Lawrence P. (Ed.); du Toit, Pieter L. (Ed.); Stein, Dan J. (Ed.); Young, Jeffrey E. (Ed.); Washington, DC, US: American Psychological Association,. pp. 111-138. [Chapter]

Burns L., & Teeson M. (2002). Alcohol use disorders comorbid with anxiety, depression dn rug use disorders: Finding from the AustrlianNational Survey of Mental Health and Well being. Drug and Alcohol Dependence, 68, 299-307.

Hatcher R.L., & Gillaspy J.A. (2006). Development and validation of a revised short version fo the Working Alliance Inventory. Psychotherapy Research. Vol 16, No 1, 12-25. Routledge.

Pennay, Amy; Cameron, Jacqui; Reichert, Tiffany; Strickland, Heidi; Lee, Nicole K.; Hall, Kate; Lubman, Dan I. (2011)A systematic review of interventions for co-occurring substance use disorder and borderline personality disorder. Journal of Substance Abuse Treatment. Vol. 41 Issue 4, p363-373. 11p. DOI: 10.1016/j.jsat.2011.05.004.

References (cont.)

Munder T., Wilmers F., Leonhart R., Wolfgang H., & Barth J. (2010). Working Alliance Inventory-Short Revised (WAI-SR) Psychometric Properties in Outpatients and Inpatients. Clinical Psychology and Psychotherapy. Vol 17, 231-239. Wiley InterScience.

Sempertegui G.A., Karreman A., Arntz A., & Bekker M. (2013). Schema Therapy for borderline personality disorder: A comprehensive review of its empirical foundations, effectiveness and implementation possibilities. Clinical Psychology Review. Vol33, 426-447. Elsevier publications.

Young, J.E., Klosko, J.S., & Weishaar, M. (2003) Shema therapy: A practitioner’s guide. New York: Guilford Publications.

Thank youAny Questions?