Dr Kerry Beckley discusses Schema Therapy: a relatively new integrative therapeutic approach aimed at treating personality disorders, in particular borderline personality disorder.
While personality disorder does respond to treatment, it does not appear that any single approach or theory has a monopoly. Instead many interventions are effective in changing at least some components of personality disorder. This suggests that an integrated approach using a combination of interventions drawn from different approaches, and selected wherever possible on the basis of efficacy, may be the optimal treatment strategy (Livesley, 2001).
Schema Therapy (ST) is an integrative therapeutic approach developed by Dr Jeffery Young that is primarily aimed at treating those who have entrenched interpersonal and self-identity difficulties associated with a diagnosis of personality disorder. Young’s motivation in developing ST was as an attempt to address the needs of those for whom cognitive behavioural therapy (CBT) was not effective. It has its theoretical roots firmly embedded in attachment theory, its main premise being that personality pathology develops from unmet core emotional needs in childhood leading to the development of Early Maladaptive Schemas (EMS).
ST combines aspects of cognitive, behavioural, psychodynamic, attachment and gestalt models, and considers itself to be a truly integrative model, and one that continues to evolve as its use internationally is growing. Theoretical integration aspires to more than a simple combination of techniques as it seeks to create an emergent theory that is more than a sum of its parts (Norcross, 1997). Cognitive and behavioural techniques are still considered core aspects of treatment, but the model gives equal weight to emotion-focused work, experiential techniques and the therapeutic relationship. Like CBT, it is structured, systematic and specific, following a sequence of assessment and treatment procedures. However, the pace and emphasis on particular aspects of treatment may vary depending upon individual need.
ST places emphasis on the childhood origins of psychological problems. Young (1990) defines Early Maladaptive Schemas (EMS) as self-defeating emotional and cognitive patterns that develop early in childhood and are strengthened and elaborated throughout life. Maladaptive behaviours are thought to be driven by schemas. According to the model, schemas are dimensional, meaning that they have different levels of severity and pervasiveness. The more entrenched the schema, the greater number of situations that activate it, the more intense the negative affect and the longer it lasts. It is assumed that everyone can relate to at least some of the schemas described in the model, although these are more rigid and extreme in the individuals who seek treatment.
My own clinical experience has been primarily with personality disordered male offenders. Within a schema therapy framework, offending behaviour is understood as a maladaptive coping strategy that developed as a way of overcompensating for unmet needs in childhood. Due to the engagement and motivational difficulties that can be experienced when working with this client group, finding a theory that the person can relate to and find meaningful in terms of their experiences and difficulties is imperative. ST aims to provide therapists and clients with a common language, enabling us to conceptualise, work with and provide explanations for disturbing experiences, emotional distress and maladaptive behaviour patterns.
Schemas and Modes
Young proposes that there are eighteen EMS (see Table 1), which are unconditional assumptions about the self and others that develop in childhood and become self-perpetuating over time.
Schemas are considered more deeply held structures than are ‘core beliefs’ in cognitive behavioural therapy; they have a significant influence on the formation of identity and thus are more resistant to change. By definition, EMS are dysfunctional and result in psychological distress. They are thought to be the result both of the child’s innate temperament and of early experiences, and accumulatively strengthened through ongoing negative interactions with others. In adulthood the person engages in a variety of cognitive, affective and behavioural manoeuvres which enables them to maintain, avoid and adapt to their schemas in order to avoid experiencing overwhelming psychological distress. These coping styles take the form of Schema Surrender (giving in to the schema and accepting that the resulting negative consequences are unavoidable); Schema Avoidance (avoiding triggers internally and externally that may activate the schema); and Schema Overcompensation (acting as though the opposite was true).
While EMS are trait-like entities, that is, enduring features of the personality, “schema modes” are the state-like, changeable manifestations of schemas. Schema modes (see Table 2) are defined as ‘self states’ that temporarily come to the fore and dominate a person’s presentation, and are made up of clusters of schemas and coping strategies. Bernstein, Arntz & Vos (2007) have extended the original model to incorporate schema modes that are more commonly seen in forensic clients. In clients with severe personality disorders, whose personalities are poorly integrated, schema mode states can shift rapidly from one state to another. Clinical formulations incorporating schema modes enable the therapist to work with these sudden and extreme emotional shifts more effectively by guiding them in the use of techniques.
Where CBT aims to teach clients to suppress their negative emotions, ST uses experiential techniques to evoke affect as the therapist tries to bring about change in an emotionally connected way. In the beginning of the therapy, experiential techniques such as imagery and chairwork (Kellogg, 2004) are used more frequently in order to access the person’s core emotional experiences, whilst in the later phases of therapy, there is a greater inclusion of cognitive and behavioural strategies. In comparison to CBT, these are used in a far less structured way and the emphasis placed upon the therapeutic relationship as the primary vehicle for change remains. The key relational strategies are empathic confrontation (validating the development and continued perpetuation of schemas whilst simultaneously confronting the necessity to change) and limited re-parenting (providing what an individual needed, but didn’t get from their parents as children, within the boundaries of the therapy relationship).
The experience of childhood is always present in the therapeutic dialogue. Even when the focus is on current issues, the aim is to understand the present in the context of the past. When the person is unclear why they are acting out in a particular way, the underlying schema or mode is traced back to its function in early life – a way to cope with toxic experiences – in order to facilitate understanding of the present.
One of ST’s greatest strengths is how easily the concepts are understood and resonate emotionally with clients. Interventions are often focused around the unmet needs of the Vulnerable Child mode. If a client doesn’t like the word “child”, this can be exchanged for a term that is more acceptable to them. In my own practice, I have never met with resistance to the ‘child focused’ language. The important idea to convey is that distressing emotions in response to current issues are directly linked to early childhood experiences, and that the strategies they developed as children in order to cope are now problematic in adulthood. This concept is more effective at conveying emotional depth than is a term like “core belief” which doesn’t capture the potency of the person’s experience.
A question that is often asked is when to use the mode model as opposed to the schema-focused model. When clients have less extensive difficulties, two or three schemas might suffice in terms of understanding most of their presenting issues; in such cases the schema model alone can give them a framework for understanding specific life situations. The mode model is much broader and less specific, and is particularly useful for more complex early trauma and personality difficulties. In my own practice, I tend to start by with an exploration of core schemas for the individual, mainly from the disconnection and rejection domain, in order to facilitate the client’s understanding of the theoretical model, and then develop a mode formulation collaboratively with them if their current presentation is more helpfully understood by identifying self states. Diagrammatic formulations are really useful for conveying the therapist’s understanding of the client, and the inclusion of pictorial images to represent the different modes can be particularly effective. Making use of this in session when the person is ‘flipping’ can help both client and therapist understand what is happening in the moment.
What happens in therapy?
ST is a long-term intervention (2-3 years) and does not subscribe to a fixed protocol for session structure. Even with less severe personality disorders, under a year is rarely enough. Therapy involves a gradual weakening of the dysfunctional parts of the personality structure through the bolstering of the healthy adult part of the person. The assessment phase usually involves a great emphasis on imagery work, and on average can take two or three months. In addition to a full diagnostic assessment (which is recommended), there are a number of questionnaire measures utilised in the assessment phase which are designed to elicit information about schemas and their origins, coping strategies and modes. All of these can be found at www.schematherapy.com. The Young Schema Questionnaire (YSQ-3la; Young & Brown, 2003) and the Schema Mode Inventory (SMI; Young et al, 2008) in particular have been found to have good psychometric properties. However, the reliability of self report, particularly when the person has significant personality pathology, can be questionable; the most effective use of these tools, especially in view of their length, is not as a baseline for measuring change but rather a way of generating material for discussion during therapy.
During the change phase, imagery and role-playing continue to be employed, and are particularly useful in overcoming particularly entrenched schemas and modes. Later on in the change phase, the focus is on reinforcing these cognitive and emotional changes in order to bolster the ‘Healthy Adult’ mode. Finally, the focus is weighted further towards behavioural pattern-breaking and preparing for the ending of therapy. The way endings are managed in therapy generally is often dependent on the type of service in which the therapist works. Within the ST model, there is, if the service permits, greater emphasis on continued limited contact after the person has ended therapy than is considered appropriate in many models; the principle here is that the client may continue to invest in the therapeutic relationship until they have built alternative support structures into their lives. In my own practice, encouraging clients to maintain contact through telephone calls and letters is validating of the value they have placed on the therapy. Their motivation can be to seek advice regarding a difficulty that arises for them or to provide an update of their current circumstances, until their current circumstances mean they don’t feel the need to. This is a good example of how the ‘re-parenting’ philosophy of the approach can be extended past the therapy room.
Who does it work for?
Although ST was initially developed for treating Borderline Personality Disorder (BPD), it is also being used with a wider range of clinical presentations although the evidence base for its application outside of BPD is in its infancy. Most of the evidence thus far has been generated for clients with BPD; a multi-centre trial in the Netherlands found that ST led to recovery from BPD in about half the sample, with two thirds experiencing a clinically significant improvement (Giesen-Bloo et al, 2006). ST was also found to be about twice as effective as Transference Focused Therapy, and despite being a long term, high intensity intervention, ST was found to be less costly and to have a much lower dropout rate. Group-based ST has also been found to be an effective treatment for BPD in comparison to treatment as usual (Farrell, Shaw & Webber, 2009).
There are modifications to the phases of therapy for different personality disorders including Narcissistic Personality Disorder (Young, Klosko & Weishaar, 2003; Barhary 2008) and Antisocial Personality Disorder (Bernstein, Arntz & Vos, 2007). ST may be of benefit for any client for whom at least some of the origins of their problems are early in life, and whose difficulties include recurring negative life patterns that relate to current life situations. In my own practice, I have found it a useful framework, albeit sometimes with adaptations, for almost all clients, including those with psychosis and learning disabilities.
The Schema Therapist
The personal qualities of the therapist are of importance in ST. The competence rating scale that is used with therapists in training is flexible enough to allow for different interpersonal styles but encourages the person to be particularly attentive to their ability to ‘re-parent’ effectively. A good ST therapist should be personally affected by their therapy with clients, and emphasis is placed on the need genuinely to care about them. The therapist also needs to be flexible; therapists who are most comfortable with a structured, predictable protocol are usually not well suited to ST. The approach requires constant adaptation and responsiveness, based on the formulation of the person whose presentation can change moment by moment. The ability to be comfortable being openly warm and caring, and able to share these feelings with the patient in order to create a re-parenting bond is vital. This requires the therapist to have a clear understanding of their own emotional needs through the formulation of early experiences and schema development. The principle of ‘complementarity’, the process by which an individual’s behaviour can ‘pull’ the other into a familiar pattern of interacting, (Safran & Segal, 1996) is central. Within the ST model, this has been described as schema chemistry (Dr Jeffrey Young, personal communication, 11 August 2009), and is understood as the interpersonal activation of schemas between individuals. Sometimes this can impact on the therapist-client fit as when the therapist’s own schemas become activated by the interpersonal, schema-driven patterns of the client. Schema chemistry is also a very useful concept in understanding the patterns of interaction that take place within institutions (Beckley, 2010).
Physical touch is considered ‘acceptable, but not essential’. It is of particular use for those clients where emotional deprivation was significant in childhood. If a therapist is too inhibited to touch, they may be emotionally reticent and this would be an important focus in clinical supervision. As a female therapist working in a forensic environment, it is not considered acceptable for me to use touch as this could create a source of confusion at times, and may lead to boundary violations. I am, however, able to recognise when I feel it would be appropriate to use touch and instead convey care through words. Emotional connectedness is achieved through a willingness to get ‘close’ to clients. In the concept of neutrality, there is a notion of distance from the patient, and many psychodynamic therapists place value on that distance. ST can be liberating for those therapists who are suddenly given the theoretical permission to intervene in ways they always wanted to.
The International Society of Schema Therapy (ISST) has published guidelines regarding the requisite training needed to become an accredited practitioner (www.isst-online.com). Training is at three levels (Basic, Standard & Advanced) that are determined by hours of workshop attendance and supervised practice. There are currently two training providers within the UK and it is expected that others will be established in due course. Practitioners who reach the advanced stage are eligible to provide training to others. There are still relatively few of us practicing in this way but it is hoped that the greater availability of UK training will lead to a greater number of therapists using this approach.
Dr Kerry Beckley is a Consultant Clinical Psychologist and Accredited Schema Therapist. She was previously a Senior Clinical Tutor on the Trent Doctorate in Clinical Psychology Programme and developed the Schema Therapy Programme within the Personality Disorder Directorate at Rampton Hospital. She currently works in forensic services in Lincolnshire.
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