Schema TherapySchema TherapyA Very Brief IntroductionA Very Brief Introduction

Thomas Irelan, Ph.D.Thomas Irelan, Ph.D.Department of Clinical & Counselling PsychologyDepartment of Clinical & Counselling Psychology

NHS GrampianNHS Grampian

9 June 20119 June 2011

Schema Therapy is:Schema Therapy is:

• An integrative theory and treatment that An integrative theory and treatment that combines cognitive, behavioural, interpersonal, combines cognitive, behavioural, interpersonal, and experiential techniquesand experiential techniques

• Designed to treat the chronic, characterological Designed to treat the chronic, characterological aspects of disorders that have their origins in aspects of disorders that have their origins in childhood and adolescencechildhood and adolescence

Origins of Schema TherapyOrigins of Schema Therapy

• An expansion of cognitive therapy for complex patients An expansion of cognitive therapy for complex patients (severity, duration, and co-morbidity) and personality (severity, duration, and co-morbidity) and personality disordersdisorders

• These patients have more rigid cognitions and behavioursThese patients have more rigid cognitions and behaviours• The gap between cognitive and emotive change is much The gap between cognitive and emotive change is much

greatergreater• Intimate relationships are more central to their problemsIntimate relationships are more central to their problems• Often will not engage with traditional CBT techniquesOften will not engage with traditional CBT techniques

Schema Therapy vs Cognitive TherapySchema Therapy vs Cognitive Therapy

• Greater emphasis on the therapeutic relationshipGreater emphasis on the therapeutic relationship• More emphasis on affect and mood statesMore emphasis on affect and mood states• More discussion of childhood origins and More discussion of childhood origins and

developmental processesdevelopmental processes• More emphasis on lifelong coping stylesMore emphasis on lifelong coping styles• More emphasis on core themesMore emphasis on core themes

Young’s Early Maladaptive Schemas (EMS)Young’s Early Maladaptive Schemas (EMS)

• A broad, pervasive theme or pattern regarding A broad, pervasive theme or pattern regarding oneself and one’s relationships with others and the oneself and one’s relationships with others and the worldworld

Emotions

Images Memories

Thoughts

BodilySensations

Schema

General Definition of a SchemaGeneral Definition of a Schema

• Schemas continue to be elaborated over time Schemas continue to be elaborated over time through through assimilationassimilation and and accommodationaccommodation

• Schemas may be adaptive or maladaptiveSchemas may be adaptive or maladaptive• A A scriptscript is a schema for an event is a schema for an event

Young’s Early Maladaptive Schemas (EMS)Young’s Early Maladaptive Schemas (EMS)

• Developed during childhood or adolescence as a Developed during childhood or adolescence as a result of result of core emotional needscore emotional needs not being met not being met adequatelyadequately

• Elaborated throughout one’s lifetimeElaborated throughout one’s lifetime• Dysfunctional to a significant degreeDysfunctional to a significant degree

Characteristics of EMSsCharacteristics of EMSs

• A theme or understanding, not just a beliefA theme or understanding, not just a belief• Drives behaviours (rather than behaviours being Drives behaviours (rather than behaviours being

a part of the schema)a part of the schema)• Dimensionality: i.e. variation in degree of Dimensionality: i.e. variation in degree of

intensity, pervasiveness, and frequencyintensity, pervasiveness, and frequency• Many are pre-verbal and associated with the Many are pre-verbal and associated with the

amygdalaamygdala

Characteristics of EMSsCharacteristics of EMSs

• Capable of generating high levels of disruptive Capable of generating high levels of disruptive affect, self-defeating, and can be harmful to othersaffect, self-defeating, and can be harmful to others

• Capable of interfering significantly with getting core Capable of interfering significantly with getting core needs metneeds met

• Deeply entrenched patterns central to one’s sense of Deeply entrenched patterns central to one’s sense of selfself

• Triggered by everyday eventsTriggered by everyday events

The 18 Early Maladaptive SchemasThe 18 Early Maladaptive SchemasDisconnection & RejectionDisconnection & Rejection

• Emotional DeprivationEmotional Deprivation• AbandonmentAbandonment• Mistrust/AbuseMistrust/Abuse• Social IsolationSocial Isolation• DefectivenessDefectiveness

Impaired AutonomyImpaired Autonomy• FailureFailure• DependenceDependence• VulnerabilityVulnerability

Impaired LimitsImpaired Limits• EntitlementEntitlement• Insufficient Self-ControlInsufficient Self-Control

Other-DirectednessOther-Directedness• SubjugationSubjugation• Self-SacrificeSelf-Sacrifice• Approval SeekingApproval Seeking

Overvigilence & InhibitionOvervigilence & Inhibition• Emotional InhibitionEmotional Inhibition• Unrelenting StandardsUnrelenting Standards• Negativity/PessimismNegativity/Pessimism• PunitivenessPunitiveness

Origins of EMS: TemperamentOrigins of EMS: Temperament• EMS form through the interaction of temperament EMS form through the interaction of temperament

and early life experiences (including cultural factors)and early life experiences (including cultural factors)• Dimensions of temperament:Dimensions of temperament: Shy ↔ OutgoingShy ↔ Outgoing

Non-Emotional ↔ EmotionalNon-Emotional ↔ Emotional

Calm ↔ AnxiousCalm ↔ Anxious

Pessimistic ↔ OptimisticPessimistic ↔ Optimistic

Passive ↔ ActivePassive ↔ Active• Result is variance in levels of resiliencyResult is variance in levels of resiliency

Origins of EMS: Early Life ExperiencesOrigins of EMS: Early Life Experiences

Core emotional needsCore emotional needs of the individual are not met of the individual are not met through:through:

• Toxic frustration of needs (deprivation)Toxic frustration of needs (deprivation)• Traumatisation and victimisationTraumatisation and victimisation• Over-indulgenceOver-indulgence• Selective internalisation or identification with Selective internalisation or identification with

significant otherssignificant others

Core Emotional NeedsCore Emotional Needs• SafetySafety• PredictabilityPredictability• Love, nurturance, and attentionLove, nurturance, and attention• Acceptance and praiseAcceptance and praise• EmpathyEmpathy• Guidance and protectionGuidance and protection• Validation of emotions and needsValidation of emotions and needs

The goal of Schema Therapy is to help patients find The goal of Schema Therapy is to help patients find adaptive ways to meet their core emotional needs (by adaptive ways to meet their core emotional needs (by changing maladaptive schemas, coping responses, changing maladaptive schemas, coping responses, and modes)and modes)

Schema Coping StylesSchema Coping Styles

Surrender (freeze)Surrender (freeze)• ComplianceCompliance

Avoidance (flight)Avoidance (flight)• Substance abuseSubstance abuse• DetachmentDetachment• Social isolation, Social isolation,

avoidanceavoidance• Stimulation/workaholismStimulation/workaholism

Overcompensation (fight)Overcompensation (fight)• Aggression, hostilityAggression, hostility• Excessive self-relianceExcessive self-reliance• ManipulationManipulation• DemandingnessDemandingness• PerfectionismPerfectionism• OvercontrolOvercontrol

Schema PerpetuationSchema Perpetuation

• Cognitive distortions and coping styles produce Cognitive distortions and coping styles produce behaviour that leads to self-fulfilling prophecies; either behaviour that leads to self-fulfilling prophecies; either results are assimilated into the schema or selectively results are assimilated into the schema or selectively processed if they do not fit the schemaprocessed if they do not fit the schema

• Repetition results in self-defeating life patterns and Repetition results in self-defeating life patterns and schemas are perpetuatedschemas are perpetuated

Schema TherapySchema Therapy

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

Schema TherapySchema Therapy

Phase 1: Assessment and EducationPhase 1: Assessment and Education• Determine suitability for Schema TherapyDetermine suitability for Schema Therapy• Introduce modelIntroduce model• Go through questionnaires (Young Schema Questionnaire Go through questionnaires (Young Schema Questionnaire

and/or Schema Mode Inventory and Young Parenting and/or Schema Mode Inventory and Young Parenting InventoryInventory

• Imagery for assessmentImagery for assessment• Develop shared formulation and goals for treatmentDevelop shared formulation and goals for treatment

Schema TherapySchema Therapy

Phase 2: ChangePhase 2: Change• Cognitive StrategiesCognitive Strategies• Experiential Strategies (imagery, two-chair work, etc.)Experiential Strategies (imagery, two-chair work, etc.)• Behavioural Pattern-BreakingBehavioural Pattern-Breaking• Use of the Therapeutic RelationshipUse of the Therapeutic Relationship• Mode WorkMode Work

FutureFutureSolutionsSolutions

PresentPresentProblemsProblems

Past OriginsPast Origins

SchemasSchemas

The Therapy RelationshipThe Therapy Relationship

Schema Therapists are:Schema Therapists are:• • personalpersonal• • objective and compassionateobjective and compassionate• • open and directopen and direct• • flexibleflexible• • focussed on meeting the emotional needs of theirfocussed on meeting the emotional needs of their

patientpatient

The Therapy RelationshipThe Therapy Relationship

AssessmentAssessment• • watch for schema triggering during sessions andwatch for schema triggering during sessions and

point out to the patientpoint out to the patient• • identify and discuss schemas that were activatedidentify and discuss schemas that were activated• • link schema activation in the session withlink schema activation in the session with

experiences outside of therapyexperiences outside of therapySelf-disclosureSelf-disclosure

• • judiciously based upon the needs of the patientjudiciously based upon the needs of the patient• • can be especially helpful with Social Isolationcan be especially helpful with Social Isolation

schemaschema

The Therapy RelationshipThe Therapy Relationship

Limited ReparentingLimited Reparenting •• meeting the unmet emotional needs of their patients in meeting the unmet emotional needs of their patients in

healthy ways within the bounds of a therapeutic relationshiphealthy ways within the bounds of a therapeutic relationship

Empathic ConfrontationEmpathic Confrontation• • by validating schemas coping styles based on their origins by validating schemas coping styles based on their origins • • gently and firmly pointing out the problems they create in the gently and firmly pointing out the problems they create in the present (including in the therapeutic relationship)present (including in the therapeutic relationship)• • how they prevent the patient from getting his or her how they prevent the patient from getting his or her emotional needs met (including the therapeutic relationship)emotional needs met (including the therapeutic relationship)

Schema Mode Work: HistorySchema Mode Work: History

• Developed for more severe clients (BPD, NPD, Developed for more severe clients (BPD, NPD, ASPD)ASPD)

• Places more focus on here-and-now mood statesPlaces more focus on here-and-now mood states• Provides more effective strategies for overcoming Provides more effective strategies for overcoming

avoidance and overcompensationavoidance and overcompensation

What is a Mode?What is a Mode?

• The specific schemas that are currently activated The specific schemas that are currently activated for any individualfor any individual

• The predominant state we are in at any given timeThe predominant state we are in at any given time• Schemas= traits, modes= statesSchemas= traits, modes= states• An aspect, side, or part of a person or his/her An aspect, side, or part of a person or his/her

personalitypersonality

Schema ModesSchema Modes

Child ModesChild Modes• Vulnerable ChildVulnerable Child• Angry/Enraged ChildAngry/Enraged Child• Impulsive/Undisciplined ChildImpulsive/Undisciplined Child• Contented ChildContented Child

Adult ModesAdult Modes• Punitive ParentPunitive Parent• Demanding ParentDemanding Parent• Healthy AdultHealthy Adult

Maladaptive Coping ModesMaladaptive Coping Modes• Compliant SurrendererCompliant Surrenderer• Detached ProtectorDetached Protector• OvercompensatorOvercompensator

Current Uses of Schema TherapyCurrent Uses of Schema Therapy

• Used with BPD, NPD, ASPD, Cluster C PDsUsed with BPD, NPD, ASPD, Cluster C PDs• Eating DisordersEating Disorders• Forensic settingsForensic settings• Substance abuseSubstance abuse• Couples therapyCouples therapy

Current Developments (International)Current Developments (International)

• Research being done in all areas on previous slideResearch being done in all areas on previous slide• Group models being developed, with research trials Group models being developed, with research trials

beginning for group ST with Borderline Personality beginning for group ST with Borderline Personality DisorderDisorder

Current Developments (Scotland)Current Developments (Scotland)

• First cohort being trained to accreditation in First cohort being trained to accreditation in Schema TherapySchema Therapy

• Introductory trainingsIntroductory trainings• Development of supervision networksDevelopment of supervision networks

For Further InformationFor Further Information

Thom IrelanThom Irelantirelan@nhs.nettirelan@nhs.net01224 55747501224 557475

www.isst-online.comwww.schematherapy.comwww.schematherapy.com