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A Brief Introduction to Schema Focused Therapy

Prepared by Graham Taylor These brief notes have been edited from a substantially larger audiotape script we used in the past.. Please keep in mind that as a tape script it is not as "tightly" written as a paper, but it does give you a feel for the underlying theory. This material should be read in conjunction with Chapter 1 of Young's text, A Clinicians Guide to Schema Focused Therapy. Assumptions in brief therapy. There are some assumptions that we often make in short term cognitive behavioural therapy which often don't hold true for our clients with chronic problems. We assume that our clients have access to their emotions and report these with minimal training. This assumption does not hold true with many of our more challenging clients, and they may have difficulty reporting when their feeling anxious, angry, guilty or depressed. Additionally, their negative emotional states are so chronic, or their emotional stability is so fragile that they cannot access their feelings without being overwhelmed by them. The second assumption that we make is that our client has access to thoughts and memories with little training. Again this assumption often does not hold true for our clients with chronic problems and those who are emotionally vulnerable. Memories are often blocked from conscious awareness, and they have extreme difficulty putting some personal meaning to an event or identifying thoughts which accompany their distressing emotions. The third assumption that we generally make with clients is that they have an identifiable goal on which to work. A person may be depressed following a marriage break-down, they may be experiencing trauma symptoms following a distressing event, they start to develop panic attacks and become agoraphobic, they're having difficulty with their teenage children, and the like. Our difficult clients often aren't like that. They might say "my whole life is a mess", or your initial history points to such a longstanding pattern of dysfunction that it is clear that focusing on whatever the crisis was that brought them into therapy isn't going to solve their problems. The fourth assumption that we make is that the client is willing to learn some self management strategies and do some structured homework between sessions. Clients with chronic problems often don't meet this assumption. The homework is avoided, while they come up with a wide range of excuses why it hasn't been done. They've never managed to find the time to learn some simple self management strategies, and often strongly resist doing so. The fifth assumption that often proves to be untrue with our difficult clients is that they can quickly form a collaborative relationship with the therapist. Often it is the nature of their problematic relationships that form the core of the problem. Some patients struggle to get the therapist to meet their needs, or on the other hand remain so hostile and disengaged in the therapy process that it is impossible to formulate a collaborative relationship. For many people with personality difficulties, these are most clearly seen in their relations with others, and they will bring to the therapy situation exactly the same difficulties that they have with others. Some of the names given to the formal diagnoses given in DSM IV attest to this, paranoid, anti-social, histrionic, narcissistic, borderline. In

working with difficult clients the relationship itself sometimes becomes a major focus, and in the past much has been written in the psychoanalytic literature about the issues of transference and counter-transference. Short term therapeutic approaches have little to say about working in depth with the relationship difficulties that often arise in therapy. The sixth assumption that we make in short term therapy, particularly cognitive behaviour therapy, is that dysfunctional patterns of thinking and behaviour can be changed through empirical analysis, logical challenge, experimentation, graded steps and practice. The shortcomings of this assumption quickly become apparent in working with difficult and emotionally vulnerable clients. Therapy often seems to be a course of 1two steps forward and one or more steps back. After fifteen minutes of your best cognitive therapy a client will say "yes I understand up here (pointing to their head), but still it doesn't really feel true for me". Specific verus Non-specific Personality Disorders. Many of our challenging clients don't fit the above assumptions. Many of them would, if we so wished, be able to be formally diagnosed as having a Personality Disorder. In my own practice, I don't find the individual diagnostic categories in DSM IV particularly useful or relevant, as they don't define a clear therapeutic intervention as is the case with some Axis I disorders, and secondly more than 50% of my difficult clients would not fall into any one clearly defined diagnostic category, and would be lumped in that catch-all category of PD-NOS, "Personality Disorder - Not Otherwise Specified". For others of you, the concept of specific personality disorders à la DSM IV will describe many of your clients. Let us just consider what are the general DSM-IV Diagnostic Criteria for a Personality Disorder. A person needs to have an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture. This pattern is manifest in two or more of the following areas. 1. Cognition: (i.e., ways of perceiving and interpreting self, other people, and events.) 2. Affectivity (i.e., the range, intensity, lability and appropriateness of emotional response.) 3. Interpersonal function 4. Impulse control. Furthermore this pattern needs to be inflexible and pervasive across a broad range of personal and social situations. The enduring pattern must lead to clinically significant distress or impairment in social, occupational or other important areas of functioning. The pattern needs to be stable and of long duration and its onset can be traced back at least to adolescence or early adulthood. In each set of DSM diagnostic criteria for a specific personality disorder there are seven to nine items each of which identifies some characteristic trait, attitude, or behaviour strongly related to that particular disorder. For example, in the antisocial PD deceitfulness is considered a trait, which is a longstanding pattern of behaviour expressed over time and in many situations. When a person

displays a number of traits common to a diagnostic grouping they are said to have a Personality Disorder. Because many different combinations of diagnostic criteria are possible, it follows that two people sharing the same PD can in fact be quite different. Schemas on a continuum. When Beck and Young talk about schema in people with Personality Disorders they are referring to the dysfunctional beliefs that these clients hold about themselves, others and the world. But if we think about the notion of schema more broadly, we all have beliefs about ourselves, others and the world, and so it is necessary to consider a continuum from normality through to pathology with respect to beliefs. To illustrate, let me take one particular set of beliefs that is commonly found amongst therapists who have attended this workshop in Australia. Such individuals are generally high achieving, conscientious, hardworking individuals. Adaptive beliefs in such an individual might be I take pride in what I do I believe in a work ethic. I like to consider my choices before I act on something. I like to do the right thing I like to take my time and do things right These all seem very reasonable and adaptive beliefs, and indeed they are. Let's take these beliefs however and move a little towards the pathological side of the continuum, but still in a range that we would consider sub-clinical. The beliefs would then be something like ­ I feel I have to work on things until I get them right. I rarely take time off for leisure or family. I have to analyse all the alternatives before I make up my mind. I am sometimes intolerant of people whose moral standards are less than my own. Sometimes I think others will disapprove of me if they find even one small mistake Taking these beliefs a step further let us now look at how they might be in someone who clearly has an obsessive- compulsive personality disorder. Then the beliefs would be something like ­ I can't stop working on something until it is perfect, even if it already satisfies what I need it for. It drives me crazy if something is unfinished. I have never taken a holiday. I try to consider so many eventualities that it becomes very difficult to make a decision. I am disgusted by the moral laxity and indulgence I see in 99% of humanity. I find it hard to stop working until I know others will be satisfied with the job I have done And now let's take a step even further into the severely disordered end of the continuum. Now the beliefs would be something like this ­ Because nothing is ever good enough I never finish anything. I panic if I leave the office with something left undone. I usually work so late that I end up sleeping there.

I get so lost in trying to anticipate all the possibilities and details that I put things off and never commit to anything. I think anyone who deviates from the straight and narrow should be punished swiftly for their sins. I check and recheck my work until I am absolutely sure that no-one can find a mistake in what I have done. Keeping this notion of a continuum in beliefs from adaptive to severely disordered let us look at how someone with a normal personality differs from someone with a disordered one. Firstly, personality traits become more extreme in personality disorder. Assertiveness becomes aggression, helpfulness becomes self-sacrifice and subjugation, independence becomes narcissism, extroverted becomes histrionic, and so on. Secondly, the number of maladaptive traits increases. Many therapists are somewhat obsessive, but few meet diagnostic criteria for obsessive-compulsive personality disorder. Characteristics of clients with a "Personality Disorder".

Three key characteristics of Personality Disorder From a more clinical perspective we can delineate three characteristics of people with personality disorders. The first we may label rigidity. Here we note a person is inflexible in their capacity to adapt to situations, and keeps tackling them in the same way, in spite of self limiting or self defeating outcomes. As we can see from the formal criteria in DSM IV, one of the characteristics of difficult clients is the presence of rigid and inflexible traits that endure across time and across different situations. The coping strategies of most people are diverse and flexible. People with a personality disorder are more inflexible, and in stressful situations in which flexibility is required to cope, they often make matters worse with their inflexibility. Theodore Millon, one of the major theorists in the area of personality disorder notes that adaptive inflexibility and vicious circles are two of the major criteria for personality pathology. He notes " the alternative strategies the individual employs for relating to others, for achieving goals, and for coping with stress are not only few in number but appear to be practiced rigidly." He goes on to describe how patients with personality difficulties set up vicious circles of self defeating sequences by noting that "manoeuvres such as protective constriction, cognitive distortion and behavioural generalization are processes by which individuals restrict their opportunities for new learning, misconstrue essentially benign events, and provoke reactions from others that reactivate early problems".. The second characteristic is that of avoidance. Thoughts or feelings are often avoided or blocked out, because they are painful. There is a conditioning process going on here; anxiety and depression become conditioned to memories and associations, thus leading to emotional and cognitive avoidance, which is reinforced because it minimizes emotional pain. Thus our difficult clients will have trouble at times getting in touch with their thoughts and feelings. Kaplan and Sadak, psychiatrists of an analytical persuasion note that

" the defences of patients with personality disorders have been part of the warp and woof of their life histories and their personal identities. However maladaptive their defences may be, they represent homeostatic solutions to inner problems...... breaching these defences evokes enormous anxiety and depression". Not only is it the case that thoughts and feelings are avoided, the avoidance often extends to behavioural avoidance. The concept of Experiential Avoidance given prominence in Acceptance and Commitment Therapy is vital to understanding the extent of avoidance in our clients. If this concept is unfamiliar to you, you should read about it from the ACT page of our website, www.therapisttraining.com.au

The third general characteristic of difficult clients, and those with personality disorders is that of interpersonal difficulties. The dysfunctional patterns underlying their difficulties are most clearly played out in interpersonal relationships, including of course the therapy relationship. This behaviour will evoke responses in the therapist, and these responses themselves may unwittingly impede the progress of therapy. The very labels attached to the formal DSM categories attest to the interpersonal nature of the difficulties of many of the various categories: dependent, antisocial, paranoid, etc. In addition to the above three characteristics, some of our difficult clients may also demonstrate the characteristics of emotional dysregeulation. Marsha Linehan has set out a biosocial theory that the core disorder for people with borderline personality difficulties is that of emotional dysregulation. This can be seen as the resultant product of an interaction of biological disposition and the environment. A biologically vulnerable child in an invalidating environment will develop difficulties in emotional regulation. On the one hand we have emotional vulnerability which can be defined as a very high sensitivity to emotional stimuli, secondly a very intense response to emotional stimuli and third, a slow return to a baseline of settled emotions once emotional arousal has occurred. In normal language, people who are emotional vulnerable have a high sensitivity to negative events (they go off really easily) , and when triggered the reaction is very strong (when they go off, they REALLY go off), and are slow to settle to baseline (relax, settle down, let go,). Thus someone with an emotional vulnerability will be readily and markedly distressed by relatively benign negative events, and if a succession of such events occur before they have settled from the last one, their emotional state will become more and more distressed. The other aspect of emotional dysregulation is that of deficits in emotional regulation strategies. Emotional modulation consists of firstly, the ability to inhibit inappropriate behaviour related to strong negative or positive emotions. The excess of positive emotional displays of the histrionic personality are just as relevant examples of this as are the extreme depressive responses which might drive suicidal impulses. The second aspect of inadequate emotional regulation refers to the inability to organise oneself for coordinated action in the service of an external goal. In other words such a person cannot act in a

way that is mood dependent when necessary. Thirdly, we have the inability to self soothe heightened physiological arousal that the strong emotion has induced, and fourthly, there is the inability to refocus attention in the presence of strong emotion. In summary, emotional dysregulation is the combination of an emotional response system that is oversensitive and over-reactive with inability to modulate the resulting strong emotions and reactions associated with them. As a whole the disposition to emotional dysregulation is biologically based and a dysfunction in any part of the extremely complex human emotion regulation system can provide the biological basis for initial emotional vulnerability and subsequent difficulties in emotional modulation. Schemas in Cognitive Models of Personality Disorder In the last two decades, theorizing by Aaron Beck and Jeffrey Young have highlighted the importance of underlying schemas in understanding and treating people with personality problems. Beck notes that "a schema is a cognitive structure for screening, coding and evaluating the stimuli which impinge on the organism. On the basis of the matrix of schemas the individual is able to orient himself in relation to time and space and to categorize and interpret experiences in a meaningful way". He further notes that schemas may be inactive at one point in time and then "energized or deenergized rapidly as a result of changes in the time of input from the environment". He also notes that schemas will bias our interpretation of events in a consistent way. Jeffrey Young talks about Early Maladaptive Schemas by which he means the stable and enduring themes which develop during childhood and which are elaborated on throughout an individual's lifetime. More user-friendly terms for schemas are Core Beliefs or Lifetraps. Defining characteristics of Schemas (Core Beliefs). Firstly, they are unconditional beliefs about oneself, one's relationship to others, and one's relationship to the wider environment. It is the unconditional nature of these beliefs that distinguishes them from the ordinary cognitive distortions that we challenge in cognitive therapy. Secondly, core beliefs are self perpetuating and therefore they are much more resistant to change. Because they are formed early in life they form the core of a person's self concept, and views about others in the world. These core beliefs are coherent for the individual, and when challenged, the individual will often distort the experience in order to maintain the underlying schema. Thirdly, when we are talking about difficult clients we are focusing on schema which are dysfunctional in some significant and recurring manner. These schemas can lead directly or indirectly to a range of presenting symptoms or complaints such as chronic anxiety, chronic depression, dysfunctional relationships, excessive work, or other more common addictions such as alcohol or food. Maladaptive schemas or dysfunctional core beliefs are usually activated by events in the environment relative to the particular schema. A schema related to abandonment may be triggered when a person's partner leaves. A schema related to failure will be triggered only when a person fails to perform on some task. A self sacrifice schema will come into play only when the person is faced with some request by another.

Fourth, a person can experience high levels of emotion when underlying schemas are activated. If the level of evoked emotion seems disproportionately high given the triggering event, you could suspect a schema driven reaction. Fifth, early maladaptive schemas or dysfunctional core beliefs seem to be the result of experiences with parents, siblings and peers during the first few years of an individual's life. Finally, early maladaptive schemas are accepted as given truths by the person. E.g., A person with a defectiveness schema will have always seen themselves in this light. It is difficult to step out of this framework if that's all that a person has ever known. How Schemas are maintained. Let us consider now some of the processes by which schemas or core beliefs are maintained. I have already said that schemas are self perpetuating. There are three schema maintenance processes by which this is so. The first we can refer to as Schema Support. This in turn has two components, cognitive support and behavioural support. Cognitive support is where the schema is supported by highlighting or exaggerating information that confirms the schema and by negating, minimizing or denying information that contradicts the schema. We are talking here about the same sorts of cognitive distortions that Beck has written about in the area of depression, but because schemas are egosyntonic, integral to the person's view of themselves, they will be resistant to the normal challenges of cognitive therapy. The other support mechanism is behavioural support. Here we see a person engaging in repeating and yet self defeating behavioural patterns. It is important to appreciate that these patterns may have been adapted and functional at some time in a person's life, but in adult life become self defeating. For example a person with schema related to self sacrifice and emotional inhibition may have learned that it was very useful to try and please others and inhibit the expression of one's own emotions. In their upbringing perhaps this was their way of staying safe. Playing out such behavioural patterns in adult life however, is going to lead to intra and interpersonal difficulties. The second process by which schema are maintained is that of schema avoidance. When a schema is triggered the individual usually experiences a high level of emotion such as anxiety, depression or guilt. The high level of emotional intensity is unpleasant and therefore the individual often develops both volitional and automatic ways of avoiding either triggering the schema or of experiencing the emotion connected with the schema. We can think of avoidance strategies as ways a person attempts to avoid unwelcome internal experiences (memories, images, thoughts, emotions, body sensations). These may succeed in the short term in helping the person feel better, or at least avoid unwelcome experiences, and are thus reinforced. but in the longer term, such "solutions" usually serve to entrench the problem. There are three types of schema avoidance: cognitive avoidance, affective avoidance, and behavioural avoidance. Cognitive avoidance refers to the automatic or volitional attempts to block thoughts or images that might trigger the schema. This process is similar to the psychoanalytic concept of repression, denial and suppression. A person who says "I can't remember anything of my early childhood" is engaging

in cognitive avoidance. Many clients are quite adroit at steering the conversation away from topics which evoke distress, and may not be aware at a conscious level they are doing this. Affective avoidance refers to automatic or volitional attempts to block feelings that are triggered by schemas. We sometimes come across people who rarely feel extreme emotions even in situations that would certainly trigger these for most people. Dissociative strategies are an extreme example of affective avoidance. Recall that one of the assumptions that we made in brief therapy is that people have access to thoughts and feelings and can report these. The processes of cognitive avoidance and affective avoidance will produce the effect of invalidating these assumptions. The third avoidance process is that of behavioural avoidance. This refers to the tendency to avoid real life situations or circumstances that might trigger painful schema. Thus someone with abandonment schema may avoid close relationships. Someone with unrelenting standards may procrastinate on tasks or avoid them, rather than face the situation where failure could occur. The third schema support process is that of schema compensation. This refers to processes that overcompensate for early maladaptive schema. In other words the person attempts to disprove the schema by acting against it, in the opposite direction predicted by the schema. This is similar to the psychoanalytical concept of reactive formation. Schema compensation may be functional to some degree. Schema compensation processes may be seen as partially successful attempts by the person to challenge their schemas. Unfortunately, schema compensation almost always involves a failure to recognise the underlying vulnerability and therefore leaves the person unprepared for strong emotional pain if the compensation fails and the schema emerges. Here is a very clear example of schema compensation. It is taken from Earl Spencer's address at the funeral of his sister, Diana, Princess of Wales: "Diana explained to me once that it was her innermost feelings of suffering that made it possible for her to connect with her constituency of the rejected. And here we come to another truth about her. For all the status, the glamour, the applause, Diana remained throughout a very insecure person at heart, almost childlike in her desire to do good for others so she could release herself from deep feelings of unworthiness of which her eating disorders were merely a symptom".

Assessment In developing an understanding of a person's presentation we need to take into account their developmental history, and our understanding of how schema processes operate. From the moment we meet our client for the first time we are observing and beginning to form connections between specific emotions, symptoms, life problems and underlying schemas. As scientist-practitioners we are developing hypotheses about possible underlying themes. As we explore a person's developmental history we examine issues related to autonomy, connectedness, worthiness, reasonable expectations and realistic limits.

In addition to your detailed history we can also use the questionnaires developed by Jeffrey Young, which are available from his website, www.schematherapy.com . It is worth looking in particular at the Schema Questionnaire, and the Parenting Questionnaire. Changing Schemas The major types of intervention can be divided into four groups: Interpersonal, Cognitive, Emotive, and Behavioural. Interpersonal: Therapeutic relationship - transference issues. Provide a therapeutic relationship which counters EMS. Therapist takes a re-parenting role. Teach interpersonal effectiveness skills. Group therapy experiences. Cognitive: Review evidence on which schemas were built and maintained. Examine this evidence critically. Discount early family experience as reflecting dysfunctional standards and behaviours of parents. Review evidence contradicting the schema. Illustrate how the person discounts disconfirming evidence. Use Point - Counterpoint to actively challenge EMS. Use defusion techniques and mindfulness to create distance from limiting automatic thoughts. Develop Prompt Cards to summarise completed phases of therapy. Challenge the schema whenever it is activated in the therapy session or between sessions. Emotive: Affect Bridge to uncover origins of EMS. EMDR to resolve and reframe early history underlying schema formation. Create imaginary dialogues with the patient's parents or significant others. Inner Child and Gestalt techniques are useful. Emotional catharsis (but cognitive reframing is also necessary). Teach skills of mindfulness, emotional regulation and distress tolerance. Behavioural: Develop Rule Breaking tasks to challenge schema driven behaviour. In-vivo exposure. Skills training to remedy behavioural deficits.

Comparison With Other Approaches: Differences From Short-Term Cognitive Therapy Greater emphasis on the therapeutic relationship. Much more emphasis on affect - imagery, role playing, inner child work.

Longer course of treatment. More discussion of childhood origins. More active confrontation of cognitions and behaviour patterns. Differences From Psycho-Analytic Or Client-Centred Therapies Therapist is much more active. Change techniques are much more systematic. Strong emphasis on self-help assignments. Therapeutic relationship is collaborative rather than neutral.

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