2. 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
Highlights of Schema Therapy
Long term therapy supervision of Dr. S’s work with patient X

3. WHAT IS A PERSONALITY 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

4. 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%
First I will describe the BPD population, some of the storms they deal with and that professionals who treat them must take on.
Most practitioners agree that this group is among the very most difficult to manage let alone treat effectively. The adjective “borderline” is rarely used in a positive or non-pejorative way. Successful suicide rate of this disorder is estimated at 10%.
Fam Study – Perry Hoffman - Cornell

5. DEFINING BPD DSMIV: Affect Interpersonal Behavior Emotional reactivity
Difficulty with anger
Behavior
Suicidal behavior, SIB
Impulsivity - potentially self-damaging
Interpersonal
Abandonment fears
Stormy, idealize then devalue
Even defining BPD is a challenge. 4 Sectors of Psychopathology There are still many debates about how to define BPD, does it belong on Axis I or II, is it one disorder or many.
DSMIV-R defined 4 sectors of psychopathology with 8 criteria or which 5 need to be met.

6. DEFINING BPD DSMIV: cont
Self
Unstable identity
Emptiness
Reality testing
Transient, stress- related
paranoid episodes, dissociation.
Any combination of 5 symptoms earns a BPD diagnosis.

7. HYPOTHESIZED ETIOLOGY Person with BPD
Emotional Sensitivity
Negative attentional bias
Biology? Genetics? Temperament? +
Invalidating Environment
Emotional Awareness Deficits
Emotional Regulation Deficits
Cognitive Distortions
Maladaptive Core Schemas
How do we understand the development of this disorder? A model of etiology is important to designing treatment.
The current understanding of BPD psychopathology is best summarized as a diathesis stress model in which: Describe slide.
Emotional sensitivity –defined as high sensitivity to emotion, difficulty modulating negative feelings, high reactivity, high intensity and slow return to emotional baseline has been hypothesized as representing a physiological predisposition to BPD. The neuropathophysiology of distress regulation is still unknown (Donegan, 2003, fMRI studies). However we know that high amygdale activation is related to emotional distress and higher activity in left amygdale has been found in BPD subjects in a number of recent studies.
Combined with this predisposition - throw in an invalidating early environment – that can range from a “poorness of fit situation” in which an emotionally labile child is part of an achievement oriented “pull yourself up by your bootstraps” typical American family – to a family with parents absence due to death, alcoholism or physical and/or sexual abuse – and you get the deficits and distortions that we observe clinically and are the targets for psychotherapeutic treatment.

8. NEUROBIOLOGY OF PERSONALITY DISORDER BPD
Overactive 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
The basics
May be too expensive until we understand more about the underlying mechanism of BPD

9. PD CHALLENGE TO COGNITIVE 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
Completed homework is the best predictor of success in CT

10. 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
Young trained & collaborated in research with Aaron Beck in the 80s.
They were finding that Personality disorder issues reduce the effectiveness of CT.
(CT for MDD – 60% success rate, 30% of those relapse after 1 year.
Schema T originated as -Systematic additions to Cognitive Therapy developed by Young to improve the success rate of CT for patients with personality disorders.
Complex patients require more complicated treatment. Works for difficult to engage patients who have been “stuck” in other treatment.
I was trained in the 70’s in a system that became CBT. In practice I ran into the limits of CT with many patients in particular those with BPD that I was even then attracting.
Patients would say things like – I know intellectually won’t die if left alone, but feels like that will happen.

11. 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

12. 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
The psychological mechanism thought to prevent this goal being met is the formation of Maladaptive Schemas.
These are defined as:
E.g., Abandonment in Patient X – perceived instability or unreliability of those available for support & connection – true of mother in childhood, – although not true of Dr. Samavedy, Patient X acted as if it was true and berated her for perceived lack of presence or attempted to leave her before her anticipated leaving of him.

13. MALADAPTIVE SCHEMAS Abandonment Mistrust & Abuse Emotional Deprivation
Defectiveness
Failure
Unrelenting Standards
Punitiveness
Dependence
Jeffrey Young
In Young’s system: some combination of these schemas is thought to account for maladaptive behavior.

14. MORE SCHEMAS Self-Sacrifice Approval Seeking Negativity Entitlement
Insufficient Self Control
Emotional Inhibition
Social Isolation
Vulnerability
Enmeshment

15. Early Maladaptive Schemas develop when specific childhood needs are not met.

16. CORE CHILDHOOD NEEDS Safety Empathy Acceptance & Praise
Guidance & Protection
“Stable Base”, Predictability
Love, Nurturing & Attention
Validation of Feelings & Needs
Schema Theory Uses the Knowledge Base of Developmental Psychology
Childhood history is important if the First things learned are also the last thing learned – i.e., the patient is stuck in rigid maladaptive patterns

17. SCHEMAS DEVELOP WHEN Toxic frustration of needs
Traumatization, victimization, mistreatment
Over-indulgence
Selective internalization or identification
Temperament or neurobiology
can play a role
FRUSTRATION
Trauma
Spoiled
Punitive or demanding parent values

18. SCHEMAS = LIFETRAPS * They erupt when triggered by everyday events
related to the schema. *
They may not “fit”
what is needed in
one’s adult life.

19. 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

20. STEPS IN
SCHEMA THERAPY

21. STEPS Empathize with current problems & validate emotions Life History
Outline Therapy Goals
ID Schemas – education & awareness
ID Maladaptive Coping Strategies
ID Schema Modes

22. STEP ONE
Engage a relationship -avoidant patient in a healing therapeutic relationship.
Will transfer to improved interpersonal functioning outside of psychotherapy.

23. SCHEMA HEALING
We are trying to create a healthy healing, reparenting environment so they can finish the steps in childhood development that they missed
Filter and distort information and experience to fit the world view and rules of the schema.
Positive relationship in therapy can eventually be created in the outside world

24. OUR ROLE IS TO RE-PARENT IN A LIMITED WAY
We must find ways to validate their feelings and needs—
While setting limits on and challenging their unhealthy behaviors.
HEAL HERE,
TO TAKE ON THE OUTSIDE WORLD
E.g. “I know you feel crushed that Dr. F did not stop to talk to you, but dropping out of the program is not the best choice

25. LIMITED REPARENTING MEANS GIVING PATIENTS
SAFETY
RESPECT
VALIDATION OF FEELINGS
SENSITIVITY TO TRIGGERS
PATIENCE
UNDERSTANDING
SUPPORT & COMFORT
CONSISTENCY
HEALTHY BOUNDARIES

26. VALIDATION
Communicate understanding and acceptance of whatever emotion they express –e.g. crying, venting in an appropriate place
When necessary for safety, question their choice of action and suggest healthy alternatives

27. THERAPIST STYLE Empathic Confrontation
Relentless, but not blaming or critical
Stress consequences of not changing
Stress the advantages of changing
Active coaching, model Healthy Adult
push for change, while empathize with the difficulty of changing
Stress consequences of not changing - e.g., eternal search for Neverland
when pt schemas triggered - an observer.

28. THERAPIST STYLE Selective self-disclosure
Genuine, transparent and warm
When schema driven behavior occurs –point it out but don’t react negatively
Disclosure fosters real connection
BPD their issue is with lack of connection, so if you take the analytic view and emphasize autonomy, they will feel deprived

29. We can NUDGE Negative Core Beliefs
By the way we treat patients in our interactions with them.:
This is where our role is critical – our responses will either reinforce negative core beliefs or challenge them.
Pts. Feel unworthy and defective, hopeless and helpless, they fear rejection and distrust others (high % abuse experiences) (attitude of MH workers) We provide them with information that helps them reframe their self-definition, skills (distress regulation and communication), the experience of acceptance and that they matter.
This is the “Rocket Science” part of the work!
Requires understanding that schemas are beliefs we have about ourselves the world and other people that are the product of our life experiences and possibly temperament and they may be extremely inaccurate.
We require them to give up the idea of “truth”.
Requires cognitive and emotional work
Core schema change to allow patients to take action to use the skills they have learned.

30. STEP 2: LIFE HISTORY-
In contrast to CBT , SFT includes childhood

31. 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

32. 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

33. JOY - DIAGNOSES . Anger Emotional reactivity Suicide attempts
Axis I – MDD, PTSD, hx ED
Axis II BPD
Anger
Emotional reactivity
Suicide attempts
Impulsivity
Stormy relationships
Abandonment fears
Emptiness

34. 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

35. Usually,
schemas & coping styles
are not in
conscious awareness….
But can be recognized
when pointed out to
a person.

36. 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

37. CORE BELIEFS - THE COGNITIVE PART OF SCHEMAS
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.
Cognitive or thought part of schemas and the part most accessible to consciousness.
So, not only did we have to teach patients to be aware of sub-critical levels of distress and hunt for effective distress reducers and emotional management skills, but we had to create enough doubt in them that their beliefs about the themselves, others and the world were absolutely true now, that they would use what they knew.
Requires understanding that schemas are beliefs we have about ourselves the world and other people that are the product of our life experiences and possibly temperament and they may be extremely inaccurate.
We require them to give up the idea of “truth”. Requires cognitive and emotional work

38. SCHEMA PERPETUATION COGNITIVE DISTORTIONS All or None thinking
Overgeneralization
Disqualifying the positive
Jumping to conclusions
Magnification
Should statements
Personalization

39. ANY POSITIVE RESULT MUST BE WRITTEN DOWN
No memory file folders exist to store
the info that contradicts core beliefs in so,
Don’t expect them to remember getting a positive response from you until it has happened many times.
e.g., “Are you mad at me?”
Until a new positive belief forms they will keep testing.

40. STEP 4: ID MALADAPTIVE COPING STRATEGIES
Childhood survival strategies
can recur when Schema Issues
are triggered.

41. PATIENTS’ COPING STRATEGIES ARE NORMAL REACTIONS TO CRISIS
OVERCOMPENSATION = FIGHT
WITHDRAWAL = FLIGHT
SURRENDER = FREEZE
but they use them
most of the time

42. FAULTY COPING DEFENSES DEVELOP
Overcompensate – criticize others, drive people away
Surrender – accept
abusive relationships
Avoidance - isolate
Ask them for examples.

43. SURRENDER BEHAVIORS Attempts to be a perfectionist
Focuses on the negative
Minimizes importance of desires
Treats self and others harshly
and punitively

44. Avoids: AVOIDANCE BEHAVIORS Relationships Employment Negative feelings
Social situations
and groups
I’ve decided to quit my job, drop out
Of society, and wear live animals as hats.

45. 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

46. 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.

47. DETACHED PROTECTOR
E.g., Dissociation, flatness

48. ANGRY CHILD
Stereotype of person with BPD

49. VULNERABLE CHILD
Fear, regression e.g., fetal position

50. PUNITIVE PARENT
Mode where self-injury & suicide attempts occur

51. HEALTHY ADULT
The desired result of Schema Therapy

52. SCHEMA THERAPY STAGES
Emotional bonding
Get around Detached Protector
Heal Abandoned Vulnerable Child
Banish Punitive Parent
Channel Angry Child effectively
Develop Healthy Adult

53. TREATMENT STRATEGY
We teach them to understand their intense reactions to triggers so that they can learn to control the intense emotion, stop and think and make healthier choices.
This therapeutic learning occurs in small steps.
Examples

54. “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

55. HIGHLIGHTS
OF SCHEMA THERAPY TECHNIQUE

56. EXPERIENTIAL SCHEMA WORK
Counter schema modes:
“I know in my head
that I am not evil,
but I feel evil”

57. GESTALT TECHNIQUES “Empty Chair” Dialogues Example: reduce the hold
of the Punitive Parent.
Schema Therapy provides a plan for how to integrate into cognitive therapy in an empirically validated way - the experiential techniques of other therapy systems.
E.g., Dialogues between Schema and Healthy Adult, Patient’s HA and Parent
Visualization can be powerful since emotionally intense, so use as a strength – Safe Place Image and use it to evoke stron emotion in sessions.
Schema origin work to deal with it from adult strength to change at an emotional level

58. SAFE PLACE IMAGE

59. SCHEMA ORIGINS WORK

60. COMPARED TO AXIS I TREATMENT
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
Change at emotional level is not quick
CT goal is to decrease affective arousal – in pd pt, opposite problem – coping strategies block or avoid emotion – so CT strategies are counterproductive
Example – end DBT, pt has decreased symptoms but still unhappy

61. EMPIRICAL VALIDATION – BPD PATIENTS
RCT with 4 sites and 86 BPD patients
2 years Individual SFT
Arntz, et al.,
Arch Gen Psychiatry June, 2006
“Cured” – 45% vs. 22% TFP
Significant improvements in quality of life
Cost effective – 2 years still saved 500 Euros per patient compared to treatment as usual in days of work missed and use of medical care system
use the schema concept to deal with barriers to applying new skills – like defectiveness

62. The BASE Program Borderline pd Awareness Skills & Empowerment
People with
Borderline pd
Awareness
Skills &
Empowerment
The acronym BASE represents what we designed this treatment to be – the foundation for BPD – the beginning and a hypothesized prerequisite to effective treatment for many patients.

63. BASE HAS 4 OVERLAPPING COMPONENTS
Psychoeducation about BPD
Emotional Awareness Training
Skills Training
Schema –focused Therapy

64. 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
And if you conquer with them the first two challenges – you encounter the roadblock of the third – they don’t use what they have learned because of disabling maladaptive core schemas or beliefs that create a set of helplessness , hopelessness and unworthiness. Patients used their coping skills in sessions or with telephone coaching, but generalization was limited or non-existent. We stayed with the idea that our work with BPD patients needed to be an active collaboration, so we shared our puzzlement and asked them to help us understand. Patients said they felt:
That they did not deserve to do things to be less upset
They still had the idea that their feelings of upset were “wrong” as not like others
Patients often express this as “I am bad and deserve punishment”.
We speculate that the failure to address these barriers or their misinterpretation of these beliefs as resistance are a major reason for treatment failures.
We also think that a major reason for the results we are getting with some of the most severe patients- those referred for longer inpatient treatment in a state hospital after failing many BPD specialized programs may be due to our focus on this unrecognized barrier in other skills programs. With this last addition, we thought that our foundation program was complete!

65. 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
days
60 minute session
15 weekly sessions
6 month & 1 year follow-up 1

66. Inpatient BASE Program Results
Borderline Syndrome Index Pre Treatment
BPD
% patients meeting diagnosis criteria
Inpatient Borderline Intervention Analysis Results
Patient symptom level was assessed at baseline and endpoint using the Borderline Symptom Inventory (BSI). Following completion of the study, these scores were collected and analyzed.
The baseline BSI scores (mean = 34.69, SD = 9.28) and follow-up BSI scores (mean = 12.48, SD = 8.64) differed significantly when compared using a paired-sample t-test (t = 13.84(41), p < .01).
The change in BSI scores can be seen in the following bar graphs, which show the percentage of cases at baseline (graph 1) that are below or above the score of 25 which is the cut-off on this instrument for being given a BPD diagnosis.
“Not” BPD

67. Borderline Syndrome Index Post Treatment
“Not” BPD
Borderline Syndrome Index
Post Treatment
Clinical & Statistical Significance
At the end of treatment, the figures reverse and less than 15% of patients meet criteria for BPD – a finding of considerable clinical significance.
BPD

68. GAF Score Change mean = 57.51, SD = 5.91 POST Paired Sample t-test
Overall functioning was also assessed at the same time points using the Global Assessment of Functioning Scale (GAF).
Similar results were observed when functioning was examined as baseline GAF scores (mean = 28.16, SD = 10.70) and follow-up GAF scores (mean = 57.51, SD = 5.91) also differed significantly when compared using a paired-sample t-test (t = (36), p< .01).
PRE
mean = 28.16, SD = 10.70

69. Self-Injurious Behavior

70. Suicide Attempts

71. Percent of Patients Hospitalized

72. Mean Number Hospitalizations
6.0
The magnitude of these results is why we continue with the program despite skepticism and criticism of people who don’t understand what we are doing.
67% none
16% 1 brief
6% 2 brief
11% 3 brief
85% none
6% 1 brief
9% 2 brief
.24
One Year before
One Year After