CBT Specialization II (Schema Therapy)

Dr Theiler placed strong emphasis on therapist-client relationship. Concepts in CBT are good for Axis 1 e.g. anxiety, phobias but long-standing issues such as Personality Disorders (Axis 2), CBT alone are not helpful. People with PDs are more rigid in relation to cognitions and emotions. Relationships are often more critical to PDs.
Some people are not able to express and that result in inaccessibility of some cognitions.
Cognitive theories often neglect early childhood.

Schema Therapy (Jeffery Young) is a wholistic and integrative theory (combines CBT with other psychotherapies) with treatment designed to help many long-term (originating from childhood and adolescence) emotional difficulties. Early maladaptive Schemas develop when specific; core childhood needs are not met. Such as safety, a stable and predictable home life – loving, nurturing and attention-giving. There is a lack of acceptance, praise, empathy, guidance and protection. Feelings and needs are not validated.

The broad goal of Schema Therapy is to help clients adapt through changing maladaptive schemas and dysfunctional coping responses by getting their core needs met. The Early Maladaptive Schema (EMS) is defined as a pervasive theme comprised of memories, bodily sensations, emotions and cognitions regarding oneself and one’s relationships with others that are developed from birth throughout one’s lifetime (Client’s perception of reality). And they are dysfunctional to a significant degree. (Young, 1999)

The EMS is more than a belief; it is a theme in life. E.g. Abandonment, Mistrust & Abuse, Emotional Deprivation (due to Cold Parents), Enmeshment, Vulnerability, Defectiveness (due to Critical Parental Style), Social Isolation, Approval-seeking, Failure, Entitlement (Indulgent Parents), Dependence (Overprotective Parents), Subjugation (Controlling Parents) etc.

Schemas originated from negative childhood & adolescent experiences, innate temperament and cultural influences (religion, social economic status, etc). Schemas formed as a result of severe frustration of needs, traumatization, ‘too much of a good thing’, over-identification with significant other, etc.

Coping Styles in relation to Schemas – The ways in which a child copes with a dysfunctional childhood environment:
Schema surrender - --- (freeze)
Schema avoidance ------ (flight)
Schema overcompensation ---- (fight)
As such, we can go into any of the following schema modes through-out our life –

* Vulnerable Child
* Angry Child
* Detached Protector (avoidance & no emotion)
* Punitive, Critical Parent
* Overcompensator
* Spontaneous Child (may be irresponsible)
* Healthy Adult (to strengthen)

Applications of Schema Therapy

Initial Evaluation:
Suitability of Client – psychotic, drug-abuse, or when problem is situational.
What are the main presenting problems and therapy goals?

Pattern Identification:
Presenting problem
Cognitions
Symptoms
Relationships
Life & Family history
Genogram

σ Young’s Schema Questionnaire YSQ
σ Four early memories (client’s memories from childhood)
σ Parenting Inventory YPI

 Link presenting problems to life pattern
 Find emotional links

Schema psycho-education:

 Assign reading of ‘Reinventing Your Life’ by Jeff Young, Ph.D. and Janet Klosko, Ph.D. on chapters for schemas that client scored high on.
 Discuss YSQ and YPI. Look for discrepancies between the two.

Experiential Techniques for Assessment:

 For triggers, get upsetting childhood images of mother or father
 Set up imagery or dialogues with significant people for empowerment
 Ask clients what they need in the image
 Link emotions from childhood images with current life circumstances – Client vents anger and asserts rights when appropriate; client grieves for losses

Case Conceptualisation

• Background information
• Relevant Schemas
• Current Problems
• Schema triggers
• Temperament or biological factors
• Developmental origins
• Early Memories
• Core cognitive distortions
• Surrender behaviours
• Avoidance Behaviours
• Over compensatory behaviours
• Relavant schema modes
• Therapy relationship

Summary of Conceptualization presented to client for feedback and conceptualization is fine-tuned. Client and therapist agree on important problem to work on first in the Change Phase.

 Test the validity of each schema, using evidence from all periods of life
 Try to discredit evidence
 Set up dialogues between Schema Side and Healthy Adult (note positive aspects and feedback to client)

Cognitive Techniques: Self-help Assignments

 Therapist dictates flashcards (to write positive statements) using template
 Write separate flashcards for all recurring life situations/schemas
 Assign Schema Diary in later therapy

Therapy Relationship for Schema Change:

Point out when client’s schemas seem to be activated in a session
Ask client for trigger event, emotions and cognitions
Test validity of client’s reaction: distinguish accurate perceptions from schema-driven overreactions.
Therapist is aware when own schemas are being activated and obtains supervision when necessary.
Concept of Limited Re-parenting – Client internalizes therapist’s Healthy Adult mode
Therapist fulfills needs that were never adequately met, within appropriate boundaries of therapy relationship

Assign and rehearse behavioral and interpersonal changes related to presenting problem to break dysfunctional behavioural pattern.