The Wiley-Blackwell Handbook of Schema Therapy

Theory, Research, and Practice

Michiel van Vreeswijk, Jenny Broersen, Marjon Nadort

• Publisher: Wiley-Blackwell
• Year: 2012
• ISBN:
  9781118332290
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

The Wiley-Blackwell Handbook of Schema Therapy provides a comprehensive overview of developments in the theory, diagnosis, treatment, research, implementation, and management of schema therapy.

• Presentsa comprehensive overview of schema therapy - goes far beyond all previous books on the subject to cover theoretical, research and practical perspectives
• Covers the latest developments, including work on mindfulness and borderline personality disorder, as well as new applications of schema therapy beyond personality disorders
• Includes chapters by leaders in the field including Wendy Behary and Arnoud Arntz, as well as a foreword by Jeffrey Young, the founder of schema therapy

Part I: An Introduction to Schema Therapy

1

Schema Therapy in Historical Perspective

David Edwards and Arnoud Arntz

Schema Therapy (ST) evolved as a treatment for complex psychological problems over a period of some 20 years. In due course, it became sufficiently defined and operationalized that it could be manualized and evaluated in a randomized controlled trial (RCT) (Giesen-Bloo et al., 2006). As suggested by Young (2010), its recent development can be divided into three phases. The first was a period in which Young’s reflection on his own cases led to the formulation of the key concepts. He then put these to work and tested them in new cases, not only on his own, but increasingly in consultation with clinicians working closely with him. In the second phase, a group of Dutch researchers conducted the RCT and in the process large numbers of Dutch psychologists contributed to the ongoing theoretical and clinical development of the model. In the third, Farrell and Shaw published a study of a group therapy model that added yet another dimension to ST treatment.

ST is an integrative therapy that draws on many concepts and methods that had existed before it evolved with its own identity. In this chapter we will look back at developments in cognitive behavior therapy and other psychotherapies, particularly between 1960 and about 1995, that have directly influenced the theories and techniques of ST. We will also look farther back within the history of psychotherapy and point to parallels that may or may not have had a direct or traceable influence. Readers will see how ST as developed by Young is part of a broader trend in cognitive therapy of attending to information processing that is not readily accessible to conscious awareness. It will become clear how it draws on schema models and theories and incorporates methods and techniques developed within other psychotherapy traditions. Next, we will examine each of the three phases. Lastly, we will reflect on the relationship between ST and science.

Beyond Beck’s Cognitive Therapy

The Movement Towards Integration in Psychotherapy

In the 1970s and 1980s, at most universities in the US psychology departments involved in training clinicians were associated with one of two paradigms: the older psychoanalytic and psychodynamic tradition and the emerging cognitive behavior therapy (CBT). Those associated with CBT argued that theirs was the only approach founded in experimental science and began to underline the credibility of their approach by demonstrating the efficacy of CBT treatments in RCTs. They were often dismissive not only of psychodynamic approaches but also of the humanistic and experiential therapies that had only a limited influence in most universities but were a growing force outside. However, once qualified, many practitioners found the academic models too limited to address the range of clients and client problems they were presented with in practice and a chronic rift developed between university-based researchers and clinicians (Dattilio, Edwards and Fishman, 2010). In due course, some university-based clinicians and researchers experimented with the humanistic and experiential approaches. As those trained in CBT explored psychodynamic approaches more carefully (and vice versa), they began to integrate them into more comprehensive treatment models. This was reflected in the founding of the Journal of Psychotherapy Integration in 1990 and the publication of the Handbook of Psychotherapy Integration (Norcross and Goldfried, 1992). The development of ST was part of this wider process.

ST is a theoretical and technical integration that is largely the work of Jeffrey Young. He developed the approach on the basis of his own clinical observations, his reflection on cases he found difficult and challenging, and in collaboration with colleagues who worked with him using the model on their own cases as it evolved. Many of these original collaborators are acknowledged by Young, Klosko, and Weishaar (2003, p. ix). As a graduate trained in clinical psychology in the US during the 1970s, Young would have had a broad theoretical grounding. After qualifying, he did postdoctoral training in Beck’s cognitive therapy (CT) in Philadelphia and subsequently was clinical director of the Center for Cognitive Therapy in the early 1980s. At that time the basic treatment model for depression had already been developed (Beck et al., 1979) and work was underway to adapt the model for anxiety disorders as well as to test the models in clinical trials. Like many clinicians trained in treatment models designed for fewer than 20 sessions, Young found himself preoccupied with those clients who did not respond to short-term approaches. He set about identifying the characteristics of these clients and finding treatment strategies that would address the difficulties they presented. In 1984, the first author was given a seminar handout by Young entitled “Cognitive therapy for personality disorders and difficult patients,” which summarized his analysis of the problems posed by these clients. This would later be incorporated into Young’s (1990) first publication on ST and into Young et al.’s (2003) ST manual. In the process of finding ways to address the needs of these clients, Young added to the already rich array of cognitive and behavioral techniques in which he had been trained by incorporating relational perspectives, experiential techniques, and the recognition that the self is not a unity, but functionally divided into parts that can be in conflict with each other.

Beck’s Cognitive Therapy

Beck’s CT is often thought of as a brief, manualized, and highly technical approach designed for short-term interventions, like other therapies within the broad family of CBT. This is at least in part because of the constraints of outcome research that require psychotherapies to be packaged in this way. However, CT as developed by Beck and colleagues from the 1970s was never just a set of CBT techniques. Beck had been trained in psychoanalysis. Although he quickly became disillusioned with working with clients who were free-associating on a couch and began to experiment with a more pragmatic and practical approach, he did not entirely jettison his former training. By the time Young was training with Beck, CT was already an integrative therapy. This is acknowledged in the introduction to the landmark book on CT for depression (Beck, Rush, Shaw and Emery, 1979) which listed a diverse range of forerunners whose influence had been incorporated into the new approach (see also Mahoney and Freeman, 1985).

This included cognitive approaches such as George Kelly’s (1905−67) Personal Construct Theory and the work of Albert Ellis (1913−2007), whose main focus was the development of a cognitive therapy based on the classic Stoic maxim that it is not events that distress us but the meaning we give to them. Identifying distorted or exaggerated personal meanings and actively challenging them was central to Ellis’s therapy – which changed its name over the years from Rational Therapy to Rational Emotive Therapy to Rational Emotive Behavior Therapy as Ellis integrated new aspects. Behavior therapy was another important component. Joseph Wolpe (1915−97), who had developed systematic desensitization (Wolpe, Salter and Reyna, 1964), was a professor at the same university as Beck and CT was being put together at a time when many behavior therapists were taking a pragmatic approach to behavior change (London, 1972) and linking cognitive and behavioral methods into what would soon be called cognitive behavior therapy (CBT). Another important influence came from Carl Rogers’ (1902−87) client-centered therapy and from phenomenological and existential writers who emphasized understanding the lived experience of clients and the idiosyncratic nature of each individual’s patterns of thought and feeling.

Beck’s approach to intervention was very different from traditional psychodynamic practice. However, concepts from several psychodynamic theories were used as a basis for case formulation and treatment planning, provided they were grounded in evidence from the data of the case. Humorously, in 2000, during a dialogue with Albert Ellis, Beck acknowledged this when he referred to himself as “a closet psychoanalyst” (Beck and Ellis, 2000). Alfred Adler (1870−1937) was one of these influences. His break with Sigmund Freud (1856−1939) had come about because of his own cognitive emphasis and an approach to therapy that had many parallels with the pragmatic, action-oriented methods that would come to be called CBT. Another was Karen Horney (1885−1952). Her model included an understanding of the way early experiences could lead to negative experiences of self and the world, and compensatory processes that might get set up to neutralize these. This became an important feature of case conceptualization in cognitive therapy and later, ST. Beck would regularly appeal to Horney’s phrase, “the tyranny of the shoulds” (which Ellis, in his robust manner, had rebranded “musterbation”), a precursor to ST’s “demanding parent.” Two other important influences are discussed later in this chapter. Franz Alexander (1891−1964) introduced the concept of the corrective emotional experience and Harry Stack Sullivan (1892−1949) pioneered the understanding of interpersonal schemas and the way they interact in relationships. Beck et al. (1979) also acknowledged being influenced by Eric Berne (1910−70), the founder of Transactional Analysis (TA), and Jerome Frank (1909−2005), who had identified common factors contributing to effectiveness in all psychotherapies.

What distinguished the emerging cognitive and behavioral therapies was a focus on and careful analysis of factors currently maintaining clients’ problems. These included clients’ negative beliefs and assumptions and vicious cycles of thought and behavior, and the way in which these impacted within the contexts of their lives and personal concerns. Despite this emphasis, developmental analysis of factors likely to predispose clients to current difficulties has always been part of case formulation in CBT (e.g., Hawton, Salkovskis, Kirk and Clark, 1989) and case conceptualization in CT always took into account the client’s history. Emery, who worked closely with Beck (Beck and Emery, 1984; Beck et al., 1979), pointed out that clients would be more motivated to change beliefs and behaviors if they recognized how they had developed:

Discover where your beliefs come from … by going back and seeing where you adopted your beliefs you can often make them clearer to you … Many beliefs are passed down for generations. We traced one patient’s fear of going broke back three generations to immigrants from Russia who were very poor.

(Emery, 1982, pp. 186−7)

Nevertheless, pressure to manualize the therapy for treatment trials meant that there was more emphasis on immediate maintaining factors than developmental analysis of clients’ problems.

The Integration of Attachment, Interpersonal, and Object Relations Theories

The Limits of the Collaborative Relationship

An important aspect of the collaborative relationship in CT is the therapist’s empathic understanding of clients. This is directed more broadly toward appreciating what clients were struggling with in their lives and more specifically toward what they were experiencing moment by moment in the therapy session. This was the hallmark of Rogers’ client-centered approach in which the therapist offered the client a relationship characterized by unconditional positive regard, empathy, and congruence (genuineness). It had been Otto Rank (1884−1939) who, in 1935, had introduced Rogers to what at that time seemed a revolutionary approach to the therapeutic relationship. Until then he had worked in a traditional psychoanalytic model (Kramer, 1995).

In addition, however, the collaborative relationship is one in which therapists encourage clients to identify goals for therapy and to work on them together. Many clients who seek psychological help can respond quickly to this kind of collaborative, empathic, and action-oriented approach. But this does not work for a significant proportion of clients. Some don’t seem to take naturally to collaboration, but act passively and helplessly, expecting the therapist to do all the work. Others become hostile or withdrawn and unmotivated. Yet others work to change their thoughts and experiment with new behaviors but do not experience meaningful change (Young, 1984). Cognitive therapists have to find a balance between being empathic and attending to clients’ experience on the one hand, and working actively for change on the other. For some clients this balance is difficult to maintain. Some feel misunderstood when therapists encourage them to change their thoughts or try out new behaviors. Some simply won’t do homework and in other ways appear to be uncooperative. Yet if therapists merely focus on empathically attuning to them, they do not seem to make much progress in actually changing ...

Table of contents

• Cover
• Title page
• Copyright page
• List of Contributors
• Foreword
• Acknowledgments
• Part I: An Introduction to Schema Therapy
• Part II: The Indication Process in Schema Therapy
• Part III: Schema Therapy Techniques
• Part IV: Schema Therapy Settings and Patient Populations
• Part V: The Therapist
• Part VI: Research in Schema Therapy
• Part VII: Implementation and Public Relations in Schema Therapy
• Author Index
• Subject Index – Schema Therapy