Creative Methods in Schema Therapy

Advances and Innovation in Clinical Practice

Gillian Heath, Helen Startup

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781351171823
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Creative Methods in Schema Therapy captures current trends and developments in Schema Therapy in rich clinical detail, with a vividness that inspires and equips the reader to integrate these new ways of working directly into their practice.

It begins with creative adaptations to assessment and formulation, including the integration of body methods to promote engagement and to bring about early emotional change. Other chapters introduce innovative methods to lift a formulation off the page and it goes on to bring to life new developments across all aspects of the ST change repertoire, including limited reparenting, imagery, trauma processing, chair work, the therapy relationship, empathic confrontation and endings. For the specialist, there are chapters on working with forensic modes, eating disorders and couples work. Finally, the book includes chapters on the integration of key principles and techniques from Cognitive Behavioural Therapy, Emotion Focused Therapy and Compassionate Mind work into a core schema model.

The book will appeal not only to full-fledged schema therapists, but also tojunior therapists and therapists from other modalities who arewilling to enhance their ways of working.

Part I

Assessment, formulation and core needs

1 Assessment and formulation in Schema Therapy

Tara Cutland Green and Anna Balfour

Introduction

Skilful assessment and an accurate, collaboratively developed case conceptualisation¹ form the foundation of effective Schema Therapy. This initial phase involves building a meaningful relationship with your patient,² engaging them in therapy and orientating them to how Schema Therapy brings about change.

Schema Therapy views patients’ problems in terms of unmet emotional needs (past and present),³ related schemas,⁴ coping styles and maladaptive coping modes (from here on, ‘coping modes’, ‘sides’ or ‘parts’). You and your patient are somewhat like detectives, aiming to identify and put together these pieces of the puzzle to synthesise a picture of their patterns so that you can map a way forward. This occurs through the curious questioning and exploration that you would use in a standard psychological assessment, but also by noticing how your patient tells their story, relates to you and what is evoked between you. Attending to all aspects of their experience, methods such as imagery and chair work and Schema Therapy inventories also offer valuable means of gathering further information.

This focused period of exploring early experiences and current life patterns, and the links between them, can itself provide a meta-awareness that begins to loosen your patient from unhelpful habits of thought or action. Providing a framework of understanding in which they can make sense of themselves and feel accurately and deeply understood can engender hope, confidence in your ability to help them and motivation to engage in the therapy.

In this chapter, we offer some detailed approaches and creative perspectives to assessment and case conceptualisation, illustrating them through the case of Jim and his therapist, Mira.

The role of assessment and formulation

Determining suitability for Schema Therapy

Schema Therapy was originally developed for those whose problems are long-standing and have their origins in childhood or adolescence (Young et al., 2003). Aligning with this, the landmark randomised control trials (RCTs) of Schema Therapy (Giesen-Bloo et al., 2006; Bamelis et al., 2014) have demonstrated good outcomes for Schema Therapy with personality disorders. A number of authors additionally make the case, on theoretical grounds, for the use of Schema Therapy with less complex problems that require shorter term therapy, and provide supporting case studies (e.g., Renner et al., 2013; Reusch, 2015 and contributors to van Vreeswijk et al., 2012). Evidence to support its effectiveness with less complex problems is increasingly emerging (e.g., Carter et al., 2013; Renner et al., 2016; Tapia et al., 2018); however, further studies are much needed.

Thus, while NICE-recommended treatments such as Cognitive-Behaviour Therapy (CBT) might be considered as a first approach for Axis I disorders, Schema Therapy might also be considered for those patients who fail to progress with standard treatments. A recent UK study (Hepgul et al., 2016) reports that around two-thirds of individuals seeking treatment through IAPT – a time-limited, predominantly CBT service for anxiety and depression – have significant personality disorder features, the presence of which will be associated with poorer treatment outcomes (Goddard et al., 2015). Particularly in these more complex cases, Schema Therapy might usefully be considered.

However, Schema Therapy is not suitable for all patients. Original contraindications included active psychosis and chronic or moderate to severe alcohol or drug use (see Young et al., 2003). Nonetheless, clinical reports suggest that formulating psychotic experiences as expressions of toxic parent or dysfunctional coping modes can help point to underlying unmet needs, which can then usefully guide interventions. Additionally, Schema Therapy has been adapted and evaluated for substance-dependent patients, with some initial encouraging outcomes.⁵

Beginning the healing process

The assessment and formulation process allows for a particular expression of limited reparenting. Akin to the healthy parenting of a young child, you show interest in and are attentive to your patient and their activities, validate their unique internal world and offer language and concepts that help them to name and make sense of things. Patients who have lacked such parenting can, as a result, find these initial sessions healing in themselves.

Developing a road map

A full formulation provides an understanding of your patient as a person, not merely their symptoms. It becomes the road map for all that follows, enabling you to be responsive to your patient’s needs in any given moment and to draw on a range of change methods within a theoretically consistent framework.

I’ve always felt, the case conceptualization, if it’s off, the treatment won’t work, that it’s actually central to guiding what you do … if you don’t understand what happened in a patient’s childhood and adolescence as they’re growing up, you can’t get them better; you can’t do it by just knowing their schemas and their modes, you have to understand how their problems got started.

Jeff Young

Assessment

Case example: Jim

Jim, a 36-year-old construction worker, was referred by his GP for therapy for depression; he also mentioned a recent violent outburst that was concerning Jim.

Jim appeared cold and distant and avoided eye contact as he walked into his first session with his therapist, Mira. She noticed herself feeling a little on edge. When she asked him what had led him to see his GP he looked at the floor and told Mira in an irritated tone that something had happened with his girlfriend, Sarah, and said ‘I know she’s going to leave me, I just know it. If that happens I may as well end it all.’ He said he didn’t know why he was there and that ‘talking to you isn’t going to get Sarah to stay with me.’ Mira reflected, ‘You’re feeling hopeless.’ Jim snapped back, ‘No, it is hopeless.’ Mira noticed a slight pang of feeling attacked but girded her empathy, reflecting, ‘So what’s the point of being here?’ Jim responded, ‘Yep.’

Mira then enquired, ‘What is it like for you being here with me in this room?’ He said, ‘uncomfortable’ and started to fidget. ‘I’ve never seen the point of talking about this kind of stuff.’ His face flushed, suggesting shame. ‘Makes me feel pathetic, weak.’ Mira responded, ‘Well I don’t think you’re pathetic or weak. It’s clearly taken a lot of courage to come here.’

Mira sensed that he might need a bit more help to feel back in control and to regain a sense of self-esteem; it concerned her that his apparent level of discomfort might discourage him from returning for a second session. She commented on how he clearly cared a lot for Sarah and guessed he regretted the argument. He started to open up further, sharing that she was getting fed up of him being miserable – ‘and who can blame her’ – and thought she was seeing someone else. He said he prided himself on not letting emotions get the better of him but had ‘blown it’ the other week. On his way home from work he had noticed her car outside a pub; she had said she was going to her mum’s that afternoon. When she got home later, he accused her of having an affair, grabbed her phone and smashed it. At this point in the session, he put his head in his hands. Mira said, ‘You look pretty upset about that. I’m wondering what you’re feeling right now?’ He replied, ‘That bloody phone cost over £500 to replace!’ Mira noticed feeling pushed back by his deflection from her question and his annoyed tone. She paused, reflecting that his anger seemed to be directed at himself, and asked, ‘Sounds like you’re pretty annoyed at yourself for what you did?’ He replied, ‘How could I have done something so stupid – what is wrong with me? She was only at the pub to drop off a birthday card to her friend.’

Mira went on to ask more about his relationship with Sarah. Mira heard how she complains that he’s emotionally ‘cut off’ and that while she is lovely, he doesn’t put it past her that she will ‘screw me over’, as previous girlfriends and his ex-wife have done. He also said that it was Sarah who told him he needed to get help after the incident, otherwise she would leave him – but that she hadn’t moved out from where they live together and recently had told him she loved him.

Mira asked what he had meant earlier when he’d said he ‘may as well end it all’ if Sarah left him. He said he just couldn’t bear living with another failure, another rejection and being on his own again. He hadn’t made specific plans, and wouldn’t do it while his mum was still alive but did think about the high bridge nearby that was nicknamed ‘Suicide Bridge’.

Before the session ended, Mira shared with Jim, ‘I can see that you feel terrible about what you’ve done and keep having a go at yourself for it as well as being afraid that Sarah will leave you. I know that you’re really uncomfortable talking about these things but I’d like to help you feel less rough, help you understand what led to your outburst, get a kinder view of yourself and develop other ways of dealing with moments like those. You clearly care deeply about Sarah but feel insecure about the relationship. I know you think differently right now, but it sounds to me like she wants to make it work and I think I can help with that. What do you feel about giving this a try and seeing me again?’

He agreed to ‘give it a go’.

In the early sessions there are many layers to your therapeutic work. In the exerpt above, for example, Mira is attempting to create a safe setting for Jim to open up and self-reflect, to engender hope, managing her own feelings and also aiming to formulate the nature of his difficulties at a more cognitive level.

Distinctive features of assessment in Schema Therapy

An assessment interview in Schema Therapy has similarities to a standard clinical interview. A key difference, however, is that whatever you ask, be it about goals for therapy, their history or any previous therapy, you aim to discover their unmet emotional and relational needs and the origins and current expressions of their schemas and modes. You then explore together what is needed to engender desired changes. Identifying unmet needs will also indicate to you the particular qualities of your limited reparenting that will enable healing.

You will more readily help your patient to piece together relevant parts of their ‘puzzle’ if you have a good understanding of core needs and are familiar with the 18 maladaptive schemas (Young et al., 2003, pp. 14–17) and prototypical schema modes (see Bernstein and colleagues’ helpful descriptions (Van den Broek et al., 2011) and Breaking Negative Thinking Patterns (Jacob et al., 2015)).

As your patient shares with you, pay particular attention to emotions they mention (for example, fear, loneliness, frustration) or show in their face or body (for example, looking down or bouncing their foot) as these often provide a window to their ‘Vulnerable Child’ mode. Listen for explicit or implicit negative, self-directed messages, including demands or criticisms, which could express the messages of an inner ‘toxic parent’ mode. Notice the qualities of their interactions with you and how these have an impact on how you feel, in order to help discern possible ‘coping modes’, such as self-aggrandisement, excessive compliance or emotional detachment. Finally, attend to signs of your patient’s ‘Healthy Adult’, including strengths⁶ – such as creativity or courage – and interests they pursue, which can give rise to meaningful metaphors and playful interaction between you and the patient.

Imagery for assessment is a powerful experiential technique used in Schema Therapy to deepen your and your patient’s understanding of the impact of key childhood experiences, the nature of their unmet needs, related schemas and modes and their origins. This method is detailed in Chapter 2, and so will not be described here.

As Mira reflected on Jim’s first session, she hypothesised the following schemas and modes and, thus, began formulating even at this early stage.

Jim’s averted eye contact, blushing, sense of being weak and his idea that Sarah couldn’t be blamed for being fed up with him, all suggested to Mira a Defectiveness/Shame schema. She hypothesised a Punitive Parent mode, knowing that this typically accompanies this schema and delivers shaming messages. This was consistent with Jim’s implied self-talk: ‘You’re pathetic and weak’; ‘No wonder Sarah wouldn’t want to be with you’; ‘What is wrong with you?’ She noted that Jim is likely to feel shame in his Little Side, which would, in all likelihood, believe these messages, as a child would believe what they are told by a parent.

Jim’s prediction that Sarah would leave him suggested to Mira a possible Abandonment schema. His idea that she was being unfaithful, as previous partners h...

Table of contents

• Cover
• Endorsements
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Foreword
• List of contributors
• Acknowledgements
• An introduction to Schema Therapy: origins, overview, research status and future directions
• PART I: Assessment, formulation and core needs
• PART II: Creative methods using imagery
• PART III: Creative methods using chair work, mode dialogues and play
• PART IV: Empathic confrontation and the therapy relationship
• PART V: Developing the Healthy Adult and endings in Schema Therapy
• Index