Introduction to Schema Therapy

Schema Therapy Introduction

• Schema Therapy is a medium- to long-term form of psychotherapy primarily for patients with personality disorders.
• It combines elements from various therapeutic approaches, including cognitive-behavioral, Gestalt, and experiential therapies.
• Schema Therapy is often delivered in an individual format, but can also be administered in groups or mixed formats.

Main Concepts

• Early maladaptive schemas: Cognitive structures that contain self-defeating themes about oneself, others, and the environment.
• Schemas originate from universal emotional needs, identification with significant others, experiences during childhood and adolescence, and early temperament.
• There are five universal emotional needs:
  • Need for secure attachment
  • Autonomy and independence
  • Limits and boundaries
  • Validation of needs and feelings
  • Spontaneity and play
• Early maladaptive schemas can be classified into five domains:
  1. Disconnection and rejection (e.g. abandonment, emotional deprivation)
  2. Impaired autonomy and performance (e.g. dependence, incompetence)
  3. Impaired limits (e.g. entitlement, grandiosity)
  4. Other-directedness (e.g. subjugation, self-sacrifice)
  5. Overvigilance and inhibition (e.g. negativity, pessimism)

Coping Styles

• Three broad, usually dysfunctional, coping styles:
  • Schema surrender: passively giving in to a schema
  • Schema avoidance: avoiding situations that trigger a certain schema
  • Schema overcompensation: doing the opposite of a schema

Schema Modes

• A schema mode is a state-like concept that represents someone's emotions, cognitions, and behavior at a particular time.
• Young and colleagues (2003) originally distinguished 11 schema modes, but others have proposed additional modes.
• Schema modes can be categorized into four domains:
  • Child modes: feeling, thinking, and acting in a child-like manner
  • Avoidant coping modes: attempting to protect oneself from pain by means of avoiding
  • Parent modes: relating to self-directed criticism or demands that reflect internalized parent behavior and emotional stance
  • Overcompensatory modes: referring to extreme attempts to overcompensate painful feelings

Assessment Phase

• The goal of the assessment phase is to identify dysfunctional modes and early maladaptive schemas.
• The therapist works together with the patient to explore the origins and links to the patient's presenting problems.
• Various assessment sources are used, including questionnaires, observations of emotional states, and patient's clinical notes.
• The assessment phase typically lasts for about a year.

Forensic Schema Therapy

• Forensic Schema Therapy focuses on the patient's schema modes, as they are related to criminogenic needs.
• The goal is to reduce recidivism risk by targeting schema modes that represent psychological risk and protective factors for violent behavior.
• Forensic Schema Therapy is adapted to work with patients in forensic settings, taking into account the unique challenges of working with this population.

Treatment

• The entire therapy typically takes about 3 years, with diminishing frequency in the third year until termination.

• The therapist often meets twice a week or sometimes once a week.

• Limited reparenting and empathic confrontation are cornerstones of Schema Therapy practice.

• Cognitive, behavioral, and experiential interventions are used to modify schema modes.

• Schema mode work is particularly suitable for patients with severe personality disorders.### Schema Therapy in Forensic Settings

• Schema therapy is used to treat patients with Cluster B personality disorders, particularly those with a high risk of reoffending and a history of aggressive behavior.

• Exclusion criteria for forensic schema therapy include serious neurological impairments, autistic spectrum disorder, current psychotic symptoms or disorders, current drug or alcohol dependency, and current serious mood disorders.

Schema Modes

• Five schema modes: Vulnerable child, Angry child, Impulsive child, Lonely child, and Detached protector.
• Self-aggrandiser, Bully and attack, Conning and manipulating, Predator, Obsessive-compulsive, Overcontrolled, and Paranoid are some of the unhealthy modes.
• Healthy modes include Healthy adult and Playful child.

Challenges in Forensic Settings

• Forensic patients can be devaluing and hostile, making it difficult for therapists to establish a therapeutic relationship.
• Therapists may struggle with self-disclosure due to ethical and security concerns.
• Rapport building is crucial in forensic settings, but can be challenging due to the patient's low resilience.

Case Study: Max

• Max, a 35-year-old man, was sentenced to an indefinite sentence in a high-security forensic hospital for treatment.
• He has a PCL-R score of 33, indicating psychopathic range, and a history of neglect by his mother in childhood.

Research Evidence

• Studies support the schema mode concept in personality disorder patients.
• Schema therapy has been shown to be effective in reducing criminal behavior in forensic patients.
• Research has validated the concept of early maladaptive schemas and schema modes in offenders.