Group Schema Therapy for Borderline Personality Disorder

2

The Conceptual Model of Group Schema Therapy

Joan M. Farrell and Ida A. Shaw

The Group Schema Therapy (GST) model presented in this manual is consistent with the theory, components of treatment, and goals outlined for individual Schema Therapy (ST) by Young, Klosko & Weishaar (2003) and the Arntz & van Genderen (2009) publication of the treatment protocol from the successful trial in the Netherlands (Giesen-Bloo et al., 2006). Schema Therapy's conceptual model for Borderline Personality Disorder (BPD) will be briefly summarized here and the reader is referred to those volumes for additional elaboration of the individual ST model and its application. ST is an integrative treatment with roots in Cognitive Therapy (CT), learning theory, and the research of developmental psychology. ST grew out of efforts by Young and associates to treat more effectively patients with personality disorders and those who either did not respond to traditional CT or relapsed. As the name suggests, the focus of ST is at the schema level. This requires a shift from present-day issues to lifelong patterns, an adaptation required for personality disorder work. ST is based upon a unifying theory and a structured and systematic approach. ST concepts have some overlap with CT, psychodynamic psychotherapy, object relations theory, and Gestalt psychotherapy, but they also differ in important respects and have total overlap with no other model. The goals of ST reach beyond teaching behavioral skills, including the fundamental work of personality change. This change is conceptualized as involving decreasing the intensity of maladaptive schemas that trigger under- or over-modulated emotion and action states referred to as modes. The triggering of these intense states is seen as interfering with the use of adaptive coping or interpersonal skills by patients that would allow them to realize their potential and improve their quality of life.

Schema Therapy's Hypothesized Etiology of BPD

Figure 2.1 summarizes the model for the etiology of BPD posited by ST. When the normal, healthy developmental needs of childhood are not met, maladaptive schemas develop. Maladaptive schemas are psychological constructs that include beliefs that we have about ourselves, the world, and other people, which result from interactions of unmet core childhood needs, innate temperament, and early environment. They are composed of memories, bodily sensations, emotions, and cognitions that originate in childhood and are elaborated through a person's lifetime. These schemas often have an adaptive role in childhood (e.g., in terms of survival in an abusive situation - it engenders more hope for a child if they believe they are defective as opposed to the adult being defective). By adulthood, maladaptive schemas are inaccurate, dysfunctional, and limiting, although strongly held and frequently not in the person's conscious awareness. Nineteen early maladaptive schemas (EMS) were identified in patients with personality disorders (Young, 1990; Young et al., 2003). The original 15 are organized around four content areas: I Disconnection and rejection; II Impaired autonomy and performance; III Impaired limits; IV Exaggerated expectations. The three which were added more recently - negativity, punitiveness, and approval seeking - are not included in the table as there is not yet an empirical basis for placement or their existence as separate factors.

Figure 2.1 Schema therapy model. Etiology of personality disorder

Table 2.1 Schemas organized by content area

Disconnection and Rejection
(Connection and acceptance) Impaired autonomy and performance
(Autonomy and performance) Mistrust/abuse
Emotional deprivation
Defectiveness /shame
Social isolation/alienation
Emotional inhibition Dependence/incompetence
Vulnerability to harm/illness
Enmeshment/undeveloped self
Abandonment/instability
Subjugation
Failure Impaired limits
(Adequate limits) Exaggerated expectations
(Realistic expectations) Entitlement
Insufficient Self-Control Self-sacrifice
Unrelenting standards

When maladaptive schemas are triggered, intense states occur that are described in ST as "schema modes." A schema mode is defined as the current emotional, cognitive, and behavioral state that a person is in. Dysfunctional modes occur most frequently when multiple maladaptive schemas are triggered. Four basic categories of modes are defined (Table 2.2).

Table 2.2 Schema modes, their role in BPD, relationship to BPD symptoms

Role in BPD Related BPD Symptoms Child modes Vulnerable Child
Experiences intense feelings, emotional pain and fear, which become overwhelming and leads to flips into Maladaptive Coping modes that are identified as other BPD symptoms Intense, uncomfortable feelings - emotional pain and fear become overwhelming and lead to flips into Maladaptive Coping modes that are identified as BPD symptoms Abandonment fears, real or imagined Angry Child
Vents anger directly in response to perceived unmet core needs or unfair treatment A source of problems with others since anger is not just about present trigger, it is seen as inappropriate and misunderstood Intense inappropriate anger
Stormy relationships
Emotional reactivity Impulsive Child
Impulsively acts based on immediate desires for pleasure, without regard to limits or other's needs (not related to core needs) Also a source of interpersonal, work, legal problems. Action is usually self-damaging or potentially so Difficulty controlling anger
Self-injury
Impulsivity that is potentially self-damaging
Unstable sense of self Maladaptive Coping modes Avoidance
Pushes others away, breaks connections,
emotional withdrawal, isolates, avoids Most common in a continuum from "spacy" to severe dissociation or physical withdrawal. Can be in the form of pushing others away via anger - the Angry Protector Emptiness
Dissociation
Unstable identity Overcompensation
Coping style of counterattack and control. Sometimes semi-adaptive Common - Bully-Attack mode Intense inappropriate anger
Difficulty controlling anger Surrender
Compliance and dependence - gives up own needs for others, people pleasing Common and often overlooked as can flip quickly to overcompensation Unstable sense of self
Emptiness Dysfunctional "Parent" Modes Punitive
Restricts, criticizes and punishes self and others Very common, can be a source of self-injury or suicide attempts Suicide gestures or attempts Demanding
Sets high expectations and level of responsibility, pressures self/others to achieve Common also, origin of defectiveness, unstable sense of self Suicide gestures or attempts
Unstable sense of self Healthy modes Adult
Is able to meet needs in healthy way Underdeveloped Unstable identity
Emptiness Happy Child
Feels loved, connected, content Often non-existent Unstable identity
Emptiness, Mode flipping Frequent, exhausting, feels "crazy" and confusing to self and others Can account for instability affect, behavior, interpersonal, identity
Transient psychosis Emotional reactivity
Unstable identity
Stress-related psychotic states

Primary Child modes (Vulnerable Child, Angry Child, Impulsive Child) are said to develop when basic emotional needs in childhood (such as safety, nurturance, or autonomy) are not adequately met. These innate "child modes" are defined by intense feelings such as fear, helplessness, or rage, and involve the innate reactions a child has. Dysfunctional Parent modes (Punitive Parent or Demanding Parent) comprise the second category of modes. Dysfunctional Parent modes reflect the internalization of negative aspects of attachment figures (e.g., parents, teachers, peers) during childhood and adolescence. Labeling these modes "parent" is not intended to blame parents for BPD symptoms. Parents have their own schema and mode issues and may have deficits in the parenting they experienced and, consequently, impaired parenting ability. According to a review by Zanarini & Frankenburg (2007), studies report a high rate of sexual abuse - 40-70% depending upon the study. Herman, Perry & van der Kolk (1989) found that 81% of patients diagnosed...