Foreword

I am very pleased to have been invited to write the foreword for this groundbreaking resource, which will allow clinicians to integrate Individual and Group Schema Therapy (GST) sessions into complete treatment programs that can be delivered over a range of patient populations, treatment lengths, and levels of care.

Since I first heard about the extremely positive results of the authors’ randomized controlled trial of GST for patients with borderline personality disorder (BPD) in 2008, I have been very excited about the potential of the group model to make Schema Therapy more available and affordable for patients. Given the worsening climate for mental health reimbursement in this era of managed care in the United States and elsewhere in the world, Group Schema Therapy has the potential to deliver the powerful treatment strategies of the schema approach in a more cost-effective manner than has been possible with individual schema therapy – with equivalent or perhaps superior results. I am especially excited about the large-scale clinical trial that is under way at 14 sites in six different countries. Arnoud Arntz and Joan Farrell serve as the co-principal investigators of the study, testing the efficacy and cost-effectiveness of the Group Schema Therapy model for BPD patients combined with two different numbers of individual sessions.

This book, with the collaboration of Neele Reiss, the psychologist and schema therapist who pioneered GST in Germany, extends the integrated Individual and Group Schema Therapy program for use with a wide range of patient groups – personality disorder, complex trauma, chronic difficulties, those who have failed in other treatments, and those who need a higher level of care. It includes the novel concept of giving patients a “bank account” of individual ST sessions to draw on, as they need to; this concept was developed for the BPD multisite trial. Since the publication of the first book on GST (Farrell & Shaw, 2012), there have been many initiatives internationally to apply the GST model to other diagnostic groups of patients. Like individual ST, GST is trans-diagnostic – in the sense that the focus of interventions is the mode profile of the patient rather than specific symptoms. Thus, GST, like ST, should be effective for disorders other than BPD. Of course, any application needs empirical validation and I am happy to say that preliminary findings are promising. This integrated program has been tested in inpatient and day hospital settings for BPD (Reiss et al., 2013a) and mixed Cluster B and C disorders (Muste, 2012; Fuhrhans, 2012). Its use in forensic settings is being evaluated in the UK. A randomized controlled trial comparing ST to cognitive–behavioral therapy (CBT) for avoidant PD and social phobia and an experimental case series for dissociative disorders are under way in the Netherlands.

The integration of Group and Individual Schema Therapy presented here feels entirely consistent with my own individual model, in terms of the conceptual model, therapeutic alliance, and treatment interventions. The GST model encourages group members to become like a healthy family in which they can “re-family” each other, under the watchful guidance of two highly skilled therapist-parents. The sense of belonging and acceptance provided by this group analogue of a loving family seems to catalyze both the limited reparenting and emotion-focused components of ST. Furthermore, by utilizing two co-therapists for each group, GST has found a way to free up one therapist to move fluidly around the group, often working with one or two members at a time, creating novel experiential exercises to bring about change. At the same time, the second therapist serves as the “stable base” for the rest of the group, maintains an ongoing emotional connection with each member, monitors the reactions of all members, explains what is happening to educate them about what is taking place, and intervenes to shift the direction of the group to focus on the needs of other group members. I am also impressed that GST goes well beyond the traditional CBT/DBT (dialectical behavioral therapy) group format, in which members are taught skills in a seminar-like setting; and beyond non-CBT groups, in which the therapist does individual work with one member while the rest of the group primarily watches. In GST, the techniques used in Individual Schema Therapy, like imagery change work and mode role-plays, have been adapted to engage all of the members in unique exercises that make use of the power of group interaction and support. These group therapeutic factors, combined with the broad range of integrative techniques that are already part of ST, may account for the large treatment effects in the controlled outcome study I mentioned earlier, as well as in preliminary data from other ongoing studies of GST.

The authors describe a systematic approach to ST treatment, while retaining the flexibility that I have always valued so highly in developing Individual Schema Therapy. The treatment suggestions are specific and well organized, while avoiding the temptation to write a therapeutic “cookbook” for therapists to follow in a rote manner. The authors have preserved the core elements of ST by developing “limited reparenting” intervention strategies for each mode that arises, seizing “experiential moments” to do emotion-focused work that brings about change at a deep level. Like individual ST, their group model blends experiential, cognitive, interpersonal, and behavioral work. The program presented here divides ST interventions into four main components: Schema Therapy Education, Mode Awareness, Mode Management, and Experiential Mode Work. There are sessions of each component that target the main schema modes one at a time. The individual and group sessions are coordinated by mode. The individual ST sessions give therapists the option of a cognitive, experiential, or behavioral pattern-breaking intervention. The authors provide specific therapist script examples that allow access for the beginner using ST, yet have the essential flexibility of ST so that they can be adapted to meet an individual patient’s mode and need. The combination of structure and flexibility in this manual make it accessible to practitioners at all levels of experience with ST. The book is written at a level that should appeal to a very broad range of mental health professionals, including psychologists, social workers, psychiatrists, counselors, and psychiatric nurses, as well as interns and residents.

The experience that the authors have gained over 30 years of training therapists throughout the world, and of leading GST groups with a broad range of clinical populations, is evident throughout the volume. This book is the first published treatment manual for integrating Individual and Group Schema Therapy, and succeeds in providing the most essential information that clinicians will need in order to develop and implement such programs. The program sessions can be delivered in intensive form for higher levels of care, such as inpatient and day therapy, or spread over a year of outpatient treatment. The program could begin with more sessions per week, then taper in intensity and be moved to outpatient care. The user-friendly format of the book includes patient examples, descriptions of group and individual sessions, and examples of therapist scripts to explain core ST concepts in language easily understood by patients, along with patient handouts, exercises, and assignments. This material is presented in the manual itself as well as being available in downloadable form on the Wiley website for use with patients.

On a more personal level, I had the opportunity to experience GST first hand as a participant at an advanced training workshop that I invited Joan and Ida with Neele to teach for the senior schema therapists at our New York institute. I am even more excited about the potential of ST in a group after this experience, and would love to conduct an ST group like this myself once I have learned the necessary skills. Joan Farrell is an outstanding schema therapist who serves as the “stable base,” emotional center, and “educator” for the group as a whole – a role I can imagine myself learning to fill, given enough time and experience. What truly amazed me – perhaps because her style is so different from mine and Joan’s – was the remarkable group work of Ida Shaw. It is hard to convey the level of originality, creativity, and spontaneity she brings to the group experience. She is able to blend elements of gestalt, psychodrama, role-playing, and her own infectious style of play into an approach that perfectly fits the intensive demands of schema mode work, cajoling patients to change in profound ways. The group exercises in this manual will allow schema therapists to try out some of her unique work. Neele Reiss adds the perspective of the “next generation” of schema therapists who are intent upon practicing and empirically validating ST. She collaborated on inpatient studies of the integrated model for BPD patients (Reiss et al., 2013a) and her current work applies ST interventions to problems like test phobia and eating disorders.

I highly recommend this outstanding manual to all mental health professionals working with more complex, chronic, and hard-to-treat patient populations – especially those who are looking for an evidence-based,...