CBT 5 & 6 - Schema Therapy

Third wave CBT

First wave CBT - focused on classical and operant condition Second wave CBT - cognitive processing Third wave CBT - examine a core inner structure of the patient - (E.g. self-structure) NOTES: First wave CBT - Observable Second wave CBT - cognitive processing - Core belief, intermediate thoughts etc Third wave CBT - Something that you cant really see

Schema therapy - Therapeutic Style CONT

1)Empathic reality testing - Balance between empathy and helping patients to see the reality of their behaviors and thinking Creating a balance between empathy and reality testing - is like re-parenting... NOTES: - Empathic reality testing - This is the hallmark of reparenting - Ex. Whats the consequence of if you don't do this - Children usually don't have the scope of seeing what the consequences are because they see what they want to see

Maladaptive Coping

Three basic responses to threat: Fight, Flight or Freeze. Three different coping styles in Schema Overcompensation - Fight Avoidance - Flight Surrender- Freeze NOTES: - 3 types of coping in schema therapy - Child would either do one of these if being caught trying to sneak another sweet snack - Fight - I did not do that - Flee - drop it and just leave - Freeze - just stand there and look - Surrender = play into the EMS

EMS

EMS - may lead to suffering - but it is all the person knows and feels comfortable with People are drawn to events that trigger the schema People regards schemas as a priori truths and influence the processing of all other experiences Unfortunately, this leads people to inadvertently recreate in their adult lives the conditions in childhood that were most harmful to them. NOTES: - This EMS is countered to first wave because first wave says if its not reinforcing, you wont do it - However, if all you knew is suffering your life, that is what you are drawn to in EMS - People are drawn to event that triggers the schemas - going to recreate the schema - Ex. Some of us in our life that we might be attracted to those who are not good for us - but we are still drawn to the - this is because we feel comfortable and trigger the schema - Schemas - Like a filing cabinet of your experiences - Or - Operating system of a computer - sifting through data constantly - The one that sticks out, reify the schema - Unfortunately, this leads people to inadvertently recreate in their adult lives the conditions in childhood that were most harmful to them. - Key piece: the EMS's inadvertently, recreate in their adult lives what is harmful to them - Its multiple noxious experiences that can lead to a bigger EMS

Schema Technique CONT 2

Experiential techniques have two main goals: 1) To trigger the emotions connected to the EMS 2) Reparent the patient in order to heal these emotions and partially meet the patient's unmet childhood needs. Experiential techniques allow for a movement that their schemas are intellectually false to the place that EMS are emotionally false NOTES: - Cannot not use experiential techniques unless you have a solid therapeutic alliance - It is very emotionally charged and can be traumatizing in a sense - You need to know if you are ready and especially if your client is ready because it can be overwhelming - You have to become the vessel of the emotion - People can intellectually see that they have unrelenting standards but need to get them feeling that and that is more difficult - Ex. Son knows his father was very critical - he can intellectually say it and he can feel it

Certain Assumptions must be Met for CBT to be Successful CONT

Patient should have enough psychological flexibility that goals can be met in a brief amount of time. Patients can easily engage in a collaborative relationship with the therapist to achieve a goal in a short amount of time. Patients will have an identifiable problem that is easily discernible. NOTES: - A lot of CBT models are brief - In Traditional CBT, young said that once you get the depression down, the client should be ok - However, some clients are very complex and require more time than 15-20 weeks - Patients will have an identifiable problem that is easily discernible. - Not easy to see what you are dealing with

Certain Assumptions must be Met for CBT to be Successful

Patients must comply with the treatment protocol. They are assumed to want to change and with enough reinforcement they will change Patients can access and report their emotions and cognitions. Patients can use logical decision making and empirical analysis as a way to change their behavior. NOTES: - Patient must do the treatment protocol - Able to see their core beliefs to some degree - See their Automatic beliefs - Etc. - That patient must want to change - Psychodynamic does not assume the client wants to change - - 3rd wave CBT - Contemporary - - 1st and 2nd wave CBT - Traditional - - Patients can use logical decision making and empirical analysis as a way to change their behavior. - "oh my automatic thoughts are driving my behavior"

Schema operations

Schema Perpetuation - all the thoughts, behaviors and feelings that continually reinforce the schema Occurs through three primary processes: cognitive distortions (Beck), self-defeating life patterns, & coping styles Schema Healing - primary goal is to deactivate problematic schemas so they have less toxic value NOTES: - Cognitive distortions - the way we think will reinforce the schema - All the WAVES feed on each other, that is how Dr. P sees it while others see it as different - You are never going to eradicate the schema - You want to make it less toxic, less influential for the client - White board NOTES - 1st wave - behavioral (operant and conditioning) - 2nd wave - cognitive distortions - Both of these deal with symptom issues - 3rd wave - schema (functional issues) - Functional = occupational, emotional, social, interpersonal functioning - You can eliminate the depression with 1st and 2nd wave but they can relapse because the functional issues (day-to-day living issues) is always present (3rd wave) - Sometimes the problem is time, so in a hospital setting, you need to just get the symptoms alleviated and they are out - does not touch upon the functional issue - Patients relapse not because of the symptoms but because their lives are so dysfunctional that they will relapse and start to drink or whatever

Schema Modes

Schema modes are the current ways or moment to moment ways of behaving EMS and Coping styles are like traits but that does not mean they are active or activated State model - is the mode or behavior that the patient is exhibiting. NOTES: - State model - is the mode or behavior that the patient is exhibiting. - This is the behavior or enactment that occurs within the therapeutic session

Schema operations CONT

Schema work at its core is really about reparenting in a sense. Providing the safe and secure environment to examine the toxicity of the EMS and subsequent behaviors. May not be able to eradicate the Schema but can make it... Less toxic Less triggering Less problematic behavioral patterns NOTES: - Schema is about reparenting - Because a lot of the EMS's come out of an insecure environment and our job is to provide a safe environment to examine the toxic EMS's - You are the secure object for the client when they are being insecure and showing you their EMS - Reparenting = you become the secure object and model to them how to cope with that

Maladaptive Coping CONT

These three coping styles emerge when the child feels threatened. The child will avoid, overcompensate or surrender to the situation Surrender - yield to the schema and believe that it is true; act in ways that confirm the schema Avoid - arrange their lives so schema is never activated Overcompensation - doing the opposite of what the schema demanded These coping mechanisms were highly adaptive in childhood, but became maladaptive in adulthood Child was always defiant with alcoholic father - but now in adulthood defiance with everyone has left him alone and lonely. NOTES: - freeze, flee, or fight was adaptive in childhood but is not maladaptive in adulthood - Child was always defiant with alcoholic father - but now in adulthood defiance with everyone has left him alone and lonely.

Contemporary CBT What is the black box?

- Black box NOTES: - Stimulus activating event (antecedents) cognition and beliefs - 2nd - today we are adding schemas (3rd wave) Response Behavior (symptom presentation)

Schema therapy - Therapeutic Style

1)Empathic confrontation - therapist empathizes and understands the reasons the patient has the beliefs that they do and that those beliefs are based on early childhood experiences - while also confronting the patient that their beliefs are inaccurate and lead to unhealthy life patterns NOTES: - There are ways to be very empathic but also confrontational - Confrontational in the sense that it is very reflective for the patient

What is a Schema?

A broad organizing principle for making sense of one's life experience NOTES: - Schema is 3rd wave CBT - - Schema - A navigational map that comes from early childhood experiences - helps you traverse the difficulties associated with the world - Some peoples navigational systems are good and protect them = sense of self intact - Some peoples navi system are bad and leads them to problems over and over again - - We all have schemas and they all drive us towards certain situations - Ex. Asked women at a party "who are you most attracted to" - All of these women were children of alcoholics - 75% of them wrote the person that is in recover without knowing that they were in recovery - Your schema attracts you to those that enacts your schema - make you feel most comfortable with

Beck and Schemas

Beck did write about schemas, but often saw them as core beliefs - Young's definition of schemas centers around: "Schemas, many of which are formed in early life, continue to be elaborated and then superimposed on later life experiences, even when they are no longer applicable." Young et al (2003) page 7 NOTES: - Schemas - Informs core beliefs - Youngs book is bible for schema therapy - "Schemas, many of which are formed in early life, continue to be elaborated and then superimposed on later life experiences, even when they are no longer applicable." Young et al (2003) page 7 - We use these schemas even when they don't make sense later in life - they are hard to change - Schemas = hardware of your computer - Core belief is one component of your computer - its not the full system - Young is interested in the maladaptive schemas - Schemas - Early life experience - Family interaction - Childhood experience

EMS CONT 9

Domain 1 - Disconnection and Rejection -unable to form secure or satisfying attachments with others Domain 2 - Impaired Autonomy and Performance - inability to separate from one's family and function independently Domain 3 - Impaired Limits - not developed adequate internal limits in regards to reciprocity or self-discipline Domain 4 - Other Directedness - an excessive emphasis on meeting the needs of others rather than their own needs Domain 5 - Overvigilance & Inhibition- suppress spontaneous feelings and impulses NOTES: Domain 1 - Disconnection and Rejection -unable to form secure or satisfying attachments with others - Attachment Domain 2 - Impaired Autonomy and Performance - inability to separate from one's family and function independently - Separation and Individuation Domain 3 - Impaired Limits - not developed adequate internal limits in regards to reciprocity or self-discipline - Limit setting - Boundaries Domain 4 - Other Directedness - an excessive emphasis on meeting the needs of others rather than their own needs - People pleasers - Balance between self and others - having a balanced approach to ones needs and the needs of other people Domain 5 - Overvigilance & Inhibition- suppress spontaneous feelings and impulses - Emotional dysregulation - Heightened state of reactivity - always on alert -

Early Maladaptive schemas(EMS)

EMS - Young's theory *Problematic ways of interpreting the environment. These schemas are one's cognitive and emotional patterns. Core internal model that leads someone through life* *EMS develop through early childhood experiences... these childhood experiences shapes the schema* Not all EMS come out of trauma or abuse - could be out of being overprotected or sheltered EMS are destructive independent of their origin- EMS come out of repeated noxious experiences NOTES: - Internal working model - This is your schema - The model that you use to navigate the world - If your model is corrupted, you are going to interpret the environment that is not realistic or valid - Inaccurate interpretation of the world - Ex. Internal working model of distrust when you meet someone, even if they are trustworthy, they will not trust them - White board notes: - Beck - Difference between schemas and core beliefs - EMS Schemas (directly related to the early development - the way that you navigate) Core beliefs (this is just thinking - the way that you think) intermediate beliefs (thinking) AT situational (thinking) - Ex. Ever see someone in your life that you think is cool? Yes - that's schema based - its instantaneous - Ex. Bollywood films are terrible - but Dr. P saw them a lot and even if they are terrible, she will still enjoy watching them because it reminds her of her childhood - Not all EMS come out of trauma or abuse - could be out of being overprotected or sheltered - Overprotection and sheltering can create an EMS as well - Certain caregivers that overprotect their little ones - Certain cultures that reinforce this - This can also produce an EMS - Some people become over entitled with overprotection - "the world is here to serve me" - EMS are destructive independent of their origin- - Doesn't matter where they come from because they affect peoples behaviors, confidence, self esteem etc - EMS come out of repeated noxious experiences - Comes from multiple experiences, not just one

Young's EMS

Early maladaptive schemas (EMS) 1) Broad, pervasive theme or pattern 2) Comprised of memories, emotions, cognitions, and bodily sensations 3) Regarding oneself and one's relationship with others 4) Developed through childhood or adolescence 5) Elaborated throughout one's lifetime 6) Dysfunctional to a significant degree - dysfunction in behavior, thinking, feeling and affecting the entire well-being of the client NOTES: 2) Comprised of memories, emotions, cognitions, and bodily sensations - When you eat something that will remind you of your childhood - A song that was profound that you heard before - elicit an emotion or feelings that you might have had before 5) Elaborated throughout one's lifetime - Certain experiences that you may have along the way that reinforce or magnify the maladaptive schemas - Ex. Child looses parents early on - Gets married but then divorces - This comes back to abandonment and loosing parents early in life 6) Dysfunctional to a significant degree - dysfunction in behavior, thinking, feeling and affecting the entire well-being of the client

EMS CONT 5 Erikson (1950) psychosocial stages

Erikson (1950) psychosocial stages - that the successful resolution of each stage leads to an adaptive schema, whereas failure to resolve a stage leads to EMS. Most concerned with EMS because that leads to chronic psychiatric problems. NOTES: Erikson (1950) psychosocial stages - that the successful resolution of each stage leads to an adaptive schema, whereas failure to resolve a stage leads to EMS. - This maps on exactly to Young's EMS's

Problems with Traditional CBT

Even after treatment many patients relapse Many times after the symptoms have been addressed through traditional CBT, there are interpersonal and behavioral functioning problems that still persist Many patients don't have clearly articulated primary diagnoses and their problems are more chronic in nature (e.g. series of broken relationships, never able to hold down a job, problems with immediate family etc. no clear diagnosis but you can see that theres a problem) NOTES: - A lot of flak that young got when he came up with 3rd wave CBT - He noticed an interesting event = even after 2nd wave cbt, many patients relapsed - Ex. Dr. P had a patient - very accomplished patient - Very smart, very educated, family etc. - He was depressed because company going through financial problems - He as very insightful and can examine his automatic thoughts - He said his depression was all good but then came back - He said that when he came back, he gets irritated with people and starts to lash out - Even though he has no behavioral problems (depression) he still had interpersonal problems (lashing out at people) - Traditional CBT - First and second wave CBT - Relational issues never covered in first wave and second wave CBT - CBT - Emphasizes measurement outcome - This is why treatment plans look very structured

Schema Techniques CONT

Examining the advantages and disadvantages of specific coping styles or the behavior - Eg. What do you get out of avoidance or what do you get out of drinking too much....

EMS CONT 4 Example of SEVERE EMS

Example of SEVERE EMS If both parents are are extremely critical and it comes early in life and is frequent - then anyone can trigger this schema However, if a person experiences criticism in adulthood and it happens occasionally and it is milder and given by one parent, then the schema may only be triggered in certain circumstances (e.g demanding authority figure). NOTES: If both parents are are extremely critical and it comes early in life and is frequent - then anyone can trigger this schema - If parents say its never good enough, its never good enough even if you are in grad school - **You are getting A's and B's in grad school and only 1 % in the population is getting a doctorate = you are good, it is enough** However, if a person experiences criticism in adulthood and it happens occasionally and it is milder and given by one parent, then the schema may only be triggered in certain circumstances (e.g demanding authority figure). - Have one loving parents and one demanding parent

EMS CONT 6 Four types of early life experiences cause EMS

Four types of early life experiences cause EMS 1) Toxic frustration of needs - does not receive enough from parents/caregivers - emotional deprivation 2) Trauma or victimization 3) Provide too much of something that the child's growth is stunted (e.g coddled indulged) 4) Selective internalization or identification with significant other -becomes like the parent - eg. If parent abusive the the child become abusive NOTES: Toxic frustration of needs - does not receive enough from parents/caregivers - emotional deprivation - Issues regarding poverty - Being displaced from your home - Emotional needs and physical needs - 3) Provide too much of something that the child's growth is stunted (e.g coddled indulged) - Given too much to where they cannot develop autonomy - Also having too much money to where they get coddled financially - Get a lot of things without having to work for it - Selective internalization or identification with significant other -becomes like the parent - eg. If parent abusive then the child becomes abusive - Becomes the bully in recess place - The person internalizes the person scripts - If they heard they were not good enough early on - they selectively hear that one and don't hear the other ones

Schema technique CONT 3

Imagery - minimal instruction as what to capture patient's interpretation not therapist's interpretation - goal is to elicit core emotions "Now close your eyes and let an image float to the top of your mind." Don't force the image tell me what you see." Describe the image - "Imagery is not free association but rather like watching a movie - I want you to become part of the movie and live through all of the events that unfold. " Imagery - To make the experience more vivid.... Therapists asks questions to make it vivid like "what are you hearing? What is the look on your face? Is the patient in the image? What is the patient feeling? Ends imagery session by asking the patient to open their eyes and as questions - what was the experience like for you, what did the image mean to you, what were the themes, what themes are related to the schemas

EMS CONT

Most EMS are accurate in terms of reflecting the tone of the environment - "like my home was always cold and uninviting " But the person may not understand why or the attributions for their behavior maybe incorrect NOTES: Most EMS are accurate in terms of reflecting the tone of the environment - "like my home was always cold and uninviting " - ex. My home was always cold and uninviting - Most people can access this - But the person does not understand why this happens or their attributions may be inaccurate - Don't know why their home was cold and uninviting (don't understand why) - Or they attribute it to them doing something wrong and that's why its cold and uninviting (attributions may be incorrect) - Schema drives personality trait - personality trait gets reinforced - then that drives the schema - goes into a loop

EMS CONT 8 Young has 18 schemas

NOTES: - Young has 18 schemas - You can choose from these schemas when you are coming up with your conceptualization - Clients that are very sick are usually in the Domain 1: Disconnection and rejection - Domain 1 and 2 tend to be unconditional and domains 3, 4, and 5 tend to be conditional

Schema technique CONT 4

Need to start and stop with an image of a safe place when doing imagery work - need to work with the client to create a safe image For some clients it is hard for them to come up with a safe image. NOTES: - After doing imagery work, you now need to have a safe place for them to deescalate

EMS CONT 3 Schemas are dimensional

Schemas are dimensional - the more severe the schema, the greater number of situations that activate it. The more severe the schema the more intense the negative affect is when schema is triggered and the longer it lasts. NOTES: Schemas are dimensional - the more severe the schema, the greater number of situations that activate it. - More entrenched, the more severe the schema is, the louder the schema is = the more things activate or trigger it - Some schemas are very loud and everything triggers it The more severe the schema the more intense the negative affect is when schema is triggered and the longer it lasts. - A very severe schema can have a negative affect and it will linger

EMS and Temperament

Temperament can elicit certain types of caregiving reactions. If a child is difficult, parents maybe more likely to be abusive. Temperament is inborn Labile - Nonreactive Dysthymic - Optimistic Anxious - Calm Obsessive - Distractible Passive - Aggressive Irritable - Cheerful Shy - Sociable NOTES: EMS and temperament is interacting

Schema Techniques

Testing the validity of the schema - Have the person write down evidences supporting the schema (many patients this is easy for them to do)... Therapist may need to help them come up with evidence that counters the schema Reframing the supporting evidence for the schema - that many times clients blame themselves for the what has happened to them... "My father didn't love or pay attention to me." Rather (reframing) - "My father didn't know how to love anyone." NOTES: - The empty well metaphor - You go to the well and you search for water and when you pull the bucket up, its empty - You go towards your father, he is the empty well, you pour your water expecting to get water (Love back) but its empty - They keep going towards the water when there is not water to be had

Two types of Schemas

Unconditional Schemas - are shaped by what was done to the child and the child had no escape from it Conditional Schemas - often results as an attempt to get relief from the unconditional schema NOTES: - Two types of schemas - Unconditional schema - Didn't do anything to elicit it, it just happened to them - Early developmental pieces that inflict and put onto the child and they had no choice but to deal with it - Domain 1 - Rejection and abandonment = unconditional schemas - Conditional schema - Attempt to get relief from unconditional schema - Result of trying to deal with the unconditional schema White Board notes: - Unconditional schema is defectiveness - Develop an EMS to cope = conditional - Unrelenting standards - "If I am perfect, then I am worthy." - Aspiring for perfection so I don't feel unworthy (defective)

2 types of Schemas CONT

Using conditional schema to relieve unconditional schema Develop "Unrelenting Standards" in response to Defectiveness If I am perfect, I will be worthy of being loved. NOTES: - Unconditional schema = core defectiveness - If you feel defective and ashamed, you will develop a schema of unrelenting standards - If I am perfect, I will be worthy of being loved.

Schema technique CONT 5

When client become more comfortable with imagery work - you have them dialogue in the image and start use their own words to confront some of the images that have been controlling and/or eliciting their behavior. NOTES: - There are ways for you to get into the image - "Can you put me in the image? What do you want me to say to your father?"

EMS CONT 2

Young theorizes that maladaptive behaviors develop as a response to schemas. Behaviors are DRIVEN by the schema, but are not part of the schema... Repetitive behavioral patterns that continue to occur within and outside of session are probably linked to the schema in some way (e.g the enactment, transference and countertransference). NOTES: - Repetitive behavioral patterns that continue to occur within and outside of session are probably linked to the schema in some way (e.g the enactment, transference and countertransference). - There is something that is getting invoked in you as the therapist and/or patient, maybe that is your schema or maybe there's an enactment - This is driven by the schema - Occurs within and outside the session - Repetitive relational templates (transference and countertransference, enactment)

EMS CONT 7

Young's model does not assume that children identify with and internalize everything their parents or caregivers do; rather, we have observed that they selectively identify with and internalize certain aspects of the significant others. Some of these identifications and internalizations become schemas, and some become coping styles (modes). NOTES: Young's model does not assume that children identify with and internalize everything their parents or caregivers do; rather, we have observed that they selectively identify with and internalize certain aspects of the significant others. Some of these identifications and internalizations become schemas, and some become coping styles (modes). - Not everything a parent does get internalized but kids select certain things and gets turned into EMS, schemas or coping styles - Ex. Boy said his dad never loves him because he is always gone = but the kid could have selectively chose this and maybe the father is actually a good guy in other aspects of his life