Integrative Psychotherapy – Mental Health Matters

What is Schema Therapy?

Published on 08/27/2021 by Andrew Marshall1 Comment

Introduction

Schema therapy was developed by Jeffrey E. Young for use in treatment of personality disorders and chronic DSM Axis I disorders, such as when patients fail to respond or relapse after having been through other therapies (for example, traditional cognitive behavioural therapy, CBT). Schema therapy is an integrative psychotherapy combining theory and techniques from previously existing therapies, including CBT, psychoanalytic object relations theory, attachment theory, and Gestalt therapy.

Concepts

Four main theoretical concepts in schema therapy are early maladaptive schemas (or simply schemas), coping styles, modes, and basic emotional needs:

In cognitive psychology, a schema is an organised pattern of thought and behaviour. It can also be described as a mental structure of preconceived ideas, a framework representing some aspect of the world, or a system of organizing and perceiving new information. In schema therapy, a schema specifically refers to an early maladaptive schema, defined as a pervasive self-defeating or dysfunctional theme or pattern of memories, emotions, and physical sensations, developed during childhood or adolescence and elaborated throughout one’s lifetime. Often they have the form of a belief about the self or the world. For instance, a person with an Abandonment schema could be hypersensitive (have an “emotional button” or “trigger”) about their perceived value to others, which in turn could make them feel sad and panicky in their interpersonal relationships.
Coping styles are a person’s behavioural responses to schemas. There are three potential coping styles. In “avoidance” the person tries to avoid situations that activate the schema. In “surrender” the person gives into the schema, doesn’t try to fight against it, and changes their behaviour in expectation that the feared outcome is inevitable. In “counterattack”, also called “overcompensation”, the person puts extra work into not allowing the schema’s feared outcome to happen. These maladaptive coping styles (overcompensation, avoidance, or surrender) very often wind up reinforcing the schemas. Continuing the Abandonment example: having imagined a threat of abandonment in a relationship and feeling sad and panicky, a person using an avoidance coping style might then behave in ways to limit the closeness in the relationship to try to protect themselves from being abandoned. The resulting loneliness or even actual loss of the relationship could easily reinforce the person’s Abandonment schema. Another example can be given for the Defectiveness schema: A person using an avoidance coping style might avoid situations that make them feel defective, or might try to numb the feeling with addictions or distractions. A person using a surrender coping style might tolerate unfair criticism without defending themselves. A person using the counterattack/overcompensation coping style might put extra effort into being superhuman.
Modes are mind states that cluster schemas and coping styles into a temporary “way of being” that a person can shift into occasionally or more frequently. For example, a Vulnerable Child mode might be a state of mind encompassing schemas of Abandonment, Defectiveness, Mistrust/Abuse and a coping style of surrendering (to the schemas).
If a patient’s basic emotional needs are not met in childhood, then schemas, coping styles, and modes can develop. Some basic needs that have been identified are: connection, mutuality, reciprocity, flow, and autonomy. For example, a child with unmet needs around connection – perhaps due to parental loss to death, divorce, or addiction – might develop an Abandonment schema.

The goal of schema therapy is to help patients meet their basic emotional needs by helping the patient learn how to:

Heal schemas by diminishing the intensity of emotional memories comprising the schema and the intensity of bodily sensations, and by changing the cognitive patterns connected to the schema; and
Replace maladaptive coping styles and responses with adaptive patterns of behaviour.

Techniques used in schema therapy including limited reparenting and Gestalt therapy psychodrama techniques such as imagery re-scripting and empty chair dialogues (Refer to techniques in schema therapy, below).

There is a growing literature of outcome studies on schema therapy, where schema therapy has shown impressive results (Refer to outcome studies on schema therapy, below).

Early Maladaptive Schemas

Refer to List of Maladaptive Schemas.

Early maladaptive schemas are self-defeating emotional and cognitive patterns established from childhood and repeated throughout life. They may be made up of emotional memories of past hurt, tragedy, fear, abuse, neglect, unmet safety needs, abandonment, or lack of normal human affection in general. Early maladaptive schemas can also include bodily sensations associated with such emotional memories. Early maladaptive schemas can have different levels of severity and pervasiveness: the more severe the schema, the more intense the negative emotion when the schema is triggered and the longer it lasts; the more pervasive the schema, the greater the number of situations that trigger it.

Schema Domains

Schema domains are five broad categories of unmet needs into which are grouped 18 early maladaptive schemas identified by Young, Klosko & Weishaar (2003):

Disconnection/Rejection includes 5 schemas:
- Abandonment/Instability.
- Mistrust/Abuse.
- Emotional Deprivation.
- Defectiveness/Shame.
- Social Isolation/Alienation.
Impaired Autonomy and/or Performance includes 4 schemas:
- Dependence/Incompetence.
- Vulnerability to Harm or Illness.
- Enmeshment/Undeveloped Self.
- Failure.
Impaired Limits includes 2 schemas:
- Entitlement/Grandiosity.
- Insufficient Self-Control and/or Self-Discipline.
Other-Directedness includes 3 schemas:
- Subjugation.
- Self-Sacrifice.
- Approval-Seeking/Recognition-Seeking.
Over-vigilance/Inhibition includes 4 schemas:
- Negativity/Pessimism.
- Emotional Inhibition.
- Unrelenting Standards/Hypercriticalness.
- Punitiveness.

Schema Modes

Schema modes are momentary mind states which every human being experiences at one time or another. A schema mode consists of a cluster of schemas and coping styles. Life situations that a person finds disturbing or offensive, or arouse bad memories, are referred to as “triggers” that tend to activate schema modes. In psychologically healthy persons, schema modes are mild, flexible mind states that are easily pacified by the rest of their personality. In patients with personality disorders, schema modes are more severe, rigid mind states that may seem split off from the rest of their personality.

Identified Schema Modes

Young, Klosko & Weishaar (2003) identified 10 schema modes grouped into four categories. The four categories are: Child modes, Dysfunctional Coping modes, Dysfunctional Parent modes, and the Healthy Adult mode. The four Child modes are: Vulnerable Child, Angry Child, Impulsive/Undisciplined Child, and Happy Child. The three Dysfunctional Coping modes are: Compliant Surrenderer, Detached Protector, and Overcompensator. The two Dysfunctional Parent modes are: Punitive Parent and Demanding Parent.

Angry Child	This is fuelled mainly by feelings of victimisation or bitterness, leading towards negativity, pessimism, jealousy, and rage. While experiencing this schema mode, a patient may have urges to yell, scream, throw/break things, or possibly even injure themselves or harm others. The Angry Child schema mode is enraged, anxious, frustrated, self-doubting, feels unsupported in ideas and vulnerable.
Impulsive Child	This is the mode where anything goes. Behaviours of the Impulsive Child schema mode may include reckless driving, substance abuse, cutting oneself, suicidal thoughts, gambling, or fits of rage, such as punching a wall when “triggered” or laying blame of circumstantial difficulties upon innocent people. Unsafe sex, rash decisions to run away from a situation without resolution, tantrums perceived by peers as infantile, and so forth are a mere few of the behaviours which a patient in this schema mode might display. Impulsive Child is the rebellious and careless schema mode.
Detached Protector	This is based in escape. Patients in Detached Protector schema mode withdraw, dissociate, alienate, or hide in some way. This may be triggered by numerous stress factors or feelings of being overwhelmed. When a patient with insufficient skills is in a situation involving excessive demands, it can trigger a Detached Protector response mode. Stated simply, patients become numb in order to protect themselves from the harm or stress of what they fear is to come, or to protect themselves from fear of the unknown in general.
Abandoned Child	This is the mode in which a patient may feel defective in some way, thrown aside, unloved, obviously alone, or may be in a “me against the world” mindset. The patient may feel as though peers, friends, family, and even the entire world have abandoned them. Behaviours of patients in Abandoned Child mode may include (but are not limited to) falling into major depression, pessimism, feeling unwanted, feeling unworthy of love, and perceiving personality traits as irredeemable flaws. Rarely, a patient’s self-perceived flaws may be intentionally withheld on the inside; when this occurs, instead of showing one’s true self, the patient may appear to others as “egotistical”, “attention-seeking”, selfish, distant, and may exhibit behaviours unlike their true nature. The patient might create a narcissistic alter-ego/persona in order to escape or hide the insecurity from others. Due to fear of rejection, of feeling disconnected from their true self and poor self-image, these patients, who truly desire companionship/affection, may instead end up pushing others away.
Punitive Parent	This is identified by beliefs of a patient that they should be harshly punished, perhaps due to feeling “defective”, or making a simple mistake. The patient may feel that they should be punished for even existing. Sadness, anger, impatience, and judgement are directed to the patient and from the patient. The Punitive Parent has great difficulty in forgiving themselves even under average circumstances in which anyone could fall short of their standards. The Punitive Parent does not wish to allow for human error or imperfection, thus punishment is what this mode seeks.
Healthy Adult	This is the mode that schema therapy aims to help a patient achieve as the long-lasting state of well-being. The Healthy Adult is comfortable making decisions, is a problem-solver, thinks before acting, is appropriately ambitious, sets limits and boundaries, nurtures self and others, forms healthy relationships, takes on all responsibility, sees things through, and enjoys/partakes in enjoyable adult activities and interests with boundaries enforced, takes care of their physical health, and values themselves. In this schema mode the patient focuses on the present day with hope and strives toward the best tomorrow possible. The Healthy Adult forgives the past, no longer sees themselves as a victim (but as a survivor), and expresses all emotions in ways which are healthy and cause no harm.

Techniques in Schema Therapy

Treatment plans in schema therapy generally encompass three basic classes of techniques: cognitive, experiential, and behavioural (in addition to the basic healing components of the therapeutic relationship). Cognitive strategies expand on standard CBT techniques such as listing pros and cons of a schema, testing the validity of a schema, or conducting a dialogue between the “schema side” and the “healthy side”. Experiential and emotion focused strategies expand on standard Gestalt therapy psychodrama and imagery techniques. Behavioural pattern-breaking strategies expand on standard behaviour therapy techniques, such as role playing an interaction and then assigning the interaction as homework. One of the most central techniques in schema therapy is the use of the therapeutic relationship, specifically through a process called “limited reparenting”.

Specific techniques often used in schema therapy include flash cards with important therapeutic messages, created in session and used by the patient between sessions, and the schema diary – a template or workbook that is filled out by the patient between sessions and that records the patient’s progress in relation to all the theoretical concepts in schema therapy.

Schema Therapy and Psychoanalysis

From an integrative psychotherapy perspective, limited reparenting and the experiential techniques, particularly around changing modes, could be seen as actively changing what psychoanalysis has described as object relations. Historically, mainstream psychoanalysis tended to reject active techniques – such as Fritz Perls’ Gestalt therapy work or Franz Alexander’s “corrective emotional experience” – but contemporary relational psychoanalysis (led by analysts such as Lewis Aron, and building on the ideas of earlier unorthodox analysts such as Sándor Ferenczi) is more open to active techniques. It is notable that in a head to head comparison of a psychoanalytic object relations treatment (Otto F. Kernberg’s transference focused psychotherapy) and schema therapy, the latter has been demonstrated to be more effective in treating Borderline Personality Disorder.

Outcome Studies on Schema Therapy

Schema Therapy vs Transference Focused Psychotherapy Outcomes

Dutch investigators, including Josephine Giesen-Bloo and Arnoud Arntz (the project leader), compared schema therapy (also known as schema focused therapy or SFT) with transference focused psychotherapy (TFP) in the treatment of borderline personality disorder. 86 patients were recruited from four mental health institutes in the Netherlands. Patients in the study received two sessions per week of SFT or TFP for three years. After three years, full recovery was achieved in 45% of the patients in the SFT condition, and in 24% of those receiving TFP. One year later, the percentage fully recovered increased to 52% in the SFT condition and 29% in the TFP condition, with 70% of the patients in the SFT group achieving “clinically significant and relevant improvement”. Moreover, the dropout rate was only 27% for SFT, compared with 50% for TFP.

Patients began to feel and function significantly better after the first year, with improvement occurring more rapidly in the SFT group. There was continuing improvement in subsequent years. Thus investigators concluded that both treatments had positive effects, with schema therapy clearly more successful.

Less Intensive Outpatient, Individual Schema Therapy

Dutch investigators, including Marjon Nadort and Arnoud Arntz, assessed the effectiveness of schema therapy in the treatment of borderline personality disorder when utilised in regular mental health care settings. A total of 62 patients were treated in eight mental health centres located in the Netherlands. The treatment was less intensive along a number of dimensions including a shift from twice weekly to once weekly sessions during the second year. Despite this, there was no lessening of effectiveness with recovery rates that were at least as high and similarly low dropout rates.

Pilot Study of Group Schema Therapy for Borderline Personality Disorder

Investigators Joan Farrell, Ida Shaw and Michael Webber at the Indiana University School of Medicine Centre for BPD Treatment & Research tested the effectiveness of adding an eight-month, 30-session schema therapy group to treatment-as-usual (TAU) for borderline personality disorder (BPD) with 32 patients. The dropout rate was 0% for those patients who received group schema therapy in addition to TAU and 25% for those who received TAU alone. At the end of treatment, 94% of the patients who received group schema therapy in addition to TAU compared to 16% of the patients receiving TAU alone no longer met BPD diagnostic criteria. The schema therapy group treatment led to significant reductions in symptoms and global improvement in functioning. The large positive treatment effects found in the group schema therapy study suggest that the group modality may augment or catalyse the active ingredients of the treatment for BPD patients. As of 2014, a collaborative randomised controlled trial is under way at 14 sites in six countries to further explore this interaction between groups and schema therapy.

What is Integrative Psychotherapy?

Published on 01/27/2021 by Andrew Marshall1 Comment

Introduction

Integrative psychotherapy is the integration of elements from different schools of psychotherapy in the treatment of a client.

Integrative psychotherapy may also refer to the psychotherapeutic process of integrating the personality: uniting the “affective, cognitive, behavioural, and physiological systems within a person”.

Background

Initially, Sigmund Freud developed a talking cure called psychoanalysis; then he wrote about his therapy and popularised psychoanalysis. After Freud, many different disciplines splintered off. Some of the more common therapies include: psychodynamic psychotherapy, transactional analysis, cognitive behavioural therapy, gestalt therapy, body psychotherapy, family systems therapy, person-centred psychotherapy, and existential therapy. Hundreds of different theories of psychotherapy are practiced (Norcross, 2005, p.5).

A new therapy is born in several stages. After being trained in an existing school of psychotherapy, the therapist begins to practice. Then, after follow up training in other schools, the therapist may combine the different theories as a basis of a new practice. Then, some practitioners write about their new approach and label this approach with a new name.

A pragmatic or a theoretical approach can be taken when fusing schools of psychotherapy. Pragmatic practitioners blend a few strands of theory from a few schools as well as various techniques; such practitioners are sometimes called eclectic psychotherapists and are primarily concerned with what works. Alternatively, other therapists consider themselves to be more theoretically grounded as they blend their theories; they are called integrative psychotherapists and are not only concerned with what works, but why it works (Norcross, 2005, p.8).

For example, an eclectic therapist might experience a change in their client after administering a particular technique and be satisfied with a positive result. In contrast, an integrative therapist is curious about the “why and how” of the change as well. A theoretical emphasis is important: for example, the client may only have been trying to please the therapist and was adapting to the therapist rather than becoming more fully empowered in themselves.

Different Routes to Integration

The most recent edition of the Handbook of Psychotherapy Integration (Norcross & Goldfried, 2005) recognized four general routes to integration: common factors, technical eclecticism, theoretical integration, and assimilative integration (Norcross, 2005).

Common Factors

The first route to integration is called common factors and “seeks to determine the core ingredients that different therapies share in common” (Norcross, 2005, p.9). The advantage of a common factors approach is the emphasis on therapeutic actions that have been demonstrated to be effective. The disadvantage is that common factors may overlook specific techniques that have been developed within particular theories. Common factors have been described by Jerome Frank (Frank & Frank, 1991), Bruce Wampold (Wampold & Imel, 2015), and Miller, Duncan and Hubble (2005). Common factors theory asserts it is precisely the factors common to the most psychotherapies that make any psychotherapy successful.

Some psychologists have converged on the conclusion that a wide variety of different psychotherapies can be integrated via their common ability to trigger the neurobiological mechanism of memory reconsolidation in such a way as to lead to deconsolidation (Ecker, Ticic & Hulley 2012; Lane et al. 2015; Welling 2012 – but for a more hesitant view of the role of memory reconsolidation in psychotherapy see the objections in some of the invited comments in: Lane et al. 2015).

Technical Eclecticism

The second route to integration is technical eclecticism which is designed “to improve our ability to select the best treatment for the person and the problem…guided primarily by data on what has worked best for others in the past” (Norcross, 2005, p.8). The advantage of technical eclecticism is that it encourages the use of diverse strategies without being hindered by theoretical differences. A disadvantage is that there may not be a clear conceptual framework describing how techniques drawn from divergent theories might fit together. The most well known model of technical eclectic psychotherapy is Arnold Lazarus’ (2005) multimodal therapy. Another model of technical eclecticism is Larry E. Beutler and colleagues’ systematic treatment selection (Beutler, Consoli, & Lane, 2005).

Theoretical Integration

The third route to integration commonly recognised in the literature is theoretical integration in which “two or more therapies are integrated in the hope that the result will be better than the constituent therapies alone” (Norcross, 2005, p.8). Some models of theoretical integration focus on combining and synthesizing a small number of theories at a deep level, whereas others describe the relationship between several systems of psychotherapy. One prominent example of theoretical synthesis is Paul Wachtel’s model of cyclical psychodynamics that integrates psychodynamic, behavioural, and family systems theories (Wachtel, Kruk, & McKinney, 2005). Another example of synthesis is Anthony Ryle’s model of cognitive analytic therapy, integrating ideas from psychoanalytic object relations theory and cognitive psychotherapy (Ryle, 2005). Another model of theoretical integration is specifically called integral psychotherapy (Forman, 2010; Ingersoll & Zeitler, 2010). The most notable model describing the relationship between several different theories is the transtheoretical model (Prochaska & DiClemente, 2005).

Assimilative Integration

Assimilative integration is the fourth route and acknowledges that most psychotherapists select a theoretical orientation that serves as their foundation but, with experience, incorporate ideas and strategies from other sources into their practice. “This mode of integration favours a firm grounding in any one system of psychotherapy, but with a willingness to incorporate or assimilate, in a considered fashion, perspectives or practices from other schools” (Messer, 1992, p.151). Some counsellors may prefer the security of one foundational theory as they begin the process of integrative exploration. Formal models of assimilative integration have been described based on a psychodynamic foundation (Frank, 1999; Stricker & Gold, 2005) and based on cognitive behavioural therapy (Castonguay, Newman, Borkovec, Holtforth, & Maramba, 2005).

Govrin (2015) pointed out a form of integration, which he called “integration by conversion”, whereby theorists import into their own system of psychotherapy a foreign and quite alien concept, but they give the concept a new meaning that allows them to claim that the newly imported concept was really an integral part of their original system of psychotherapy, even if the imported concept significantly changes the original system. Govrin gave as two examples Heinz Kohut’s novel emphasis on empathy in psychoanalysis in the 1970s and the novel emphasis on mindfulness and acceptance in “third-wave” cognitive behavioural therapy in the 1990s to 2000s.

Other Models that Combine Routes

In addition to well-established approaches that fit into the five routes mentioned above, there are newer models that combine aspects of the traditional routes.

Clara E. Hill’s (2014) three-stage model of helping skills encourages counsellors to emphasize skills from different theories during different stages of helping. Hill’s model might be considered a combination of theoretical integration and technical eclecticism. The first stage is the exploration stage. This is based on client-centred therapy. The second stage is entitled insight. Interventions used in this stage are based on psychoanalytic therapy. The last stage, the action stage, is based on behavioural therapy.

Good and Beitman (2006) described an integrative approach highlighting both core components of effective therapy and specific techniques designed to target clients’ particular areas of concern. This approach can be described as an integration of common factors and technical eclecticism.

Multitheoretical psychotherapy (Brooks-Harris, 2008) is an integrative model that combines elements of technical eclecticism and theoretical integration. Therapists are encouraged to make intentional choices about combining theories and intervention strategies.

An approach called integral psychotherapy (Forman, 2010; Ingersoll & Zeitler, 2010) is grounded in the work of theoretical psychologist and philosopher Ken Wilber (2000), who integrates insights from contemplative and meditative traditions. Integral theory is a meta-theory that recognises that reality can be organised from four major perspectives: subjective, intersubjective, objective, and interobjective. Various psychotherapies typically ground themselves in one these four foundational perspectives, often minimising the others. Integral psychotherapy includes all four. For example, psychotherapeutic integration using this model would include subjective approaches (cognitive, existential), intersubjective approaches (interpersonal, object relations, multicultural), objective approaches (behavioural, pharmacological), and interobjective approaches (systems science). By understanding that each of these four basic perspectives all simultaneously co-occur, each can be seen as essential to a comprehensive view of the life of the client. Integral theory also includes a stage model that suggests that various psychotherapies seek to address issues arising from different stages of psychological development (Wilber, 2000).

The generic term, integrative psychotherapy, can be used to describe any multi-modal approach which combines therapies. For example, an effective form of treatment for some clients is psychodynamic psychotherapy combined with hypnotherapy. Kraft & Kraft (2007) gave a detailed account of this treatment with a 54-year-old female client with refractory IBS in a setting of a phobic anxiety state. The client made a full recovery and this was maintained at the follow-up a year later.

Comparison with Eclecticism

In Integrative and Eclectic Counselling and Psychotherapy (Woolfe & Palmer, 2000, pp.55 & 256), the authors make clear the distinction between integrative and eclectic psychotherapy approaches: “Integration suggests that the elements are part of one combined approach to theory and practice, as opposed to eclecticism which draws ad hoc from several approaches in the approach to a particular case.” Psychotherapy’s eclectic practitioners are not bound by the theories, dogma, conventions or methodology of any one particular school. Instead, they may use what they believe or feel or experience tells them will work best, either in general or suiting the often immediate needs of individual clients; and working within their own preferences and capabilities as practitioners (Norcross & Goldfried, 2005, pp.3-23).

References

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