There are several exciting "new" proven-effective psychotherapies now available to mental health patients with Borderline PD. I place "new" in quotations because, for instance, Schema Therapy has been around since the early 1990’s. However, Schema Therapy as well as Mentalization Therapy, Transference-Focused Therapy and Dialectical Behavior Therapy have either just recently been shown to be effective in patients with Borderline PD, or their effectiveness has been reconfirmed through replication studies.
I am discussing these therapies on this blog because several of these studies were published in 2006. I believe familiarity with them has now filtered down to board exam question-writers as well as oral board examiners. I recommend you familiarize yourself with the therapies I mentioned above for the Psychiatry Part 1, Part 2, and MOC exams for 2008. In addition, Child & Adolescent Psychiatrists at a minimum should be comfortable with the concepts and interventions of DBT, which is a therapy used with adolescents at suicidal risk.
In addition to my excitement related to the increased evidence of the effectiveness of these therapies, I am also pleased by the cross-incorporation of CBT techniques into therapies with psychodynamic roots and with psychodynamic concepts and techniques into therapies with CBT roots. Both DBT and ST originated through the work of learning theorists, Marsha Linehan with DBT and Young with ST. I am continually amazed at just how many psychodynamic concepts and techniques play a role in these new cognitively based therapies. So, let me provide an introduction to ST based on the slide shows available on www.schematherapy.com.
Introduction to Schema Therapy
- Schema Therapy is a form of Cognitive Behavioral Therapy that is adapted for use in patients with a personality disorder and depression.
- Why is an adaptation of CBT needed?
- Cognitions and behaviors tend to be more rigid and resistant to change among patients with PD.
- Problems with Intimate relationships tend to be more central and severe in patients with PD.
- Patients with PD are less likely to follow through on the homework assignments that are part of CBT.
- What is a Schema?
- A Schema is "a broad, pervasive theme or pattern
- comprised of memories, bodily sensations, emotions, and cognitions
- regarding oneself and one’s relationships with others
- developed during childhood and adolescents, and elaborated throughout one’s lifetime."
- A maladaptive schema is one that causes pain, dysfunction, and not getting one’s core needs met.
- How do Maladaptive Schemas develop?
- Every child has core needs that need to be met in order to develop into a healthy adult.
- The core needs include safety and stability, love and nurturance, guidance and protection, and validation and praise.
- When these core needs remain unmet during the developmental years, maladaptive schemas and coping strategies emerge.
- Maladaptive coping strategies include avoidance and overcompensation, that is, the going to extremes in order to cover up one’s percieved weaknesses and shortcomiings. This may include a person who works extreme hours to avoid being faulted and exposed as deficient.
- Examples of Early Maladaptive Schemas
- Abandonment
- Mistrust and Abuse
- Enmeshment
- Dfetiveness
- Social Isolativeness
- Entitlement
- Unrelenting standards
- Negativity
- Insufficient Self-Control
- Overcontrol
- Goals of Schema Therapy
- ST helps the patient meet their core needs in adaptive ways.
- This is done through helping the person change their schemas and coping strategies to more productive ones
- Interventions of ST
- Consistent with CBT approaches, ST has two main phases.
- Phase 1: Identify maladaptive schemas and coping strategies and which situations trigger them.
- Phase 2: Change the maladaptive schemas and coping strategies into ones more effective at meeting the person’s core needs. This includes the following interventions.
- Cognitive Restructuring: As in CBT, this refers to changing cognitive distortions that are a main component of the schema.
- Behavioral Restructuring: Just as persons engage in cognitive distortions, they engage in counterproductive behavioral patterns. These are identified and changed.
- Emotional Experiencing: The patient is helped to experience, accept, and come to terms with sadness, loss, guilt, shame and anger. This is done by imaging and role-playing scenarios that are likely to trigger such emotions that, again, are part of the maladaptive schema.
- Therapy Relationship: The therapist helps the patient identify triggering situations within the therapy relationship and to practice changing them. The therapist may engage in limited reparenting. Notice the similarity here to both forms of transference-analysis and self-psychological "corrective emotional experiences.
Beat The Boards! Course Participant’s Feedback
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Today’s Quote
Dr. Joshua Grossman share with us "an old Yiddish saying."
"The greatest goal is seeking a goal."
Thanks and take care,
Jack Krasuski MD
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