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Arntz & Jacob's new book "Schema therapy in practice": links with attachment theory and with therapies for self-compassion

Yesterday I wrote a post "Arntz & Jacob's new book 'Schema therapy in practice: some introductory comments" about the recently published and potentially broadly applicable extension of this Dutch team's previously successful treatment approach for borderline personality disorder.  So the authors comment "While schema therapy was originally developed for clients with borderline personality disorder, this book takes a much broader approach and shows how it can be applied across different personality disorders, as well as to chronic axis-I disorders." Not exactly the holy grail, but pretty much any experienced psychotherapist is likely to be interested in hopeful new developments that might be useful in treating more difficult personality disorders and other chronic sources of psychological pain.  How do these schema ideas dovetail with other currently evolving treatments in this area?  Are the ideas contradictory?  Are they simply an alternative that can be used when other approaches have failed?  Or are there ideas here that can be linked in with other encouraging developments in treating these often unresponsive forms of suffering?

Arntz & Jacob talk about schema therapy's "integration of insights, methods, and techniques derived from a range of schools, including attachment theory, cognitive behavior therapy, and experiential therapies into a comprehensive model formulated in terms of the most prominent current psychological paradigm, the cognitive model".  Gosh, there are a turbulent, swirling, evolving "mess" of different therapies that use these kinds of ideas.  When "assailed" by so many therapeutic schools, so many different voices, one good place to start is to ask what hard evidence there is to support any of the competing ideas.

So attachment theory ideas are really pretty well evidence-based and I've written about them extensively on this blog.  See, for example, the links in "My own favourite top 15 ... attachment ... "Attachment territory is largely the foundation underpinning schema therapy's (ST's) model of disrupted child development and ST's labelling of toxic "inner parent" learned beliefs and associated "wounded child" deep emotional pain.  There is much more research evidence supporting attachment theory than there is supporting schema therapy.  ST takes some of the ideas from attachment research and develops them while largely ignoring other well-evidenced attachment developments.  In the blog post "Assessing attachment in adults" I've discussed the large research effort that has produced the four quadrant Avoidance/Anxiety model of "coping responses" to poor childhood attachment experiences.  I feel a little irritated that Arntz & Jacob have run with an ST coping responses model that doesn't more obviously acknowledge or use this attachment research.  So ST enumerates a complex mesh of coping self-protection modes that I suspect could be usefully better integrated with avoidant/anxious attachment research findings.  Key attachment theorists have also explored extending attachment ideas into other areas of behaviour - see the post "Behavioural systems (attachment, care giving, exploration, sex & power): hyperactivated, hypoactivated or just about right?".  Again, I suspect that ST could learn usefully from this work.  Encouragingly there is much exploration in the attachment field on how insecure attachment can be helped and, at least partially, transformed into more secure attachment.  This is central to ST's therapeutic focus as well.  See "Boosting self-compassion & self-encouragement by strengthening attachment security: twelve practical suggestions" for more on this.  And there is potentially two way benefit transfer here.  Attachment theory informs different forms of therapy, rather than being some kind of therapy in its own right.  Schema therapy is, in part, a practical application of aspects of attachment theory.

And this links easily to the evolving literature on self-compassion and, to an extent, mindfulness.  There's lots of information about these approaches on the "Compassion & criticism" and "Wellbeing, calming & mindfulness" pages in the "Good knowledge" section of this website.  See too the description of a presentation on "Compassion-focused therapy" at this year's main UK cognitive therapy conference.  There is so much overlap between ST, attachment research and the surging therapeutic interest in compassion.  The current emphasis on nourishing self-compassion is heavily coloured by ideas from Buddhist meditation - see, for example, the recent paper "Enhancing compassion: A randomized controlled trial of a compassion cultivation training program".  Schema therapy can learn from & incorporate many of these ideas & practices.  ST however has useful lessons for the "compassion enhancement" field.  ST emphasises imagery methods "rescripting" key early memories and "dialogue" techniques focusing on "unfinished business" with past attachment figures and with introjected, self-attacking attitudes.  This often isn't done so well in compassion trainings, possibly because ST is typically one-to-one based and "therapeutic" in style, while compassion training is often group-based and "adult-learning" class in style.  However these broad brush differences aren't this straightforward on closer examination, and there is some therapeutic one-to-one compassionate mind training, and there are fascinating group ST developments too.

Interestingly the contrasts that Anrtz & Jacob highlight between ST & standard CBT apply to a large extent to the contrasts between ST & standard compassion training.  So in their new book, they write: "Compared to CBT, schema therapy has a more intensive focus on the following three issues: 1.) Problematic emotions, which are in the foreground, alongside the cognitive and behavioral aspects of the patient's problems and symptoms. Schema therapy makes intensive use of experiential or emotion-focused interventions - ones that have previously been developed and used in gestalt therapy or psychodrama. The main experiential intervention techniques consist of chair dialogues or imagery exercises ... 2.) Childhood issues, which are of much greater importance than in standard CBT ... Biographical information is mainly used to validate patients by enabling them to understand the childhood origin of their problematic behavioral patterns ... 3.) The therapeutic relationship, which plays a very important role in schema therapy ... the ... relationship is conceptualized as 'limited reparenting', which means the therapist takes on the role of a parent and displays warmth and caring behavior towards the patient - within the limits of the therapeutic relationship ... Particularly for patients with personality disorders, the therapeutic relationship is regarded as the place in which patient is allowed to and dares to open up and show painful feelings, try out new social behaviors, and change interpersonal patterns for the first time." 

And I would highlight here ST's emphasis on "limited reparenting" - a brave underlining of the key importance of the therapeutic relationship.  This is a fascinating, challenging, and apparently crucial aspect of ST that I suspect lies at the heart of its contribution to this field.

Tomorrow's post looks at ST's focus on "problematic emotions" and "childhood issues" and the potential cross-fertilization with trauma-focused cognitive therapy and Marylene Cloitre's work on child abuse - see "Arntz & Jacob's new book "Schema therapy in practice": links with trauma-focused CBT and Marylene Cloitre's work on complex PTSD".  

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