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BABCP spring meeting: Arnoud Arntz on schema therapy for personality disorders (2nd post)

I have already written a brief introductory description of the two day British Association for Behavioural and Cognitive Psychotherapies (BABCP) Spring Workshops and Conference in Belfast last month.  I reported that I had been to Arnoud Arntz's workshop on Schema-Focused Therapy.  I have been to several training days with Arnoud before, but it was helpful getting an update on what he is doing.  And at the conference proper, one of the highlights for me was a first report by Arnoud of results from a major new study on the treatment of six different personality disorders using schema therapy.  

The official workshop description ran: Schema Therapy (ST) developed from CBT as it is applied to axis-I disorders. In trying to apply ordinary CBT techniques to axis-II disorders, clinicians experienced  limited effects. The developers of ST therefore started to develop new methods and to integrate techniques derived from other models, including attachment theory, CBT and experiential (especially Gestalt Therapy).  Instead of being an eclectic approach, ST aims to offer an integrated method based on the cognitive (schema) model of psychopathology.  Like the early learning theories, ST assumes that people have basic needs, which drive their behaviour, and that when these needs are not adequately met, psychological problems develop.  When basic needs are not adequately met in children, dysfunctional schemas and coping strategies develop that may lead to personality disorders.  For severe psychopathology like personality disorders, ST uses the concept of schema mode, which refers to the moment-to-moment state of the individual, characterized by typical combinations of emotions, cognitions (schema content), and behaviour.  Schema Mode models have now been developed and tested for almost every personality disorder, and help patient and therapist to understand the strong moment-to-moment changes personality disorder patients often experience, and to choose the appropriate  technique to address the mode that is activated during the session.  

Learning  objectives
1.  to understand and apply the schema mode model of BPD, so that BPD-symptoms and behaviours can be understood
2.  communicating the mode model to patient
3.  to be able to detect the mode the patient is in, and choose appropriate techniques, eg overcoming coping modes (overcompensating avoidance, surrender); treating vulnerable child modes (imagery rescripting and caring part of the therapy relationship); dealing with angry and impulsive child modes, treating dysfunctional parent modes (demanding, punitive, eg  via chair dialogues); strengthening healthy adult mode (implicit and explicit techniques)
4.  to be able to choose focus and type of technique according to the phase of therapy

Implications  for the everyday practice of CBT:
Schema Therapy has now been tested as a treatment for cluster-C, cluster-B, and paranoid personality disorder, and effects are often very favourable compared to other approaches. New applications include personality disordered patients in high security forensic hospitals, and group-ST which seems to be especially effective in Borderline PD. Evidence from recently completed and preliminary evidence from running trials will be presented. The results indicate that Schema Therapy is an effective and cost-effective treatment. Neuroscience studies suggest that Schema Therapy not only leads to symptomatic change, but also to changes at deep brain levels, where emotional responsivity is regulated.  Applications of ST in some Axis I disorders and with milder personality issues are being developed and it is argued that it helps to address some limitations of CBT working with recurrent problems in intimate relationships and with processing memories and behaviour patterns from childhood.

Arnoud Arntz studied Physics and Mathematics as well as Psychology  at the University of Groningen. He completed his PhD on psychological aspects of pain at the University of Maastricht.  In the same period he participated as therapist and researcher in the establishment of the academic Experimental Psychopathology unit at the Maastricht Community Mental Health Center.  He was appointed as full professor in 2000 and scientific director of the research institute of Experimental Psychopathology in 2001.  With Marcel van den Hout he is chief editor of the Journal of Behavior  Therapy and Experimental Psychiatry.  His fields of interest are the  experimental study of pain, anxiety disorders and personality disorders, with a  special interest in investigating information processing in these areas.

References:
1. Arntz, A. & Jacob, G. (2012). Schema Therapy in Practice: An Introductory Guide to the Schema Mode Approach. Wiley-Blackwell
2.  Giesen-Bloo, J., van Dyck, R., Spinhoven, P., van Tilburg, W., Dirksen, C., van  Asselt, T., Kremers, I., Nadort, M., & Arntz, A. (2006). Outpatient Psychotherapy for Borderline Personality Disorder.  Archives of General Psychiatry, 63, 649 - 658.
3. Young, J.E., Klosko, J., & Weishaar, M.E. (2003). Schema Therapy: A Practitioner's Guide.  New York: Guilford.

When I first came across Schema Therapy many years ago, I was very dismissive of it.  It seemed an unnecessary fruit cocktail of techniques that had been thrown together and then practised with very little hard evidence that this melange of a therapy added anything useful to the cleaner more rigorous CBT methods we already had at our disposal.  My rather condescending dismissal of the approach changed with the 2006 publication of Arntz & colleagues' paper "Outpatient psychotherapy for borderline personality disorder: Randomized trial of schema-focused therapy vs transference-focused psychotherapy."  In 2007 I went to a four day training with Arnoud, and Schema Therapy has been one of my more important therapy tools ever since.  The main reason I travelled to Belfast for the Spring conference was to go to Arnoud's workshop and get an update on where his work has got to in the six years since I last trained with him.  I'm glad I did.  See tomorrow's blog post for how it went.

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