Schema Therapy with Couples

A Practitioner's Guide to Healing Relationships

Chiara Simeone-DiFrancesco, Eckhard Roediger, Bruce A. Stevens

• Editorial: Wiley-Blackwell
• Año: 2015
• ISBN:
  9781118972717
• Edición: 1
• Categoría: Psychologie
• Categoría: Klinische Psychologie

Schema Therapy for Couples represents the first practitioner guide to detail effective Schema Therapy techniques in couple and relationship therapy.

• Shows how the distinctive features of ST make it ideal for addressing the cognitive and emotion-focused problems typical in couple relationships
• Presents and integrates a series of innovative tools and interventions such as Schema Therapy with Needs versus Wants, Mode Cycle Clash Cards, limited re-parenting visualization, and chair work
• Authored by an international team of experts in couples therapy and Schema Therapy

1
What Schema Therapy Offers

1.1 What is Hidden, What is Seen

For couples, the most common clashes are around the “rough edges” of personality. Indeed, there is a great silence in relationship therapy about the influence of personality disorders. Research has established that such traits are very common. Only 23 percent of the general population is relatively free of them; over 70 percent of people “have some degree of personality disturbance” (Yang et al., 2010).

It makes sense that character traits will cause relationship difficulties. We are attracted to a personality but live with a character. If there are long-term character problems, which is another way of describing personality vulnerability, then relationship difficulties are inevitable.

Richard had a history of many short-term relationships, which were perhaps more sexual “flings” to avoid boredom. He would leave when lovers became more “needy”. He had been sexually abused as a child and never experienced warmth or protection by a parent or step-parent. He knew only criticism. Eventually, he married Carol because he wanted a stable relationship to raise children. When he had an affair, it was devastating to his wife. It was hard to even talk issues through because Richard avoided conflict. A lot was happening in this relationship that was far from obvious.

Some couples deny any problems, even to the point of separation and divorce, but there is a long history of hidden clashes underlying the deterioration of their relationship.

Reflect: What has been your most difficult couple to treat? Why? Do you recognize possible traits of personality disorder?

1.2 Listening to the Evidence

There is currently a crisis in relationships, and couples commonly present for therapy. So why not simply use the available evidence-based treatment for relationships? The answer is not straightforward. There is good research. John Gottman (1999) has contributed enormously to what we know through his “Love Lab.” He has provided years of longitudinal data on couple processes. This includes easy-to-understand principles thoroughly grounded in extensive research. This can inform our practice. While Gottman and his colleagues have not yet produced randomized controlled trials, his work would meet the criteria of the American Psychological Association’s policy statement on evidence-based practice in psychology: “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (see APA, 2006).

Sexton and Gordon (2009) distinguished three levels of evidence:

1. evidence-informed interventions based on pre-existing evidence
2. promising interventions, but preliminary results not replicated
3. evidence-based treatments with systematic high-quality evidence demonstrating efficacy with clinical problems that the interventions are designed to address.

There is some Level 3 support for behavioral marital therapy (Jacobson & Margolin, 1979), cognitive behavioral marital therapy (Baucom & Epstein, 1990), integrative couple therapy (Jacobson & Christensen, 1996), and emotion-focused therapy for couples (EFT-C; Greenberg & Goldman, 2008).

In our experience, EFT-C works with many, and perhaps most, couples. But there is no specifically evidence-based therapy for couples with personality disorder (or for couples with strong traits, even if not diagnosed). What exists is evidence of the effectiveness of individual treatment for individuals with personality disorder, initially borderline personality disorder (BPD). It makes clinical sense that difficult couples may need an enhanced approach with ST or dialectical behavior therapy (Linehan, 1993). Both employ stronger interventions aimed at changing ingrained aspects of character. A 2010 review concluded that dialectical behavior therapy has Level 3 and ST has Level 2 evidence for effectiveness with adults diagnosed with BPD (APS, 2010, p. 112). A study of ST treatment of BPD inpatients using groups has reported large effect sizes (Farrell & Shaw, 2012), and a study has recently indicated the effectiveness of ST with other personality disorders (Bamelis et al., 2014).

We believe that ST has significant advantages over dialectical behavior therapy,² so applying ST to working with couples (schema therapy for couples, ST-C) is the focus of this book. We hope that it may prove to have some of the strengths already demonstrated by ST case conceptualization and interventions in individual and group therapy.

1.3 Beyond Just Cognitive Therapy

One of the strengths of ST is its origins in cognitive therapy, which has the advantage of conceptual clarity and ease of understanding. Now, in the twenty-first century, it incorporates a good deal more than talk. This includes both non-verbal cognitions (imagery) and embodiment techniques (Rosner et al., 2004). It is essentially integrative.

Aaron Beck (1963) initiated the “cognitive revolution” and developed what is now extensively researched cognitive behavioral therapy for the treatment of depression. This approach was then applied to the whole range of psychological disorders. But cognitive behavioral therapy did not prove as effective with the personality disordered, which led to “third wave” therapies, including dialectical behavior therapy and ST.

While Beck referred to schemas, it was more in the sense of clusters of negative beliefs about the self. A similar understanding of schemata is found in the work of Theodore Millon, in which patterns of dysfunction are foundational to personality disorder (Millon, 1990, p. 10). Jesse Wright and colleagues followed in this approach and noted that people typically have a mix of different kinds of schemas: “even patients with the most severe symptoms or profound despair have adaptive schemas that can help them cope … efforts to uncover and strengthen positively oriented beliefs can be quite productive” (Wright et al., 2006, p. 174).

1.4 Jeff Young and the Development of Schema Therapy

ST was developed from cognitive therapy as a means of treating difficult people. Jeffery Young et al. (2003) linked maladaptive schemas to neglect and toxic childhood experiences. They reflect the unfulfilled yet important needs of the child and represent adaptations to negative experiences, such as family quarrels, rejection, hostility, or aggression from parents, educators or peers, as well as inadequate parental care and support (van Genderen et al., 2012). This approach has more of an emotional focus and a willingness to explore the childhood/adolescent origins of psychological problems.

Young identified a comprehensive set of early maladaptive schemas, which were defined as “self-defeating emotional and cognitive patterns that begin early in our development and repeat throughout life” (Young et al., 2003, p. 7). Schemas are identified by clinical observation (Arntz & Jacob, 2013). The expression of such patterns has different levels of severity and pervasiveness. The idea of schema activation is fundamental to an understanding of Young’s contribution. A more severe schema is distinguished by how readily it is activated, the intensity of affect and how long distress lasts (Young et al., 2003, p. 9).

ST provides a blueprint for the child and later adult’s world. While schemas might have had some survival value for the child (Kellogg, 2004), by adulthood they are “inaccurate, dysfunctional, and limiting, although strongly held and frequently not in the person’s conscious awareness” (Farrell & Shaw, 2012, p. 9).

Young et al.’s (2003) understanding of schemas drew on a variety of sources. Indeed, they outlined parallels and differences with major approaches, including Beck’s “reformulated” model, psychoanalytic theory, Bowlby’s attachment theory (especially internal working models), and emotion-focused therapy (EFT). ST has integrated techniques adapted from transactional analysis and gestalt therapy (Edwards & Arntz, 2012). Jeff Young (2012) also described ST as an individual therapy with systemic implications. There is a breadth, applicability and ease of understanding that encourages a broader application.

Young (1999, p. 20) also identified needs of childhood in five “domains,” which can be seen as five tasks for therapy:

• connection and acceptance
• autonomy and performance
• realistic limits
• inner-directed ness and self-expression
• spontaneity and pleasure.

1.5 The Schema Model

Young identified the following 18 schemas: Abandonment (instability), Mistrust-Abuse, Emotional Deprivation, Defectiveness-Shame, Social Isolation (alienation), Dependence Incompetence, Vulnerability to Harm or Illness, Enmeshment (undeveloped self), Failure (to achieve), Entitlement Grandiosity, Insufficient Self-control (or self-discipline), Subjugation, Self-Sacrifice, Approval Seeking (recognition seeking), Negativity Pessimism, Emotional Inhibition, Unrelenting Standards (hyper-criticalness), and Punitiveness. Maladaptive schemas hinder people from recognizing, experiencing, and fulfilling their own needs (Arntz & Jacob, 2013).

Reflect: You can think about schemas as patterns of vulnerability, or as domains in which emotional learning took place in childhood.

Young also looked at patterns of response to schema vulnerability, including surrender, avoidance, and compensation leading to specific coping behavior. The 18 maladaptive schemas are very comprehensive, especially when coupled with three response patterns. However, there are potential treatment difficulties:

1. Complexity. The whole list of the schemas with response patterns is potentially 54 different schema–coping presentations. While most people may only have a few schemas with characteristic r...