Schematherapie

Schema therapy is a cognitive behavioral therapy (CBT) development mainly for the treatment of personality disorders and other chronic mental disorders. It is characterized by an integration of cognitive, emotional and behavioral intervention methods derived from different therapeutic approaches with an emphasis on a specifically supportive therapeutic relationship. The original approach focused mainly on early maladaptive schemas. Current developments, however, concentrate on the concept of schema modes, describing different schema-associated emotional states. The schema mode approach is also used for specific case concepts for personality disorders. Effectiveness of schema therapy has been shown for borderline personality disorder. Current studies investigate the effectiveness of schema therapy for patients with other chronic mental conditions and as a group therapy approach. This paper provides an overview about case conceptualization and treatment, presents main research findings and discusses open questions and problems.     

A new look at the schema therapy model: organization and role of early maladaptive schemas

This study reexamined the organization of Young’s 18 early maladaptive schemas and their hypothesized associations with experiences of need-thwarting parental experiences in childhood and the “vulnerable child” mode of emotional distress in adulthood. A large Danish sample (N = 1054) of 658 clinical- and 391 nonclinical adults completed measures of early maladaptive schemas, parenting styles, and the vulnerable child mode. We identified four higher-order schema domains as most appropriate in terms of interpretability and empirical indices (“Disconnection & Rejection”, “Impaired Autonomy & Performance”, “Excessive Responsibility & Standards”, and “Impaired Limits”). All four schema domains were differentially associated with conceptually relevant need-thwarting parental experiences. Apart from “Impaired Limits”, the schema domains meaningfully accounted for the association between need-thwarting parental experiences in childhood and emotional states of feeling like a “vulnerable child” in adulthood. We conclude that four domains of early maladaptive schemas are empirically and conceptually consistent with Young’s schema therapy model of personality pathology and longstanding emotional disorders. Findings warrant replication using different populations and if possible a prospective multi-method design. A scoring key for computing the four schema domains is provided.     

Maintaining a healthy diet: Effects of personality and self-reward versus self-punishment on commitment to and enactment of self-chosen and assigned goals

Abstract

A theory decomposing volition into four modes of central organization of executive control functions is outlined. These modes include (1) an autonomy-oriented mode (“self-regulation”) which is facilitated by challenging conditions and positive mood, (2) a self-suppressive mode oriented toward external-control (“self-control”) facilitated by negative mood and two modes associated with volitional inhibition (“state orientation”). Two experiments are reported that test predicted interactions between dispositional and situational factors in determining commitment to and actual enactment of self-chosen versus assigned activities directed at changing nutritional behavior. The results confirm the predicted disordinal interactions: The degree of commitment to and enactment of intended behavioral changes depends upon an interaction between personality (volitional styles), type of self-regulatory task (eat more healthy versus avoid unhealthy food), and instructional focus on easy versus difficult steps (Study 1) or self-reward versus self-punishment strategies (Study 2). Practical implications for designing intervention procedures according to individual personality characteristics and situational constraints are discussed.     

Forensische Psychiatrie zwischen Therapie und Sicherung

The therapeutic tasks of forensic psychiatry range between the field of tension of “improvement” and “security” of entrusted persons. With respect to these aspects a paradoxical position of politics and society can be seen: whereas, regulatory security aspects are emphasized and detention measures are required with respect to the treatment measures according to §63 and §64 of the penal code (StGB) and any relaxation of rules is critically viewed, under pressure from the European jurisprudence preventive detention has been declared as a therapeutic measure. The superordinate priority of these measures is to prevent recidivism. This article firstly summarizes the empirical evidence concerning the efficacy of forensic psychiatric treatment of relevant disorders. From this it becomes obvious that the data are unreliable due to relevant risk aspects; therefore, the comparison of safety and therapeutic interests remains a challenging undertaking. A working approach that can successfully encompass both aspects is long-term case management, which is in a position to do justice to both the inpatient interaction and dynamic aspects of the treatment process beyond detention. Because the effectiveness of aftercare has been confirmed, we propose the implementation of forensic outpatient treatment as an alternative to forensic inpatient treatment.     

The splitting between separate and symbiotic stätes of the self in the psychodynamic of schizophrenia

Abstract

We explore the problematic dynamics in the relationship between societal systems of care and the chronically excluded, with particular reference to severe personality disorder and the “difficult-to-reach” patient. The individual who “refuses” is often met with a violent response: yet his violence must be understood as related to an experience of being violently excluded. We reformulate personality disorder as a disturbance of “groupishness” and suggest, as a paradigm for the problem of refusal, the story of Diogenes the Cynic, who “holed himself up” in a barrel; and of his legendary encounter with Alexander the Great, who tried unsuccessfully to persuade him to “come in from the cold.” We suggest it may be as important to focus on Alexander's violence as on that of Diogenes, and we examine modes of violence deployed by society against the excluded outsider, with particular reference to the hostile attribution of intentionality to the personality disordered individual's acts of violence and self-harm. We conclude by considering both the merits of the democratic therapeutic community model as a response to severe personality disorder and the dangers, inherent in this model among others, in an unconscious identification with Diogenes in his barrel.     

Group-Schematherapy for Adolescents: Results from a Naturalistic Multiple Case Study

Personality disorders are complex mental health problems, associated with chronic dysfunction in several life domains. Adolescents suffer from these disorders as well. The present study is a naturalistic case study, investigating whether group schematherapy (GST) can be applied to adolescents with personality disorders or personality disorder traits. Four clinically referred patients were included and completed questionnaires on quality of life, symptoms of psychopathology, schema modes, early maladaptive schemas, and schema coping styles. Patients participated in weekly GST sessions complemented by weekly or 2-weekly individual sessions. The parents of the adolescents participated in a separate parent group. From pre- to post-treatment, results demonstrated improvements for some patients in quality of life and symptoms of psychopathology. Changes in a number of modes and schemas were observed in all patients from pre- to post-therapy. In addition to assessing changes from pre- to post-treatment, the current study investigated the temporal changes in modes during therapy as well. Results demonstrated that maladaptive modes decreased, whereas healthy modes increased for all patients across the course of therapy. The present study provides preliminary support for the applicability of GST for adolescents as well as the effectiveness of GST. It is a starting point for further research on this intervention.     

From Traumatic Language to Posttraumatic Language: The Development of Language in Therapy According to the “Phenomenon of Hope” Model

Hope and language are part of the human development process starting from birth and continuing through all the stages of development. They are tools that help us to cope in complex situations. Environmental failure produces trauma, which damages the “self” and impairs the development of hope and language. The individual experiences “pessimistic hope” and “drained hope” and begins using “concrete language” and “pseudo-language.” Such profiles and languages indicate functional difficulties, including the inability to establish mature intimate personal relationships. When traumatic events such as those experienced in military combat compound childhood trauma (environmental failure), mental and functional difficulties buried by our defense systems may rise to the surface and worsen and chronic complex trauma may ensue. Psychotherapy for chronic complex trauma is complex. The therapeutic approach that is used in the “hope phenomenon” model includes five therapy stages that allow us to examine the effect of a trauma on personality and function. Here we examine the link between the five stages of therapy and the use of language. According to my experience, patients use concrete language and pseudo-language in the beginning of the therapeutic connection. As this connection and therapist-patient alliance evolves and deepens and the client and therapist move through the various stages, the patient then starts to use “plural language.” Concrete language and pseudo-language are used in the pessimistic hope and drawn hope stages, respectively, until a profile characterized by a realistic and mature hope emerges. This profile goes hand in hand with an ability to use plural language. This article examines the development of hope and language in a complex posttraumatic stress disorder (PTSD) patient who was treated using the hope phenomenon model. Consent for the therapy details to be used in this article was given by the patient.     

An empirical test of schema mode conceptualizations in personality disorders

Although the use of schema modes in schema-focused therapy (SFT) has been very popular since its introduction, Young's schema mode concept remained largely empirically untested. In order to provide insight into the mode conceptualization of personality disorders (PDs), the current study assessed the relationships between 14 schema modes and all PDs. Relationships between dimensional PD scores and self-reported mode scores were tested in a mixed study group of 489 participants, consisting of axis I and axis II patients, and non-patients. Psychopathology was assessed by means of the Structured Clinical Interview for DSM-IV axis I and axis II disorders (SCID I and SCID II) or the Structural Interview for DSM-IV Personality Disorders (SIDP-IV), and modes were assessed by the Schema Mode Inventory. Kendall's partial tau coefficients, controlling each PD-mode correlation for all other PD scores, indicated unique mode profiles for all PDs and corroborated most of the hypothesized PD-mode correlations, supporting the construct validity of the mode model. Nevertheless, the high number of correlations found for some PDs raises concerns about the specificity of the mode model. Implications for both research and therapy are discussed.     

Die Therapeutenrotation

For seven years, the so-called “rotation of therapists”, has been a central part of OLITA, the outpatient longterm intensive therapy for alcoholics. Thus far, the participation of several equally responsible therapists in the treatment of a patient has rarely been seen as a defined therapeutic approach. The present work discusses whether the “rotation of therapists” has any essential influence on the success of OLITA. It considers both, potential advantages and disadvantages for patients and therapists and tries to identify conditions under which this approach appears to promote therapeutic interactions. Following an overview of the present knowledge regarding the therapeutic interaction in addiction therapy, a method is described which may be seen as the precedent of the “rotation of therapists”, the multiple psychotherapy. Finally, the practical procedure in OLITA is outlined as well as its theoretical background. New areas of application for the “rotation of therapists” are discussed.     

L’intelligence artificielle peut-elle aider à estimer le risque de récidive dans les comportements violents ?

In forensic psychiatry, magistrates raise the question of the existence of a risk of recidivism and dangerousness to psychiatric experts. Follow-up studies in forensic psychiatry showed that the psychiatric elements predictive of recidivism were mainly related to serious mental illnesses, toxic consumption, addictions, high levels of impulsivity, low insight, associated personality disorders, in particular antisocial personality disorders. There are also protective factors, in particular the observance of treatments. Given the complexity of psychiatric and criminological risk factors and protection, can artificial intelligence (AI) help psychiatrists and magistrates to improve the predictivity of recidivism?MethodsSystematic review of the literature on AI applications in the prediction of recidivism in forensic psychiatry, conducted according to PRISMA criteria, using the: “Artificial Intelligence”, “Recidivism”, “Personality Disorder”, “Impulsive” Behavior”, “Alcohol abuse”, “Drug Abuse”, “Schizophrenia”, “Bipolar disorder” on the PubMed, Science Direct, Clinical Trial and Google Scholar databases.ResultsThe vast majority of studies come from legal or computer reviews and very few from medical databases. The studies evaluating the AI in Forensic Psychiatry most often used Machine Learning based on sociodemographic, sociological and criminological data, notably the age of the first offense and the number of previous convictions. To date, there are very few studies evaluating psychiatric parameters, focusing on psychopathic personality disorders.Discussion/conclusionThe applications of the AI in Forensic Psychiatry are still very premature. However, some psychiatric criteria should be more prominent in this field, especially those from Webster's HCR-20 and Hare PCL-R scales. The challenge will also be to find relevant behavioral, psychological and psychiatric keywords to include in AI.     

Psychoanalytische Intervalltherapie

The history of focal therapy clearly reveals it to be closely linked with short-term therapy. This fact can often lead us to take a rather limited view of the focal therapeutic approach, since in reality it can also be a useful concept for long-term treatment. Experiences with therapy performed on an interval basis show that development happens in stages and that a new step forward – a “quantum leap in development”– can only be achieved when the time is right. This step frequently requires that the patient have their own experiences, undergo their own suffering and develop an Ego-dystonic reaction towards their characteristic behavioral conditions which can often only be achieved outside the therapeutic environment. In this context, it becomes even more significant that we understand and take into consideration the “self-analytical function of the Ego”. If these preconditions are met, then it may even be possible to achieve profound structural changes in a longer-term therapeutic process, assuming that this therapy is performed in focal stages rather than continuously.     

The Interactive Effect of Impression Motivation and Cognitive Schema on Self‐Presentation in a Personality Inventory1

Applicants usually try to put their best foot forward during personnel selection. Although past research has revealed meaningful individual differences in applicants' self‐presentation in personality tests (often called “faking”), it only concentrated on main effects and ignored the interaction of interindividual and intraindividual differences. Based on impression management theory, we hypothesized that interindividual differences in applicants' impression motivation interact with intraindividual differences in the perceived relevance of personality facets (applicants' cognitive schema). Results of hierarchical linear modeling analyses showed that both impression motivation and cognitive schema significantly affected self‐presentation. Furthermore, for participants with high levels of impression motivation, cognitive schema showed a stronger impact on self‐presentation than for those with low levels of impression motivation.     

Behandlungsleitlinie Persönlichkeitsstörungen

The S2 guidelines for the treatment of personality disorders (PD) are summarized. In the diagnostic assessment of personality disorders a clinical interview should be supplemented by (semi-) structured clinical interviews and self-report measures for the categorical and dimensional assessment of PDs. The results of the assessment process should be communicated to the patient based on a psycho-educational framework. The diagnosis should always be linked to the patient’s individual history. Psychotherapy is the treatment of choice for personality disorders. A detailed analysis of the patient’s problems as well as the definition of a hierarchy of treatment goals are part of the process of treatment planning. For three PDs empirical evidence for treatment approaches is available: (1) dialectical behavior therapy, mentalization-based therapy, schema focused therapy and transference focused therapy all proved beneficial in the treatment of borderline personality disorder. Cognitive-behavior therapy proved helpful in the treatment of (2) dissociative personality disorder and (3) avoidant personality disorder. There is limited evidence for interpersonal therapy and psychodynamic therapies in the treatment of avoidant personality disorder.     

Is psychoanalysis alive and well at 85? A rejoinder

Psychoanalysis has declined in public interest and scientific validity. It has become a “dead science” and an anachronistic system of beliefs. Its goal of total personality reconstruction is frustrating and futile. Psychoanalytic practice became a form of “exclusive salvationism,” and unconscionable, when it excluded the spouse from participation in the total treatment plan. More frequent interviews over a longer period of time do not produce a therapeutic effect that is “deeper,” and there is no reason to believe that fewer interviews are superficial, or temporary, and that prolongation of an analysis is more likely to produce better therapeutic results. Research studies do not produce any clear-cut winners when psychotherapies are compared. Psychoanalytic theories rest more on argument than on scientific evidence. The patient’s needs seldom, if ever, correspond to the therapist’s theoretical preoccupations, system of beliefs, and indoctrination. Research psychologists, philosophers of science, and eclectic psychiatrists have expressed their dissatisfaction with unproven psychoanalytic doctrines and the concept of “mental energy.” Psychoanalysis is not a pseudoscience, but a “half-science,” whose poetic mythology requires translation into the prose of science.     

The Clinical Challenge of Mentalization-based Therapy with Children Who are in “Pretend Mode”

ABSTRACT

The “pretend mode” is one of the so-called “pre-mentalizing modes of thinking”, which were first introduced by Target and Fonagy over 20 years ago. In a series of papers about play and reality, “pretend mode” thinking was understood as a mode of pre-mentalizing thinking which is typical in the early years, but which can reappear in a more problematic way in adults. Although the concept of pretend mode was first introduced in a developmental context, as a clinical term it has primarily been discussed in the context of adult or adolescent psychotherapy. This paper suggests that the pretend mode is a valuable clinical concept for therapists working with school-age children, but that its use in this context needs some clarification. After reviewing how pretend mode has been understood as a normal part of early development, this paper goes to demonstrate the various roles of pretend mode in clinical work with school-age children and sets out a number of clinical strategies that may be used in therapeutic work.     

Reversal theory and personality: A review

Reversal theory is a new “mode-based” theory of motivation and personality which challenges some fundamental assumptions in these two fields and systematically develops an alternative account which emphasizes the complexity, changeability, and even inconsistency of much of behavior and experience. The present paper introduces some of the main concepts of the theory, including those of metamotivation, reversal, telic and paratelic modes, and telic dominance, and shows how the general approach involved can be characterized as “structural phenomenological.” The experimental, psychometric, psychophysiological, and other types of research which have been generated by the theory are reviewed and shown to be generally supportive of it.     

Sexueller Sadismus und Sexualkriminalität

The categorization of sadism has turned out to be a versatile phenomenon, which covers a spectrum from harmless symbolic rituals to extremely violent acts where strong impulses or prolonged fantasies and rituals are involved. As the phenomenon is versatile its causes and appearances vary as well, although so-called BDSM (bondage & discipline & dominance & submission & sadism & masochism) practitioners and persons with severe sadism in a forensic context share only few common preferences. Based on own clinical experiences with sadism in forensic patients the authors support the proposed revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) especially the diagnostic disjuncture of sadism and masochism. Sexual sadism appears more frequently in forensic contexts in combination with sadistic, antisocial and borderline personality disorders but rarely with masochism. Masochism is otherwise reported to be more prevalent in patients of general psychiatry, however, combined with depression or dependent personality traits rather than with sadism. Moreover, the authors believe that if use of the diagnostic term sadism is perpetuated the establishment of the proposed new diagnosis “paraphilic coercive disorder” is unnecessary. The diagnostic term is also important for treatment and assessment. Despite the lack of reliable long-term studies with larger samples, it is reasonable to assume that medication, sometimes even anti-androgenic treatment, can be indicated in patients with severe sadism.     

Coordination tending towards an anti-phase relationship determines greater sway reduction during entrainment with a simulated partner

The increased risk of falls in the older aged population demands the development of assistive robotic devices capable of effective balance support. For the development and increased user acceptance of such devices, which provide balance support in a human-like way, it is important to understand the simultaneous occurrence of entrainment and sway reduction in human-human interaction. However, sway reduction has not been observed yet during a human touching an external, continuously moving reference, which rather increased human body sway. Therefore, we investigated in 15 healthy young adults (27.20±3.55 years, 6 females) how different simulated sway-responsive interaction partners with different coupling modes affect sway entrainment, sway reduction and relative interpersonal coordination, as well as how these human behaviours differ depending on the individual body schema accuracy. For this, participants were lightly touching a haptic device that either played back an average pre-recorded sway trajectory (“Playback”) or moved based on the sway trajectory simulated by a single-inverted pendulum model with either a positive (Attractor) or negative (Repulsor) coupling to participant's body sway. We found that body sway reduced not only during the Repulsor-interaction, but also during the Playback-interaction. These interactions also showed a relative interpersonal coordination tending more towards an anti-phase relationship, especially the Repulsor. Moreover, the Repulsor led to the strongest sway entrainment. Finally, a better body schema contributed to a reduced body sway in both the “reliable” Repulsor and the “less reliable” Attractor mode. Consequently, a relative interpersonal coordination tending more towards an anti-phase relationship and an accurate body schema are important to facilitate sway reduction.     

Mending the Mind

Cognitive behavior therapy (CBT) offers an alternative paradigm to psychoanalysis for understanding human behavior and the mechanisms of change. Dialectical behavior therapy (DBT) grew out of this tradition conceived originally for the treatment of suicidal patients with borderline personality disorder. Unlike psychoanalysis, DBT does not recognize unconscious meanings or motivations and instead focuses on sequences of measurable behavior and the contingencies that reinforce them. The treatment protocol emphasizes a deficit model and is structured around specific targets and goals combined with “skills” training (i.e., specific skill sets to help with emotional, cognitive, and behavior dysregulation) Combining an overarching dialectical philosophy, emphasis on the therapeutic relationship and mindfulness, DBT offers a comprehensive therapeutic approach including individual sessions and group work.

The directive methods of CBT have often been viewed as antithetical to analytic reflection; such active therapeutic techniques on the part of the psychoanalyst are often seen as impeding the necessary free associative processes necessary for the acquisition of insight and for change. Whereas psychoanalysts help patients recognize dysfunctional patterns of behavior within the transference and alternative ways to view the transaction, they often do not help a patient implement new behaviors into their lives in systematic ways.

Both psychoanalysis and DBT have much to offer and to gain. In time translation and mutual inclusion of new ideas may help bridge the gap.     

The Role of Personality in Psychotherapy for Anxiety and Depression

ABSTRACT A trait approach to personality has many implications for psychotherapy. Given that traits contribute to the expression of symptoms of common psychiatric disorders, are moderately heritable, and relatively stable (yet also dynamic to some extent), long‐term change in symptoms is possible but is likely to be limited. Analogous to the manner in which genes set the reaction range for phenotype, standing on certain traits may set the patient's “therapeutic range.” On the other hand, some of the same traits that may limit the depth of therapeutic benefits might also increase their breadth. In addition, taking the patient's standing on different traits into account can inform the choice of therapeutic strategy and targets and can affect the formation of the therapeutic alliance and compliance with self‐help exercises. Finally, other aspects of personality beyond traits, such as ego development and narrative identity, also appear to have important implications for psychotherapy.