Jordan, J., Wilson, J., Carter, J., & McIntosh, V. (2006).
Cognitive therapy and schema therapy in depression.
New Zealand Clinical Psychologist, 16(2), 19-23.
Cognitive therapy and schema therapy in depression
Jennifer Jordan, Jenny Wilson, Janet Carter & Virginia McIntosh
Schema therapy is one of a number of new at the Department of Psychological Medicine, at
therapies arising out of the cognitive behaviour the Christchurch School of Medicine. therapy (CBT) modality. Jeff Young builds on standard CBT but also draws from a rich The case - Anna tradition of other psychotherapy techniques Anna is a 28 year old woman self-referring for (Young, Klosko, & Weishaar, 2003). This therapy for recurrent depression and an complex therapy package is designed to assist exacerbation of longstanding anxiety symptoms. with complex chronic difficulties, including Anna described an unhappy childhood due to her personality disorders. This therapy has fathers alcohol problems and his unpredictable considerable face validity and has been well emotional and physical abuse towards her disseminated and adopted in clinical practice mother. Anna was close to her mother (who also internationally, including in New Zealand. The experienced anxiety and low mood) but dreaded aims of this paper are to describe CBT (J. S. her fathers rages. She did well at school socially Beck, 1995) and schema therapy approaches for a and academically. She opened a successful craft composite typical depressed client to illustrate store in her early 20s. She married Dan within 3 similarities and differences. We also present some months of their meeting and became pregnant initial impressions as clinicians delivering both immediately, giving up her business to focus on treatments in a research trial. family life. Anna became depressed after the birth of her first child, having trouble adjusting to her CBT is the most heavily researched new life, and again four years ago, related to psychotherapy orientation. Large evidenced- marital tension. Dan was often irritable and based reviews and meta-analyses of treatment for critical. He worked long hours and played sport, depression show CBT to be superior to no- taking little responsibility around the home. Anna treatment comparison groups, treatment as usual, tended to bottle up anger but said I cant leave - supportive psychotherapy, and psychodynamic marriage is for life. Anyway, he is never violent approaches in achieving increased rates of and he is a good father to the kids. Anna had recovery. CBT appears to be equivalent to gradually lost touch with friends. interpersonal psychotherapy and, in some studies at least, to have comparable efficacy to Cognitive behaviour therapy antidepressants but to be better at preventing A CBT formulation was developed. Childhood relapse (see reviews: ; A. T. Beck, 2005; Butler, predisposing factors included perfectionism, a Chapman, Forman, & Beck, 2006; Churchill, maternal history of mood and anxiety, an 2003). Increasing evidence that depression is a unpredictable abusive early environment leading recurring condition and the unacceptable to learned helplessness and witnessing her proportion for whom CBT does not help mother being abused but minimising this. adequately has prompted the continuing search Predisposing factors in adulthood included a for more effective treatments. There is no critical, emotionally unavailable husband, social published evidence of efficacy of schema therapy isolation, and loss of a previous successful work for depression although there are research trials role. Anna internalized Dans criticism, believing underway of schema therapy for substance abuse, she was incompetent. Her beliefs about marriage personality disorder, depression, and binge eating kept her in the relationship. Triggering events disorders, the latter two studies being undertaken included a role change and a deteriorating marital relationship after the birth of her first child. Maintaining factors included ongoing criticism Schema therapy from her husband, limited coping resources, A schema formulation was developed using communication deficits, limited social support, information from a clinical interview, schema and few positive events in her life. questionnaires, assessment imagery, and discussion with Anna. On the Young Schema The first phase of therapy focussed on Questionnaire, Anna scored highly on three of establishing initial behavioural change. Session 1 eighteen maladaptive schemas: Self Sacrifice, included psycho-education about the CBT model Unrelenting Standards, and Punitiveness. of depression and how CBT works (active collaboration, homework), and goal setting. Annas temperament may have predisposed her Relevant homework was set, including activity to certain schema. For example, her quiet nature scheduling and self-monitoring. Annas goals may have made her more inclined to adopt a self- were to feel calmer, happier, less irritable, to sacrificing schema rather than an abusive and improve sleep, improve relationships with her aggressive response to her father. Annas schema husband, friends, and family (increase social (comprising memories, body sensations, and contact, assertiveness), to get on with life (get a emotions) were hypothesised to result from part-time job, more interests), and to enjoy life unmet childhood needs, particularly the lack of more. The structure of sessions was established protection and nurturance, and the requirement with agenda setting, and review of homework that she overlook her own needs to keep the tasks (e.g. pleasurable and mastery activities and peace. Assessment imagery enriched the increasing social support). Relaxation, slow information Anna gave on assessment. Imagery breathing, and sleep hygiene strategies were used included recollections of witnessing abuse that to assist with symptom relief. In Phase II, the her mother seemed powerless to prevent, and cognitive module was introduced with education self-sacrificing efforts to get things right in an about negative automatic thoughts (Ive stuffed often futile attempt to avoid her fathers rage. up againIts all down to meI should be able Imagery also identified an Emotional Deprivation to cope), and how to challenge these. schema that Anna had not been aware of. It was Cognitive skills were consolidated and difficult for Anna to recognise the absence of behavioural changes maintained during this nurturing in her life, however it had a significant phase. Annas perfectionism meant that she was impact on her and played a central role in her very conscientious with homework, so therapy cluster of schemas. progressed quickly. She embraced the cognitive model, evaluating her thoughts and changing her Annas schemas were maintained by several negative cognitive biases to more realistic and mechanisms, including cognitive distortions (e.g. helpful appraisals. Assertiveness skills were black and white thinking about her performance) helpful for relationship issues, and problem and self-defeating life patterns (e.g. choosing a solving strategies were used to assist her in critical partner). They also included schema deciding options for jobs and life goals. coping styles and responses such as surrendering (e.g. overworking in response to Unrelenting Phase III tasks included preparing for the end of Standards), avoidance (e.g. avoiding negotiating treatment reviewing progress with goals and household issues with Dan), and how to address outstanding issues, anticipating overcompensation (e.g. doing too much for future stressors, and developing an individualized others while neglecting her own needs). Clinical relapse prevention plan. Anna reported that she depression may have been a trigger for, or a was happier, sleeping well, and relating better to consequence of the schema operating. During the her husband, friends, and family. She was more course of therapy Anna manifested characteristic confident and assertive, enjoying a new part-time schema modes such as Vulnerable Child (Little job, and generally felt more in control of her life. Anna), Punitive Parent, Angry Child (Raging Anna), Detached Protector (Switched-Off Anna), Critical Perfectionist, and People Pleaser. Simplifying a complex schema formulation with difficult situations. This resulted in some these user-friendly metaphors made therapy more improvement in the quality of her relationship straight-forward for therapist and client. with Dan, with an awareness that problems in The first two treatment sessions focused on that relationship may need further work in the activating Annas Healthy Adult mode, future. Anna was clearer about her needs and encouraging activity and pleasant event found appropriate ways to meet those needs, scheduling in order to elicit a shift in depressive including taking regular time out to follow her symptoms. Middle sessions used a variety of interest in handcrafts and spending time with experiential, cognitive, and interpersonal supportive friends. techniques with imagery and role play of schema modes predominating. During later treatment Discussion sessions Anna was actively encouraged and As noted earlier, schema therapy has arisen from challenged to make significant changes in order within standard CBT but incorporates many CBT to fight the schema and strengthen Healthy Adult concepts and strategies within a broader behaviours. integrative model along with other techniques and concepts from modalities outside CBT. Anna experienced a gradual lift in depressive Table 1 summarises similarities and differences symptoms, feeling a little better during scheduled between these two therapies. Although there is a pleasant events and experiencing something great deal of overlap with CBT, key differences in shifting following key imagery exercises. This schema therapy are the greater emphasis on full was followed by changes in the way she related to expression (rather than control) of affect Dan (becoming more assertive and refusing to (especially anger), experiential techniques to elicit take his critical comments personally). She affect, the therapeutic relationship, childhood became more self-reflective and reported origins of schemas, coping styles, and core choosing to act from a Healthy Adult mode schema. rather than one of her Child modes in several Table 1: Comparison of cognitive therapy (Beck) and schema therapy (Young) Cognitive therapy Schema therapy Goals Assist client to overcome Help client get core needs (control) emotional problems met in an adaptive manner by monitoring and changing through changing maladaptive thinking schemas, coping styles, responses and modes Schema Central cognitive structures Extremely stable and enduring within the mind, the patterns. Comprised of specific content of which memories, bodily sensations, are core beliefs. emotions and cognitions Comprised of cognitions Number of Three broad categories: Eighteen specific schema schema Helplessness Inadequacy Unlovability
reaction activation and deactivation. Specifically worked on with range of strategies Overall Top down Bottom up strategy Structure Formal agenda, structured Informal agenda, limited structure Problem focus Present/current problems Lifelong problems Therapy focus Automatic thoughts Schemas, coping styles, modes Therapist Active, collaborative, Active, empathic style empiricism confrontation Therapist- Primary way to motivate. One of four equal therapy client Focus on only if impeding components. Limited re- relationship therapy parenting. Identificatio Through negative automatic Variety of specific tools n of schema thoughts and themes
Childhood Not a specific focus of Specific focus of therapy
experiences therapy Strategies Education Education Cognitive Cognitive Behavioural Behavioural Experiential (limited) Interpersonal Shared case Experiential (extensive) conceptualization Shared case conceptualization Homework Homework Cognitive therapy Schema therapy Length of Short term Longer term treatment
After Carter (2005).
As therapists using both therapies within
randomised controlled trials, our experience and Conclusions clinical impressions are that schema therapy feels Schema therapy is an interesting new therapy very different from CBT. CBT is more familiar with face validity and widespread clinical and straightforward, offering greater structure adoption but with little empirical basis as yet. As and coherence. With CBT, clients who embrace therapists we can see advantages and challenges the CBT model appear to do well while others in CBT and schema therapy for particular clients. who dislike or struggle with aspects of CBT may Delivering both therapies within the constraints require modification of the usual presentation to of a research trial is a challenging and stimulating assist them in utilising therapy. endeavour. Research trials comparing schema therapy and CBT are underway but it will be Schema therapy is less structured, more flexible several years before data are available about the and creative, and the imagery takes us into the relative efficacy of these two therapies and unknown in a way that standard CBT does not whether the theoretical departures of schema usually do. The more central role of affect creates therapy from CBT and therapist anecdotal greater depth in the therapeutic relationship, impressions of differences are present and which may be more challenging for therapists. detectable. Schema formulation is more complex than CBT formulation. We have used modes References conceptualization more frequently than expected Beck, A. T. (2005). The current state of cognitive therapy: modes is an economic way of making sense of A 40-year retrospective. Archives of General Psychiatry, 62, 953-959. client history and functioning with the complex Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New schema model, explaining how various schemas York: The Guilford Press. and coping strategies inter-relate and play out Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. differently within each mode. Clients who T. (2006). The empirical status of cognitive-behavioral embrace the schema model appear to derive therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17-31. considerable benefit and make significant Carter, J. D. (2005). Comparison of cognitive therapy and schema changes intra- and interpersonally. Others, therapy. Unpublished manuscript, Department of particularly those who usually avoid affect, may Psychological Medicine, Christchurch School of find imagery difficult or uncomfortable, and we Medicine & Health Sciences, University of Otago. have had to find more concrete or perhaps less Churchill, R. (2003). A systematic review of controlled trials of the effectiveness and cost-effectiveness of brief intense ways of working with these clients to psychological treatments for depression. [On-line]. implement schema principles. Many questions Available: still arise in the application of schema therapy http://www.hta.nhsweb.nhs.uk/execsumm/summ535.htm,Ret principles and our supervision group has been rieved 3 July 2006.Young, J. E., Klosko, J., S., & invaluable in helping us develop ways of adapting Weishaar, M. E. (2003). Schema therapy: A practitioner's guide. New York: The Guilford Press. or extending schema therapy for particular clients. Jennifer Jordan, Jenny Wilson, Psychology Centre, Department of Canterbury; Janet Carter, Department of Psychology, University of Canterbury & Virginia McIntosh, Department of Psychological Medicine, Christchurch School of Medicine and Health Sciences.