Implementation of a schema therapy awareness group for adult male low secure patients with comorbid personality difficulties: reflections and challenges

Publication Date30 January 2020
Date30 January 2020
DOIhttps://doi.org/10.1108/JFP-10-2019-0045
Pages41-56
AuthorJoseph Aaron Lowenstein,Jennifer Stickney,Ida Shaw
SubjectHealth & social care,Criminology & forensic psychology,Forensic practice,Sociology,Sociology of crime & law,Law enforcement/correctional,Public policy & environmental management,Policing,Criminal justice
Implementation of a schema therapy
awareness group for adult male low
secure patients with comorbid personality
difculties: reections and challenges
Joseph Aaron Lowenstein, Jennifer Stickney and Ida Shaw
Abstract
Purpose The purpose of this study/paper is to describe the implementation of a six-month schema
therapy awareness (STA) group. Research supporting individual schema therapy (ST) as an effective
interventionfor personality disorder is growing steadilywithin a number of settings including with forensic
patients. Alongsideindividual ST, positive results havebeen reported for group ST. However, to the best
of the authors’ knowledge,no current published research exists withregard to the use of group ST within
forensicpopulations and more specificallywithin a low secure environment.
Design/methodology/approach This paper describes the implementation of a six-month schema
therapyawareness (STA) group with individuals situatedwithin a low secure environment.
Findings For individuals transitioning into the community from a secure setting, the focus of risk
management shouldattempt to move away from external controlstowards more of a reliance on internal
factors. In ST, this is achieved by understanding the role of schema modes (and underlying schemas)
that are linked to an individual’s offences/risk and developing this understanding into a coherent and
accessibleformulation for the individual to makechanges.
Research limitations/implications Further robust research evaluating clinical change is
recommendedas the next step.
Practical implications The group protocol is described along with the challenges and potential
solutions experiencedduring the implementation. This providesan opportunity for other professionalsto
replicatethis approach in the future.
Originality/value With regard to group ST within forensic populations, the research is sparse at
present and this studyfocusses on practical application of theory and the challengesof operationalising
a STA group.
Keywords Implementation, Awareness, Group schema therapy, Low secure unit,
Personality difficulties, Schema therapy
Paper type Case study
Schema therapy (ST; Young et al., 2003) is a psychological intervention with the
primary aim of treating individuals diagnosed with personality disorder (PD) or
significant PD traits including entrenched interpersonal and self-identity difficulties
(Beckley, 2013). The approach is considered integrative, encompassing cognitive,
behavioural, psychodynamic and gestalt, but with its theoretical foundation strongly based
within attachment theory (Younget al., 2003).
The main premise of ST is that problematic personality-driven pathology develops from the
integration of innate temperament and an individual’s experience of not having core
emotional needs met in childhood. This leads to the development of early maladaptive
Joseph Aaron Lowenstein
and Jennifer Stickney are
both based at The STRIVE
Team, Dorset HealthCare
NHS Foundation Trust,
Poole, UK. Ida Shaw is
based at the Schema
Therapy Institute Midwest,
Indianapolis, Indiana, USA.
Received 9 October 2019
Revised 3 January 2020
Accepted 4 January 2020
DOI 10.1108/JFP-10-2019-0045 VOL. 22 NO. 2 2020, pp. 41-56, ©Emerald Publishing Limited, ISSN 2050-8794 jTHE JOURNAL OF FORENSIC PRACTICE jPAGE 41
schemas (EMS) defined as self-defeating emotional and cognitive patterns (Young, 1990).
These EMSs can subsequently become triggered in later life evoking powerful emotions
(e.g. fear, anger or sadness) and resulting in maladaptive behaviours as a method of
attempting to avoid experiencing overwhelming psychological distress. These maladaptive
behaviours can take the form of one or more of the following copingstyles:
accepting the resulting negative consequences are unavoidable and hence
acquiescing to the schema (surrender);
avoiding triggers internally and externally that may activate the schema (avoidance); or
acting out in opposition to the EMS (overcompensation) (Young et al., 2003).
Individuals diagnosed with more severe PDs often present with a larger number of EMS,
meaning that using techniques emphasizing EMS and coping responses often becomes
too complicated. In addition to this, individuals with severe PDs have been found to rapidly
switch between emotional states, resulting in a lack of clarity about targeting interventions
appropriately. In response to this, the schema mode work model was developed (Young
et al., 2003) and it comprises a set of techniques that enables the therapist to work with the
rapidly fluctuating emotional states and coping responses. Schema modes are defined as
the emotional state or “part of the person” that dominates a person’s thoughts, feelings and
behaviour at a given moment in time (Younget al., 2003).
Efficacy of schema therapy
Research supporting ST as an effective treatment for PD continues to grow; however, it has
been highlighted that while there is evidence of changes in problematic EMS and schema
modes, there is still a lack of understanding with regard to the underlying mechanisms of
change [for systematic reviewssee either Masley et al. (2011),Bakos et al. (2015) or Taylor
et al. (2017)]. The strongest evidence to date regarding the effectiveness of the approach
has been reported in a three-year multi-centre randomised clinical trial conducted in The
Netherlands. This study compared transference-focused psychotherapy with ST for
individuals with a diagnosis of borderline personality disorder (BPD). The findings indicated
that individuals assigned to the ST treatment were significantly less likely to drop-out, and
overall experienced higher remission rates, a larger reduction of BPD symptoms and
improvement in general psychopathology over the treatment course andat 12-month follow-
up (Giesen-Bloo et al., 2006). In addition, ST was reported to be more cost-effective than
transference-focusedpsychotherapy (van Asselt et al.,2008).
Additional studies support these findings with regard to the effectiveness of ST within
outpatient settings (Nordahl and Nysaeter, 2005;Sempe
´rtegui et al., 2013) and medium-
secure settings (Murphy and McVey, 2001), demonstrating significant improvements in
quality of life (Jacob and Arntz, 2013) as well as a reduced frequency and duration of
therapy (Nadort et al.,2009).
Group schema therapy
In addition to individual ST,group therapy protocols have also been developed with positive
results reported. For example, in a randomised controlled trial (RCT) involving 32 female
individuals with a BPD diagnosis, 30 sessions of group ST and treatment as usual (TAU)
were compared with TAU alone. The study reported that the group ST treatment
demonstrated significantly larger treatment effects, fewer dropouts, shorter duration and
required less therapist time (Farrell et al.,2009). In addition, Dickhaut and Arntz’s (2013)
report showed statistically significant results over a longer two-year period in terms of
reducing BPD-symptoms and scores on schema mode measures as well as improvements
in general psychopathology,quality of life and happiness.
PAGE 42 jTHE JOURNAL OF FORENSIC PRACTICE jVOL. 22 NO. 2 2020

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