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Practice Education Advocacy Research

OUR MIX TAPE UNDERSTANDING THE EXPERIENCE OF SCHEMAS, ATTACHMENT AND PAIN DR KAREN T. HALLAM SENIOR RESEARCH FELLOW RESEARCH MANAGER, YSAS HONORARY FELLOW THE UNIVERSITY OF MELBOURNE HONORARY FELLOW VICTORIA UNIVERSITY


TODAYS WORKSHOP

Take a hitchikers tour through Part 1. Foundations of therapeutic styles Attachment Schemas Formulation approaches Part 2. Application of theory to a case study with in depth discussion of formulation and therapy approach


TRIGGER WARNING

This workshop necessarily discusses the experiences of people who have experienced abuse, have engaged in suicidal behaviour and have witnessed family violence and suicide. Please keep this in mind when considering the right workshop for you. If the content raises immediate concerns for you I am happy to debrief at the end of the workshop, if you are engaged with a therapist or health care team I also encourage you to discuss with them at your next opportunity. Thank you Karen


WHAT MAKES A SKILLED THERAPIST? Background factors Interpersonal skills Emotional Intelligence Affect regulation Context Therapeutic

orientation

Therapeutic skills and techniques

Therapeutic Approach

Eg schemas, mindfulness etc


THERAPEUTIC ORIENTATION

Psychoanalytic/ Psychodynamic

Humanistic Existential

Cognitive therapies


THERAPEUTIC APPROACH

The method you learn to do things within and outside of your own orientation. Often learned from where you study and work Continue to develop and expand over time Should be formulation based (must combine both of the following) Nomothetic

–  Formulation based on general laws/rules –  Typical of DSM diagnoses (if you have … it wil look like…)

Idiographic

–  What might work for … –  Takes into account complexity of the individual –  Our experience and needs vary between people


THERAPEUTIC TECHNIQUES

Nuts and bolts of what you might do in any one session Well practiced and shared in the most effective way for the person based on formulation


FOCUSING ON THERAPEUTIC APPROACH… WHAT IMPACT DOES EARLY EXPERIENCE HAVE?


ATTACHMENT

Many animals (including humans) have an instinct to have a stable and safe attachment with the primary caregiver Caregiver is ideally a secure base from which to venture and explore environment

Ideally a tension between preserving familiarity and novelty seeking When caregiver not tuned in with child/ abuses child/ abandons child may lead to insecure attachment formation While they begin in childhood, they are adaptable (but tough to change) over time


ATTACHMENT STYLES

Secure: Comfortable displaying interest and affection. Comfortable being alone and independent. Can identify and assert their boundaries. Loyal, sacrificing, able to accept rejection and trust/be trusted (50% population) Secure attachment is developed in childhood by infants who regularly get their needs met, as well as receive ample quantities of love and affection Anxious (Preoccupied): Often nervous and stressed about their relationships, requiring constant assurance. Being alone is difficult and they struggle to trust people. They can irrational, sporadic, and overly-emotional when feeling threatened and complain that potential/current relationships are cold and unresponsive Anxious attachment strategies are developed in childhood by infants who receive love and care with unpredictable sufficiency.


ATTACHMENT STYLES

Avoidant (Dismissive): Extremely independent, self-directed, and often uncomfortable with intimacy. They struggle with commitment and the feeling of suffocation . They both yearn for but fear intimacy, hence pushing people away (often pre-emptively), they may construct their lives in such a way that they don’t need others Developed in childhood by infants who only get some of their needs met while the rest are neglected (for instance, he/she gets fed regularly, but not held enough). Anxious-Avoidant (Fearful): Struggle with both avoidance and anxious styles. Fear intimacy and connection, distrust others and lash out at people who try to get close to them, often attract abusive others (shit magnet) Anxious-avoidant types develop from abusive or terribly negligent childhoods.


HOW ATTACHMENTS PLAY OUT


LIKE SANDS THROUGH THE HOURGLASS…

Six years of age

25 years of age

40 years of age


IF THEY ARE SO STABLE, WHY DID THEY CHANGE?

When I was 25, I showed up to begin a long course of psychodynamically oriented psychotherapy… At the beginning of the session my therapist asked me “How can I help?” I replied “I’m that Simon and Garfunkle song”

25 years of age

https://www.youtube.com/watch?v=PKY-smJ6aBQ


HOW ABOUT YOU?


WHAT ARE THE ADVANTAGES AND DISADVANTAGES OF YOUR OWN ATTACHMENT STYLE?

The role of the therapist is to provide a secure basis for person To establish and experience a securely attached relationship

To provide a secure base to venture from to undertake behavioural challenges etc (motivating, nurturing etc)

To provide a person to return to following exploration to discuss/

synthesise and prevent distortion (reflective space) •  Secure therapist works well with all clients as provide a secure base •  Avoidant therapist works well with secure, avoidant but less well with anxious •  Anxious therapist works well with secure clients but struggles with anxious clients and wont

retain avoidant clients


HOW DO WE RELATE ATTACHMENTS AND SCHEMAS?

Over time children learn to predict and respond to the behaviours of attachment figures and modify their own response

These are internal working models (eg parentified child) Jeffrey Young has proposed these become early maladaptive schemas Early maladaptive schemas are broad, pervasive themes or patterns Comprised of memories, emotions, thoughts (cognitions) and bodily sensations Regarding ourselves and our relationship with others. Throughout life we may reinforce and elaborate these themes


EARLY MALADAPTIVE SCHEMAS

EMS

Form core of our

sense of self

Rigid beliefs and

feelings

Triggered by events

Drive behaviour

Vary throughout life and in intensity

Rigid beliefs and

feelings

Outside our awareness

Resistant to change

Self perpetuating

Impact how we see situations and

events


ORIGINS OF SCHEMAS

It is argued that four main types of events in childhood develop early maladaptive schemas (check out the similarities with attachment theory) 1. Toxic Frustration

–  Refers to an absence of healthy, loving and nurturing experiences

2. Traumatization and victimization

•  Consists of specific traumatic or abusive experiences

3. Too much of a good thing •  Where parents/ superiors/ guardians do not set realistic limits are

overprotective or over involved

4. Selective internalization or identification with significant others •  Internalization of aspects of parents or other important adults thinking

or behaviour


DOMAINS AND SCHEMAS

Domain Schema

Disconnection and rejection Abusive, traumatic childhoods, unstable family life, rejection and humiliation, feel different or lacking in some way, long periods of insecurity and inconsistent parenting

Mistrust/Abuse Abandonment/Instability Emotional Deprivation Defectiveness/Shame Social Isolation/alienation

Impaired autonomy and performance Often over protected and controlled as children or neglected and ignored, undermined and made to feel incompetent or encouraged to be dependent on another

Dependence/Incompetence Vulnerability to harm Enmeshment Failure

Impaired limits Internal sense of control under developed, difficulty respecting the rights of others, un-boundaried family, children did not have structure and rules

Entitlement Insufficient Self Control

Other directedness Experienced conditional love, family overly concerned with appearances, parents focused on own needs

Subjugation Self-Sacrifice Approval Seeking

Over-vigilance and inhibition Strict parental control to gain compliance, ever watchful, frightened of overly severe punishment for expressing feelings

Negativity/Pessimism Emotional Inhibition Unrelenting Standards Hypercriticalness Punitiveness


HOW WE COPE WITH SCHEMAS (COPING STYLES) We all respond differently to experiences That is why in a family experiencing violence, one child might become aggressive, another may become passive which puts them at higher risk of being a victim again while the other become rebellious and defiant This is partly because we have different temperaments at birth and partly because of the social context that each child finds themselves in These coping styles are normal and helpful in assisting the child to cope with complex contexts and problems. We also continue with these coping styles into adult life when thy are no longer helpful and may begin to impact on our self concept, relationships and how we cope with what the world sends our way


SCHEMA COPING

Schema modes describe the schemas that are triggered at any one point in time In essence a schema is considered a trait A schema mode represents a state


SCHEMA MODES

The schema or schemas currently activated or shown in our behaviour Often easier to work with in sessions than individual schemas Four main mode types •  Child Mode •  Dysfunctional Coping Mode •  Parent Mode •  Healthy Adult Mode


CHILD MODES

Associated with intense negative emotions such as rage, sadness and abandonment Resemble the concept of the ‘inner child’ Might include

Vulnerable child Angry child Impulsive child Lonely child


DYSFUNCTIONAL COPING MODES

Avoidance Modes Detached Protector (deaden inside) Detached self soother (eg drugs and alcohol, food, sex) Angry protector (wall of anger to push others away)

Surrender Modes

Compliant mode (gives in) Overcompensation modes

Self eggrandizer Bully/Attacker Manipulator Predator Over controller


DYSFUNCTIONAL PARENT MODE

A highly emotional mode Considered internalisations of dysfunctional parental responses to the child In dysfunctional parent modes, people keep putting pressure on themselves or hating themselves Might include

Punitive critical parent Demanding parent


HEALTHY ADULT MODE

Mode of the healthy adult and happy child In this mode, people can view their life and themselves in a realistic way They are able to fulfil their age appropriate obligations and care for their wellbeing and needs

The happy child in this mode is able to experience fun, joy, and play (we can let go and be happy but also be an adult)

SLIDE HEADING


Unlike you guys last year, most people don’t want to sit down and fill in a questionnaire And some people who fill in the questionnaire don’t feel confident or comfortable being honest in it So how do we find out what’s going on for the person in front of you? We have three typical approaches

Co-development of schema profile Thinking about it on our own when the YP is not around Supervision and reflection from sessions

So how do we know what someone’s schemas are?

SLIDE HEADING


First, use your own experience of the young person How do they make you feel Do you get frustrated, hopeless, angry, sad etc Do you feel yourself trying to do things for them Do you find yourself encouraging them to try things Or do you find yourself trying to stop them doing things that are unhelpful

Irving Yalom Use your own feelings as precious and valuable information. If a client bores you for example, then they may likely bore others as well. Use that. Say to the client, “I notice I have been feeling disconnected from you, somewhat distanced…is your feeling similar?…let’s try and understand what is happening.”

Identifying schemas in supervision

SLIDE HEADING


Pull out the schema tables by Young Simply circle the ones that jump out for a specific client

Identifying schemas yourself

EMS Surrender Avoidance Overcompensation

Abandonment / Instability

Chooses partners who cannot make a commitment/unfaithful and remain in relationship

Avoids intimate relationships. May drink, overeat etc. when alone to avoid schema

Clings to and smothers partner, jealous of time with partner and may push partner away

Abuse/ mistrust

Selects abusive partners and stays in abusive relationships

Avoids trusting anyone or becoming vulnerable in any way

Uses and abuses others (“get them before they get me”)

Emotional Deprivation

Selects emotionally depriving partners and does not ask for needs to be met

Avoids intimate relationships altogether

Emotionally demanding with partners and friends

Defectiveness shame

Selects critical and rejecting friends and partner. Puts self down

Avoids expressing true thoughts and feelings and letting others close

Criticises and rejects others while seeming to be perfect

Social Isolation

At social gatherings focuses exclusively on differences from others rather than similarities

Avoids social situations and groups

Becomes a chamelion to fit into groups

Dependence/ Incompetence

Asks significant others to make decisions “”what do YOU think I should do?”

Avoids taking on new challenges such as travel, studies

Becomes so independent they cant rely on asking for help

Vulnerability to harm

Obsessively reads about catastrophes and follows bad news, worries they will happen to them

Avoids going places that do not seem totally safe

Acts recklessly without regard to danger

EMS Surrender Avoidance Overcompensation

Enmeshment

Tells parent everything, even as adult, always lives with partner

Avoids intimacy, stays independent

Tries to become opposite of significant other

Failure Does tasks in a half hearted or haphazard manner

Avoids work challenges completely or procrastinates

Becomes an overachiever by ceaselessly driving self

Entitlement

Bullies others into getting own way

Avoids situations where they are average or not superior

Attends excessively to the needs of others

Insufficient self control

Gives up easily on routine tasks

Avoids employment or accepting responsibilities

Becomes overly self controlled or self disciplines

Subjugation

Lets others control situations and make choices

Avoids situations that might involve giving or taking

Gives as little as possible to others

Self sacrifice

Gives a lot to others and asks for nothing in return

Avoids situations involving giving or taking

Gives as little as possible to others

Emotional Inhibition

Maintains a calm and unemotional demeanour

Avoids situations in which people discuss or express feelings

Awkwardly tries to be the life of the party, even if it feels forced

Unrelenting Standards

Spends large amounts of time trying to be perfect

Avoids or procrastinates in situations and tasks in which performance will be judged

Does not care about standards, can be careless

SLIDE HEADING


Lynchpin hypothesis approach

Co-development of a schema profile

SLIDE HEADING


Lynchpin hypothesis approach

Co-development of a schema profile

An empty vessel to be

used

Pathetic A limp body

Suicidal

Sexual object

Alone Ruined

Broken/used

Afraid

Disposable

Less than

Schemas we identified •  Mistrust/Abuse •  Defectiveness •  Vulnerability to harm

SLIDE HEADING


Now we have identified the attachment concerns, early maladaptive schemas, coping styles and perhaps some schema modes we need to begin therapy Phases Establishment of rapport, trust and working alliance Agreeing on the need for integration of schema modes/ a change

(and moving away from some) Learning to safely activate schemas Engaging in activities specifically targeting

Child mode (experiential work) Dysfunctional coping styles (CBT and exposure style work) Dysfunctional parent mode (limited reparenting)/ safe attachment Nurturance of the healthy adult mode (celebration of joy, sharing of sadness etc)

Approaching schema work

SLIDE HEADING


Like a controlled explosion This should ONLY be done by a skilled schema therapist

ACTIVATING THE SCHEMAS

https://www.youtube.com/watch?v=dx0IMHco81I

SLIDE HEADING


That’s (most of) the theory done, next I put it all into practice by sharing with you one of my own formulation based therapies with a young client with a severe mood disorder Lets have a cup of teaJ

After the break


OUR MIX TAPE UNDERSTANDING THE EXPERIENCE OF SCHEMAS, ATTACHMENT AND PAIN – PART 2 DR KAREN T. HALLAM SENIOR RESEARCH FELLOW RESEARCH MANAGER, YSAS HONORARY FELLOW THE UNIVERSITY OF MELBOURNE HONORARY FELLOW VICTORIA UNIVERSITY


EXISTENTIALISM IN THERAPEUTIC CONTEXTS

My therapeutic orientation is largely existential/humanistic This approach posits the question how shall I live?” This is constructed day to day by our beliefs and actions

–  Self construct (who and what we are) –  World construct (how we see world)

This self and world construct allows us to put meaning into our lives that may otherwise be unanchored

Psychoanalytic /Psychodynamic

Humanistic Existential

Cognitive therapies


FOUR PILLARS OF EXISTENTIAL PSYCHOTHERAPY Mortality Greatest fear may not be death but extinction and the extinguishing of our identity and place

Isolation/Connection On a fundamental level we mostly need to belong. With connections we ‘live on’ and are memorialised or remembered even if we die Meaning Making sense, coherence or order out of our existence and having a purpose or goal to strive for Erikson (1963) would say that meaning in adolescence is developed through a focus on

–  Forming intimate relationships

–  Establishing a stable sense of self (identity) –  Being creative and productive

Freedom When we separate from others our personal control increases but at the cost of connection. We may give up freedom by partnering or finding a group. Captivity is a genuine fear for many


EXISTENTIAL PSYCHOTHERAPY

The purpose is to help clients become aware of their existence to the degree that they are aware of their full potential and choose how they act The core of this approach puts the relationship between the therapist and client as central,

–  fellow travellers –  exploring relationship, society, self concept etc –  non judgemental

Central belief “It is the relationship that heals”


THE EXISTENTIAL VACUUM

If meaning is what we desire, then meaninglessness is a hole, an emptiness, in our lives Whenever you have a vacuum, things rush in to fill it We attempt to fill our existential vacuums with “stuff” eg eating beyond all necessity, sex for the sake of the high or feeling alone, power, busy-ness, conformity, conventionality Or alternatively, we fill the vacuum with anger and hatred and spend our days attempting to destroy what we think has hurt/is hurting us.


FIRSTS…

Client Client who made me cry Client who scared or hurt me Client who suicided Client who recovered, survived and thrived Client who I let really matter to me, pushed me, tested me and really needed me. In turn, the client who turned me into the therapist I am today


ATTACHMENT WORK APPROACH Recognise her ambivalence Leverage off my own experience of this style Recognise past history with ‘all the rest’ and that I cannot be another ‘all the rest’ Follow her lead Recognise based on attachment, schemas and interpersonal style that her attempting boundary pushing, transgressions is unlikely Don’t push Be honest as hell, be a fellow traveller


BEING PRESENT… THE HERE AND NOW

The importance of using the here and now is based upon assumptions of the importance of interpersonal relationships and the idea of therapy as a social microcosm. Our interpersonal environment influences us and our self image is formulated to a large degree based upon what we perceive important figures in our lives appraise us to be. The interpersonal problems of the person will manifest themselves in the here-and-now of the therapy relationship. The use of the here and now is my most important therapeutic skill and tool


ESTABLISHMENT


WE ALSO TALKED ABOUT ME Based on my formulation and chosen approach I knew that connection and a caring and steady attachment figure was what she needed. We could build skills on that. I took a fellow traveller approach She asked me if I had an ambivalent attachment style too

I answered She asked me if I had a hard life

I answered She asked me what gave me hope in my own life

I answered, one of my answers was helping her She asked me if we might have been friends if we met in different circumstances

I said no… because she wouldn’t have let me , she didn’t really have friends. But if I had seen her as I did in sessions, we would definitely have been friends

She asked me how to let people in

We began the next phase of therapy


HOW DID I DECIDE WHAT TO DISCLOSE

I was led by my therapeutic approach (Yalom) And the formulation I give what the person needs, no more, no less Its always about what they need to hear, not what I want to say Its never about superficial connection •  Deliberate (a planned choice) •  Measured (only what is needed) •  Discussed (in supervision)

Here and now

Fellow Travellers

Personal


RE-ESTABLISHING CONNECTION Difficult to access wounded or angry child schema modes to express distress Better success with challenging and understanding schema surrender, over compensation and avoidance

Behavioural challenges (e.g hw it felt talking to me, small experiments with workmates etc) Scaffolding trust (together, workmates, brother, selected friends)

Sam had strong skills in using CBT in challenging her negative parent modes

E.g. Even if it were true, what would be the worst thing that would happen? Schema focused work (we talked, catharsis of unexpressed sadness and anger)

First around mum Then around dad

But fundamental assumption… it is the relationship that heals


THANK YOU FOR YOUR TIME AND ALLOWING ME TO SHARE SAMS STORY

If you wanted to contact me you can reach me at [email protected] Or by phone on 0409-250-147 K

our mix tape understanding the experience …...practice education advocacy research our mix tape...

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