The Official Publication of the
International Society of Schema Therapy
In This Issue
A Hierarchy of Confrontational Interventions Facing 8 Dysfunctional Parent Modes by Ofer Peled (Israel)
Schema Therapy with Children and Adolescents an Extract of Mode Work by Christof Loose (Germany)
Experiential Strategies in Group Schema Therapy by Dr. Rita Younan (Australia)
Memory Reconsolidation: Can we Unlearn Emotional Learning? by Dr. Bruce A. Stevens (Australia) & Dr. Pierre Cousineau (Canada)
Imagery Rescripting, Practical ways to Improve Skills by Chris Hayes (Australia)
Experiential Strategies in Group Schema Therapy
Dr. Rita Younan
ISST Advanced Certified Schema Therapy Trainer – Supervisor
The Victoria Clinic, Melbourne Australia
When I was asked to write this paper on “how to do experiential strategies in group” it got me thinking – what is different about implementing Schema Therapy experiential interventions in a group versus individual? This is something I do day to day, (for the last four years in fact) as part of my role as the Program Director of a Group Schema Therapy Program at a private psychiatric hospital in Melbourne, Australia (The Victoria Clinic). Although GST is theoretically consistent with individual ST and most individual interventions can be adapted to use in groups, a group does offer some additional creative opportunities. GST strategically uses the therapeutic factors of the group modality as described by Yalom. We also know from the Farrell, Shaw & Webber (2009) rct and the published pilot done in the Netherlands (Dickhaut & Arntz, 2014) that a group seems to catalyse the therapeutic effects of ST for patients with BPD. For this article, I discussed the issue with Joan Farrell and Ida Shaw, the developers of Group Schema Therapy for Borderline Personality Disorder and the creative minds behind the imaginative ways in delivering emotion focused techniques within the group setting.
The advantage of doing emotion focused work within a group setting is that affect can be amplified by the presence of more people in the therapy space. Similarly to individual ST, emotional material can be explored and used as a learning tool for the root experiences associated with a patient’s schema modes with the advantage of the opportunity for group members to learn from each other and from others experiences. Trauma processing work, like imagery re-scripting, can be conducted in groups as well and group members can add a different kind of support than therapists. Sometimes just observing other group members doing emotion-focused techniques triggers emotional responses that reach the Vulnerable Child mode of observing members. Vicarious learning is a group opportunity for patients with avoidant features. In order to keep this brief I have focused on a few techniques that give a snapshot of Experiential Strategies in GST. For a more detailed read please refer to Group Schema Therapy for Borderline Personality Disorder, Farrell, J.M. & Shaw, I.A. (2012) and Farrell, J.M., Reiss, N., & Shaw, I.A. The Schema Therapy Clinicians Guide: A complete Resource for Building and Delivering Individual, Group and Integrated Schema Mode Treatment Programs.
Below are a few interventions that one could use within a group format as per Group Schema Therapy (GST) with Borderline Personality Disorder (BPD) protocol by Farrell & Shaw (1994).
The Art of Story Telling
Imagery work is a powerful experiential intervention used in Schema Therapy for healing the Vulnerable Child Mode. In GST imagery change work or rescripting can be delivered in two main ways: individual rescripting with group involvement and group as a whole rescripting. Needless to say it is crucial to establish safety before doing any imagery work with patients who present with a history of trauma and neglect. For patients with BPD connecting with their Vulnerable Child Mode is usually met with negative and rejecting feelings. Therapeutic stories of little children in situations where they have needs are often used to assist patients in having compassion for a child’s emotional needs. This slowly paves the way for patients to consider how helpless children can be and how dependent they are on a good parent to have core needs met including feeling safe, secure and predictable. Through the story patients are encouraged to think about what messages the child in the story would have taken from the experience about her self-worth and the normality of needs being met by the adults in her world. Patients are then encouraged to think about their Vulnerable Child and their needs in the same way to transfer compassion for stranger children to themselves. Here’s an example:
Alla & The Thunderstorm
“A little child four years of age, woke from the crackling and banging sounds and loud rumblings of a thunderclap that was so loud she felt like it was shaking her bed. The noises were followed by bright flashes of lightening that left behind scary images on her walls. At the very next thunderclap she flew from her bed and ran to her parent’s room feeling so frightened that all she could do was shake and cry. Her crying turned into a scream at the next sound of thunder. Her parent woke and started to yell at her, stop crying they said: “It’s just a thunderstorm, stop being such a big baby. Go back to bed before you wake the entire household.” She went back to her room but couldn’t stop crying. She bit down on her blanket so no sound would escape. She tried covering her ears so she wouldn’t jump at the thunder, and she closed her eyes to stop seeing the scary arm that were reaching out to grab her from the walls. She bit down harder and kept her eyes closed, blocked her ears and kept repeating this over and over. After a while she didn’t jump anymore, even though the thunder was louder, nor did she shake and duck when the creepy arms tried to get her. She just sat there staring off into space.”
This story provides an example of the kind of situations in childhood where needs were not met and schemas and modes develop. It does not need to be a situation of abuse, rather a time when a child was left on his or her own to deal with intense feelings before he/she had the resources to do so. In such situations a version of fight, flight or freeze will occur. One of the most common child responses in the thunderstorm story is Detached Protector. Another possible response would be Angry Child. The use of stories however, really encourages a discussion around children and needs in a safe way for participants, and encourages self-disclosure.
The importance of the happy-joyful child
The importance of spontaneity and play in child development has been well documented as well as the importance of evoking and strengthening the Happy or Contented Child Mode (summarized in Lockwood & Shaw, 2012). Play and creativity facilitate healthy emotional development and provide the earliest learning about social interactions. In the case of patients with BPD spontaneity and play were invariably not met, and not present in their family environments. Through play when adult schema’s like Emotional Inhibition can be targeted as well as Mistrust/Abuse and Social isolation/alienation. Imagery involving play can be a safe way to initially engage patients who have a strong Mistrust/Abuse schema and/or are unable to connect with their Vulnerable Child Mode.
In GST Happy Child imagery is often used to evoke, joyful feelings and as a balance to the difficult and painful work of healing the VCM. An imagery exercise that we use in group is “the visit to the toy shop” (Shaw, 2010). In this image patients are encouraged to get an image of their little selves, with the other group members standing at a bus station waiting for a bus to arrive to take them to a surprise outing. The five senses are used as in traditional imagery to fully engage them in the experience. Patients are instructed to notice what it feels like travelling in the bus, the view from the window, the songs they sing together whilst they eagerly await arrival to designated destination point. Once they arrive they are told that they can see out the window where we have come to; a toy store so big that there are sooo many different toys in there that they are going to be given time to search through the entire building. They are also told that the group facilitator has won the lotto and they can buy ANYTHING they want from the toy store. The participants are talked through the different aisles they encounter and can access. Reference is made to their group peers and how they look, act and behave in the toy store. The image is brought to life as much as possible. When the imagery exercise is complete, patients open their eyes and are asked to describe their experience and what toys they selected. As a facilitator whether you are the observing therapist or the one telling the story, it is a delight to see the patients faces light up as they are truly involved and lost in the image, some laugh out aloud, others are smiling, others have a concentrated look as they are trying to locate that “right toy”.
The use of Happy Child Imagery is also a good way to deal with a group that is stuck or in need of a shift in affect. This must be done with a significant amount of enthusiasm, and some therapists who have their own Emotional Inhibition Schema may struggle with this exercise. Ida Shaw has a contagious and exuberant way of delivering this imagery; in her training one can really get lost too in the joy of the exercise.
Healthy Adult Representation – Group Based Transitional Object
An unstable identitfile:///Users/chrishayes/Downloads/treey is a core symptom of patients who present with BPD. Individuation and identity formation is the latter phase of the GST process. The close analogue to the adolescent “peer group” these patients missed and, provides a healing role in this unfinished stage of identity formation. An example of a creative experiential group exercise that targets the Defectiveness/Shame schema found in many BPD patients and to strengthen the Healthy Adult file:///Users/chrishayes/Downloads/treeMode is the group multi-bead bracelet.
In a group session, therapists provide patients with a selection of inexpensive beads and group members and therapists select a bead for each member that represents a personal characteristic of him or her that they like or value. The “identity bracelet” for each person is built by group members taking turns to presenting a bead and making a statement about what it represents. This process continues until all patients have a completed bracelet. A visualisation exercise follows in which patients are instructed to connect with the positive feelings of receiving the bracelet in imagery while wearing the bracelet and putting their hand over it. In this way the bracelet can be a physical anchor upon which to build a more stable positive identity supported by their positive peer group. Beads can be added over the life of the group to represent important experiences like a moment of belonging in their VCMs.
This activity is likened to the behaviour seen in adolescents who often trade pieces of jewellery or clothes with best friends as part of bonding and identification process that underlines identity formation. This emotional learning experience was usually one missed for patients with BPD who grow up in invalidating or abusive childhood environments without a sense of belonging to a healthy peer group or any group at all.
“The Group Army”- Fighting the Punitive/Demanding Critic Mode
Imagery work in which the group and therapists become a “protective army” can be developed to support a patient in banishing their Punitive Parent. One powerful exercise is building a parent or critic figure out of cloth that patients can draw in whatever way they want and then write their critic messages on. This figure can be placed in a chair to concretely represent their Critic Mode, lending reality to mode dialogues and evoking strong emotions, including fear, anger and rejection. The parent “effigy” can be locked away by the therapists to underline its powerlessness to do harm in the present day. Joan Farrell has a favourite demonstration of the power of the Punitive Parent being an illusion. She holds the effigy up and compares it to the well-known movie character the Wizard of Oz. She suggests that like the Wizard, the Punitive Parent is an illusion, a screen that hides a powerless character. She holds the figure up to full height and then lets it drop into a pile on the ground stating, “like the Wizard, the Punitive Parent is all smoke and mirrors”. After completing this exercise, just like experiential work in individual schema therapy, patients always comment on the power of the exercise, despite their preconceived ideas, and invariably turn to their fellow group members and offer their appreciation of them joining the fight against their Punitive Critic Mode.
Imagery Rescripting - The power of the Group
Healing the Vulnerable Child in Imagery can be done in a number of ways in GST: a) historical rescripting (e.g. trauma) b) using the cue for the group as a whole of a time when they needed a good parent c) Getting an Image of their VC and hearing Good Parent messages spoken by the Therapist d) through story telling as previously described or e) through the use of an Affect Bridge
Joan and Ida recommend that therapists set the stage for trauma rescripting in group by giving a demonstration in which the group with the second therapist rescript a medium level of difficulty memory of the other therapist. The approach is that the therapist tells about a memory as a child of an experience in which a good parent is needed and no one is there. After this the group discusses what the therapist as a child needed, what his/her feelings were and how the needs could be met. The rescript developed by the group members is checked out with the therapist presenting the memory and additions or subtractions are made. The other therapist then instructs the group with him/her to close their eyes connect with their VCM and listen to what is said as a good parent to the therapist with the memory. They are told to try to take in the positive reparenting messages and listen to the therapist’s tone. At the end the group discusses how this went and the effects. The therapist sharing the memory describes the new message she can take away from the rescripted experience. The group s then asked who among them has a similar level of difficulty memory they would like the group to rescript. Over time the group can also be involved in the implementation of the rescripted memory. They may join a lonely child on the school playground or help rescue a child from abusers. This use of selective self-disclosure from the therapist strongly facilitates patients being willing to rescript their memories. It shows them that IMRS is not as scary as they thought and that they do not need to re-experience trauma, rather stop before the trauma actually happened and experience a rescue or what should have happened. The therapist rescript also provides the corrective emotional experience of being treated as if they have worth and value, i.e. they can contribute something to the therapist.
I’d like to thank Joan and Ida for their training, supervision and help in program development in GST and their input for this tiny window into the wonders of delivering Experiential Strategies in a Group Setting.
Arntz, A. (2012). Group schema therapy for borderline personality disorder: A step-by-step treatment manual with patient workbook. J. M. Farrell, & I. A. Shaw (Eds.). John Wiley & Sons
Arntz, A. & Gendern Van, H. (2013). Schema Therapy for Borderline Personality Disorder. Wiley – Blackwell.
J. M. Farrell, & I. A. Shaw (2012). Group schema therapy for borderline personality disorder: A step-by-step treatment manual with patient workbook. John Wiley & Sons
Farrell, J. M., Reiss, N., & Shaw, I. A. (2014). The Schema Therapy Clinician's Guide: A Complete Resource for Building and Delivering Individual, Group and Integrated Schema Mode Treatment Programs. John Wiley & Sons
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