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The Schema Therapy Bulletin

The Official Publication of the 

International Society of Schema Therapy

SECURE NEST IN VIENNA: ENHANCING THERAPEUTIC WORK USING TECHNOLOGY

SALLY SKEWES (AUSTRALIA)

From June 30 to July 2, we had the opportunity to showcase Secure Nest (SecureNest.org) for the INSPIRE 2016 biennial conference in beautiful Vienna. It was exciting to participate in a conference which embraced technology, the provision of Wi-Fi throughout the convention centre and a mobile app which kept us informed of event schedules and encouraged connection between attendees was a welcome addition. The ISST community provided a supportive environment in which to facilitate an interactive workshop and present findings of the first research study exploring user experience of Secure Nest.

Developed in Australia, Secure Nest is a new e-health tool which has been specifically designed to complement Schema Therapy. Secure Nest has the potential to enhance therapeutic work by providing a sense of ongoing contact, connection, sharing, and promoting self-expression and autonomy; valuable aspects of limited reparenting which is an essential active ingredient” of Schema Therapy. Secure Nest provides therapists with the opportunity to meet patients’ needs outside of the therapy hour using an online platform.

Secure Nest was developed in consultation with internationally renowned Schema Therapists, who we are grateful to count as our dear friends and colleagues. While the primary language is English, it was recently translated into Dutch and the platform was designed with multi-lingual capabilities with the intention to provide additional translations in the future.

Just as the conference focused on applying the many aspects of mode work in Schema Therapy, Secure Nest is an online platform based on the schema mode model. The features of Secure Nest stay true to the Schema Therapy conceptual model. For example, ‘My Modes’ provides an individualised case conceptualisation that the client can access anytime via an internet connected computer or mobile device. The ‘Identify My Modes’ and ‘Mode Diary’ features can facilitate mode awareness and reflection in the present moment by providing opportunities for easy identification of modes in the day to day lives of our clients, therefore keeping the modes fresh in the clients’ mind. ‘Managing My Modes’ provides a central location where all exercises and strategies (including audio recordings) can be accessed, for responding to each mode. ‘My Goals’ provides a visual reminder of the clients’ goals throughout the site using a small personalised icon. We appreciated the curiosity and active interest the participants showed at the workshop, in particular with regard to the features of Secure Nest.

We have also recently completed the first pilot qualitative study exploring user experience of Secure Nest. Susan Simpson and Rachel Samson contributed their expertise to the study. We were excited to present the findings in a Hot Topic Talk at the conference.

A growing body of research shows that using e-health tools can enhance outcomes for Borderline Personality Disorder. There are several benefits of e-health tools, including:

  • • Facilitating the availability and equitable delivery of treatment according to patient need.
  • • Providing the potential to add significant value to Schema Therapy at a minimal cost.
  • • Offering a potential solution for reducing the number of face-to-face sessions.

Our study was the first of its kind to explore the qualitative experience of therapists and clients using an e-health tool, which has been specifically designed for Schema Therapy. A therapist focus group and individual client interviews were conducted to explore the potential utility of Secure Nest as an adjunct to Schema Therapy within an outpatient psychology clinic setting. Our sample was mixed, with a predominant diagnosis of BPD and high levels of co-morbidity. Clients started using Secure Nest at varied points in Schema Therapy. All clients used Secure Nest for 12 weeks, alongside a 1hr weekly face-to-face Schema Therapy session. We used thematic analysis to analyse the data and identify themes, which were agreed upon by all authors.

To provide a sneak peek into the themes, the qualitative findings show that Secure Nest complements Schema Therapy by:

  • • Providing a sense of ongoing contact, connection and sharing.

Oh, it's nice, like connected, warm … that she thinks of me between sessions, to keep that connection going, so when I go away out the door it's not just a polite see you later, she's not like that anyway… but it just gave me more sense that she's gone into the site and logged in and just thought of me to do something and it's very personal stuff in there, so yeah, I felt connected and thought of.”

  • • Meeting patients’ needs outside of the therapy hour.

I can read her Healthy Adult responses and think oh, okay, that's a good way of looking at it … I'm not as distressed for as long because it's before I see her for the next therapy session, It's definitely…a great thing, yeah definitely.”

  • • Facilitating mode awareness and reflection in the present moment.

If anything it's good, it's a positive because they can really, I mean if you're in, say, having a fight with someone or whatever and then you fill out the mode diary, you know it's very raw and it's exactly how you're feeling so … it can be very much in the moment if you fill out the mode diary then and there, so you can really get exactly how you're feeling.”

  • • Providing ease of access and organization.

The fact that it's just there, definitely, it's a huge help. Whereas if I had a piece of paper, a pen and filled out the schema diary I'm just not as motivated, I mean, my phone is there and I use my phone so yeah without a doubt if you go to an appointment or do anything you've just got it there with you.”

Client concerns were raised with regards to:

  • • Disclosing sensitive information.

I think pouring out your heart sort of on the internet and then when you save it it's like it's there isn't it, you can't just rip it up.”

  • • Early maladaptive schemas triggered by response time.

I guess it can also be a trigger for [me as] a client, only because if the therapist doesn't respond, you [wonder] why they aren't responding...”

The main themes identified from the therapist focus group include that Secure Nest provides a sense of working collaboratively, at inter and intra session level – like a ‘joint project.’ Therapists reported increased inter-session connection and object permanence, as Secure Nest functions as a transitional object. Therapists observed the disinhibition effect – Secure Nest provides graded exposure to being vulnerable. Secure Nest is helpful for keeping track of large quantities of information, and the conceptualisation is readily available. Therapists reported that using Secure Nest requires familiarity with technology.

The findings indicate that Secure Nest adds value to therapeutic work by enhancing limited reparenting aspects of therapy in real-time, even between sessions. Secure Nest is a tool which has the potential to support therapists in providing high intensity treatment.

Future studies are needed to verify findings. We are currently planning a Randomised Control Trial comparing blended Schema Therapy (e-health) with Group Schema Therapy.  We hope to offer workshops in Australia based on the protocols developed for the study.

We have recently improved Secure Nest with the addition of new features following feedback from therapists and clients who have been using Secure Nest, including those who attended the conference. The updates include:

  • • ‘My Journal’ – A new space for clients to keep an online journal.
  • • ‘Copy Content’ – A button which makes it easy to copy text from the case conceptualisation.
  • • ‘Mode Diary’ – Now includes the opportunity for therapists to add feedback to entries and a way to pin past entries at the top of the list.
  • • Expanded compatible audio file types (which can be uploaded into ‘My Files’), improved progress charts in ‘Ratings’ and additional context provided for platform activities which show in ‘Notes.

We invite anyone who wasn’t already familiar with Secure Nest to visit the site, SecureNest.org, where you have the option of signing up for a free trial.

Why Schema Therapy?

Schema therapy has been extensively researched to effectively treat a wide variety of typically treatment resistant conditions, including Borderline Personality Disorder and Narcissistic Personality Disorder. Read our summary of the latest research comparing the dramatic results of schema therapy compared to other standard models of psychotherapy.

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