Month: March 2020

Schema Therapy for Complex Posttraumatic Stress Disorder

By Jeff Dwarshuis LMSW ACSW

What Is Schema Therapy?

Schema Therapy is a branch of Cognitive Therapy that was developed by Jeffrey Young PhD and includes several different psychotherapeutic interventions including Behavioral, Gestalt, Psychoanalytic and Relational Therapies. Schema Therapy argues that if individuals are abused or neglected as children, they may develop “maladaptive schemas”. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder.  Maladaptive schemas (Known simply as schemas) can be defined as self-defeating emotional and cognitive patterns that begins in early childhood and continue throughout life. The goal of Schema Therapy is to eliminate the schema(s) by recognizing and challenging it and replacing it with more effective behaviors.

Schema Recognition

The first step in Schema Therapy is schema recognition or evaluating if an individual has any schemas. This can be done in several ways. First, individuals can read “Reinventing Your Life” by Jeffrey Young PhD and complete a brief set of questions on each schema listed throughout the book. This will illustrate both the existence and intensity of the schema. Second, in a therapeutic setting, an individual can complete a questionnaire which will identify the presence of certain schemas as well as their intensity.  After a schema is recognized, the person can read schema descriptions, provided in the book or by the therapist. These descriptions can bring clarity and definition to emotional and relational hardship.

Testing Schema Validity

After an individual knows about their schemas and understands the description of the schema, they can begin to challenge the schema by testing its validity. Schemas, in general, are inaccurate negative representations of the person and can reasonably be disproven through evidence. However, people often will identify with their schemas and see a schema as a representation of who they are. Therefore, creating a list supporting how the individual sees themselves relating to the negative qualities of the schema can easily be done while creating a list of evidence about how the person is different from the schema can be difficult.

Testing the validity of the schema can be done by first listing all evidence from the past and present to support the reality of the schema. There should be a general consideration of these questions. How does this description of the schema apply to me? How do I act it out? How might others see me as acting out this schema? Following this, the person should make a list of all the evidence that refutes the schema. The person can do this by evaluating their realistic accomplishments, intentions and capacity shown throughout their life that are different from the schema.    

Schema Reframing

After testing the schema’s validity, the individual should challenge the reality of the schema by reframing it. This can be done by taking each piece of evidence that supports the schema and attributing it to another more rational cause. For example, instead of thinking “I am unlovable” the person might instead say “I was not given enough attention and was taught to think I was unlovable” or instead of thinking “I am a failure” the person might list or say “I was not given enough opportunity to recognize my potential.” Typically, these causes have to do with the person’s childhood family, especially the parents who had control over the person’s life and events that may have contributed to the schema development. It is important to not personalize the schema but to rationally consider the influences of its development.

Identifying the Advantages and Disadvantages of the Coping Behaviors

Schemas are themselves emotional and cognitive patterns and each person has a set of behaviors that are used to deal with, display, represent or ignore the schema(s). These behaviors are called “coping responses”. Coping responses generally fall into the behavioral categories of avoiding, surrendering or overcompensating for the schema. One can think about and then list these coping responses then evaluate both the pros and cons of what the coping responses do or don’t do. It is important to recognize that these behaviors may have been adaptive as a child but are no longer beneficial or appropriate as an adult. Then, after listing the coping responses, one can list and use an alternative healthy behavior.

Schema Problem Solving

With the initial exercises completed one is a better position to coordinate and use the learning on a day to day basis. The goal is to use some of the understandings and growing awareness from the previous exercises an apply them together to daily relational and emotional challenges perpetuated by the schema(s).

Completing the framework sentence below will allow for spontaneous change and the elimination of schemas. The goal is to get to the point of being able to do the exercise automatically in real life settings.  

I feel (emotion) because of (causal event). This event has triggered my (schema) and has caused me to want to do (coping behavior). Although my schema causes me to believe that I am (negative self-belief) I am (rational positive self-belief) as evidenced by (supporting evidence). Although I would like to do (negative behavior) instead I will do (positive behavior).

Resources

Schema Therapy – A Practitioner’s Guide by Jeffrey Young PhD, Janet Klosko PhD and Marjorie Weishaar PhD (2003)

Reinventing Your Life by Jeffrey Young PhD and Janet Klosko PhD (1993)

Schema Therapy by Eshkol Rafaeli, David Bernstein and Jeffrey Young (2011)

Negative Thinking Patterns: A Schema Therapy Self – Help and Support Book by Gitta Jacob, Hannie Van Genderen and Laura Seebauer

Cognitive Therapy – Basic and Beyond by Judith Beck (1995)

Cognitive Therapy for Challenging Problems by Judith Beck (2005)

Cognitive Therapy for Personality Disorders – A Schema Focused Approach by Jeffry Young (1999)

Cognitive Therapy of Personality Disorders by Aaron Beck, Arthur Freeman and Denise Davis (2004)

 

Polyvagal Problem Solving for Complex Posttraumatic Stress Disorder

By Jeff Dwarshuis LMSW ACSW 

Polyvagal Theory and Psychotherapy 

Polyvagal Theory was developed by Dr Stephen Porges PhD in the 1994 as a method of understanding the relationship between individual heart rate variability and the Autonomic Nervous System. In recent years the field of psychotherapy has had great interest in Polyvagal Theory as Polyvagal Theory has been able to provide plausible neurophysiological explanations for several of the experiences described by individuals who have experienced trauma. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder. This interest has led to numerous psychotherapeutic interventions assisting people with self-regulation, relational management and an articulation of the subjective experiences of danger and safety.

One of Polyvagal Theory’s applications to therapy is the evaluation and problem solving of both the safety and danger in life events.  This is done by listing both the safety and danger in specific settings while considering three things. These are the quality of social connectedness, the details of the social context and the related individual body reactions the situation creates. Polyvagal Theory assumes, of course, that there are both dangerous and safe situations, but that people will have emotional, physical, cognitive and relational hardship if their perception of those safe or dangerous situations is inaccurate.

The Perception of Safety and Danger 

It is important that people approach relationships and daily tasks with an accurate assessment of both the safety and the danger involved in those settings. In some cases, people who have a history of abuse, neglect or trauma will misread situations and inaccurately see a situation either as more dangerous than it is or safer than it is. Exaggerating danger might be shown by being easily offended, having difficulty accepting criticism or having irrational fears like phobias, generalized anxiety or panic. Also, people might misread situations as being safer than what they are. This happens when people stay in abusive relationships, voluntarily frequent threatening environments or allow verbal, physical or emotional boundary violations.

The Polyvagal Exercise for Safety and Danger Recognition 

The Recognition of Danger  

The first step in this Polyvagal exercise is to recognize danger. To do this, imagine or recall an event in the past, present or future that causes some level of negative emotional reactivity such as anxiety, terror, anger, confusion or sadness. With this event or future picture, address the three topics below and list your responses by first evaluating the sense of danger or threat the memory or event causes. Use the stated questions as a guide.

1. Polyvagal Body Language – Polyvagal Theory highlights the importance of the evaluation of other peoples’ body language and what it says about their level of social connectedness to both you and others. First, see the picture or memory and begin to evaluate the people in the picture and ask these questions. Is the person(s) looking at you and visually engaged? Do they have an angry or warm look in their eyes and around their eyes and forehead? Do they seem to be working to listen to you including the subtle changes in your voice tone and volume? Does the direction of their body and head reflect an interest in you and a desire to be engaged? Does their body, head and eyes indicate an active yet subtle reciprocity to your level of engagement with them? Does the movement of their mouth or the tone of their voice indicate a predictable, safe and appropriate response to your behavior? List your answers.

1. Context – Second, again imagine or recall the picture and think about the context of the situation considering time, location, patterns and repeated behaviors. Reflect on these questions. Does this situation happen often or is it a rare or one-time occurrence? Does this situation fit a pattern of behavior by the individual(s) that makes you think they might repeat dangerous or threatening behavior to you? Look at the other people in the picture. Are they reacting with fear or with comfort? Are the other people in the picture supportive of you or are they supportive or aligned with the possibly dangerous person(s)? Does this individual remind you of someone in your past who was abusive, threatening or dangerous? List your answers.

1. Body Sensations – Third, while seeing the picture or memory and then evaluating all your answers, address these questions. What do I feel in my body? Where do I feel reactivity to this picture in my body? Evaluate its location and intensity then try to name what emotion is causing the body reaction. Then ask these questions. Is this a positive or negative emotion? Do I feel safe or in danger? List your answers.

The Recognition of Safety 

The second part of this Polyvagal exercise is to recognize safety. Polyvagal Theory is the study of the physical experience of safety and danger. Included in this experience is the concept of Ventral Vagal State. Ventral Vagal State is a physical, emotional and cognitive experience facilitated by a set of nerves in the upper part of the body connecting the brain to the heart, neck, face, mouth, eyes and ears. The Ventral Vagal State is responsible for detecting, accepting, evaluating and reciprocating states of social safety. Also, it regulates the other defensive states known as fight, flight or freeze which are activated in situations that are dangerous or perceived to be dangerous. Being in a safe situation and then actively looking for and seeing safety will activate the Ventral Vagal State. The activation of the Ventral Vagal State will then facilitate self-regulation and eliminate unnecessary defensive thoughts, feelings and behaviors.

Return to the imagined picture or memory and reread all the questions in the topics of Polyvagal body language, context and body sensations. This time, instead of listing cues of danger, list cues of safety.

Polyvagal Problem Solving

Evaluating all the information you have listed about danger and safety recognition, ask yourself this question. Do I see this memory or event as being safer or more dangerous than it is? If you see it as more dangerous than it is, begin to evaluate and list what you can do to notice more safety and then decrease your perception of danger. Ask yourself the following questions. Can I connect with others in the picture who seem safe? Can I question the validity of seeing something as dangerous when it is safe? Can I test myself to not react to my perception of danger and observe how the event plays itself out? Also, actively think about and notice the cues of safety you listed and notice their validity. Use relaxation methods to calm your body reactions. Diminishing the perception of danger and nurturing the reality of safety will increase your Ventral Vagal State and facilitate the feelings of trust needed for connection. It also will diminish fight, flight or freeze behaviors that create conflict, confusion, self-questioning and disconnection.

If you see the situation as safer than it is and didn’t initially see the danger, it will be necessary to problem solve how to make the situation less dangerous. Use your list of noticed dangers as a starting point. Simply listing possible or existing dangers can assist in noticing the actual danger in the situation. Also, this list of danger might allow you to make sense of why your body was detecting danger while your thoughts were disconnected from the danger. Consider decreasing the danger by asking these questions and making changes. Do I need to leave the situation or set other physical, emotional or communicative boundaries to increase my personal safety? Can I effectively influence the threatening or dangerous individual to calm them enough, so I feel safe?

Make It Automatic

Polyvagal Problem Solving is a powerful method of self-regulation and relational management for those with Complex Posttraumatic Stress Disorder. Using this exercise frequently will assist you in fine tuning your recognition and reactions to the daily events around you and provide you with a method of physical, emotional and relational welling being and safety. The goal is to get to the point of being able to do the exercise automatically in real life settings.

Resources

The Pocket Guide to Polyvagal Theory: The Transformative Power of Feeling Safe by Stephen Porges (2017)

The Polyvagal Theory in Therapy by Deb Dana (2018)

The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment Communication and Self-Regulation by Stephen Porges PhD (2011)

Traumatic Stress: The Effects of Overwhelming Experience on The Mind, Body and Society by Bessel Vander Klok, Alexander Mc Farlane, and Lars Weisaeth (2007)