Psychiatry & Psychotherapy Podcast - Borderline Personality Disorder: Psychotherapy Schema Therapy

Episode Date: November 8, 2021

Schema therapy is a model of psychotherapy that was originally designed for chronic mental health problems. It comes from the Cognitive Behavioral Therapy (CBT) tradition, but also integrates different arms of psychotherapy, such as elements from the Gestalt tradition, and also aspects of object relations theory. In this episode, we have an in-depth discussion about schema therapy, which has proven to be effective in treating borderline personality disorder (BPD), with Australian schema therapist, Andrew Phipps. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com. Sign up, sign in, take the test, and the certification is email to you in seconds.

All right, before we start this episode, I wanted to begin with an introduction on the topic. So we will be talking about schema-focused therapy and borderline persidios order. I got interested in schema-focused therapy when I looked at studies that compared one active treatment of borderline per-sciis disorder with another active treatment. And I found three interesting studies, two studies that compared schema-focused therapy to transference-focused therapy, which I had already seen a lot of data as it's very useful for treating borderline person high disorder. And it showed better outcomes than transference focus therapy.

So I was like, wow, that is really interesting. And then a third study looked at it against dialectical behavioral therapy. This was a 2018 study, and they found that in this randomized trial of 24 students, 16 weekly sessions, each 45 minutes long, both had equivalent decreases in impulsiveness. So three studies I looked at, and in a future episode,

I'm really going to focus in on getting into the nuts and the bolts about the different psychotherapies and how they compare and these randomized trials that have been done on the therapies. But when I was going through this and I was thinking, well, why don't I just start with having someone on who is an expert on schematotherapy? So Andrew Phipps is a clinical psychologist and advanced schema therapist and trainer from Sydney, Australia. He has been practicing for 20 years and spending most of his work in the public mental health setting. He has a history of doing work in dialectical behavioral therapy, actually, but now has primarily shifted to being a schema-focused therapist. So I thought I would have him come on.

And then I also have Kristen Kim who did a lot of the digging and the research for me. She's a fourth year Lombalinda University medical student pursuing her desire to be a psychiatrist. She's doing residence of the applications. She did a wonderful job summarizing this episode, which I will put in the show notes. You can read the whole blog article, which goes through all the content that we discussed in another way of learning it. So please welcome Andrew. and Kristen to the show. All right, welcome to the podcast, Andrew Phipps and Kristen Kim.

Kristen, like I said, is a fourth-year medical student who's been working with me on digging into Borderline Persia disorder and psychotherapies, and Andrew Phipps is a PhD clinical psychologist from Australia who focuses on schema focus therapy. That's correct. Thanks so much for having me. Thrilled to be here. So, Andrew, how did you first hear? reach out to me. I know that you reached out to me a couple years ago and we've been kind of

corresponding. Yeah. So interesting, interesting course of events, really. So due to the work that you've done in emotion recognition and a role that I had at the time at Western Sydney University, I was doing some research into emotion recognition and in particular schemers that affect our ability to recognize emotion. And so, yeah, I reached out initially to see if I could kind of use some of your material. And thankfully, you were very happy to allow me to use some of your videos. So yeah, that was how we first got into contact a few years ago. Yeah. And so now we're planning a lecture together at one of your conferences. Yeah. So our professional body, The ISST, the International Society for Schemotherapy, we do about once every couple of months.

We do webinars and the next one that I'm planning to do is on what we call in Schemotherapy attumen, a big part of Schemeteracy's ability to attune to another person, attuned to their feelings, what it's like for them. And I'm really excited to start to integrate some of the micro-expression training that you've developed into, you know, our own ways of building our skills and attunement. So, yeah, I'm looking forward to that too. Okay, so let's like start with the very basics, like, tell me about schemath therapy, like imagining that someone in the audience has never heard of this, and how would you explain it? So schemat therapy is a model of psychotherapy, which was originally

designed for longer term more chronic mental health problems coming from the cognitive behavioural tradition but also integrating different arms of psychotherapy as well so there's elements from the gestalt tradition and also aspects of object relations theory as well our founder geoffrey young early on in the piece as the story goes was a cognitive behavioral therapist was find some difficulty or some sort of frustration in terms of working with people with the diagnosis of personality disorder in terms of that type of model, CBT, not having perhaps the outcomes that he wanted. And so he found a way to integrate these other two arms as well.

We have the idea of schemers. We have the idea of modes. But really what it comes down to is we as the therapist meeting the unmet needs. of the client. So we're finding ways to, in the context of the therapy relationship, to give the person what they didn't get growing up. And so that might be a sense of acceptance, essentially good enough just the way that you are. It could be a sense of safety. It could be a sense that it's okay to express your needs. But that really is the goal that we're working towards meeting those needs for the client and then over time teaching the client to continue to meet their own needs

and to continue to meet their own needs so they eventually don't need us anymore. So your model starts with this idea that there's this chronic deprivation of needs in childhood. Absolutely, yes. And so that leads to the formation of early maladaptive schemas. So how would you say the difference, what is the difference between early maladaptive schema and something like transference, more of the concept of like, okay, these these transferences that occur now, transfers from these past relationships into the current relationships? I think it's actually quite similar. But I guess, yes, so we would say that people in the here and now can trigger our schemas. say, for example, if we have a quite distressing schema, which comes from a very, you know,

distressing background, like mistrust abuse. If we have a client that has a mistrust abuse schema, they are likely going to, they are likely going to expect other people in their lives as well as us to potentially be a threat to them. So in that way, it's kind of like the same idea of of transference and a sense of a person which is built up from early development. So in a lot of ways, it's really similar. But I guess one difference is that we assume that schemers aren't necessarily triggered by just by other people. They can be triggered by internal stimulus.

They can be triggered by stuff that's happening in the world. And so, yeah, it's not necessarily just related to. you know, interactions with others. We see a schema as having four elements. There's a cognitive element. There's a emotional element. There's a physical sensation. And there's a memory.

And what we're trying to do in the model is trying, in the therapy is to try and get as much of that stuff kind of triggered off. So we can then go in and meet the need. I veered off there into some other sort of stuff. But I hope that, did that kind of answer the question? Yeah, that's great. And Kristen, Kim, you can jump in and ask any questions for things you don't understand

or you'd like to hear more about as well. So you said there, the one schema that you said was distrust. Mistrust abuse, yes. Mistrust abuse. And so is this a common schema that you guys identify and see how plays out? Well, it's certainly, I mean, given the topic of borderline personality disorder, it's certainly a very common schema. for people with the diagnosis of brutaline personality disorder to be presenting with.

Yeah, and obviously people with the trauma background. So people presenting with particularly physical, sexual and emotional abuse, are often presenting with that sort of schema. In addition to other schemas as well, because I guess it's not only that the person feels scared, which is the affect attached to mistrust abuse schema, they're likely also feeling like this sense that people do not care and this sense of being alone and their sense of sadness as well,

which I'm kind of touching on another scheme, which we call the emotional deprivation schema. So particularly people with the diagnosis of borderline personality disorder are presenting with quite a wide range of quite a wide range of schemas. But yes, certainly mistrust abuse is a really common one. people with that presentation or that diagnosis. So, and you said body sensation is a part of schema. Yeah, yeah.

And so with the deprivation, like what would be a common body symptom that you would see? It's usually, yeah. So emotional deprivation, the common effect is sadness. So it might be a sense of being let down. It could be a sense of emptiness at times. with mistrust abuse, the common affect or the main affect is fear. So it's usually those anxiety symptoms. So it's sort of like it could be, you know, your heart's going faster.

It could be a sense of agitation. It could be a sense of pins and needles. It could be a sense of like pressure on your chest. And I guess they're the common type of physical sensations that go along with those schemers. But obviously there can be a whole range depending on the person. Right. And then you said like images is one of the four things of the schema as well. Memories, yes.

Yeah, memories. Memories. Okay. Yeah, so one big difference between schemer therapy and cognitive behavioral therapy, for example, which is where we've essentially come from originally, is that we have a big focus on making links between developmental events, chronic unmet needs, memories, and the way that we feel in the history. here and now. So yeah, yeah, so some memories attached to schemas is actually a really important

part of what we want, what we want to understand as well. We're hoping that the client has a sense of there's actually a reason that they feel the way that they do at the moment and that's because of the stuff that's happened to them. And obviously the most straightforward way to do that is to kind to understand the events and to start to link those memories with the, the, the, the triggering in the here and now. So what were the four things again? Yeah, so there's cognition, so thoughts, beliefs, emotion, physical sensations, and memories. So we see schemers containing four things, and it's those four things. Okay, yeah. So I could see, you know, thoughts and beliefs. That's cognitive therapy. Yes, absolutely. Proper. And then so now you're adding a focus on emotion.

Yeah. Bodily sensations, which I think a lot of people dealing with trauma, there's many different trauma modalities that really focus on body sensations. And then the memories and linking how the memory is informing those schemas. And then, okay, so you have someone with the, they're kind of playing that tape, you're drawing to their memory, that schema, the memories, the body sensation, the emotions, the thoughts. And then so what are you doing in the midst of that?

So I guess we're working towards finding a way to meet the need. So if in our therapy the person starts to feel that way, perhaps they might feel, they might be feeling sad and alone. We're trying to help the person feel like, you know, get a sense that we actually are there for them. and potentially we, you know, they're not alone. We're there to support them. And essentially also we'll be there for them for as long as they need.

So we're trying to meet the need in the, in the relationship. But also we've got a whole range of techniques as well. So a big technique that we use, an experiential technique is imagery re-scripting. So say, for example, a client comes to us. They've told us about this vent. event during the week where they felt scared or they start to feel scared in the room with us. If they're feeling safe enough to do so, if they're willing, we might ask them to close their eyes, get a sense of this feeling and think of a time when they were growing up where they felt

a similar sort of experience. We come in in that event and we meet the need. We in some way, in some way fix it. We provide what they should have got growing up and essentially you know, that's the way that we meet the need. So in the work that I usually do, like, okay, I get them, they're in that memory. They're feeling that they have the bodily sensation. They have the thoughts. So it's really, okay, I'm working in the scheme already with a lot of my clients. From there, I'm trying to decrease their shame.

Yes. Make them feel that what is happening between us is. is connecting, like we are connecting in the midst of that. And yeah, there's a bunch of different ways to do that. But so it's kind of like the here and now work, right? Yeah, yeah, yeah, yeah. Absolutely. The intersubjective, the looking at the we, sort of the combination of us,

the third space. Yeah, so I guess the way that we see that is rather than we're trying to shift the idea that we are that person that created that sense of shame, the person might be triggered off with us, and we're trying to kind of show them that, of course, you feel this way. But essentially, I'm not that person. I'm a completely different person. And this is not a relationship where, you know, you need to be scared.

I guess I'm just sort of reinforcing what you're saying there. Right. So, yeah, I think the way that you just said that is similar to what I would do. It would be, you know, how do I help this person? They're realizing that the shame and the intensity of the shame is not necessarily what's going on between us in terms of their reaction to me and maybe a present issue. But then we're curious about what might be underneath it. Absolutely. And hopefully move them from a place of feeling bad about having that to a place of curiosity.

So if a person is angry at me, I'm excited that they were able to experience that, which is very counterintuitive to how normal humans interact with anger. I see it as it's energy to overcome an obstacle. I say anger as energy to overcome an obstacle. And it's often that a patient will not be able to express much anger because of, in some abuse, of situation like anger was pushed down or not allowed. Was shamed. Shamed, right. And so in therapy, inevitably, someone who's a very sort of high a trade agreeable

this person who's rarely angry will have like this, they'll have flashes of anger on their face, micro expressions of anger towards me, right? And they're almost surprised when I welcome it or get excited that they're able to express it. Absolutely. Absolutely. And it's often hard for them as well. Because as you say, for so many years, that the expression of affect or what we would see is the expression of needs has been repressed or pushed down. Right. A need, anger is movement towards a goal. Goals can be needs and needs

to protect themselves often, right, were thwarted if they had chronic abuse of different types. So yeah, having the ability to express anger in a congruent fashion and look at it and be curious about it and not be shamed in the midst of it allows for, you know, maybe them to have boundaries and other areas of their life. But I would be curious, like, how would you conceptualize that? So, yeah, great. Great question. So in our model, we have this concept of modes and we have this concept of modes. and we have this concept of child modes. So there's part of the client that feels all the feelings

and essentially feels the scheme of feelings, feels the shame. But we also have a child mode, which is called an angry child mode. And this is a part of the client that is actually, we see is extremely important because as you say, growing up, particularly people with their diagnosis of borderline personality disorder,

often had the expression of, of affect, shamed, pushed down, discouraged. And we see the angry child mode as the part of the client, which is expressing the needs. So similarly in our model, when most of the time when we, when we see anger, we're actually very welcoming and very, very, very happy and actually quite quite encouraging of that, of that expression of that emotion. And essentially what, what we're curious about is what are the needs that this person is expressing. expressing through that anger. Would you tell a patient that they're an angry child?

I would probably say, we always talk about the idea of parts. No, I wouldn't turn around and say, hey, right now you're an angry child. That might be perceived as somewhat. That might be a little bit in a little bit, right? Yeah, exactly, exactly. But it might be stuff like,

it seems like there's a part of you now that's really angry. you know, I'm really curious to understand this part of you. I really want to hear more from this part of you. And then perhaps later on when we're talking about formulation, we might sort of say, okay, so there's this really vulnerable part of you, call that the vulnerable child, or that little Stacey. And then we've got this really visceral rage part of you, which we call, in our model we call the angry child.

and for you, we'd like to give like idiosyncratic terms, so it might be like the firecracker. So sometimes when the firecracker is so fed up and so frustrated and so sick of not being listened to, the firecracker just goes off. And that part of you is really important. And we need to figure out how to make sure that the needs of that part is expressing are met. But then we would kind of start to focus on another mode, but we need to kind of make sure that it's the healthy part of you.

So we have this mode called the healthy adult mode. It's the healthy part of you expressing that need to other people, expressing that frustration, expressing that sense of injustice in a way that other people can deal with. Does that make sense? So we would use the term angry child, but perhaps not the first time someone's expressing anger. Okay. Yeah. Yeah, I think I'm starting to understand your model a little bit.

I'll have you converted by the end of this conversation. Yeah. Hopefully. I just... I shouldn't be so confident. Well, I think that we can all learn from each other's experiences. And I think I'm open to gaining any wisdom I can, you know? Cool.

I still think that the... I like to use words like, I think what you're trying to. trying to do was adaptive or is adaptive to some capacity. Yeah. Yeah. We have to look at the goals and we have to look at what obstacles they were there. But specifically with people who have not been able to have a lot of anger in their life, it's almost as if the expression of anger and therapy is so close to shame for them, you know,

that I would be very careful to use my words carefully so they don't experience shame for, for having boundaries or for having anger. Absolutely. Yeah, absolutely. It's interesting that you're talking about ideas of adaptive behaviors as well. So we kind of have this, within the concept of modes, we have this concept of coping modes. So at any one time, people are in,

we see at any one time people are in a mode. They might be in a feeling mode, like a child mode. They might be in, you know, in a more kind of, healthy adult mode, which is adaptive and quite self-compassionate, attentive to our own needs, as well as aware of the needs of others. But we might also see ourselves as in a coping mode. So these are a set of behaviours that we've needed to develop as a way to cope with the environments that caused the schema, the environments where the needs were unmet,

and as well as cope in the here and now with the scheme is getting triggered. So a common one might be like detaching from feelings, you know, dissociation, shutting off feelings because developmentally it was kind of like the only way to survive. If you were showing your emotions and if you were feeling stuff, it'd just be raw all the time. So a lot of our clients are presenting with a difficulty kind of getting in contact with their feelings. And another example might be deliberate self-harm, like a way to kind of regulate your affect

or using drugs or alcohol as a way to kind of self-sooth. So the function of these behaviours at one time in the person's life has been actually not just functional but necessary for survival. But the difficult thing is that because at one point they've been necessary for survival, it's actually to give them up is actually quite scary. So a big part of the work in terms of getting through to that part of them that feels the feelings in order to meet the need. is trying to what we call like bypass or reduce these coping strategies in the here and now.

And initially we're trying to reduce the coping strategies in the therapy itself. So when you talk about like, I'm going to kind of go back and then we'll kind of jump forward as well. You talk about like the adult being the adult having self-compassion. Have you heard in DBT this idea of like wise mind? Yes, absolutely. the rational mind and the emotional mind, and they're sort of combined. Yes, yeah. You know, and in the wise mind, you have intuitive thinking, you have this balance between

the rational and the emotional, you're living mindfully. Like, is this at all kind of like what you mean by the adult mode? Yeah, yeah. I think it's a similar concept. So we, and I'll kind of go back a bit as well, is that we kind of see particularly, people with more longer term, what we use the term, characterological problems, you know, like borderline personality disorder, for example,

but also like things like chronic depression, this part of them, this healthy adult part of them, is underdeveloped. So the idea is that we're trying to model that healthy adult for them. We're trying to be the healthy adult and to meet the needs. But yeah, absolutely, it's a very, very similar concept in a way in terms of the capacity to both, both be looking into the world and using evidence, but also being mindful that we are just the way

that we are and we feel the way that we feel and now are both very valid. It's not just about trying to convince ourselves that the way that we feel is wrong and we should be a different way. It's about kind of accepting that we would come back to the vulnerable trial. Mo that is a part of us that just feels these feelings for a reason and is, and in some ways, is, is always going to be that way. And it's about kind of forging a life for yourself,

which takes into account what that part of you needs. I hope that makes sense, but I think I'm just, mainly just sort of validating that, that, yeah, the concept of, of,

of wise mind in DBT, um, you know, is a, is a similar concept of the, um, the healthy adult in, um,

schemer therapy. Or, have you ever heard of, like, the psychic equivalence mode in mentalization-based therapy? No, I've not really, I've not really delved into MBT, but I'm curious to hear about it. So the basic idea is that when someone gets very stressed, they can go into this, like, psychic equivalence mode, where they believe their reality is the only reality. So like, you know, in a normal sort of mentalizing mode of sorts, you know, you would be able to say, oh, you know, you're thinking this, but I don't really know. Or like, this is the narrative that you have of me, but it's like, I'm not sure if that's true, but I'm putting it out there as like a little hypothesis, right?

Whereas the psychic equivalence mode, it's like the thoughts that I have of what you're feeling and thinking are like completely absolute. And no matter what you say to me, you are not going to be able to break me from believing that. If I'm in this heightened state of arousal, which I think is a helpful concept for borderline percius disorder and like this, they're going into the psychocryphalism mode. And it's like, you have to bring them down physiologically before they can start to question what your thoughts are, what your feelings are. Yeah. Yeah, absolutely. Right.

And I'm wondering if there's any sort of similarity between that and how you describe the child modes and the adult mode. Yeah. So I guess in that same process, we're trying to do two things. We're trying to, if someone in our therapy room is distrary. distregulated, scared, we need to meet that need. We'd need to create a sense of safety, which would also include bringing down affect. It might be, you know, just really simple stuff. Like, hey, let's just take a few deep breaths. Let's take a few deep breaths and, you know, just remind yourself that, you know, this is a safe place. I'm here, you're here.

If you really want to leave, the door's over there at any time, you can kind of leave. So meeting that need for the person, creating a sense of safety, and I guess agency as well, that they're not stuck. They're not in a position where they don't have any power. So we're trying to meet that need, and we might use some other techniques as well. But then we're also trying to build the part of them that can actually distinguish between what's happening in the here and now and what happened to them growing up. and we see that as the healthy adult mode.

But before we do that, in our model, we have to meet the need. We have to meet the need. The person needs to have a felt sense of safety in order to be able to develop this other part of them that can meet the need for themselves. We have this concept called limited reparenting, and that's essentially what we're trying to do throughout the therapy. Yeah, talk to me.

about this idea of limited reparenting. Yeah, so limited reparenting is really the idea that within the appropriate boundaries of the therapeutic relationship, we're meeting the needs of that person that were unmet growing up. So, yeah, again, it can be safety, security. Yeah. It sounds like Franz Alexander's like corrective emotional experience. Yeah, absolutely. We use the same term.

Yeah, we're doing all this stuff as a way to provide a corrective emotional experience. Absolutely. Yeah, one of my mentors, Dr. Tar, he trained with Franz Alexander. So he's like a total fan. For those of you who wonder if Friends Alexander is still alive, he's not. My mentor is in his 90s. And so he has that history of having met a lot of the great people that we read about. Okay, so there's the reparenting, which is supplying within the appropriate bonds of the therapeutic relationship, what the patient needs, but did not receive by their parent and childhood.

Yeah, yeah. And so we see, I guess, in terms of, I guess you can kind of think of it as a continuous. between care and limits. So most of our clients that are presenting to therapy, particularly clients with a diagnosis of borderline personality disorder, requiring more of the care. So it might be about a sensitive acceptance, a sense of safety, you know, a sense of being listened to, nurturance. But it's, it could also be that they need, they need more direction and guidance because a lot of our clients presenting have missed out on having a strong person to encourage them that can do stuff, to do stuff which is actually difficult and challenging.

And, you know, it's sort of not all about the warm, fuzzy sort of stuff as well. Like a lot of our clients, I guess, you know, we're thinking in terms of, you know, some of the other, you know, cluster B types of diagnoses, narcissistic personality. disorder, anti-social personality disorder. Sure, people with that diagnosis do need care and guidance, but often what they're also needing is they're needing firm limits. They've not, often not had someone in their life has been strong enough to let them know that this behavior now is, it's not okay. And this is what you're doing now, well, I can understand, and this is, I'm going to go into like an example of what we call empathic confrontation. And so while I know that you're,

you know, you're coming here and you're scared and I know that there's a part of you that's, that's worried about me and is worried that, you know, I'm going to hurt you as well, I'm going to leave you or I don't care as well. And I really want to look after that part. But you need to know that this aggressive and threatening behavior is not good for us. It's not good for our relationship. And when you do it, there's a part of me that does it finds it hard to connect with you. And to be honest, it's a part of me that just wants to kind of bail, just wants to leave.

And I don't want that. I want to be able to stick with the vulnerable part of you that needs care. So yeah, I'm kind of just demonstrating this idea of like empathic confrontation with being empathic to the behavior and understanding that, of course, they're not doing it for no reason. There's a reason behind it, which is actually probably, you know, very adaptive and functional at one time of their life, but it's, yeah, has, we're confronting them on the damaging nature of it. Yeah, I like that combination of empathy plus limits, you know? Yeah, yeah.

That's good. I want to jump, I want to hear more about imagery rescripting. What are the type of steps that you use for someone when you're in the midst of their schema? Yeah. So, imagery re-scripting, there's a whole range of different kind of techniques and steps. But perhaps one of the most common ones, and often a type of model or type of steps that we start with is what we, some what we call like a float-back imagery or some people call it like an affect bridge. So the first thing that we're trying to do is to attune to, a feeling or an event in the here and now. So we ask the person to kind of, okay, close your eyes and get an image of having that

argument with your partner the other day. And as they're looking at you and kind of they have that, you know, that look of disgust on their face, how do you feel? So we're trying to get a sense of the feelings. The person might say, I'll just feel bad. I might just feel shame. Okay. So hang on to that sense of shame.

but allow the image in the here and now to float away. So we're at first imagining an event in the here and now, attuning to a tuning to the schemer, to the, yeah, tuning to the schema. And we're making a link. So we think, you know, let go of this image in the here and now where, you know, you're feeling shame and you feel like you've done something wrong

and maybe you've got this pit in your stomach and allow yourself to think of a time when you're much younger when you had a similar sort of experience. And so we're making that link and we're asking the client to kind of recreate the image, be that little kid. So you're there. What do you see as you look around? What's going on?

Who's there? What are they saying? And then once we've got a sense of what the person needs, what that young person needs, we ask them to come into the image. So I'd like you to bring me into the image. Would that be okay? Can you see me there? And once we're there, we're actually going, we're meeting the need.

So we're providing a sense of safety, protecting that young person from perhaps a perpetrator, meeting that need of acceptance by letting them know that they're great the way that they are. So yeah, so we imagine an event in the here and now, tune to the image, sorry, tune to the feelings, make a link, recreate the event. We come into the image and then we meet the need. So the way that you're meeting the need in their image is to actually tell them to imagine you in the image? Absolutely, yeah, as an adult. So we are the way that they are, the way that we are in the here and now. And the client is taking the perspective as the child.

So ask them to be the child, close your eyes, be that little eight-year-old person. What do you see? What do you feel? And then we come in as an adult. So let's say something horrible is happening to them. Yeah. And you come into the image. What are you doing to meet their need?

Something's horrible happening. We're providing protection, providing safety. So say, for example, you know, a person's, you know, they're reliving a trauma event. So before the event occurs, hopefully we're coming in and we're doing whatever is needed to create that sense of safety. So when we bring me into the image and I want you to see me standing, in between you and your perpetrator?

What's it like to know that I'm now there for you and I'm not going to let them hurt you? How are you feeling right now? And obviously just our presence is often not enough. So they might say, you know, I still feel scared because he's so big. Then we're using fantasy as well. So we're like, okay, so make me bigger. Can you make me bigger?

So now I'm towering over top of them and I'm saying to them, you are never going to hurt little tenure again. We would do a whole bunch of stuff. Like we can kind of, you know, bring in Kevlar-clad, fit child protection offices. What's it feel like to have all these people around you protecting you now?

So the way that we do is not so important, but we use fantasy, but the most important thing is we're trying to meet the need. I could see how that would work. Because every time we bring a memory to our mind, the memory changes. Yes. So essentially you're inserting yourself into the memory.

The way that I've done it traditionally is just to bring the empathy and like in that memory, bringing a sense of empathy and compassion and together with the person in the here and now seems to change the memory as well. Like I've had people who, for example, before the memory, they'll feel like this, this, they'll have like dreams of this like tsunami coming over that. and then after doing this type of work, in the dream, the tsunami will be coming over them, but I will be there to protect them and create like a bubble around them, you know, and to bring them out.

But I don't know. Yeah, beautiful. Oh, wow. That's amazing. So we would do that. We would do it directly. We might use something like that. But that's beautiful, isn't it? I mean, that's what happens, isn't it?

Is that the, and we find in our model, or even with the imagery re-scripting, the memories don't necessarily change, but the emotions attached to them and the meaning attached to them changed. So just to use an example, one of the, early on in my schema journey, I used to do a lot of DBT,

I coordinated a DBT program with some amazing folks in southwest, southwest Sydney. And towards the end of the time, working with that person in DBT, we decided I was, you know, upskilling myself, with schemor therapy, but is an imagery rescripting. And did the rescripting. I came in, you know, I put the blame, fear and square on where it deserved to be.

The person came back next week and said that, you know, that experience is the first time I realized that I actually wasn't evil. And for me, that was incredible. It's like, yeah, wow, I can, you know, we have this technique. We have this capacity to, in our language, you know, provide a corrective emotional experience. experience. Yeah. Kristen, I know you read a section in a book here on image rescripting. Do you have any questions on that in particular? You know, it's really nice to have this like first person experience of what you're actually intending to do. I think in the book, they kind of were like, oh, you re-script it. And it didn't seem very

impactful. And I think they like didn't like specify, oh, like this is actually you're inserting yourself into their narrative in a way. And at first I was like, oh, like, would that be helpful? Or, you know, like, if I were in that situation, like, would I, what I want them to be there? So I'm guessing this, like, definitely has to, like, come after a lot of work together because I'm thinking, like, okay, if I'm in my most vulnerable state, like, would I want someone who's, like, you know, new to my life to, like, insert themselves? Like, would I be able to trust them in that kind of way. Sure.

Yeah. Sure, yeah. We need to be timing this stuff well. Like most people, I find working to private practice sitting now, like most, most people are quite happy. And as well, they're coming requesting schema therapy. So they have a sense of the sort of stuff that goes on anyway. You can do this stuff quite, quite early.

But for a lot of people, yeah, it's, you know, that we need to kind of. of, you know, build a sense of trust and build a sense of consistency in order to, yeah, in order for the person to make themselves vulnerable in that, in that way. Yeah. And I think in the book, too, they had like different goals of what they wanted imagery, scripting to be too. Like, okay, like then you can like refer to your future self and effective problem solving like in the future.

I was wondering if you could talk about that as well. Yeah, absolutely. So again, this idea. of schema therapy having therapist meets the need, coaching or teaching the client to meet their own need, and then client continues to meet their own needs by themselves. So early on in imagery rescripting, we're coming in and we're meeting the need.

Over time, as the therapy is progressing, we're changing it. we start off with a childhood image and then we ask the client to shift perspective and to come in as an adult from the healthy adult side of them and then the two of us are there and I'm there with you and we're looking at little James and you know do you have a sense of what little James needs would you like would you like me to kind of look after him or would you want to have a go I'm trying to care for him so it's his idea of teaching teaching the client to meet their own emotional needs. So we might do that for a while. Then after time, after a while, what we're doing

is asking the client to come in just as, just by themselves as an adult and to meet their own needs. So it's this progression from therapist being the healthy adult and meeting the needs to the client being their own healthy adult and being able to kind of care for themselves and meet their own needs over time. And there's other versions of imagery that we do in the here and now as well. But these kind of more imagery rescripting based on childhood events and childhood memories are the most common. It kind of reminds me of the butterfly effect.

I don't know if you've seen that movie. Oh, not for a while. But there, yeah, right? It was like, I don't know, this was totally unplanned 2004. It's coming into my mind. Yeah. It's like there's this scene of, or it's basically a movie where, there's this kind of repeating of this trauma,

but then his future self comes back and speaks to the person who's traumatizing the kids and freaks them out, you know? And so, I don't know why, but it's kind of like, you're kind of coming back as an adult and speaking to these cowards who are hurting these children, you know? Yeah, yeah, absolutely.

So another example is that, in Rocket Man, in one of the final scenes when Elton John is in that AA group or the NA group, I can't remember which one it was, he confronts his father in that image. And then the child version of Elton John comes in and he meets the need. I can't remember exactly what it is, but it's in the realms of care. and validation and acceptance. So it's another example of, yeah, another great example of what we'd call mode work

or limited reparenting or providing a corrective emotional experience. That's the thing. Part of the problem with schema therapy is once you get your head around different modes and different schemers, all your TV, all your movies is ruined because you can't switch off. You keep seeing modes and schemas and all sorts of stuff coming out. And this butterfly effect sounds like a really great example. I'm going to have to check that one out.

Yeah, I'd have to re-watch that one. I remember it being hard for me to watch back then because if the content was disturbing. Yeah. This was before I was a therapist, psychiatrist. Have you found that? Sorry, this is totally, you'll edit this out. But have you found that as you do more and more therapy over the years,

your capacity for traumatic films is greatly reduced because you have so much of it in your that's my experience. I shouldn't assume other people have the same sort of experience. No, no, and we're not going to edit this out. This is good stuff. I think my audience enjoys these digressions because they're, they stimulate their own understanding or their own thoughts. I would say Yeah It's like now When I read certain things

It's like my image of what's happening Yeah Like some of the border stuff Like it's so hard Because I know Like the You know The child

Sex slavery Stuff like that It's so disturbing to me Because I know Because you know After you've been in the room with patience We feel a little at least a little bit of what their client's feeling,

and that's the process of empathy, and we do it, and we choose to do it. Or, I don't know, like, I'd be curious about your experience of what's going on in Australia right now, with just the, you know, I see these video clips of the lockdowns and just very authoritarian restrictions. Is that affecting the psychology of the people you, treat? I think the biggest thing, the biggest thing is, and I don't personally, I don't necessarily think it has spiked with the numbers spiking in Sydney and New South Wales, the fear, but very much, like, you know, in our model, we have this, have a vulnerability to harm schema. And so people

historically with that schema, and often people that have grown up in, in, in, in, environments like war-like environments or environments with, you know, parents that were very, very worried about sickness and illness, those people are finding it really difficult at the moment because they're being triggered off. I don't think it's, for me anyway, in my experience, I don't think it's so much about the lockdown itself, but more about the sense of worry and fear, which has affected all of us across, I think across the world in terms of, in terms of like COVID and risk and stuff like that.

But yeah, certainly, yeah, this period, I don't know if you've experienced this as well, that in Australia, there has never been a greater need for mental health care. It's absolutely incredible. Like so many people are anxious, all their stuff's getting triggered off. Is that the same in the States as well? I would say it's I would say absolutely I think people are very they're stressed in different ways you know yeah interestingly in Florida where I feel like you know once again I'm like walking around a farmer's market today

no one has a mask on life is completely back to normal yeah my kids my kids are in school without masks and I'm and then I see these like apocalyptic pictures of Australia with like people getting shot with water cannons and um I saw one clip today where there was like just about it looked it looked like 10,000 people just protesting on the street I mean are you seeing these images on your television are they it's I'm I'm seeing them on alternative media so maybe you're not seeing this stuff like I'm seeing it no we are we are seeing it, the greater majority, because it's interesting that, that whereas in the states, the big COVID spike happened very early, this is our spike now. Like with this delta variant, we're getting

more cases than we ever, we ever have. And so, we're seeing that too. There was an initial spike and then this delta spike is happening, right? And it's, it's, it's, it's, It's on the downturn in Florida, from what I can tell. But, you know, I got the Delta. Like, there were other people that I know that got it. So I think, like, there's my cognitive mind right now, which doesn't really fear much stuff, especially now. Because the post-getting it, your chances of re-getting it or getting sick are so low. But when I had it, I definitely had a lot of fear.

That was interesting. And so that took me to those dark places, like in the middle of the night, you know, where you're like, what's this going to be like 12 days from now, you know? Am I going to be in the hospital? Am I going to be needing to be, you know. I'm glad you're okay. Yeah. Oh, man.

But so I personally think the fear is a big part of this. And there's no way that we don't feel the fear. and then that sort of chronic stress. But I'm just curious because you're on the, like, you're on the front lines. Like, how locked down is it for you just to give my audience a picture of who might not see these videos like I do? So, schools are closed. Schools are closed if you're a frontline worker or if you've made the decision that you just simply can't work with your kids at home. kids can still go.

Schools aren't actually strictly closed, but they're encouraging, we're encouraged as much as possible to keep kids at home. We're encouraged as much as possible to, you know, stay at home. The main real restrictions are on movement. So it's like, unless you have a valid reason for work or childcare, you can't move out of five kilometers from your home. In enclosed spaces, you've got to wear a mask.

I mean, for the majority of us, we mostly have this mindset that, okay, this is a short period of time. Let's work from home if we can. Let's wear masks and let's, you know, flatten the curve. And then we can kind of go back to the way things where beforehand are as close as possible. And I guess, yeah, the stuff that you're seeing is actually quite, it's quite isolated. Most people, most people by and large are actually just quite happy to do the social distancing

stuff, quite happy to be working at home, quite happy to be wearing masks. But I think, you know, there's a, there is a small proportion that kind of aren't happy with it. And I don't want to over generalise, but it does seem to be also, the same group that don't want to get vaccinated, for example, don't want to get the COVID vaccination. So it's interesting hearing from an overseas perspective, because for us, this is, you know, the protests are, yeah, quite isolated, but it's interesting to hear that it's sort of made such news overseas.

You know, the only place I see them actually is on TikTok. So I feel like TikTok, it's like you get some person, shooting with their camera, like this protest. And it gets really popular. And it gets very popular, yeah. So maybe there's a phenomenon there. But I do think that I appreciate this sort of the unfiltered newscast of TikTok from time to time. I wouldn't say I get all my news from there.

But yeah, sorry, I'm like, bring this into the conversation here. No, no, no, it's fine. It's fine. It might be frustrating for you to. to be in the midst of it, of course. Yeah, look, it's hard, you know, it's, it's hard trying to do everything at once. Like with myself and my family, we're, we're pretty lucky that we're able to, I can still work from home, I can just work over telehealth.

My partner, she can find a way to work from home as well as a, as a researcher. But yeah, some families are really doing it tough. And, you know, I think, you know, again, this is over generalizing, but for single people as well, it's really, really difficult, the isolation. I think it's hard for kids as well. I was hearing that, like, at the BMC, some of the children would plan with each other to, like, act mentally ill at the same time. So at least they could see each other at the behavioral medical center. Yeah, wow.

Just because we hadn't seen other people in so long. I thought that was really sad. Talk to a teacher from California today, one of our kids' old teachers, She saw our kids on FaceTime with their faces, you know, unmasked. And she was like, oh, it's so good to see kids with, you know, their expressions. And she's, it's, it's, you know, there's so much emotion that happens on the face. And so I think the kids are really suffering without seeing the full face of their, of their friends and such. So I'm sure we're going to see ripples of this in the mental health.

sphere for a long time. Yep. And bringing it back to schemas, we see this period of time where I think in a bunch of years, this vulnerability to harm schema being so common because of the way that we all feel at the moment, I guess, into different degrees.

Yeah. Well, kind of wrapping this up here, any final thoughts that you would like our audience to know about schema therapy, kind of just this intro lecture to schema therapy or maybe where they can learn more if they're curious? Like where's a good place to start? Good, good question. Our professional group that I, if you Google ISST, there's a bunch of resources there. You know, you can watch some webinars on there. There's a lot of free stuff on YouTube as well, a group that I'm

I work with Schemotherapy Training Australia. We've got a bunch of YouTube clips on Schemotherapy. I think that's the best place to start. It's not too confronting. It's free. You get to hear someone talk about a particular approach. I guess in terms of final statements, I don't know what to say.

I love Schemotherapy. It matches, you know, the way that I think about care, what kind of people need sort of, you know, matches the way that I want to be as a therapist. But that doesn't have to be for everyone, of course. In scheme of therapy, the idea was we're trying to be, you know, as authentic, warm, real as possible. which, you know, times involves, you know, a sense of, well, you know, level of self-disclosure and stuff like that. I love it.

I think it's a great model. But, yeah, it's not for everyone. And some people, and I know we're kind of focusing on this topic of treatment of borderline personality, sort of, it may not be the approach, the approach that someone is ready for right now. what someone might need more so is a more skills, regulation skills, in which case like a DBT approach might be more useful. Cool.

Yeah. It's been great having you on. Oh, thanks so much. If you enjoyed this, we'll be putting all of our notes on our website, Psychiatrypodcast.com. I'll also link Andrew's page over in Australia. I'm sure he probably could provide some coaching, not therapy coaching all the way from Australia

if you live somewhere else. I don't know. Am I wrong about that? Oh, no, no, no, in terms of telehealth therapy. Or if someone wanted to learn about schemat therapy or get mentored in it? Yeah, absolutely, yeah. Myself and a bunch of colleagues do, you know, a lot of supervision in the model in Australia and overseas as well.

so yeah absolutely I think the exchange rate is pretty decent for the US right now so you might get a discount yeah but it's been good good seeing you again and we'll leave it there for today yeah thanks so much David

and Kristen thanks so much