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International Society of Schema Therapy
In This IssueIn this November Issue - Case Studies in Schema Therapy by Lissa Parsonnet & Chris Hayes The Hedgehog and the Prickles - A Case Study of Dealing with Avoidant Coping Mode by Galit Goren Gilad (Israel) Schema Therapeutic outpatient treatment of a 15-year-old boy with hypochondria against the background of a car accident caused paraplegia early in childhood by Christof Loose (Germany) Mad for Connection - A Case Study in Schema Therapy for Anorexia Nervosa by Dr. Suzy Redston (Australia) Meet the ISST Board - Interview with Travis Atkinson by Vivian Francesco (USA) | SCHEMA THERAPEUTIC OUTPATIENT TREATMENT of a 15-year-old boy with Hypochondria Against the Background of a Car Accident Caused Paraplegia Early in Childhood by Christof Loose (Germany) The reasons for the referral were vast: fear of dying, fatigue, and depression symptoms such as inactivity as well as social and emotional retreat; the teenager could not think about anything else other than his (to him unknown or awkward) physiological experiences such as dizziness or an extra systole could be the first signs of life-threatening diseases (e.g. brain tumor or heart disease). Numerous medical examinations, sometimes in emergency medical consultation, revealed no medical diagnosis. Since these problems did not only occur only at home, but also at school, significant social integration and achievement problems also arose. For example, about once or twice daily the patient had to leave the classroom, complaining about symptoms, and demanding immediate access to a rest room, where a personal school assist would help him to rest until the symptoms faded. After usually about 20-30 min, he returned to the classroom, to be met with the dismissing looks from peers and also at times from teachers. Treatment Phase 1: Resources, Strengths, & Positive Schemas
Treatment Phase 2: Psychoeducational Model With the aid of a mode sketch (Fig. 1) we could shed some light into the so-called "black box" from a mode’s perspective: What exactly happens on the inner stage (mode level), when a stimulus (S, here the symptom dizziness) hits on a wounded person, and what response (R) is going to happen (, here “panic” feelings)? Along the sketch, we worked out different modes like the happy, clever & wise, self-assertiveness and resources modes, but also the vulnerable & fearful child mode. As the dysfunctional mode, that conceptualize the symptom, the patient would chose with a little smile the "dying-mode". When working closer with the latter we figured out three significant needs that was behind this mode: attachment, autonomy, and self-esteem. Attachment because he wanted to be emotionally close to a significant other, to be accepted with all his history and disabilities; autonomy since he felt deeply dependent on others (wheelchair), and now wanted to dominate others (Patient: They shall do what I want); and self-esteem since he needed desperately a good friend who would stick to him when peers are accusing him of “playing the dying swan”. Early maladaptive schemas were – due to paraplegia - vulnerability and defectiveness / shame (depicted in Fig. 1 as "wounds"), which were explored from every aspect (memory, cognition, emotion, and body sensation), identified by its triggers (e.g. dizziness) and validated against the background of the accident early in life. Fig 1: Mode sketch with small figures as modes of the patient; according to Loose, Graaf & Zarbock, 2013, 2015, adapted from Schulz von Thun, 1999, figures created by Graaf). Maladaptive schemas are depicted as wounds, in this case vulnerability (*), and defectiveness/shame (**), which were triggered by the situation of harmless dizziness or similar bodily sensations. This model gave the patient a plausible, self-supporting, and individually tailored explanation why even harmless dizziness or other physiological sensations may have led to such deep fears, which could culminate at times in panic feelings of imminent death. The identified needs of attachment, autonomy, and self-esteem could in the next step (treatment phase 3, see below) be met more readily by the clever & wise mode, for example by speaking first on the inner stage with other inner team members (modes), then on the outer stage with parents, and peers about the need e.g. to be emotionally understood. Treatment Phase 3: Mode work
In the accompanying parental work, psychoeducational classical schema-mode-clashes between parents and patients were illuminated and concrete functional strategies for dealing with dysfunctional modes were developed. Treatment Phase 4: Script, and Exposure (CBT-techniques)
Homework exercises helped to deal with typical situations, strengthened the patient’s and parent’s self-confidence, and consolidated the script’s measures already prepared in the therapy. For school situations similar exercises were planned, prepared, and conducted, involving a classmate who was willing to provide support and who had attended a therapy session on one occasion. Treatment Phase 5: Relapse prevention The frequency and lengths of therapeutic sessions were gradually, and in agreement with patient reduced, repeating not only the script’s details, but also resources, strengths, positive schemas from treatment phase 1 (relationship building), updating the explanation model from phase 2 (psychoeducation), practicing chair dialogues, and finally classical CBT-technique like exposure and self-assertiveness training procedures (phase 3 and 4), all accomplished by the patient’s clever & wise mode. Results: Sum scores of problematic behaviour in questionnaires like SDQ (Goodman, 1997) and depression inventory were assessed in a pre-post-12-monthsFU-design and yielded substantial improvement during the therapy and sustaining positive effects in the follow-up measurements. Additionally, the frequency of interruptions in the classroom 12-month after treatment’s completion could be reduced significantly, and social integration improved substantially as well (meeting peers more frequently). Summary: The combination of schema therapeutic, mode- and need-guided treatment on one hand, and CBT-procedures yielded lasting effects on a teenager’s hypochondria symptoms with a relatively small number of sessions (24+6 for parents, each 50 min). Mode dialogues first with smurfs, and then with chair work exercises were possible in spite of the fact that the patient was confined to his wheel chair.
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