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SYMPOSIUM 4 | DAY 1: 10.30 AM - 12.00 PM

Forensic Schema Therapy: Current Applications 

by Simon Draycott, Louise Sainsbury, Chris Harrop, Olivia Thrift, Tanya Petersen, and Lisa Wright

Chair: Simon Draycott

Schema therapy is going from strength to strength in forensic settings across Europe and beyond. In the United Kingdom, it has become a key treatment model in a variety of settings, including high secure hospitals, prisons and probation services. It has been applied in working with diverse populations and with diverse focuses, including workforce development, consultation, supervision and of course direct individual and group therapy. This symposium will present a range of current applications of schema therapy in UK forensic settings, which will form the basis for an upcoming edited book on the topic.

Segment 1

Title: Adapting schema therapy for forensic settings: The "forensic" modes

Presenters: Simon Draycott (possibly joined by Louise Sainsbury)

As schema therapy has been applied within forensic settings, it has been adapted and refined in order to meet the specific challenges of this population. "Forensic" schema modes have been suggested, including Conning-Manipulative and Predator. Other modes which are ubiquitous and present challenges in therapy include the Paranoid Over-Controller and the Angry Protector. This presentation will discuss how these modes can play out in therapy with forensic clients, and how schema therapists have learned to work with and challenge these modes.

Segment 2

Title: A Schema Approach to Psychosis in Forensic Settings

Presenter: Chris Harrop

Service users in forensic settings often present with multiple co-morbidities, including psychosis and personality disorder, such that the existing evidence base for treatments does not always apply. However, the wide array of difficulties seen in these service users can be accommodated within a schema based framework. A synthesis of the literature will be presented to provide a rationale for using a schema approach with service users in forensic systems where psychosis is prominent. Broadly, it is argued that behavioural sequences that can result in risk behaviour are strategies that have origins in childhood adversity when schematic representations of self and others were also being formed. Some psychotic experiences are framed here as anomalous perceptions that are memory fragments of maltreatment in childhood, that trigger schemas, strong emotions, and lead to methods of coping which can include violence and sexual violence. Service users appear to lack a coherent self, and, it is argued, this is due to dissociative or avoidant coping with strong emotions, which were learnt as survival strategies in childhood. The proposal here is to extend the mode concept to encompass the kinds of behaviour in those who experience symptoms of psychosis or other perceptual anomalies, as part of the framework on which to understand risk behaviour and to base interventions derived from schema therapy.

Segment 3

Title: Working with Women with a diagnosis of Personality Disorder in Secure Services

Presenters: Olivia Thrift / Tanya Petersen

This presentation will discuss the use of schema therapy with women presenting with PD in secure women’s services including locked rehab, low secure and medium secure settings. It will focus on the complexity of working with mixed PD features and the role of complex trauma and profound emotional neglect that is commonly seen in the histories of women in secure services. We will then look at the nature of secure settings and the role of this type of environment in reinforcing vs healing unmet needs, and explore some key issues that commonly present themselves in female secure settings including prolific self harm, intimate relationships between patients and regressive and/or dependant behaviour. These behaviours commonly activate powerful modes in staff, and we will discuss the impact these modes have on relationships (staff to staff, staff to service user and relationships between service users) and the culture/safety of wards. We will consider how a team based schema formulation can be used to better understand and work with these issues, including incorporating the schema formulation into care plans and what a healthy adult response to these issues might look like at both an individual and team level. We will discuss providing individual ST in this setting but not before emphasising the systemic challenges that can arise when doing this and the importance of a supportive system that can provide a platform for the individual work.

Segment 4

Title: Schema Therapy in Sex Offender Intervention

Presenters: Lisa Wright

Psychological interventions aimed at reducing risk of sexual re-offending in the UK are usually based on Cognitive Behavioural Therapy and involve attempts to alter thinking patterns, attitudes and behaviours. The incorporation of Schema Therapy into sex offender intervention allows us to develop a more comprehensive and individualised understanding of the offending behaviour and provides alternative methods of change. The ST approach is compatible with the theories and models that have been used for a number of years to understand sexual offending and guide its treatment (for example, Finklehor, 1984; Marshall and Barbaree, 1990; Ward & Gannon, 2006; Ward & Keenan, 1999; Ward and Siegert, 2002) and allows the client to develop an emotional connection to the origins of his offending behaviour. Conceptualising offending behaviour as part of a coping mode generates some distance from the offending, which can reduce the levels of shame that are experienced in this client group and that can impact on ability to engage in intervention. Clients are helped to identify their own schemas and modes, and as they become more familiar with their own schemas and modes they can begin to anticipate trigger situations, practice healthy adult responses in session and put these responses into practice outside sessions. Clients identify the schemas and modes that were involved in their offending behaviour and this formulation, presented in diagram form is used to guide further intervention. The introduction of the model, the methods used to increase self understanding and the development of the offending formulation will all be described in detail, focusing particularly on these processes within groups for male sex offenders, with the overall intention of reducing risk of re-offending.

About the Presenters:

Louise Sainsbury

Louise Sainsbury is a chartered Clinical and Forensic Psychologist and has worked in the UK NHS for over 25 years.   She has been using Schema Therapy in UK high secure NHS mental health services for over 15 years.  She has been delivering long term individual and group schema therapy with clients with complex and often contradictory mental health presentations and forensic histories. Louise is a certified Trainer/Supervisors in Individual and Group Schema Therapy and provides training and supervision to a wide range of professionals.  She has specific expertise in the application of Attachment Theory within Schema Therapy and especially in applying this when working with patients with avoidant personality disorder, as well as borderline personality disorder, within a forensic context. Louise is also a consultant with 'Schema Therapy Solutions UK' and provides accredited schema therapy training and supervision.

Tanya Petersen

Tanya Petersen is the Clinical Lead for the Women’s Service at the Edenfield Centre,  an NHS medium secure unit in Manchester.  Previously, she worked as a Clinical Psychologist at Ashworth Hospital, a high secure forensic psychiatric facility in the north of England.  Chris Harrop and Neil Gordon have been her inspirations with regard to schema therapy, which she first used at Ashworth.  She now uses it to inform every aspect of my work and thinking at Edenfield: directly with the women, and at a systemic level with staff.  She is working towards my accreditation as a Schema Therapist with the International Society of Schema Therapy (ISST).

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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