The Schema Therapy Bulletin

In This Issue

In 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)

MAD FOR CONNECTION - A CASE STUDY IN SCHEMA THERAPY FOR ANOREXIA NERVOSA

by Dr. Suzy Redston (Australia)

The following describes the case of a man referred for psychotherapy after years of various treatments for anorexia nervosa restrictive subtype both voluntary and involuntary.

The use of schema mode allowed the understanding of behaviours that were life interfering and until we adopted a schema mode approach had been managed by the patient (client) being obsessional about adherence to rules in all conditions and at the expense of all else.

Tom* had a childhood with every need unmet. He was a non-identical twin and although born first the needs of his physically weaker twin were prioritised in the first weeks of life.

Developmental Origins 

Tom was born the 7th child of Elizabeth and the second of George.

He was a non-identical twin.

His Mother had married Frank and had five daughters, the eldest of which died in her youth. She then left Frank for George with whom she had five children, the last two died in-utero. This family of origin was chaotic and basic childhood needs were not met for any of the children. The girls stayed with their father but would visit their Mother when they wanted. The boys lived with their Mother in a two-bedroom home and the twins shared a bed in the lounge room sleeping on the same bed – top and tail.

George was an alcoholic who would disappear for months and return without warning. He was sexually abusive to his wife and Tom recalls hearing him raping his Mother, she would scream fir help, and Tom would  try to get into the bedroom to help but the door had been blocked by something heavy from the inside. From Tom’s experience his Mother withdrew any vestiges of affection from when he remembers trying to save her and he, believed this was because he had been unable to save her. 

Tom describes his father as being a figure in his life who abandoned him, abused him physically & verbally. However there were times when Tom would go and stay at his father’s house to escape abuse at home. 

His Mother was unhappy and provided no structure for the children. Tom wondered as an adult, that she was on strong tranquilisers to manage chronic anxiety & depression. He does not recall having any rules to follow (or break). She focused on the negative aspects of any external influences on her household and blamed others for all the problems she faced with day to day tasks, parenting and her own relationships. She was an absent Mother both emotionally and physically. She was leave her children for hours alone and return without explanation. There was never enough food or clothing for all the children and the home was filled with junk found on hard rubbish days, in charity shops or being given away. She was avoidant of any interactions with her children and Tom often felt he needed to shout at her to get her to notice him. 

Tom and his twin were sexually assaulted by their older brother from a pre-adolescent until Tom left home at about 16 years-old and although his Mother knew, there was nolimits set. A male neighbour had also assaulted Tom sexually, this man was asked to babysit and this re-enforced Tom’s feelings that one of his roles in life was to satisfy the needs of others.

The food that was in the house was often well past the use by date and not enough for all the people living leading to constant competitions and fighting for food between the children. The boys were often sent to school in dirty clothes, without food and late even though the school was about 200 meters from the house. 

At school Tom was often bullied and ostracized thus he developed habits of finding safe places to be during breaks one being under the school bell on a window alcove. Did not have a strong peer group at either primary or high school. Never felt he could let others know about his life at home.

Core Childhood Memories or Images

At about 7 being very hungry and his Mother was standing at the stove staring out the window. Tom holding onto the stove and yelling as loud as he could to his Mother that he was hungry. He does not recall how she responded but remembers feeling furious and un-contained. 

Walking along a main shopping street in the inner city yelling abuse at his older brother who was walking on the other side. It was the brother who would sexually abuse him. Screaming out “you’re a pervert” “you’re an abuser” and knowing people were staring at him & looking across the road at his brother who was walking quickly and saying nothing. All the time Tom knew that when he got home his brother would beat him & rape him yet felt powerful in the moment and liked the feeling. Was abused badly when he got home and his brother complained to Elisabeth that he had blood on his penis so she accompanied him to the hospital for a check-up. Tom was so furious because it was clearly from raping him that he decided he would move out if his Mother did not kick his brother out. When they returned nothing was said so Tom took his mattress and started to leave - his Mother tried to keep him by pulling on the mattress. 

He eventually left that night and stayed living on & off the streets for about 5 years or more.

He also recalls many episodes of his Father & older brother ganging up on him calling him a sissy, as he was quite an effeminate young man. He identified as homosexual from as early as he can remember and this intra-familial stigma confused him. 

When he was in transitional housing for at risk youth was told his Mother had died at home on the toilet. His older brother (who had abused him & his twin) had remained at home and had found her. He recalls being shocked & sad but also resentful that she had still allowed the most violent brother to stay while all the others had left and were in various forms of state care or on the streets.

With possible biological vulnerability to mental illness and addiction from both parents Tom having a serious life-threatening illness is not surprising.  

Tom appears to have an assertive temperament and describes being always much more vocal than his twin. He was the first-born twin but smaller. Tom would also fight back and not surrender easily when his brother of father was abusing him physically. This leads me to think that he was born with quite a brave assertive temperament that wasn’t allowed to evolve into a healthy adult but will be a great strength for his recovery as the maladapted modes are resolved. 

Core Unmet Needs

From my understanding of Tom, his answers on the various Schema questionnaires and his core problems I think none of his basic childhood needs were met. 

1.Secure attachment (safety, stability, nurturance and acceptance) Tom describes never feeling he was safe or accepted at home. He had a Mother who did not protect or nurture him and a Father that came and went without any predictability. As a twin he had also always had to share - first the womb & then the breast milk.  Experience of neglect of all needs for a secure attachment.

2.Autonomy (competence & identity). The bullying he experienced both at home & at school made it very difficult for Tom to establish his own identity. The constant criticism from others also challenged his sense of achievement and competence - even as a small child he was not given any sense of competence in normal childhood achievements.

3.Freedom to express emotions as there were no limits set on the behaviours of any of the children and no validation Tom has not got a sense of how to express emotions in an appropriate manner is very scared of exposing any vulnerabilities as his early life was so lacking in any nurturing. Rather he experienced verbal & physical abuse when he expressed any of his own needs or was completely ignored.

4.Spontaneity & Play it was not safe to be spontaneous or play even when a small child as his oldest brother was so violent and punitive with his siblings. 

5.Realistic limits & self-control Finding a sense of self-control has been very difficult for Tom as he did not see it around him in his immediate family and, he has only truly found it with a severe eating disorder.

At the time of original referral and for the first two and half years of therapy were very difficult. Tom remained engaged mostly as he wanted to have a forum to ventilate how others were always failing him by not following rules. 

Most Relevant Schemas

1. Mistrust and Abuse - abuse from immediate family members & people known to the primary care provider.

2. Abandonment - Both Mother & Father were experienced as abandoning him both emotionally and physically.

3. Punitiveness - developed as he needed to be hyper vigilant to reduce the abuse he was subjected to.

4. Emotional deprivation - Rejected from toddler by a father who came & went without any understanding by the children. His Mother appears to have been unable to give any emotional connections to her children and did not assist them to understand and learn their own emotional state. 

6.5. Lack of self-control - Impaired limit setting by his Mother towards the behaviours happening between her sons, physical & sexual abuse. Not being sent to school with any guidance from home or capacity to be a part of the peer group.

Overcompensating Behaviours:

1. Aggression and hostility Tom will be scathing and accusatory of people when he feels they have breached his confidentiality, autonomy or broken a rule. He often will reduce people to tears or they walk off while he is still furious. This may also take the form of being hyper critical of others and being unable to consider alternative motivations for a person’s behaviour other than the ones he has assigned.

2. He will be the dominant sexual aggressor in his interactions.

3. Anger and fury with writer when a session starts late and interprets it as rejecting & disrespectful and will delay what he wants to talk about while he manages the anger.

4. Eating disorder is a mode that emerges when he is not feeling that others are hearing him as he needs. 

The vulnerable child mode is often overshadowed by the angry/impulsive modes.I hypothesise that in the next few years there will be the emergence of some more child modes such as the vulnerable & lonely child but currently they are well protected by these more assertive modes.

Every twelve months of therapy I would ask Tom what he was goals of therapy were and he would always include “finding a life partner”.

This was also always the most sabotaged goal outside of therapy by his behavious including avoidance. 

Core Cognitions & Distortions

1. No-one will ever protect me so I must make sure I protect myself.  I see all the potential criticism in what people do and say to me and I know I shall be negatively judged by others.

2. People are not following the rules and rules must be the priority, there are no exceptions. They must be held to account to me or else they disrespect me and are criticising me behind my back. When there are no rules the world becomes dangerous and chaotic. When I lived outside the rules I could not protect myself.

3. All people are going to reject me and let me down so I must reject them first.

Therapy Relationship

The therapeutic relationship with Tom has been difficult to establish and at times he has behaved in ways that have felt like he wants me to reject him. He has unleashed his angry child towards me as he assumed I had acted against him outside the therapeutic space. He was so vicious and managed to attack me and trigger my own core anxieties. I was unable to contain him and I eventually cried in response to his relentless personal attack on me. I apologised and explained that this was in part in response to him building up to a dramatic permanent exit. However, it ended with him telling me “cancel all the further appointments as I cannot trust you” and I told him his appointments would be there for him. He returned the following week and there was a big shift in his approach to therapy and he began to let glimpses of his vulnerable and sad child into our space.

From this shift, we were able to put the angry child into the corner of sessions and work with the vulnerable child and soothe the parent modes. He was able to stop needing rules and accept the complexity that is life – full of grey areas. For the next twelve months or so the treatment was around allowing vulnerability into the space and experiencing this safely. 

For Tom he wants to have a meaningful intimate relationship and possibly a life partner. Our focus was on helping him contain the angry child, angry protector and demanding parent by learning to notice the shifts, question if needed and ask himself “what do I need from this interaction”. This continued into the near future and with imagery, role play and limited re-parenting we were able to uncover and soothe the sad and vulnerable child.

While working in schema mode approach over two years Tom was able to learn to soothe his child modes and developed a more adult approach to managing when these child modes were triggered.

We used imagery reconstruction, making sure the intellectual (avoidant self) is noted and asked to sit in an alternative chair and constant reparenting.

Finally this year he ceased therapy with no anorexia nervosa and has is working on a  doctorate of philosophy (PhD) that brings together his past experiences as an involuntary patient in psychiatry hospitals for treatment of life threatening anorexia nervosa and his interests in ethics. 

He is now dating and no longer therapy.