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Schema Therapy for Children & Adolescents: Four Case Studies of Inpatient and Outpatient Treatments

by Christof Loose, Lars Wöckel, Julia Patti, Margitta Krahmer, Ursula Neumann & Lukas Oberschneider

General Abstract:

Schema Therapy (ST) is an integrative approach developed by Jeffrey Young as a treatment for less responsive clients in CBT. Schema Therapy for children and adolescents (ST-CA), an adaptation of ST, is a treatment suited for young clients with all kind of emotional and behavioral difficulties. It uses powerful emotional and relational techniques as well as cognitive and behavioral interventions for change. These interventions take in account the developmental tasks and address the core emotional needs for attachment, autonomy, self-esteem, spontaneity & play, and finally identity, structure, and realistic limits. Altogether, we present four different single case studies (aged 6-17 years), three of them inpatient, one outpatient treatments. Detailed, vivid descriptions including pictures of the material used illustrate the treatment of each case in a lively way. Most of the treatment’s results are underlined by pre-post-data and descriptions of the techniques (e.g. case conceptualizations, using play material, chair techniques etc.), and strategies (e.g. limited reparenting-concept, focusing on the emotional need that is behind the symptom etc.) will explain the high level of feasibility and broad acceptance by the young clients observed in the sessions. Colleagues who are not so familiar with ST-CA will get an easy to understand introduction as well as vivid pictorial demonstration of what ST-CA is like.

Segment 1:

Title: Schema therapy inpatient treatment in a 6-year-old girl with OCD, comorbid encopresis and depressive symptoms – focusing on the work with the parents

Presenter: Julia Patti

Objective Case study of a 6-year-old girl with OCD, comorbid encopresis and depressive symptoms, treated as an inpatient. Even after months of outpatient psychiatric treatment, the patient was most limited in her social and public relations. The case presented focuses on the relevance of including the parents through schema therapeutic work with them.

Methods After an unsuccessful inpatient treatment with CBT we installed a schema therapeutic setting. We investigated the parents’ schema landscape in the present, defined which modes exist and how the parents are triggered through the child’s behavior. Schema therapeutic cards were used for visualizing the schemas. We sketched a “schema genogram” over 3 generations with both parents and outlined what kind of schemas and modes the family had accumulated over generations. We identified mode clashes between the child and the parents as also between mother and father and created alternative strategies for situations in which the parents felt triggered.

Results By using schema therapeutic methods with the girl and especially with the parents, a deeper understanding of functioning of the girl’s symptoms was achieved. The parents could create a more stable attachment to each other by reducing the dysfunctional, maladaptive emotional and behavioral patterns. Symptomatology of OCD and depression in the patient was significantly reduced.

Conclusion This case report illustrates that a schema therapeutic approach is a good treatment alternative compared with CBT. It also demonstrates how important and essential schema coaching for parents can be if you want to understand the functioning of the child’s symptoms.

Segment 2:

Title: Inpatient schema-/modebased therapy in a 16-year-old adolescent with school absenteeism – an example

Presenter: Ursula Neumann

Introduction: Schema therapy is one of the so-called "third-wave therapies" of cognitive behavioral therapy and has been developed for non-respondent patients. Since many students with severe school absenteeism and associated mental disorders show low therapy motivation and compliance as well as chronic avoidance behavior, schema therapeutic techniques should be useful for the treatment of these youths. We present an example of inpatient treatment of a 16-year-old youth with long during scholl absenteeism and depression.

Method: The implementation of schema therapy at a psychiatric and psychotherapeutic inpatient unit for adolescents with school absenteeism and associated mental disorders is presented. A case example demonstrate how schema therapeutic techniques can be adapted to the specific needs of school avoiding patients with internalizing symptoms. Multiprofessional Interventions that target chronic avoidance tendencies and that can be integrated in daily routines during inpatient treatment are highlighted.

Results: The chronic avoidance behavior could be broken and the patient did first steps back to school. Without the schema-and modebased therapy the Patient wouldn’t have stayed so long in therapy.

Conclusion: Working with different modes of the patients expecially seemed to be useful in those with low therapy compliance and generalized avoidance behavior and lead to better comprehension of their symptoms. Furthermore, all involved professions reported that techniques such as modus feedback were rather easy to apply, even in difficult therapy situations. In severe cases of school absenteeism, avoidance or refusal behavior not only occurs with regard to school attendance, but also extends to efforts of parents, teachers, and mental health professionals to help the affected youths. Novel therapy approaches developed for difficult-to-treat-patients such as the schema therapeutic one presented here offer new ways of building and sustaining a therapeutic alliance and enable therapists to resolve both school refusal and "therapy refusal".

Segment 3:

Title: Schema therapeutic outpatient treatment after one year DBT-A in a 17-year-old girl with NSSI, PTSD, atypical anorexia nervosa and social phobia

Presenter: Margitta Krahmer

Objective: Therapeutic outcome in a 17-year-old female teenager with multiple psychiatric diagnoses resp. symptoms (severe NSSI, atypical anorexia nervosa, social phobia, depression and suicidality).

Methods: A 14 months DBT-A-treatment with weekly sessions didn’t achieve a substantial symptom reduction. The following schematherapeutic treatment enabled the young patient to develop a deeper understanding of unmet emotional needs, their active patterns, and ultimately the functionality of their behaviors. Based on a deeper understanding of coherences between the biography and the functionality of presented symptoms a case conceptualization had been established. At this time being a couple of schematherapeutic techniques (e.g. mode interviews, chair dialogues, imagery rescripting) are particularly being used in our weekly sessions.

Results: The results achieved so far appear in a stronger commitment (compared to the DBT-A-approach) in terms of a greater readiness to deal with the various symptoms, in a more functional way to focus emotional needs and to handle interpersonal conflicts, in a weight gain (BMI 17.4 to 19.3) und reduced self-harming behavior (1-2 NSSI per week before, now 1 NSSI every 4-5 weeks).

Conclusion: Scientific studies have repeatedly demonstrated the efficacy of DBT-A-treatment in patients with severe NSSI. This case study illustrates that in patients who were not motivated and/or able to make favorable behavioral changes in the context of DBT-A-treatment - even when applied for a longer time - a schematherapeutic approach may be an efficient method, to develop a deeper awareness of the functionality of one's own behavior and thus contribute to the desired symptom reduction.

Segment 4:

Title: Schema therapeutic inpatient treatment of a 14-year-old girl with depression: A way to feel better

Presenter: Lukas Oberschneider

Objective: Single case study of a 14-year-old girl, that showed symptoms of depression for over a year (e.g. sadness, emptiness, hopelessness, guilt, worthlessness, irritability, low energy, indecisiveness). The symptoms prevented her from functioning in her everyday life (occurring home and school). She wasn’t able to go to school, was snapping at her parents or getting into arguments without good reason, stopped spending time with friends and family and lost interest in other things she used to enjoy. More often she identified suicidal thoughts, so that especially her parents were looking for help.

Methods: In an inpatient psychotherapy treatment, we had to build a stable relationship by exploring resources, strengths, and positive schemas. Afterwards we outlined a psychoeducational model, followed by creating a mode sketch and finally using schema therapy cards for visualization. Therefore we investigated wishes, needs, emotions and functionality of each mode and supported training in daily life.

Results: By using schema therapy methods and integrating the parents, the inpatient was supported in building up a stronger feeling of self-efficacy, what caused a reduction of depressive symptoms significantly. Additionally, the possibility was given after treatment’s completion to go to school regularly, to cultivate better social relationships and to find a way to deal with emotions.

Conclusion: The combination of schema therapeutic, mode- and need-guided treatment and work with parents yielded lasting effects on that girls depressive symptoms.

About the Presenters:

Christof Loose
Christof Loose, PhD, is affiliated with Heinrich Heine University at the Institute of Experimental Psychology in the Department of Clinical Psychology, and has a private practice in Dusseldorf, Germany. He is an Advanced Certified Schema Therapist, Supervisor and Trainer in Individual and Children and Adolescents Schema Therapy. Christof was the chair of the Workgroup for Schema Therapy for Children and Adolescents (ST-CA) for several years, and is the editor and author of several ST-CA books and videos (DVDs) in Germany. He conducts workshops and seminars in ST-CA worldwide.

Lars Wockel

PD Dr. Lars Wöckel, MHBA, Child & Adolescent Psychiatrist, Practice atthe Universities of Tübingen, Central Institute of Mental Health Mannheim,Frankfurt/Main and Aachen (Germany), Habilitation (Ph.D.) for Child and Adolescent Psychiatry and Psychotherapy (RWTH Aachen), Umhabilitation (University of Basel, Switzerland), since 2010 Head of Department and Member of Executive Board of Center of Child and Adolescent Psychiatry and Psychotherapy, Clienia Littenheid AG, Switzerland, certified Behavior Therapistand Supervisorin Behavior Therapy and Systemic Family Therapy.

Julia Patti

Julia Patti is specialized in child & adolescent psychotherapy. She used to work for a mental unit specialized in child and adolescent psychiatry in Switzerland for inpatient clients (Clienia Littenheid AG). Currently she is living in Denmark where she has worked in an international psychology group in Copenhagen with outpatients (MacFarlane psychology group). She is doing further education for schema therapy as well as research about the effects of schema therapy.

Margitta Krahmer

Dr. Phil. Margitta Krahmer is a Switzerland based psychotherapist for children and adolescents and works for a mental unit specialized in child and adolescent psychiatry (Clienia Littenheid AG) both in outpatient and in inpatient senior positions. She is a certified Trainer/Supervisor in Schema therapy for Children and Adolescents (according to ISST e.V.) and a certified DBT-A Therapist.

Ursula Neumann

Ursula Neumann is a psychotherapist for children and adolescents in the LVR-clinic Essen, since 2017 in further education to schema therapist, development and implementation of schema therapy in a psychiatric inpatient unit for adolescents with school absenteeism and associated mental disorders2004 master degree in catholic theology, 2007 basic curriculum in family systems therapy, 2008 master degree psychology 2010 clinical psychologist, University Clinic Freiburg, 2016 certified cognitive-behavioral therapist for children and adolescents, Address: Clinic for child and adolescent psychiatry, psychosomatics, and psychotherapy, LVR-clinic Essen, clinics and institute of the University of Duisburg-Essen. Email 

Lukas Oberschneider

Lukas Oberschneider works as intern in his training to become a specialist in child and adolescent psychiatry on the schema therapy based inpatient therapy ward for children and adolescents of the Clienia Littenheid AG in Switzerland. Born and grown up in Austria, he studied medicine in Munich and worked at the department for pediatric psychosomatics and psychotherapy of the Dr. von Hauner Children's Hospital in Munich. Additionally to working with schema therapy, he is completing the psychotherapy training at the C.G.-Jung Institute for Analytical Psychology and Psychotherapy in Zurich.

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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