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Group Schema Therapy for Personality Disorder

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Cognitive Group Therapy. (2014) Editors: Larsen, B & Nyland, T. Hans Reitzels

Forlag (in Danish)

Chapter 8. Highlights of Group Schema Therapy

Joan M Farrell and Ida Shaw

1. Introduction

Schema Therapy (ST), developed originally for individual psychotherapy, grew

out of efforts by Young to more effectively treat patients with personality disorders and

those who either did not respond to traditional cognitive therapy or relapsed (Young,

1990; Young, Klosko & Weishaar, 2003). Farrell & Shaw (1994, 2012) developed Group

Schema therapy (GST) for the treatment of patients with Borderline personality disorder

(BPD). GST has demonstrated its effectiveness for BPD in reducing symptoms and

producing a high recovery rate that includes improved functioning (Farrell, Shaw &

Webber, 2009). ST, whether individual or group, is a comprehensive evidence based

approach to the treatment of a wide variety of psychological disorders. GST has been

adapted for the treatment of other personality disorders and features as well as complex

trauma and chronic depression (Farrell, Reiss & Shaw, 2014). Studies of its

effectiveness for Avoidant PD, Antisocial PD, mixed PD groups, Eating Disorders, Post-

traumatic Stress disorder, Dissociative disorders, Substance Abuse and Psychopathy in

treatment programs of lengths from 30 sessions to two years; inpatient, outpatient and

day hospitals, public, private and forensic settings are underway internationally.

GST (as described in manuals by Farrell & Shaw, 2012 and Farrell et al, 2014) is

consistent with the theory, components of treatment and goals of ST developed by

Young (Young, Klosko & Weishaar, 2003). Like individual ST, GST strategically

integrates aspects of other psychotherapy models such as cognitive and

psychodynamic psychotherapy, object relations theory and Gestalt psychotherapy, but

remains unique having total overlap with no other model. ST is based upon a unifying

theory and a structured and systematic approach. One of the unique aspects of ST is its

strategic integration of experiential, cognitive, and behavioral pattern breaking

interventions to accomplish the goals of the model. Inclusion of all three is necessary to

maintain the integrity of the ST model. We speculate that the large treatment effect

sizes for both individual, group and combination ST demonstrated for BPD patients are

due, in part, to this integrative approach that facilitates deeper level and long lasting

personality change.

2. The Schema Therapy Model of Personality Disorders

Early Maladaptive Schemas (EMS) are psychological constructs that include

beliefs that we have about ourselves, the world, and other people, which result from

interactions of unmet core childhood needs, innate temperament, and early

environment. ST views this interaction in terms of a plasticity or differential susceptibility

model. This expanded definition of EMS goes beyond that of Cognitive-behavioral

therapy to include memories, bodily sensations, emotions, and cognitions that originate

in childhood and are elaborated through a person’s lifetime. These EMS often have an

adaptive role in childhood (e.g., in terms of survival in an abusive situation), however, by

adulthood, they are inaccurate, dysfunctional, and limiting, although strongly held and

frequently not in the person’s conscious awareness. Young (Young et al., 2003)

identified 18 early maladaptive schemas (EMS) in patients with personality disorders

(Table 1).

TABLE 1: EARLY MALADAPTIVE SCHEMAS ORGANIZED BY CONTENT AREA

DISCONNECTION & REJECTION IMPAIRED AUTONOMY & PERFORMANCE
Mistrust/ Abuse Dependence/Incompetence
Emotional Deprivation Vulnerability to harm/illness
Defectiveness /Shame Enmeshment/Undeveloped Self
Social Isolation/Alienation Abandonment/Instability
Emotional Inhibition Subjugation
Failure
IMPAIRED LIMITS EXAGGERATED EXPECTATIONS
Entitlement Self-Sacrifice
Insufficient Self-Control Unrelenting Standards
OTHER
Negativity/Pessimism
Punitiveness
Approval Seeking/Recognition-Seeking

When maladaptive schemas are activated, intense states occur that are described in ST

as “schema modes”. A schema mode is defined as the current emotional, cognitive, and

behavioral state that a person is in. Dysfunctional modes occur most frequently when

multiple maladaptive schemas are activated. Four basic categories of modes are

defined: Innate Child modes, Dysfunctional Parent modes, Maladaptive Coping modes,

and Healthy modes.

Innate Child modes (Vulnerable Child, Angry Child, Impulsive/Undisciplined

Child) are said to develop when the basic emotional needs in childhood (such as safety,

nurturance, or autonomy) are not adequately met. These “child modes” are defined by

intense feelings such as fear, helplessness or rage, and involve the innate reactions a

child has.

Dysfunctional Parent modes (Punitive Parent or Demanding Parent) reflect the

selective internalization of negative aspects of attachment figures (e.g. parents,

teachers, peers, etc.) during childhood and adolescence.

Maladaptive Coping modes are defined as an overuse of survival based coping

styles (fight -overcompensation, flight - avoidance, or freeze - surrender). All have the
goal of protecting the person from experiencing pain, anxiety or fear. These maladaptive

coping modes operate outside of conscious awareness and a goal of ST is that patients

become aware of their coping modes and learn healthier, more adaptive coping

responses. Maladaptive Coping Modes incorporate the idea of defence mechanisms, a

concept previously missing in cognitive therapy, and allow for a better understanding of

personality disorders for clinicians and patients. The overcompensating coping style

(“fight”) contains modes in which a person acts in opposition to the schema or schemas

that are triggered. One example is the: Bully-attack mode in which the pain a person

experiences resulting from a schema is retaliated against by causing pain to another.

The avoidant coping style (“flight”) involves physical, psychological and social

withdrawal and avoidance. Avoidant modes include the Detached Protector (DPM), a

mode that ranges from a person being “spacey” or briefly losing focus in an interaction

to severe dissociation. This is a very common mode present when patients enter

therapy as it operates to protect the Vulnerable Child mode (VCM) from overwhelming

fear or painful feelings. Surrender is the third coping style (“freeze”) and it represents

giving in or giving up to the schema present. For example, if the triggering schema is

defectiveness, a surrender response would be to accept that you are defective and

behave accordingly; for example, never taking on challenges, working to not be

exposed as incompetent.

The Healthy and functional Modes are the Healthy Adult mode (HAM) and

Happy Child mode (HCM). The HAM includes functional thoughts and behaviors, and

the skills needed to function in adult life. The HCM is a resource for playful and

enjoyable activities, especially in social networks. Many patients were neither allowed

nor encouraged to play, thus missing opportunities to explore their likes and dislikes and
take part in our earliest social interactions with peers. The healthy modes tend to be

severely underdeveloped in patients with personality disorders.

Modes are often triggered by events that patients experience as highly emotional.

Modes can switch rapidly in patients suffering from severe personality disorders,

resulting in the sudden changes in behavior or seemingly disproportionate reactions that

are one source of patients’ interpersonal difficulties and emotional and behavioral

instability. Modes can also stay rigidly entrenches as is the case with many AvPD

patients. Common negative coping responses: aggression, hostility, manipulation,

exploitation, dominance, recognition-seeking, stimulation-seeking, impulsivity,

substance abuse, compliance, dependence, \excessive self-reliance, compulsivity,

inhibition, psychological withdrawal, social isolation, and situational and emotional

avoidance can be understood in mode terms.

Table two provides a basic description of the four types of schema modes.

Table 2 BASIC SCHEMA MODES

INNATE CHILD Vulnerable Child Innate responses to unmet needs
MODES Angry/Impulsive Child
MALADAPTIVE Avoidant Protector Over-used survival responses to
COPING MODES Overcompensator trauma or unmet needs- flight, fight
Compliant Surrenderer and freeze
DYSFUNCTIONAL Punitive Parent Selective internalization of negative
PARENT MODES Demanding Parent aspects of early others
HEALTHY Happy Child Underdeveloped
MODES Healthy Adult

Figure 1 summarizes the model for the etiology of personality disorders posited by ST.

INSERT FIGURE 1 HERE

2.1 An Example of the Schema Therapy Model of Personality Disorder: Borderline

Personality disorder

The symptoms of personality disorder can be described and understood in terms

of the operation of schema modes. Here as an example the ST conceptualization of

BPD is described. A similar description of symptoms in terms of schema modes could

be made for the other personality disorders. Abandonment fears describe the emotional

state of the Vulnerable Child Mode. Intense anger, at times accompanied by the

uncontrolled expressions of anger, occurs in the Angry Child (ACM) and Impulsive Child

(ICM) modes. The ICM fuels action that is potentially damaging as well as being one

source of self-injurious behavior. The Dysfunctional Parent Modes (DyPM) are another

source of self-injurious behavior, to fulfil their dictate that the child deserves punishment

or is a failure. The parent modes can also be a source of suicide attempts as they

remove all hope and their judgments condemn the patient to misery and feelings of

worthlessness. The DPM can be a cause of self-injurious behavior, particularly cutting

or burning the skin in order to feel something. The DPM explains the experience of

emptiness, which can be intolerable and lead to suicide attempts. If you are detached

from your feelings, a central part of who you are, your identity will not be stable. Mode

flipping accounts for some of the emotional reactivity seen in BPD patients and

consequently their unstable relationships and sense of self. Other personality disorders

can just as easily be described in mode terms providing user-friendly, understandable

language for patients and the foci for psychotherapeutic intervention for therapists.

Mode language focuses more on the role of learning and less on psychopathology,

giving patients hope regarding change.

3. Goals and Stages of Schema Therapy

 The primary goals are the same for individual or group ST: helping patients

change dysfunctional life patterns and get their core needs met in an adaptive manner,

by changing schemas and modes. These goals reach beyond teaching behavioral skills,

to include the fundamental work of personality change. This change is conceptualized

as decreasing the intensity of maladaptive schemas that trigger the under or over

modulated emotion and action states referred to as modes. The triggering of these

intense states is seen as interfering with patients’ use of adaptive coping or

interpersonal skills that would allow them to realize their potential and improve their

quality of life. The only BPD treatment that has demonstrated improvements in quality of

life and overall functioning is ST. These results are discussed later on in the chapter.

In terms of each type of mode the goals can be elaborated as:

To develop the Healthy Adult Mode so that she/he is able to:

1. Care for the Vulnerable Child Mode. Healthy adult competence is accessible when
fear, sadness or loneliness, which reflect unmet childhood needs, are triggered.
2. Become aware of and replace the Maladaptive Coping modes. For example, be able
to experience emotions when they arise, connect with others and express your
needs. Coping choices are made that meet the person’s need and the reality of the
adult situation they are in rather than defaulting to maladaptive coping modes like
avoidance.
3. Replace the behaviour of the Angry/Impulsive Child mode with appropriate and
effective ways to express emotions and needs; e.g., the ability to express needs in
an assertive adult manner and anger in a healthy way. The long-term consequences
of actions are considered.
4. Overthrow and Banish the Punitive Parent mode; get rid of the harsh internalized
critic replacing it with the ability to: motivate oneself in a healthy positive manner;
accept one’s mistakes and when needed make retribution for them. Moderate the
Demanding Parent mode to have realistic expectations and standards.
5. Free the Happy Child mode so that she/he can explore the environment to learn
about what gives her/him joy in life and can play.
 The goals of each of the modes must be met but their specific or order must be

based upon the presenting modes, needs and pace of each individual group. An

important caveat of ST is that the mode(s) patients are in much be considered in

choosing interventions for a session. Groups, even more so than individual patients, are

dynamic entities with a life and course of their own. Another way to describe this is that

the goal remains the same, but the plan for accomplishing it may change. For example,

if you have planned an experiential exercise for combatting the PPM and you find your

group all in VCM you would attend to safety and comfort and may or may not actively

deal with the PPM in that session. We refer to this as “seizing experiential moments”

since they cannot be revisited in the way cognitive or behavioral work can. This

approach reflects the flexibility of ST combined with strategic interventions.

The Stages of GST and the Goals of each stage

1. Bonding and Emotional regulation
• Healing the Vulnerable Child
• Bypassing the Maladaptive Coping modes
• Affect regulation and coping skills
2. Schema Mode Change
• Replacing Maladaptive Coping modes with adaptive choices
• Combating the Punitive Parent and Demanding Parent modes
• Rechanneling the Angry and Impulsive child
3. Autonomy
• Individuation: following natural inclinations
• Developing healthy relationships
• Gradual termination with the option of future contact

Groups also have naturally occurring stages, summarized as “forming, norming,

storming, working and autonomy”. All stages are facilitated except for “storming”.

Conflict in groups, particularly with BPD patients, must be firmly managed by the

therapists until a much later stage when the group is able to deal with it.
2.3 Therapist approach in ST - Limited Reparenting

Limited reparenting is both a therapist style and an “active ingredient” or core

component of change work. Limited reparenting is defined as: acting as a good parent

would in meeting child mode needs within the bounds of appropriate therapy

relationship. This means providing protection, validation and comfort for the VCM; the

opportunity to vent and be heard, for the Angry Child and, empathic confrontation and

limit setting for the Impulsive Child mode. The behaviors of the schema therapist can be

summed up as “doing what a good parent would”. Early in treatment strong parenting is

needed as patients are frequently in child modes and have an underdeveloped HAM.

Later on there is more HAM presence and the therapists’ role changes to being

“parents” of adolescents and then eventually adults. In this later phase patients still

need the therapists to maintain connection, but are able to do some parenting of

themselves and each other. The language, sophistication, and the use of specific ST

techniques must be adapted to the developmental level, comorbid disorders, and

psychological health of the group members. Some techniques and terminology that may

be helpful with BPD patients may not be acceptable to Narcissistic Personality Disorder

patients, etc. When working with the Vulnerable Child mode, we sound like parents

talking to a young frightened child. When confronted with Maladaptive Coping modes

we can become very firm, while at the same time not losing touch with connection and

empathy with the feelings and needs underneath the mode).

The goal of limited reparenting is to establish an active, supportive and genuine

relationship with the patient that provides a safe environment for the patient to be

vulnerable and to express emotions and needs. The therapist’s provision of limited re-

parenting within the psychotherapy relationship allows the patient to fill in critical early
gaps in emotional learning via secure attachment and accurate mirroring that leads to

experiencing feeling valued and worthy often for the first time. Initially, the therapist tries

to compensate for the deficits in their emotional needs being met. ST assesses the

strength of patients’ HAM and fills gaps in learning about needs through an initial phase

in which therapists meet needs directly, providing new positive experiences. The new

experiences, interactions and implicit attitudes that make up the process of meeting

core emotional needs become the building blocks for the Healthy Adult Mode. The

unmet childhood needs include: safety, consistency, validation, appropriate boundaries

and healthy limits. Over time, the experience of the therapy relationship fosters patients

learning to care for their own needs in an effective manner and eventually to attain

autonomy and healthy interpersonal functioning. This approach to needs is in sharp

contrast to most other models, which focus too early on patients meeting their own

needs. Table 3 describes the relationship among the mode a patient is in, the unmet

childhood need involved and the needed therapist intervention.

INSERT TABLE 3 ABOUT HERE

Adaptations of limited reparenting are necessary when used in a group. Group

therapists must focus on and balance the collective need of the group versus an

individual’s needs as a parent would for a group of siblings. Group reparenting may be a

closer approximation to patients’ developmental experience, unless they were only

children. This closer match with the early environment has the potential to expand and

strengthen schema healing experiences. In GST needs are met by both the therapist

and the group. GST offers additional opportunities for emotional learning and

socialization from these interactions with “sibling” group members and from the
experience of belonging to a group “family”. Two of the first and primary tasks of the

schema therapist, whether working in individual or group, are establishing connection

and safety. In both modalities this comes from the therapist communicating validation,

acceptance, liking, that you care and they matter, that you are trustworthy, reliable and

consistent. In the group it is also a therapist task to facilitate connections between and

among patients, facilitate their bonding with each other and helping them develop a

sense of belonging in the group. Belonging comes initially from discovering that they

share the experience of some common problems and feelings, along with the common

childhood experience of some unmet childhood needs. Over time, belonging can

expand as they share emotional experiences in the group and develop shared

memories. In intensive settings with multiple weekly group meetings we emphasize the

aspects of the group that are like a family. This adds “re-family” experiences to the

limited reparenting of ST.

In the group establishing firm ground rules regarding the way patients treat

each other, physical boundaries, respect and commitment and enforcing them is crucial.

Therapists need to tell patients in group that they will keep them safe and behavior must

be consistent with this promise. As a “good parent” the group schema therapists

enforces limits for the good of all, and attempts to treat all patients as equal and in a

manner perceived as fair. This means managing conflict and stopping negative attacks

including those that are mode driven (e.g. bully-attack mode behavior). It is important to

manage conflict in early sessions until the group has the strength to deal with it in a

healthy manner and resolve differences or misunderstandings. Group is an excellent

place for patients to learn conflict resolution and relationship management with therapist

guidance. A group presents therapists with both opportunities and challenges not
present in individual ST. Therapists must model a strong, consistent, affirming, and

supportive presence for each patient and the strength to reparent the group. Part of the

foundation of ST is secure attachment; in a group the secure connection this requires is

best accomplished by two therapists. The ideal number of therapists is a function of the

developmental level of the group members. With BPD patients, we are dealing with

people stuck at childhood developmental levels with early emotional learning deficits

(e.g. lack of secure attachment, deficits in emotional awareness). With forensic patients,

two therapists are needed to maintain safety and the ground rules as well as setting

limits on the overcompensating modes that frequently occur in this group. Two

therapists for Avoidant patients help keep anyone from “falling through the cracks“ and

getting lost in the group. If only one therapist is possible in a setting it will be helpful to

increase the amount of structure (e.g., homework review, working together on

assignments, more use of written exercises). Connection is maintained in part by one of

the therapists making eye-contact in a directed manner around the group. The eye

contact when returned can be followed by a nod or little smile, some non-verbal

acknowledgment. Even when patients do not return eye contact they report that they

are aware of being checked on and that this is reassuring. One of two therapists can

also move to sit closer to a patient in distress without stopping the work the other

therapist is leading. He/she may give the patient in distress a piece of soothing fleece, a

shawl, another comfort object kept in the group room. The two therapist roles are

equally important. One therapist can stop the action if the individual focus has gone on

too long and the rest of the group is detaching or the tension level in the group needs to

be reduced. For example, saying, “We need to stop for a moment and check in with the

rest of the group. Everyone just take a nice, deep breath and shake out your shoulders“.
This is followed by a brief check-in and regrouping before going back to the work or

changing direction somewhat to better meet the needs of more group members. As a

beginning co-therapist team it is helpful to plan ahead of time who will take what role in

terms of material to present, leading an exercise, etc. Over time it becomes second

nature for one therapist to move to role 2 when the other is in role 1.The “dance“ of the

two group therapist is described extensively in Farrell & Shaw (2012) and demonstrated

in a DVD series of Farrell & Shaw leading a group of patients with BPD (played by

schema therapists) (Zarbock, Rahn, Farrell & Shaw, 2011).

4. The Interventions of GST: Cognitive, Experiential and Behavioral pattern-

breaking

A defining aspect in all ST is the balance among experiential or emotion focused

work, the cognitive processing of awareness and insights that occur in the course of the

experience and behavioral pattern breaking. Highlights of these interventions are

presented here. A complete description including sample therapist scripts, written

handouts for patients, exercises and homework as well as the plan for their delivery and

adaptation to various populations are presented in detail in Farrell & Shaw 2012 and

Farrell, Reiss and Shaw, 2014.

4.1 Cognitive Interventions

Cognitive interventions appeal to reasoning and engage the thinking, rational part of

patients in fighting their maladaptive schemas and recognizing schema modes. We

usually start with cognitive work to build a verbal framework for later experiential work.

Cognitive interventions are usually better tolerated, less anxiety producing and more

familiar to patients than experiential work. It is important to create doubt about the core

beliefs, or cognitive components of schemas, in order to motivate change. To patients

schemas are facts, the way they view the world, themselves and other people. The idea

that schemas distort our view is an alien one in the beginning of ST, unless a patient

has done other cognitive therapy. The cognitive component of schemas, core beliefs, is

based upon early learning experiences. In people with severe personality disorders,

these beliefs are extremely rigid and entrenched. It is a case of the “first thing learned”

also being the “last thing learned” and part of the reason this group of patients is so

stuck in their maladaptive patterns. The main cognitive techniques used in ST are pro

and con lists, information, self-monitoring, evidence logs, flashcards and work to identify

the cognitive distortions involved in maintaining schemas.

4.2 Experiential, Emotion-focused Interventions

These interventions operate at the level of emotion and provide the corrective emotional

experiences necessary to change EMS. Young (2003) describes this component of ST

as “fighting schemas on the affective level.” These are the interventions that can change

the felt aspect of schemas and modes. Patients often tell us “I know in my head that I

am not worthless, but I feel bad and worthless”. Learning occurs more dramatically and

faster in the presence of affect. Experiential interventions evoke affect. Groups are a

particularly good venue for this work because of the augmenting effects of groups on

emotional experiences. We think this is due in part to group being a close analogue to

the family of origin with all of its implicit associations and memories. The main

experiential interventions of GST are imagery work including imagery rescripting, mode

role plays and dialogues, use of transitional objects, play and other creative and

symbolizing work (e.g. specific exercises we have developed like the VCM “treasure

box” and identity bracelets (see example 3). Some interventions target early

developmental levels and facilitate internalizing the therapist as a “good parent” and
learning to self-soothe. There is a range of corrective emotional experiences possible to

facilitate in the ST group. Some examples are: experiences of acceptance and

belonging, universality, feeling that you matter, have worth and competence and that

you are lovable. To increase emotional awareness we have patients self-monitor a

range of aspects of their experience in everyday life and when doing experiential

exercises in group. We begin with kinesthetic exercises as we have found that most

BPD patients are at the sensor-motor level of emotional awareness. According to Lane

and Schwartz (1987) this is the level at which action urges are experienced without

verbal labels.

4.3 Behavioral pattern breaking interventions

As we know from psychotherapy outcome research, behavioral pattern breaking

is an important component of change. Behavioral change starts in psychotherapy

sessions then moves to the patient’s world outside of therapy. An advantage we have in

the group is its capacity to be a microcosm of the real world. The group can be a safer

place for patients to try out new healthier coping strategies, to risk being vulnerable, and

a place to practice new behaviors and receive constructive feedback. The behavioral

pattern breaking stage of treatment in ST is the point at which the patient is aware of a

schema driven dysfunctional mode being triggered and is able to choose a healthier

response that will get his/her needs met. It is important during this stage to continue to

collect evidence about the improved outcome of these new strategies and to practice

and fine tune them.

The group itself is an important source of interpersonal learning, offering modeling and

opportunities for vicarious learning. Our patients frequently have told us that it took

watching an ACM tantrum in a peer for them to truly understand the effect of that
 behavior on others and to be motivated to change. The ST group functions as a

supportive family, usually the first time a patient with BPD has experienced this. We first

learn about ourselves from the reactions of others to us and from the descriptive labels

we are given. The group is a place to have early misinformation corrected. The

comments and new positive labels from peers can be powerfully challenging to the

defectiveness/shame schema. Group is a place to practice forming and maintaining

healthier relationships, explore boundaries, communication, conflict resolution and

negotiation when needs conflict. Because the impairment of personality disorders has

such a large interpersonal component, one might argue that an interpersonal setting

has some real advantages as the setting for healing work to occur.

5. The Format of Group Schema Therapy

TABLE 4: MODELS OF GROUP THERAPY

MODEL EXAMPLES GOALS THERAPIST ROLE USE OF EACH MODEL IN GST
Interaction Interpersonal Change • Outside of group • Uses group dynamics as a source
or Process groups problematic • Stimulates interaction, but of change (group curative factors)
group Psycho- behaviors using does not guide it • Therapist is part of group and
dynamic group dynamics. • All can start interaction at actively leads and directs
groups High emotions and any time members
Encounter conflict are
groups desired.
Person- Gestalt Work on individual • Focus on & support the • Work is done on individual needs
oriented Cognitive needs and goals. protagonist and goals, but always linked back
Group Therapy • Foster instrumental group to the commonalities among
Psycho-drama conditions members
Problem- • Structure the session • Members aid in individual work
solving • Members aid protagonist and join into the work
Therapy in their goal • Attention to group process is
prioritized over instrumental
conditions
• Aid among members is mutual
Psycho Manualized Knowledge & • Teaching information • Psyched and guidance are
educational group therapy Skills • Teaching skills provided in child modes
or Disorder- for specific Empowerment • Structure the session • Rather than a “middle patient” –
specific disorders:(e.g., (expert on own • Guide the group attention to all patients’ needs
Group depression, illness) • Focus on the “middle and goals are balanced
anxiety, BPD) patient”. • Experiential work is prioritized
over skills
Group GST Schema mode • Conduct the group in a All of the above are aspects of
Schema (Farrell & change that allows manner that harnesses GST however, they are
Therapy Shaw, 2009; changes in group process & curative strategically directed by the
2012) dysfunctional life factors therapist(s) as “good parents”
Combines patterns and • Act as a good parent
aspects of all allows getting core matching group’s
three with needs met in an developmental level
total overlap adaptive manner. • Encourage group
with none. members participation in
reparenting
GST combines aspects of the other forms of group therapy strategically and

always with direction from the therapist(s) as “good parents” Table 4 summarizes the

main models of group therapy and their integration into GST. (Farrell, Reiss & Shaw,

2014)

In GST we facilitate the therapeutic factors innate to well run groups: universality,

belonging, altruism, existential factors, corrective recapitulation of the family, vicarious

learning, in-vivo learning, expanded information sources (Yalom & Leszcz, 2005) – in

the service of ST goals and interventions. A summary instruction regarding therapist

tasks could be: “Do group schema therapy, not just individual ST in a group.” The switch

from individual to group ST requires using the potential of the group for any individual

work and making any individual work relevant for all. A goal of group ST is that every

patient have some defined role in experiential exercises, no one is left just watching. It

may be the role of an assigned observer who has a specific monitoring task, or if

someone is in some distress the task for them may be taking care of themselves by

taking a seat out of the action wrapped in a shawl, but no one is left out.
 Sessions are 90 minutes long with a 10-15 minute break.

Typical Session Structure:

1. Begin with a safety exercise (e.g., Safety Bubble, later on Safe Place image or
Good Parent Script)
2. Set agenda collaboratively with the group based on the mode of the week,
3. Provide a cue for all to respond to (e.g., ask all to briefly answer one homework
question)
4. Experiential or cognitive exercise
5. Break
6. If 4. Was experiential, process cognitively. If 4 was cognitive, use a related
experiential exercise
7. Additional discussion as needed
8. Something for the Happy Child
9. Wrap-up and distribute homework
10. Brief safety exercise

The general order of interventions is based upon the tasks involved. For example,

maladaptive coping modes of DP must be cleared away so that the VC can be reached.

The PPM and DePM must be held at bay for the VC to feel safe enough to be present.

Once the VC is available, the needs of the patient can be identified and met more

directly. This healing process reduces the frequency of AC or IC modes erupting and

interfering with functioning and interpersonal relationships. During this process the HC

is encouraged to come out and play and the HA is strengthened.

.6. Examples of Interventions and Group Session

6.1 Early Group Sessions: Facilitating Cohesiveness and Connection

In the first group session we utilize a ball of yarn to demonstrate the role of connection

in the ST group. What follows is the way we present the exercise.

The Group Connection exercise

“We are going to do an exercise now with this ball of yarn. First I am going to wrap it
twice around my hand so that I have a firm connection and then I am going to throw it to
one of you. When I do, I will say my name and my role in the program. The other
therapist(s plural as needed) will all do the same thing. I would like each of you to tell us
your name and where you are from. Wrap the yarn around your hand, not too tightly and
when you are ready to throw the ball, make eye contact with the person you are
throwing to and let it go. That will help their chance of catching it. The last person who
will be thrown to is (name the other therapist)”.

Patients and therapists toss the ball of yarn back and forth, each person connecting to
the yarn by wrapping it around their hand so that a web of connections is constructed
within the group circle. After all are connected once with the yarn we have them make
another connection around the circle from person to person. Then we comment on the
added connections. [make sure that you have a large enough ball to include everyone
with the two connections.]

“Now we are going to make a second connection. Wrap the yarn around your hand
again and then pass it to the person on your right and say your name one more time.
When it gets to T2 he/she will throw it across to me. [After this is accomplished] Be
aware of all the connections we have right now, feel the strength of them, (the therapists
playfully tug their various connections making eye contact with group members and
smiling.) [In the rare occurrence of the yarn breaking – quickly tie a knot to bring the
ends together and say, “Fortunately even if a connection breaks briefly here it can be
restored.”] Take a snapshot of our connection matrix in your mind’s eye that you can
later bring to mind to remember your place in the group. Look at all the connections and
see how we are all linked together. Every one of you is important to the group. You
matter and are needed to make our group strong and whole”.

The next part of the exercise starts with the therapist and asks what each person wants one
of their connections to represent or contribute to the group. The therapist who has not been
leading so far pulls on one of the strings attaching her/him to the group and says:

“I want this string to represent trust. (Then he/she looks to the right hand patient). What do
you want your connection to the group to represent? (This is repeated until all have had a
turn. After that the therapist again points to the connections.) Let’s feel the strength of our
connections again. (tug playfully). I want you to pay close attention to what happens if I do
this (T1 lets go of the yarn). Could you feel it? What if one more lets go? How was that, what
did it do to our connection? (leave time for some responses) That is what happens when
one of us is not here –a connection is lost. [After brief discussion] Let’s restore our
connection now. How does it feel when we do that? [despite patients just meeting each
other they usually respond to the connection being dropped. If no one verbalizes this, the
therapist can model a reaction of some loss or difference in energy or even temperature –
less warm.] We aren’t going to keep this in place all the time, but when we want to really feel
our connection reinforced we can bring it out. For now let’s lay it down on the floor in front of
us. We do have some ways to keep your awareness of our connection in the group.”

This is usually a positive exercise for patients. If a problem arises we respond to it in terms
of the ST model. For example, if someone feels uncomfortable with the connection, we do
not force it, rather support them connecting at whatever level they can. That may mean
sitting in the group with the connecting yarn attached to their chair not their body or if they
do not feel safe connecting with the group as a whole, but have therapists or patients they
feel safe with, let them use a piece of yarn to connect with that person. Our goal here is the
beginning of a connection that accepts differences as well as similarities

We emphasize connection since work on secure attachment is an important goal of ST and

bonding is where treatment begins. At this point we want to give patients a tangible object
that symbolizes their membership in the group. One of the variations we use is to give each
patient a glass bead that represents the group to place on the string and have the person
sitting next to you in the circle tie the bracelet with bead onto your wrist. We call this one the
“bead of membership” and it is very popular with male and female patients. We have people
who we met with years later who still had their beads made into a key chain or on the string
in their purse.

6.2 Group Identity bracelets to combat Defectiveness/shame EMS

We also use beads and other transitional objects to stimulate recall of EMS

contradicting experiences in group. One example that we utilize to impact the

defectiveness schema so common in personality disorder patients and to strengthen

their budding positive sense of identity is the “group identity bracelet”. In a group

session, the therapist provides a selection of inexpensive beads and group members

and therapists select a bead for each member that represents a personal characteristic

of him or her that they like or value. The “identity bracelet” is built for each person by the

group members taking turns presenting a bead they have selected and making a

statement about what it represents. This process continues until all patients have a

completed bracelet. The therapist then leads an imagery exercise that includes feeling

the bracelet on one’s wrist, going over in visualization the experience of receiving the

beads with the instruction to let the bracelet represent and anchor in memory what it felt

to take that in. This experience can then be recalled with the therapist or group’s help.

In a later group session, a group member was talking about how she “knew in her head”

that she was not a hideous monster, but she “felt like one”. She was asked to recall the

bracelet experience, and a smile came to her face as she extended her wrist with the

bracelet on it. We had her put her other hand over it, close her eyes and recall the

experience as fully as possible. She was able to do this and the positive feelings of

acceptance and value that came to mind combated her old feeling of “being bad” and

even capable of “contaminating” anyone she touched. The use of the bracelet to trigger

memories of schema contradicting experiences was repeated many times and the

group as a whole was given the assignment of touching their bracelet and recalling the

experience at times when the PPM or DePM threatens to disconnect them from others.

The group bracelet representing positive peer group feedback became a physical

anchor upon which to build a more stable positive identity. Before this experience, Jill

would rarely leave her home because she feared being pointed to and called names as

she had been as a teen in a small rural town. This is an example of using the therapy
group to heal adolescent mode vulnerable child experiences. In this example, a tangible

object that represented the experience of being accepted and cared for in a peer group

broke through to a patient usually locked in detached protector with a vicious punitive

parent berating her defectiveness. Jill’s dramatic facial transformation from pain and no

eye contact to reflexively touching it while looking up and smiling when reminded of her

bracelet is evidence of being affected at the emotional level. This reaction continued

whenever she was reminded of the bracelet and she was still wearing it when

discharged from the hospital.

6.3 Mode dialogues to banish the Punitive Parent Mode and get through the
Maladaptive Coping Modes
Mode dialogues are an important intervention in ST that allows a patient to

experience their various modes in an intensified way. These interventions are

particularly helpful for the goal of banishing the PPM. In groups we have patients or

therapists play some of the modes involved in a situation a patient is struggling with. In

the beginning it is usually the therapist who plays the “good Parent” part of the HAM to

challenge the PPM. The patient often plays her/his PPM as she/he knows best what its

messages are. Mode dialogues can be used directly or with particularly avoidant or

detached patients they can be used as vicarious learning opportunities – one of the

therapeutic factors unique to groups. A patient may start by just observing a mode

dialogue of another patient’s PPM. Patients are often afraid to play themselves even

with the support of the therapist as a good parent. They can have their role be played by

another group member, while they watch and listen, taking in the limit setting by the

good parent and her encouragement and comfort. While observing, the patient should

be in whatever degree of safety she needs – e.g., safety bubble, covered up, holding
co-therapist or other member’s hand, etc. Over time, this patient can play herself

protected by the group and/or therapists, and eventually play her HAM banishing her

PPM. Observing mode dialogues can be a helpful “one step removed” starting point for

the experiential work with PPM that patients, in particular those who were abused, are

terrified of, but desperately need. An example is Rhoda, a patient who was very afraid

to participate actively in mode dialogues. In one group session, she was willing to have

others play her modes. Rhoda, listened to the therapist confront her PPM (played by a

peer) about the way she had treated Rhoda as a child. After the PPM was banished

Rhoda said in a very emotional voice “I don’t know where I would be today if I had heard

good things like that growing up”.

Sometimes a mode dialogue designed to help banish one group member’s PPM

may vicariously affect another group member’s avoidant MCM. This happened with

Jane, a patient very resistant to discussing or even acknowledging having a PPM,

despite having survived horrific childhood sexual abuse including being “rented out” for

sex by her adoptive mother. Mode dialogues as vicarious learning can also break

through Angry DPM. Jane’s MCM tended to be the angry version of DPM. This version

of detachment uses anger as a barrier to keep others away. She frequently came into

group announcing in an angry voice “I am not answering any questions today”. On such

a day we were conducting a mode dialogue in which a patient (Diana) played her PPM

and the therapist played the “Good Parent” part of HAM defending the VCM. After a

short intense interaction, the therapist said “It is time for you to leave, you old bitch. Get

out of here and leave Diana alone!” (this language and approach were appropriate for

the patient’s experience and the severe abuse from her adoptive mother). The rest of

the group applauded and the patient playing her PPM nodded smiling. She was asked
“what did you like best of what was said in your defense?” Jane, who had been sitting at

the edge of her chair while the “banishing” was going on, jumped in immediately “I loved

it when you said “get out of here you old bitch”. She followed this with talking about how

she wished she could do that with her mother, but was afraid to. Diana said, “I can

understand that, I was scared at first. I liked everything the therapist said to her and the

“old bitch” was the best, because that is really what they are. I am sick of living with her

in my head, I want her out for good.” As the session continued Jane shared some more

information about her childhood that neither the group nor the therapists had heard

before. This example illustrates the power of the vicarious learning opportunities group

provides in getting around the MCMs. In contrast, when Jane’s Angry DPM had been

empathically confronted in previous groups, she either charged angrily out of the

session or shut down completely. This was the first time she had revealed such

personal information to the group or admitted that her childhood was not idyllic.

6.4 Imagery rescripting in Group for the Vulnerable Child Mode

We begin all imagery rescripting sessions by having all patients access their safe place

image. We remind them before we start VCM work that they can always return to that

image if they feel too frightened or overwhelmed by a mode image. This instruction

serves a dual purpose as the ability to go to a SPI when needed is a skill they need to

develop to balance default triggering of a MCM. Next we instruct them to switch to an

image of their vulnerable child. We have them stay with that for a few minutes then

come back to being in the group with eyes open. We ask about their experiences.

Usually there will be some group member who reacts emotionally, often because they

are dealing with a situation in the present that is connected to the VCM image they went

to. We have that person go back to the image, describe it and identify what the
emotions and need are so that the group can work creatively to supply the need or help

the person get the need met.

Deb was someone whose self-aggrandizing and passive aggressive MCMs

behaviors caused her to be disliked and scapegoated outside of sessions. She was not

always included in social invitations from the group. Deb immediately said that she had

been in VCM all week because it was the anniversary of a dear friend’s death. She told

us that this was really hard because she made her first suicide attempt just after this

friend died. Deb also said that she had been doing some minor cutting during the week.

Ida, the therapist, had her go back to the image of little Deb and describe it. Deb said

with difficulty that she was “8 or 9 and on the school playground all alone, feeling lonely

and weak”. Ida asked if she could move to sit next to her Deb said yes. Ida asked if she

would like her to hold her hand. Deb said yes. Ida said something about what a precious

little child Deb was. With some additional questioning, Deb communicated feeling that

“she mattered” with Ida sitting by her and that she was “part of something”. The needs

identified were worth and connection. Ida said some reassuring good parent things

about the worth of “Little Deb”. Joan attempted to pull the group into the imagery by

asking if Deb could be aware of “all of her little friends” on the playground too who

would be happy to play with her. Unfortunately, Deb nodded “no”. Because of this

answer, to avoid further alienation from the group Ida had her open her eyes. We pulled

the rest of the group in by asking if their little VCM ever felt what Deb had expressed.

Each shared some of their VCM feelings and seemed to be in touch with those feelings

emotionally, which had an overall connecting effect for the group. At that point, Joan

asked the group if they felt comfortable taking each other’s hands as a circle of little

friends for each other. They did so. We asked them to try to experience the warmth,
connection and belonging of the circle and let that in. Joan then asked them to be aware

also of their strong healthy adult women and the strength, resources and support of the

group (this was done because it was year two of the group. Earlier on we would not

have focused on the HAM). We discussed the experiences of each member during the

imagery exercise then moved on to rescript another patient’s memory.

After this session the group invited Deb to go with them for coffee. In subsequent

sessions they were able to give Deb feedback about how off-putting her bragging was

and how appealing she was when she was “more real” and let them know her as she

did in the imagery work. She was no longer treated like a scapegoat and was much less

overcompensating in her presentation in the group. Not every member in every session

does specific individual imagery work, but all are involved in the group imagery. We

keep the individual focus relatively brief (not more than 12 minutes), using it as a

launching pad of sorts for work that is targeted at common issues of the group. In this

way the group is always brought into any individual work. We avoid experiences that

would feel like individual therapy while a group is just watching.

7. Clinical considerations

7.1 Patient Populations that can be treated with GST

GST can be implemented across a wide range of patient populations, treatment settings

and lengths. It is ideal for are those with personality disorders (PD) or PD features,

those with chronic depression or interpersonal problems, complex trauma and those for

whom other treatment approaches have failed. In general, these are patients who are

treated in higher levels of care and whose life potential is tragically not realized in the

quality of their lives. The model of ST can be described as “trans-diagnostic”. All ST,

group and individual, approaches treatment by targeting maladaptive schema modes

rather than specific symptoms or disorders, thus transcending psychiatric diagnoses

and impending changes in diagnostic classification. The use of GST for Avoidant PD,

Social Anxiety, Eating Disorders, Post-traumatic Stress disorder, Narcissism, Antisocial

PD, mixed personality disorder, Dissociative disorders, Substance Abuse and

Psychopathy is being implemented and evaluated internationally. We suggest that

homogeneity may be important for some groups of patients. These include BPD and

Antisocial PD. Avoidant PD and Dependent PD can be treated with BPD. It may be

possible to treat Narcissistic PD and Antisocial PD together in a group, but this is

untested. For the BPD group studies to date Narcissistic and Antisocial PDs have been

excluded. Both men and women are included in the ST groups.

7.2 Training and Treatment Manuals for GST

Like most approaches to psychotherapy that go beyond skills training, ST

requires specialized training to meet adherence and competence standards. Farrell &

Shaw (2012) published a comprehensive manual for using GST with BPD. A second

manual for developing and implementing individual and group ST programs for wide

range of personality disorders, complex trauma and other challenging populations has

been published (Farrell, Reiss and Shaw, 2014). This manual was designed to make

IST, GST, and their integrated combination accessible for a wide range of

psychotherapists of multiple theoretical orientations including those working in intensive

settings like inpatient and day therapy programs. The manual provides a detailed step-

by-step guide for a ST fundamentals program with 12 IST and 42 GST sessions. Each

session is described in terms of goals, therapist interventions, tips on management and

sample session scripts for therapists to adapt, and corresponding information handouts,

ST exercises and therapy assignments. The individual sessions are designed to be

complementary to the group work and the schema mode being focused on while still

allowing individual needs to be met. How to balance individual and group focus is

discussed throughout. This level of detail will allow therapists new to ST to conduct

sessions with confidence and coordinate group effectively with individual work. It will

also allow more experienced individual schema therapists to begin leading ST groups

effectively. The program is not a rigid protocol, but rather a framework combining

flexibility with standardization. The structured yet flexible format serves a number of

purposes: the manual can be used as a detailed plan for implementing a structured,

integrated program of individual and GST in higher level of care settings with multiple

sessions per week; as a research protocol for psychotherapy outcome studies; or

clinicians can select individual or group sessions, or the combination, to work on

specific schema modes. Therapists can choose whether to implement the program as a

whole, or to select individual sessions, group sessions or a combination of both to suit

their group and its needs.

7.3 Length of treatment

A number of time frames are in use for GST. The group in our RCT (Farrell et al,

was 30 weekly sessions 90 minutes in length added to 20 months of non-ST treatment

as usual (TAU). We have pilot studies of the combination of group and individual ST in

inpatient settings. Those studies evaluated programs of approximately 120 hours of

group and 18 hours of individual ST over a three-month period. These effect sizes were

similar to those demonstrated in the outpatient RCT. The collaborative multi-site study

going on currently is comparing two combinations of GST and individual ST as shown in

Table 5. Comparing the two formats will give us additional information about the relative

power of group versus individual St, or how much individual ST is needed to support
GST. In clinical practice, shrinking mental health dollars and related staff reductions

may be the variable that determines which format is possible.

Table 5: Group Formats and Lengths that have been evaluated for BPD
Format Year One Year Two
Mo 13-18 19-21 22-24
Primarily Group 2x week group 1x week group Biweekly group Monthly group
12 individual 3 individual 2 individual 1 individual
Group plus 1x week group 1x week session Biweekly group Monthly group
individual 1x week individual alternated group 2 individual 1 individual
& individual
Inpatient 12 weeks of No year two
12 hrs group/week
1x week individual
Outpatient 1x week group for 8 Weekly individual for months 1 and 2 of year two
Farrell-Shaw months
1x week individual
TAU for 12 months
Outpatient 1x week group
Dickhaut-Arntz 1x week individual

If this seems like a lot of treatment, one has only to look at the epidemiological data on

the use of mental health services of BPD patients and the length and intensity of

treatment with the aim of recovery, not just symptom control, to appreciate the

practicality of the combined group and individual ST approach to treatment.

8. Evidence for the model’s effectiveness

8.1 Individual ST for BPD Studies

Individual outpatient psychotherapy for patients with BPD has demonstrated

effectiveness in reducing all major symptom domains and improving quality of life in two

randomized controlled trials (Giesen-Bloo et al., 2006 and Nadort, et al, 2010). In the

first study ST comparing it to Transference Focused Psychotherapy (TFP), ST had

lower dropout rates and higher rates of recovery or significant improvement at the end

of the study. ST patients reported an increased quality of life and a lower dropout rate.
In addition, ST has growing evidence for its cost effectiveness for the individual modality

(Giesen-Bloo et al., 2006; Nadort et al., 2009).

8.2 Group ST for BPD Studies

Farrell & Shaw’s GST model (Farrell et al., 2009) was tested in a randomized

controlled trial for outpatients with BPD. In this trial 30 sessions of GST were added to

treatment as usual for one of two randomly assigned groups of patients. Significant

reductions across all symptoms specific to BPD as well as global severity of psychiatric

symptoms were found in the treatment group compared to little response in the TAU

control group. In addition, the treatment effect sizes for the 30-group session, 20

months of non-ST individual psychotherapy were double those found in the studies of

three years of individual ST for BPD. This suggest that something about the group

modality catalyzes or augments the effects of ST. A 12-week intensive inpatient

program for BPD that combined 120 GST sessions with 12-18 individual ST sessions

group therapy sessions for patients with BPD was implemented and evaluated by Reiss,

Lieb, Arntz, Shaw & Farrell (2013). In the three pilot studies reported reductions in BPD

specific measures as well as general psychopathology were found and subjective

patient satisfaction with the ST treatment programs was high. The treatment effect sizes

were similar to those found in the Farrell et al (2009) study. Dickhaut and Arntz (2014)

reported the results of two pilot studies of combined group and individual ST in two

years of treatment. They found that BPD manifestations reduced significantly, with large

effect sizes, and 77% recovery at 30 months. Large improvements were also found on

general psychopathological symptoms, schema (mode) measures, quality of life, and

happiness. An international trial comparing two formats of combined GST and individual

ST compared to “usual community treatment” for BPD is underway with 448 patients at
14 sites in six countries led by Arntz and Farrell. This study compares a two-year

tapering schedule of GST and IST to the treatment that a BPD patient would routinely

be assigned to at the study site. ST Format one is primarily group (108 groups, 18

individual) and ST Format 2 is an approximately equal mix (68 group, 63 individual).

This important study will allow us to evaluate how much individual therapy may be

needed to effectively treat BPD patients – an important question in the time of shrinking

mental health dollars and difficulty finding individual psychotherapy for this challenging

patient group with high disability. Combining more frequent GST sessions with

strategically planned individual sessions has the potential for making this promising

treatment more widely available in a larger number of settings. The BPD international

trial will also evaluate cost-effectiveness. Jacob & Arntz (2013) in a meta-analysis of

published ST studies on BPD concluded that the average drop-out rate in ST is very low

and the reductions in BPD symptoms compares favorably to Dialectical Behavior

Therapy, TFP or Mentalization Based Therapy. ST has thus demonstrated effectiveness

in the treatment of patients with BPD across inpatient and outpatient treatment settings

using individual, group and combined formats. ST is an approach that is rated positively

by both patients and therapists (Spinhoven, Giesen-Bloo, van Dyck, Kooiman & Arntz

2006; Reiss et al, 2013).

8.3 GST Studies with other patient populations

Some research on ST has been conducted in other patient populations. In a

population of war veterans with Posttraumatic Stress Disorder, Cockram et al. (2010)

found that ST within a group trauma treatment program had positive effects in reducing

Posttraumatic Stress Disorder, depression, and anxiety symptoms. An integrated

program combining multiple GST sessions with a limited number of IST sessions in a
structured program has been evaluated with promising results (Muste, Weertman,

Claassen, 2009). There is a need for further controlled outcome studies to evaluate the

effectiveness of GST with less homogeneous populations.

In conclusion: GST is a unique integrative treatment that combines cognitive,

experiential and behaviorally interventions in a group structure that combines elements

of interpersonal, psychoeducational and protagonist focused approaches all with active

and strategic therapist intervention. GST makes active use of the therapeutic factors of

the group modality to catalyze and augment change in the EMS and schema modes

that underlie personality disorder psychopathology. It has a growing evidence base with

significant treatment effects on BPD symptoms, overall functioning and quality of life

and compares favorably to other approaches to BPD treatment.

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