Motivational Concept. Six stage schema-andmode-driven. behaviour therapy for children and adolescents

Transcription

1 Motivational Concept Six stage schema-andmode-driven behaviour therapy for children and adolescents A mode-driven six-stage-model by Christof Loose 22 August 2011 Stand: contact: [email protected] Seite 1 von 11

2 Schema- und mode-driven behavior therapy for children and adolescents Schema therapy is an innovative psychotherapy developed by Dr. Jeffrey Young (e.g. Young et. al., 2008) and integrates elements of cognitive therapy, behavior therapy, object relations, and gestalt therapy into one unified, systematic approach to treatment. Although, it was developed for adults in the first place, the approach is in part also useful to the treatment of children or adolescents (c/a). The indication is a self-defeating emotional or behavior pattern accompanied by - no hope of improvement, - total identification with the problems ( that is me ), - overreacting to the same kind of situation ( emotional button ), - low self-confidence, - little social, emotional und familiar resources, - lacking interest in a therapist-patient-relationship, - avoiding cognitions and feelings that have to deal with the patient s problems, - strictly sticking to old dysfunctional attitudes and behavior patterns, - the desire to derive comfort exclusively, instead of help for change. Schema therapy can be integrated into well-known and approved concepts like the Self- Management-Therapy (e.g. Kanfer, et al., 2006) Self-Management-Therapy 1. Creation of a good stable patient-therapist-relationship 2. Build-up of motivation to change; what exactly should be different und why 3. Analysis of behavior: description of the problem and search for sustaining conditions 4. Agreement of individual goals (Goal Attainment Scale, GAS) 5. Choice, planning and conduction of methods 6. Evaluation of outcome 7. Consolidation of success, prevention of relapse, possibly new goal agreement (back to 2) Concerning stage 3 (Analysis of behavior) the so called SORKC-Model 1 is important to mention, whereas the O (organism) designates the individual biological and learn-historical initial conditions and/or characteristics of the person on the stimulus. The change of O (i.e. patterns, conviction and samples of thinking and feeling) is the goal of schema therapy. As a more practical way to work on patterns, the mode-model was developed that aims to tackle the problems on the R -level. The mode-model is easier to understand and therefore suitable for the treatment of children. However, the schemata represent the trait of a person (covered, hidden); the mode can be understood as a state of the person that is right now guiding the feelings and behavior and therefore uncovered, direct observable (compare Roediger, 2009, p. 66). Subsequently, there will be a rough sketch on the six stage schema-and-mode-driven model that is focussed on the process to gain the patience compliance. 1 S (stimulus) designates an outside or internal attraction situation. O (organism) R (reaction) designates the observable response behavior, which follows the stimulus and its processing in the organism. K (Contingency) designates the temporal sequence of the behavior and reactions (frequency of C after R). C (consequence) refers to using reinforcement or punishment as consequence of a behavior. Stand: Seite 2 von 11

3 Six stage schema-and-mode-driven behavior therapy for children and adolescents V: Schema-/ Mode- Therapy VI: Consolidation of the Success attained? then stage VI attained? then stage V attained? then new stage I I: Acceptance & Providing Confidence attained? then stage II attained? then stage III II: Buildingup of Motivation for Change IV: Schemaund Mode- Diagnostic attained? then stage IV III Schema- Mode- Education (for the child & parents) Remark: What is depicted above is a stage model, i.e. don t jump from one to another stage unless the patient reached fully the stage s goal. Look out for resistance or any other opposite behavior in the process, because this special resistance might be the key (or an important part of it) to an effective help in reducing the patient s problems. However, schemata are often build-up in early childhood. It is therefore very likely, that a conflict of loyalty arises as soon as the topic falls on a theme that happened in early childhood (where the parents are the main caregivers). In order to avoid such a threatening topic, the therapist might enforce a theme that has to do with the kindergarten or school (e.g. injustice, lack of acceptance or missing support) in order to protect the family and parents. If that procedure is successful, the family has probably more trust in the therapist and might open more difficult themes of the family (e.g. instability). In any case a good preparation with the parents is inevitable to avoid uncomfortable surprises (e.g. mistrust/abuse). Stand: Seite 3 von 11

4 I: Acceptance of the Patient and Providing Confidence To have personal direct access to the patient To show empathy and understanding, creation of trust Reduction of bad selfimage and selfattribution ( the problem is me, so I am, there is nothing I or you can do ) Having patience, let the child develop his/her own speed * The literature is in German. What do you like, what do you hate? Hobbies? Dreams? Demonstration: blow up a ballon, put a sticky tipe on it, penetrate with a needle where the sticky tipe is -> no damage to the ballon. (What kind of stripe do you need to avoid problems, e.g explosiveness?) invite the patient s family, emphasize positive sides, strengths etc., Go to parks, play soccer or badminton, play games, paint, do what he/she likes *Walter & Döpfner; 2009; L08 ballon, sticky tipe, needle Achievements (e.g. sports), to invite friends to the therapy; Job of the week: Write down the most beautiful experience you ever had; watch out for positive things in therapy Present toys; encourage the patient to bring his/her own toys to show you In the centre of this stage is the unconditional acceptance of the patient including all symptoms. The stage-goal is attained as soon as the patient is able to build-up a personal distance to the problematic behavior, or at least is in doubt whether the problem is in him/her. Please, be patient, don t hurry. In the best case, the child urges to go on because he/she has already played so much that he/she is curios about the content of the next stage. Again, be sure that the problematic behavior is something outside of the child. Present him/her a little present; assign My Therapy Plan (see appendix). II: Building-up of Motivation for Change Motivational clarification Setup a Vision, create a dream of the future Make curios about the reasons for the own matters; evoke Sherlock-Holmes - attitude Found a detective agency ; designate the boss of the agency (c/a) * The literature is in German. Make clear what the short- and longterm consequences are Describe the process and outcome of famous or wellknown person the patient like; ask the miracle question What kind of personality do I have, what are my real and deep-rooted sides, and how does it come? Why I am as I am? Write down the 5 nicest and ugliest things ever experienced. *z.b. Walter et al.; 2007; G16 Books about self-developement (e.g. Der Adler, der nicht fliegen wollte*), z.b. Filme: Billy Eliot I will dance, o.ä.; Eminem 8 Mile, Tests of personality: z.b. *FPI- R, PFK 9-14; projective Tests, e.g. Picture-Frustration-Test, Mac-Arthur-Story Stem Battery, Attachment Story Completion Task Everything that make clear the influence of nursery, early experiences and biological roots Stand: Seite 4 von 11

5 The stage-goal II is attained if the patient knows and understands the short- and longterm consequences of the problematic behavior and has created an understandable model of explanation why the behavior emerged. The patient is also capable to formulate an inner distance to the behavior. From now on, the attainment of stage-goals are celebrated by one hour (of therapy), the patient can determine (usually something what happened in stage I; e.g., go to parks, play soccer or badminton, play games, paint etc). III: Schema-Mode-Education - in general (for the child & parents) Introduction in the concepts of schemata and modes Recognizing the benefit to work on the schemata and modes Appointment of a celebration Call out for a family session. What is meant by terms like schemata, modes and coping styles; first concerning the early years and experiences in kindergarten and school in order to avoid resistance because of conflict of loyalty Visualize abilities that might be reachable, reinforce the vision (stage-goal I) How and with whom do you like to celebrate the attainment of stage-goal V? According to stage III all relevant members of the family should have understood the basic terms of Schema therapy. The parents should agree in going on to find the individual schemata and modes of the child and the family. Again, be careful for resistance or oppositional behavior (e.g. mother/father/grandparents). Talk about the impression, something is not totally okay. Plan an individual celebration and create a supporting team (e.g. mother/father/brother/sister/grandparents, who can help in which way?). IV: Schema- and Mode-Diagnostic individual e.g. Schema -> glasses, spiky ball 2 ; Mode -> different facial expression; Coping style -> analogy to animals; paint pictures to different sides inside, sculpture the sides, review pictures from the kindergarten Fire the family s imagination, what would be if ; who would be happy, why? Paper and pencil, postcards Identification of relevant schemata and modes in this special child Anamnesis, observations in the therapy; Schema-or Mode- Screening: Schema-Screening for children social area YSQ etc. Schema-Screening for c/a separated in a social and familiar version; YSQ- Questionnaire, Mode- und coping style Questionnaire to keep a dairy; train to explain behavior by mode activation Awareness and Accept fully the feelings; acceptance of the own metallization; be aware of the schemata und modes right therapeutic window of emotional activation Clarification of goals Case conception *compare ROEDIGER (2009) * The literature is in German. Stage IV is finished as soon as a logical and understandable concept is written and acknowledged by the child and parents. It is convenient to stick to a 4-to-1-Rule regarding positive and negative 2 compare Loose, C. (2010) Stand: Seite 5 von 11

6 schemata/experiences/topics in order to reduce bad feelings about the family and to ensure the ongoing compliance. V: Schema-/ Mode-Therapy Learn technique to relieve stress Cognitive-behavioral techniques Erlebnisorientierte Verfahren** Behavior Theray * The literature is in German. ** Please be careful with the approach of chair-technique for c/a., because the ability to put different personal sides into different entities (chairs) might be irritating or rejecting to younger patients (e.g. talking to an empty chair) unless a have done a very good preparation before. The stage-goal is reached when a reduction of symptoms is obviously. Again, don t forget the nice hour with the patient to celebrate a further achievement of a goal attainment (see stage III). VI: Consolidation of the Success safe-place- and screentechnique, train to put it in a z.b. *REDDEMANN (2003) safe SORKC-Model; reality check z.b. *BORG-LAUFS (2005), WALTER (2007; 2009), other Role play, chair technique (fig. 4), imagination practice Flash card; braking with old behavioral patterns, practice; selfmanagement approaches Compare *ROEDIGER (2009); puppet show (finger dolls), roleplay, painting, letter writing to involved persons in the past, diary writing, Working sheets; e.g. *BORG- LAUFS (2005), WALTER (2007; 2009) Overlearning and consolidation New Goal setting, new schema/mode-work Having pratice over and over again, slow reduction of the therapeutic hours New 6-stages-plan See above See above Stand: Seite 6 von 11

7 Ideas to make clear how the appropriate protector mode works Appropriate-Protector-Mode: Analogy: Why do we wear cloth? Why do we have different clothes in different seasons? What is the reason for the knights to wear such heavy armour? Traffic: Why do we have a speed limit, seat belt law, car blinker, traffic light, bicycle ways, crosswalk? Why do people who do not know very well speak formally to each other? Talk through a Frame (without Picture) Activate and choose the right frame to find adequate protection (Fig.1) Use a protective helmet (Fig. 2) Use a mosquito net (Fig. 3), in different colors for different needs of protection Imagine to use a sunglasses during a difficult conversation Imagine to use a headphones (hearing comfortable music) Imagine to have a jalousie you might close as soon as the conversations is stressful Point out that protection is a useful thing no one has to feel shame for. Fig. 1a: Frames with different material inside; the first one has no protection, the second has a mosquito net, the third a more rough net and the last one has a transparent film in it. Concerning the wind coming from the fan the second and the third frame is ineffective. It is only the forth one that protects properly. What kind of frame/protection do you need? Fig. 1a Fig. 1b: An empty frame delivers no protection. Fig. 1b Stand: Seite 7 von 11

8 Fig. 1c: The mosquito net is a little bit better, but not sufficient. Okay, fetch the next frame. Fig. 1c Fig. 1d: Altogether, frame 1, 2 and 3 are not bad, but I m sorry, it is still windy. I think you should try the last frame. Fig. 1d Fig. 1e: This is perfect. What kind of protection/frame do you need? Fig. 1e Stand: Seite 8 von 11

9 Fig. 2a: For example, is your head in danger? Fig. 2a Fig. 2b: You re afraid of loosing your face? Fig. 2b Fig. 3a Fig. 3b Fig. 3: There is a dark mosquito net (a.) for more protection and a light one (b) for less; have a seat! How does it feel like? Can we open a bit for the conversation? Stand: Seite 9 von 11

10 The little mode The clever... mode The critical...mode Too late! Punishment? Idea Fig.4 Chair technique; be careful: the younger the patient the more irritated he/she might be by talking to an empty chair. Introduce other modes, for example by asking what kind of feeling the c/a recently had. Every feeling (e.g. anger) can be transformed into a mode (anger mode). Stand: Seite 10 von 11

11 Literatur: Borg-Laufs, M. & Hungerige, H. (2005). Selbstmanagementtherapie mit Kindern. Ein Praxishandbuch, Pfeiffer. Kanfer, F.H., Reinecker, H & Schmelzer, D., (2006). Selbstmanagement-Therapie, Ein Lehrbuch für die klinische Praxis, Springer. Loose, C. (2010). Schema Therapy for Children. Proposal of Modification. Poster-Abstract: ISST- Conference, Berlin. ( Reddemann, L. (2003). Imagination als heilsame Kraft - Zur Behandlung von Traumafolgen mit ressourcenorientierten Verfahren. Klett Cotta. Roediger, E. (2009). Praxis der Schematherapie. Grundlagen, Anwendung, Perspektiven. Schattauer. Walter, D. Rademacher, C., Schürmann, S. & Döpfner, M. (2007). Grundlagen der Selbstmanagementtherapie bei Jugendlichen. SELBST-Therapieprogramm für Jugendliche mit Selbstwert-, Leistungs- und Beziehungsstörungen. Hogrefe. Walter, D. & Döpfner, M. (2009). Leistungsprobleme im Jugendalter. Hogrefe. Young, J.E., Klosko, J.S. &Weishaar, M.E. (2008). Schematherapie. Ein praxisorientiertes Handbuch. Junfermann. Appendix: Stand: Seite 11 von 11