May 2019 Sanctuary Meeting – Sally Skewes, Advanced Schema Therapist, Secure Nest

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At May’s Sanctuary meeting, the speaker was Sally Skewes, a Clinical Psychologist specialising in Schema Therapy, which is one of the evidence based treatments recommended for BPD.

Sally explained how she uses Schema Therapy to help consumers and how she works with families.

We were all impressed with both Sally’s compassion and care for people diagnosed with BPD and also the empathy this therapy has for our loved ones. The techniques are emotion focused.

To me it seems a much more gentle therapy than DBT. The focus here is on unmet needs and attachment, whereas DBT is more about setting limits The therapeutic relationship is most important in Schema Therapy and the outcomes are good according to Sally and studies that have been carried out.

Liz and I took these notes during Sally’s talk.

  • Schema was designed to treat BPD. It has empathy for this client group.
  • Research has shown that recovery rate exceeds other psychodynamic therapies.
  • Combines attachment theory with regulating emotions
  • The language used is empathetic to the client – it is about conceptualising and describing the difficulties the client experiences
  • Looks at early childhood – any feelings of unmet need and attachment. Complex, not black and white
  • The therapeutic relationship is crucial to the change process and outcomes are good. The focus on the therapeutic relationship is a mechanism for change
  • Outcomes – most people get relief even if they have had the illness for years and been in other therapies.
  • Other therapies focus more on symptom reduction. Schema focuses on emotions. The model was developed from clinical practice. Normalising model.
  • DBT – some similarities – e.g. decrease in stress intolerance
  • DBT is more about setting limits if the client is reaching out in difficult ways such as talking of suicide.  If the client misses 3 group sessions DBT they will not allow them to continue in the group. Schema therapy is different. If someone is suicidal, they are encouraged to ring the therapist and even if the therapist is not available immediately, the consumer will wait and not self-harm etc because they know the therapist will always ring back. It’s the attachment they are seeking. If they miss a session there is an empty chair showing that the person is still a member of the group and they are always allowed back.
  • We all have schemas – they are like personality traits. Everyone has a Vulnerable Child.
  • Each Schema Therapist has to have had their own Schema Therapy to become qualified.
  • Therapy can be individual or group. Sally and her colleague only ones in Adelaide currently running groups. Groups very beneficial and effective. 25 sessions, once a week. Mixed group of 8-10. Closed group. Groups are planned but have a focus on preparing to change. They are now finding that less sessions also work.
  • Individual sessions 1-2 per week.
  • Therapy usually long-term. Groups speed therapy up.
  • Group sessions are recorded – if person misses one they can catch up, with the therapist.
  • Focus in the groups is on anything that impacts therapy or the group.
  • Safe space to share. Relationship oriented – come from a place of care.
  • Schema “meets the person where they are”. Doesn’t force them to do anything. The focus is on caring rather than rejecting. Relationships and trust are important.
  • “Limited Re-parenting” model. The therapist sees the “bad” behaviour but will always try to see what’s behind it.
  • Trickiest thing is the behaviour the person uses to cope, and the underlying stress. There is a side of the client that has learnt to use this behaviour to get needs met.
  • The therapist will check all the time which emotional state the client is in and work with that.
  • It is always the negative voice that is talking to the client – blaming, punishing, critical, targeting. They often have the angry voice (angry child) but self-punishment is always present.
  • Client is into self-punishment and shame. Need to manage this behaviour in an empathetic way. The behaviour is there to protect them. They are so vulnerable, so the therapist will never reject them or become cold but in order to cope themselves, the therapist must be aware of their own triggers.
  • Learning can be slow especially if the client doesn’t have a close relationship in their life.
  • The first year of therapy is spent around learning how to cope, manage themselves. Ups and downs.
  • Important to shift beyond the current trigger situation.
  • Clients notice subtle shifts in non-verbal communication. They can read body language. They are exquisitely sensitive
  • Healing an emotion is to change the meaning e.g. bullying – from “I’m bad” to meeting the need that arises at the time, to “There’s nothing wrong with me.”
  • In some therapies, no-one addresses how the person speaks to others. In Schema, the person is empathetically confronted, as early as possible.
  • Schema supports the person to help them express their emotion in different ways.
  • Lack of anger is a big problem – because there are no boundaries for change – leads to significant boundary issues.
  • Client may not know what has caused their anger.
  • The client can be so disconnected that they don’t remember from one week to the next. Use recorded sessions so person can hear therapist’s voice back – calming.
  • Substance abuse; They ask the client not to use substances directly before the session as it dampens their emotions. Client needs to heal underlying thoughts and replace with new way of coping first.
  • Therapist needs to be careful not to offer something they cannot continue to do.
  • Schema therapy promotes connections and these connections are brought into the group so everyone hears what’s going on. This is another difference from DBT where friendships are not encouraged.
  • It’s great if carers are involved. Parents and partners are invited in after client has had 6 sessions. to learn the framework, terms used, etc .
  • Biggest issue with Schema therapy is accessibility. Waiting list in Adelaide for Schema is around 6 months.

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Photo by Olivia Colacicco on Unsplash

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