270 Ball 8.

Young

mann, R. L., Hill, C. L., Heninger, G. R., & Charney, D. S. (1989).
The Yale-Brown Obsessive Compulsive Scale (Y-BOCS):Part I.
Development, use, and reliability.Archivesof GeneralPsychiatry,46,
1006-1011.
Greist,J. H., Jefferson,J. W., Kobak, K. A., Katzelnick,D.J., & Serlin,
R.C. (1995). Efficacy and tolerability of serotonin transport
inhibitors in obsessive-compulsive disorder: A meta-analysis.
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obsessive-compulsivedisorders. In H. R. Beech (Ed.), Obsessional
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Address correspondence to Barbara O. Rothbaum, Ph.D., Director,
Trauma and Anxiety RecoveryProgram, Emory UniversitySchool of
Medicine, t365 Clifton Road, NE, Altanta, GA30322: e-mail:brothba@
emory.edu.
Received:January 30, 1999
Accepted: December6, 1999

• • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Dual Focus Schema Therapy for Personality Disorders and

Substance Dependence: Case Study Results
S a m u e l A. Ball, Yale University School of Medicine
J e f f r e y E. Young, Columbia University

We review the theory, techniques, and development of a manual-guided individual psychotherapyfor substance-dependent individu-
als diagnosed with personality disorders. Dual Focus Schema Therapy (DFST) integrates relapseprevention for substance dependence
with targeted work on early maladaptive schemas (enduring negative beliefs about oneself, others, and events) and coping styles. The
first 3patients (one eachfrom DSM-IV Axis-II Cluster A, B, and C) treated during the pilot testing phase of the manual are summa-
rized to illustrate differences in psychopathology, personality and interpersonal functioning, early maladaptive schemas and coping
styles, and treatment response.

HE PAST 10 YEARS have seen rapid growth in the
T development of time-limited individual therapy
models for personality disorders. Disorders previously
considered untreatable, except occasionally through long-
term psychoanalysis, are increasingly being treated with
some apparent success by behavioral (Linehan, Arm-
strong, Suarez, Allmon, & Heard, 1991; Linehan, Heard,
& Armstrong, 1993; Turkat, 1990), cognitive (Beck, Free-
man, & Associates, 1990; J. S. Beck, 1994; Layden, New-
man, Freeman, & Morse, 1993), shorter-term psychody-
namic (Kernberg, Seizer, Koenigsberg, Carr, &
Appelbaum, 1989; Magnavita, 1997; Pollack, Winston,
McCullough, Flegenheimer, & Winston, 1990; Preston,
1997; Yeomans, Seizer, & Clarkin, 1992), and integrative
(Horowitz, 1997; Lockwood, 1992; Ryle, 1996; Young,
1994a) approaches. Clinical reports, single case and un-
controlled study designs suggest that cognitive-behavioral
therapy may be effective for some personality disorders,
Cognitive and Behavioral Practice 7, 2 7 0 - 2 8 1 , 2000
107%7229/00/270-28151.00/0
Copyright © 2000 by Association for Advancement of Behavior
Therapy. All rights of reproduction in any form reserved.
[ ~ Continuing Education Quiz located on p. 371.
but controlled outcome studies are very limited in num-
ber and scope (see reviews in Perry, B a n o n , & Ianni,
1999; Sanislow & McGlashan, 1998; Shea, 1993). For ex-
ample, individuals with avoidant personality disorder
have experienced improvements in social functioning
following social skills training, systematic desensitization,
and graduated exposure (Alden, 1989; Cappe & Alden,
1986), and individuals with borderline personality disor-
der experienced reduced hospitalizations following train-
ing in interpersonal skills, affect regulation and toler-
ance, and managing parasuicidality (Linehan et al., 1991,
1993). Alcohol-dependent individuals with greater soci-
opathy tend to have better outcomes with cognitive-
behavioral coping skills treatment than with an inter-
actional group therapy (Kadden, Cooney, Getter, & Litt,
1989; Longabaugh et al., 1994). Fisher and Bentley
(1996) found that a cognitive-behavioral group had
significantly better outcomes than a treatment-as-usual
group for personality-disordered substance abusers.
The above substance-abuse treatment studies have
used relapse-prevention coping skills approaches that are
not specific for personality disorders, whereas the behav-
ioral treatment studies have targeted the maladaptive
symptoms for avoidant and borderline personality disor-
der. In contrast, several cognitive-behavioral approaches
 Dual Focus Schema Therapy :~71

have been articulated (A. T. Beck et al., 1990; J. Beck, fillment of basic needs and the change process (Young;
1994; Davidson & Tyrer, 1996; Pretzer & Fleming, 1989; Young & Lindeman).
Young, 1994a) that focus specifically on the problematic Substance abuse is an important clinical disorder
beliefs, assumptions, or schemas that underlie the symp- within which to evaluate and treat personality disorders
toms of a broader range of personality disorders. These given their high comorbidity
models have developed in sophistication, promise, and and relation to symptom se-
popularity and are now at the point where the success of venty and treatment outcome DFST f o c u s e s
several clinical cases needs to be replicated through con- (see review byVerheul, Ball, & simultaneously on
trolled, empirical studies of treatment efficacy. The devel- van den Brink, 1998). The
opment of time-limited, detailed treatment manuals for need to develop or modify managing Axis-I
training therapists to deliver treatments as prescribed has existing treatments to better symptoms and
become a virtual requirement in the technology of psy- meet the special needs of per- changing
chotherapy research (Carroll, 1997). This already has sonality-disordered substance
been done by Linehan (1993), who has developed and abusers has been documented p r o b l e m a t i c beliefs,
evaluated a highly detailed training manual and program (Cacciola, Rutherford, Alter- assumptions, or
for dialectical behavior therapy for borderline personal- man, McKay, & Snider, 1996; schemas that may
ity disorder. However, there are no well-specified treat- Nace, Davis, & Gaspari, 1991;
ment manuals for the diverse range of personality dis- Rounsaville et al., 1998), and underlie the
orders, and no individual therapy has been fully articu- therapeutic attention to the symptoms of a
lated that integrates a dual focus on this broad range of symptoms of personality disor- broader range of
personality disorders and their commonly co-occurring der may reduce the severity
Axis-I disorders, like substance abuse. of substance abuse and other personality
Therapeutic approaches to personality disorders orig- Axis-I psychiatric problems (e.g., disorders and
inating out of A. T. Beck's group would suggest different depression, anxiety, paranoia) addiction.
approaches for each of the different Diagnostic and Statis- that potentially contribute to
tical Manual of Mental Disorders (DSM-1V,', American Psychi- relapse. Cognitive-behavioral
atric Association, 1994) personality disorders (see also therapy can be adapted to the treatment of personality
Nelson-Gray, Johnson, Foyle, Daniel, & Harmon, 1996). disorders and addiction by focusing on substance relapse
Evaluating relatively distinct manuals for each disorder factors (to which these dually disordered individuals may
seems impractical in a clinical trial and, in fact, may not be especially sensitive) and the processes (maladaptive
be the most useful guide for clinicians given the signifi- schemas and coping styles) that hypothetically underlie
cant overlap among personality disorders, the rare occur- the symptomatic expression of both disorders.
rence of prototypic cases in clinical settings, and their fre- The Dual Focus Schema Therapy (DFST; Ball, 1998;
quent co-occurrence (e.g., most personality-disordered Ball & Young, 1998) described in this paper is a 24-week,
substance abusers meet criteria for two or more personal- manual-guided individual therapy consisting of a set of
ity disorders). A promising, alternative approach is a core topics, the specific content and delivery of which are
schema-focused cognitive therapy (Young, 1994a) that determined by an assessment and conceptualization of
targets a smaller number of early maladaptive schemas the individual's early maladaptive schemas and coping
and coping styles observed across the various personality styles. DFST includes traditional, symptom-focused
disorders. A. T. Beck et al. (1990) and Young define mal- relapse-prevention coping skills techniques for interper-
adaptive or dysfunctional schemas as enduring, perva- sonal, affective, and craving factors (Kadden et al., 1992;
sive, unconditional, negative beliefs about oneself, Marlatt & Gordon, 1985; Monti, Abram, Kadden, &
others, and the environment that are learned early in Cooney, 1989) and schema-focused techniques for the
childhood and perpetuated and elaborated in adult- maladaptive schemas and coping styles (Young, 1994a).
hood. Over time, these deep beliefs about serf and DFST hypothesizes that a broad range of the patient's dif-
others become dysfunctional to a significant degree and ficulties can be subsumed by a single or few early map
highly resistant to change in persons with personality dis- adaptive schemas and coping styles and that targeted
orders (Young; Young & Lindeman, 1992). Individuals change in substance use and core schemas can signifi-
typically develop behavioral strategies to cope with the cantly impact a broad range of behaviors by disrupting
distressing thoughts, feelings, and impulses associated the behavioral and interpersonal chain of events that
with early maladaptive schemas. These long-standing, help perpetuate the dual disorder in adulthood. We
usually unrecognized maladaptive coping styles are present a detailed discussion of the first three cases (one
often effective in reducing the schema-evoked distress, each from DSM-IV,, Axis-II, Cluster A, B, and C) treated
but they are ultimately self-defeating and hinder the ful- using this psychotherapy manual.
272 Ball & Young

Method cused on disentangling personality disorder symptoms

from the acute and prolonged effects of substances as
Participant Recruitment
well as behaviors required to maintain a substance abuse
Ten individuals participated in the pilot testing phase
lifestyle (Rounsaville et al., 1998). Videotapes were re-
of this NIDA-funded behavioral therapy development
viewed in supervision with the first author.
project, which focused on the development and refine-
Millon Clinical Multiaxial Inventory-III (Millon, 1994).
ment of a treatment manual for personality-disordered
This 175-item, true-false, self-report inventory measures
substance abusers. The first author explained the study to
clinical syndromes and personality pathology, grouped by
the counseling staff of a large, long-term methadone
level of severity, that correspond closely to most of the
maintenance clinic of The APT Foundation in New Ha-
broader Axis-I and -II categories of the DSM diagnostic
yen, Connecticut. Counselors
system. The reliability and validity of this widely used clin-
were asked to review their
ical measure has been extensively evaluated, particularly
Dual Focus caseloads for patients whom
in drug abusers.
Schema Therapy is they suspected had a person-
NEO Five Factor Inventory (NEO-FFI; Costa & McCrae,
ality disorder and who ap-
a 24-week, 1992). This 60-item questionnaire asks participants to rate
peared interested in weekly
items on a 5-point scale (strongly agree to strongly disagree)
manual-guided individual psychotherapy in
and yields scores on the five major domains of personality:
therapy consisting addition to their less frequent
neuroticism, extraversion, openness, agreeableness, consci-
group meetings and daily
of a set of core entiousness. The reliability and validity of this instrument
methadone administration. All
has been extensively evaluated in normal and clinical sam-
topics, the specific pilot-study participants met
ples (Costa & McCrae), specifically in substance abusers
content and structured diagnostic inter-
(Ball, Tennen, Poling, Kranzler, & Rounsaville, 1997).
view criteria for at least one
delivery of which Inventory of Interpersonal Problems-Circumplex (IIP-CX;
personality disorder other
Alden, Wiggins, & Pincus, 1990). This 64-item self-report
are determined by than or in addition to antiso-
short form is derived from the Inventory of Interpersonal
an assessment and cial personality disorder. This
Problems (Horowitz, Rosenberg, Baer, Urefio, & Val-
criteria was used to ensure
conceptualization lasefior, 1988) and measures types of interpersonal prob-
some variability in diagnoses
lems in the past 30 days on a 5-point Likert scale of dis-
of the individual's given the very high preva-
tress. Each subscale corresponds to a different octant
early maladaptive lence of this disorder in meth-
within the interpersonal circumplex model of personal-
adone populations. Other
schemas and ity: assured-dominant, arrogant-calculating, cold-hearted,
study inclusion/exclusion cri-
aloof-introverted, unassured-submissive, unassuming-
coping styles. teria included the following:
ingenuous, warm-agreeable, gregarious-extraverted.
(a) DSM-IV diagnosis of opi-
Young Schema Questionnaire (longform, 2nd edition; Young
oid dependence; (b) being
& Brown, 1990). This 205-item Likert scale self-report in-
on a stable dose of methadone for at least 1 month; (c)
strument measures 16 early maladaptive schemas: emo-
not participating in additional psychotherapy other than
tional deprivation, abandonment/loss, mistrust/abuse,
drug counseling at the methadone clinic; (d) no evi-
social isolation, defectiveness/unlovability, social unde-
dence of acute psychosis or suicidality/homicidality. Of
sirability, failure to achieve, dependence/incompetence,
these 10 pilot participants, 3 were chosen for case discus-
vulnerability to harm, enmeshment, subjugation, self-
sion to represent each of the three DSM-IV clusters: A
sacrifice, emotional inhibition, unrelenting standards,
(odd); B (dramatic); C (anxious).
entitlement/insufficient limits, insufficient self-control.
Baseline Assessments There is preliminary evidence supporting the reliability
Structured Clinical Interview for DSM-1V Axis-II (SCID-II; and validity of this instrument (Schmidt, Joiuer, Young, &
First, Spitzeg, Gibbon, Williams, & Benjamin, 1994). The Telch, 1995).
SCID-II is a semistructured interview used to assess per- Young Rygh Avoidance Inventory (YRA-1; Young & Rygh,
sonality disorders. A self-report instrument is adminis- 1994). This 40-item Likert scale self-report measures one
tered first in which each dichotomous item corresponds group of maladaptive coping styles. This scale (under de-
to a DSM-IVpersonality disorder diagnostic criteria. The velopment) includes items related to various forms of es-
interviewer then queried each of the self-report "yes" re- cape or avoidance of people, situations, or mood states that
sponses of those diagnoses for which there were a suffi- activate early maladaptive schemas (i.e., social withdrawal,
cient n m n b e r of endorsed items to yield a possible diag- excessive autonomy, compulsive stimulation-seeking, addic-
nosis. The interviewer had 5 years experience in SCID-II tive serf-soothing, and psychological withdrawal).
interviewing from a prior NIDA-funded study that fo- Young Compensation Inventory (YCI-1, Young, 1995). An-
 Dual Focus Schema Therapy
other maladaptive coping style is measured by a 48-item
questionnaire (under development) that includes items
related to aggression/hostility, dominance, excessive self-
assertion, recognition or status-seeking, manipulation,
exploitation, passive-aggressive rebellion, and excessive
orderliness.
YoungParentingInventory (YPI; Young, 1994b). This 72-
item self-report gives separate Likert scale ratings for
mother and father on various parental behaviors hypoth-
esized to be the origins of schemas. It yields subscales that
correspond to the Schema Questionnaire (above) and is
under development as a scale for detecting possible un-
derlying early maladaptive schemas.
Monthly Change Assessments
WeeklySubstance Time-Line?bllow-Back.At each weekly
appointment, therapists inquired into the participant's
substance use since the prior session. Therapists rou-
tinely inquired as to use of opiates (bags), cocaine (bags),
alcohol (standard drinks), marijuana (joints), benzodiaz-
epines (pills), and other drugs as indicated. Weekly urine
testing was used to confirm self-reports of use of the
above drugs.
Brief Symptom Inventory (BSI; Derogatis, 1992). The BSI
is a 53-item self-report inventory of psychiatric symptoms
that asks participants to rate items on a 5-point scale of
distress. It yields nine primary symptom dimensions: anx-
iety, depression, hostility, interpersonal sensitivity, obses-
sive-compulsive, paranoia, phobic anxiety, psychoticism,
somatization. Because these scales appear to be very
highly intercorrelated in active substance abusers, we
used the Global Symptom Index in the change analyses
(see Ball et al., 1997).
Multiple Affect Adjective Checklist-Revised (MAACL-R;
Zuckerman & Lubin, 1985). This 132-adjective checklist
provides state and trait measures of affects and has been
used extensively in personality and clinical research to
measure changes in emotional states over time. It yields
five basic scales (Anxiety, Depression, Hostility, Positive
Affect, Sensation Seeking) and two summary scores (Dys-
phoria and Positive Affect/Sensation Seeking).
DFST Treatment Manual
Prior to beginning the study, the first author (SB) par-
ticipated in a week-long intensive training program (in-
volving lectures, videotape, and experiential exercises)
for professionals in schema-focused therapy with the sec-
ond author (JY) and then developed a first draft of the
24-week treatment manual. The second author served as
the study's consultant and provided a similar week-long
training to four additional doctoral-level clinical psychol-
ogists and helped in the revision of the second draft of
the manual at the end of the pilot testing. A detailed list-
ing of the topics, goals, and methods for each session are
listed in Tables 1 and 2 (Ball & Young, 1998). Using ses-
Z13
sion videotapes, the therapists were supervised weekly by
the first author, who received monthly supervisor consul-
tation by the second author. DFST was provided as an ad-
ditional therapy to the participant's standard methadone
maintenance (medication plus group drug counseling).
Therapists met with participants twice weekly for the first
month and then weekly for the remaining 20 weeks of the
pilot study treatment.
DFST occurs in two stages. First, the therapist inte-
grates early relapse prevention work with an identifica-
tion and education about early maladaptive schemas and
coping styles and their association with substance use and
other presenting life problems. This educational stage
(Table 1; Topics A-G) is meant to accomplish at least
three important goals: (a) initiate abstinence or signifi-
cantly reduced substance use; (b) establish a strong ther-
apeutic alliance; (c) develop a detailed case conceptual-
ization. The development of a strong therapeutic alliance
is dependent on both the patient's experience of the
therapist's limit setting and focused attention on addic-
tive behaviors as well as the therapist's interest in under-
standing the patient's personality (temperament, sche-
mas, coping style) and its origins.
Once the therapist completes this complex assessment
and develops a detailed, empathic appreciation and con-
ceptualization (Table 1; Topic H) of the history of the pa-
tient's current life problems, the stage is set for changing
the maladaptive schemas and coping styles that underlie
both the personality and addiction problems. The indi-
vidualized case conceptualization guides the develop-
ment of a technically eclectic but theoretically integrated
set of change strategies for each schema (Young, 1994a):
(a) cognitive (Table 1, Topics I-K; schema validity, dis-
putes, and dialogues; flash cards for healthier internal
voice; reframe past to create distance; identify and con-
front validity of schemas and usefulness of coping style;
substance abuse as avoidant coping); (b) experiential
(Table 1, Topics L-N; imagery and inner child work; role
play; ventilation about past and toward caregivers; work
on schema origins; letter writing); (c) behavioral (Table 1,
Topics O - Q ; change self-defeating behaviors maintain-
ing the schemas; identify life change and overcoming
avoidance; in-session rehearsal; graded task assignment;
individualized schema/coping-relevant coping skills
training; empathic confrontation); (d) therapy relation-
ship (confront in-session schemas and coping styles; lim-
ited reparenting). Other elective module session topics
are used to address persistent, treatment-interfering sub-
stance use (Table 2; Axis-I Relapse Module), extreme
avoidance and schema modes (Mode Work Module),
boundary violations and limit setting in the therapeutic
relationship, traumatic memories of abuse, managing
suicidal crises and self-injurious behavior (Therapy Inter-
ference Module).
274 Ball & Young

Table 1
Core Topics for the Dual Focus Schema Therapy Manual

Topic A: IDENTIFICATION AND ANALYSIS OF CURRENT Topic G: MALADAPTIVE BEHAVIORAL AND COPING
PROBLEMS PATTERNS
Goals Goals
1. Brief Overview of Treatment 1. Review Measures of Schema Avoidance and Compensation
2. Introduce Ongoing Focus on Substance Abuse 2. Discussion about Three Schema Processes: Maintenance
3. Identify Current Life Situations as Problems (surrender), Avoidance (escape), and Compensation
4. Develop Rapport and Working Alliance (counterattack)
3. Identification of Individual's Coping Styles
Methods
Methods
1. Develop List of Behavioral Targets for Change
1. Young-Rygh Avoidance Inventory
2. Begin Focused Life History
2. Young Compensation Inventory
3. Rapport Building
4. Give Young Schema Questionnaire and Self-Monitoring Journal Topic I-I: PROBLEM CONCEPTUAIJZATION AND FOCUS
Goals
Topic B: UNDERSTANDING HISTORICAL PATTERNS 1. Provide Patient with Case Conceptualization and Possible
Goals Techniques Used from Detailed Schema Strategies
1. Begin Linking Current Problems to Past Problems 2. Review MaJor/Core Schemas, Modes, Coping Styles, Origins
2. Pattern Identification 3. Identify 1-2 Problems, Schemas, Modes, Coping Styles for
3. Examination of Previous Efforts to Change Therapeutic Change
4. Obtain Personal History of Important Events 4. Review Self-Monitoring
5. Collect Complete Young Schema Questionnaire Methods
1. Review Schema Conceptualization Form
Methods
2. Review Self-Monitoring for 1-2 Problems, Schemas, Modes,
1. Timeline Interview
Coping for Baseline to Measure Subsequent Change
2. Give Young Parent Inventory (YPI)
Topic I: SCHEMA EVIDENCE AND COPING PROS AND CONS
Topic C: DEFINING PERSONALITY, SCHEMAS, AND COPING Goals
Goals 1. Examine the Past and Current Evidence Supporting and
1. Define Personality Disorders in Schema and Coping Terms Disconfirming Schemas and Associated Automatic Thoughts
2. Strengthen Therapeutic Alliance through Sensitive Discussion 2. Examine Pros and Cons of Maladaptive Coping Styles
of Diagnosis Methods
Methods 1. Evidence for and Against Early Maladaptive Schemas
1. Discussion of Personality, Schemas, Coping, and Disorder 2. Advantages/Disadvantages Analysis of Maladaptive Coping
2. Chapter 1 of"Reinventing Your Life" Topic J: SCHEMA CONFRONTATION AND DISPUTES
Goals
Topic D: SCHEMA EDUCATION
1. Continue Process of Cognitive Disputing Validity of Schema and
Goals Automatic Thinking
1. Review Young Schema Questionnaire Results 2. Move Schema Dialogue from Dispute Between Therapist and
2. Educate about Schemas ("deeper beliefs") Patient to an Internal Dispute Within Patient
Methods Methods
1. Young Schema Questionnaire 1. Role Play
2. Relevant Chapters from "ReinventingYour Life" 2. Point-Counterpoint Dialogue Between Schema and Healthy
Side
Topic E: SCHEMA ASSESSMENT THROUGH IMAGERY 3. Empty Chair Technique for Internal Dialogue
Goals 4. Beginning Use of Traditional Cognitive Disputes
1. Introduce Imagery Techniques to Patient Topic K: FLASHCARDS
2. GiveYoung Rygh Avoidance Inventory (YRAI) andYoung
Goal
Compensation Inventory (YCI)
1. Construct One Flashcard for Each Core Schema or Triggering
Methods Event Identified
1. Imagery and Discussion Method
2. If Blocked, Introduce Modes (especially Detached Protector) 1. Create Flashcards Using Template and Information from
Schema Conceptualization and Schema Disputes
Topic F: EARLY ORIGINS
Goals Topic L: CONFRONTING PAST/PARENTS THROUGH
1. ReviewYoung Parenting Inventory (YPI) IMAGERY
Goals
2. Discussion about Origins of Schemas
1. Review Use of Flashcards
Methods 2. Confront Origins of Schema in Parental Behavior
1. Young Parenting Inventory (YPI) 3. Express Anger Over Unmet Needs and Not Providing Good
2. Relevant Tables from "ReinventingYour Life" Care
 Dual Focus Schema Therapy Z75

C a s e Study R e s u l t s
Sally (Cluster A)
Methods Sally is a 41-year-old single, unemployed, white female
1. Imagery o f Self as Child, t h e n Adult with Parent
college graduate whose primary Axis-II diagnosis was
2. Assertive C o m m u n i c a t i o n o f U n m e t Needs a n d A n g e r
schizotypal personality disorder (secondary: schizoid,
Topic M: SCHEMA R E A T T R I B U T I O N T H R O U G H IMAGERY borderline, depressive). Her MCMI-III personality code
Goals indicated significantly elevated (base rate > 85) schizoid
1. Decreased Self-Blame for Problems a n d Schemas and depressive scales and moderately elevated (base rate
-9. Increased Recognition of Parental/Significant Other Problems 75 to 84) borderline, self-defeating, and antisocial scales.
and Limitations
In addition to drug dependence, her MCMI-III syndrome
3. Express Wish that Past Were Different, Effect on Present, and
Plans for Future (i.e., Axis-I) code indicated significantly elevated soInato-
form and major depression scales and moderate eleva-
Methods
1. Imagery Confronting Parents/Others with Responsibility tions on t h o u g h t disorder, anxiety, and dysthymia scales.
-9. Assertive Communication of Unmet Needs and Plan to BSI elevations included depression, obsessive-compul-
Change sive, and interpersonal sensitivity. She began using sub-
stances at the age of 11, had several prior substance abuse
Topic N: WRITING LETTERS
and psychiatric treatments, and had been on m e t h a d o n e
Goals
1. ReviewSelf-Monitoring from Prior Week (75 mg) for 2 years before beginning this individual ther-
2. Write Letters to Parent(s) or Significant Others Centrally apy study. Her primary substance abuse problem was al-
Involved in Schema Origin cohol, which she used on an almost daily basis. She also
Methods used either heroin, marijuana, and cocaine once per
1. Writing Letters Expressing Feelings About Parental Behavior week, d e p e n d i n g on availability.
Sally scored low on NEO Extraversion, Agreeableness,
Topic O: CHANGINGRELATIONSHIPS and Conscientiousness, and high on NEO Neuroticism,
Goals
Openness and IIP-CX Cold, Socially Avoidant, and Vin-
1. ReviewReading of Letter to Self
dictive scales. Her core early maladaptive schema was
-9. DiscussAdult Relationships as Primary Method of Reenacting
and Perpetuating Early Maladaptive Schemas abandonment, which appeared to originate from being
3. Explain Concept of "Chemistry" as a Danger Signal removed from her family as a result of parental neglect,
4. Develop Plan of Action for Changing Current Relationship abuse, and alcoholism, and then from multiple foster
Problems homes because of her conduct problems. She developed
Methods an associated schema of defectiveness, related to feeling
1. ReviewSchema-specific Relationship Patterns unwanted by her nuclear and extended family and the
-9. Problem Solving Steps for Relationships foster and social service systems of care. She developed a
Topic P: SKILL B U I L D I N G AND BEHAVIOR CHANGE behavioral pattern o f social isolation accompanied by bi-
Goals zarre behaviors that kept people from getting close and
1. ReviewAssignment from Prior Week then abandoning her. She also engaged in self-abuse, dis-
9. Collaboratively Identify a Coping Skill Limitation sociative episodes, and taking care of injured animals as
3. Break Down Limitation into Component Parts methods of coping with distressing affect related to her
4. Develop Gradual Hierarchy of Tasks to Begin Work schemas.
5. Implement Lowest/Easiest Behavioral Task from Hierarchy
Sally presented initially as a lively, extraverted, almost
Methods hypomanic, driven woman. She exhibited an extremely
1. Brief Discussion of Nature of Coping Skills perceptive and sharp sense of h u m o r that was e n h a n c e d
2. Coping Skills Hierarchy
3. Implement First Step of Behavioral Plan by a willingness to share her idiosyncratic, neologistic
thought processes. Over the course of treatment it be-
Topic Q: TERMINATION AND CONTINUING CHANGE came apparent that this driven, funny persona covered a
Goals deep depression and hopelessness that easily surfaced
1. Establish Continued Change Plan for Coping Skills and with schema-related discussions of her past and present
Relationships
experiences of feeling either left alone or taken advan-
2. ReviewRelapse Warning Signs
3. Termination tage of by others. Schema work focused on abandon-
ment, social isolation, and mistrust/abuse, and her at-
Methods
tempts to cope through dissociation or overextending
1. Change Plan for Follow-up
2. Relapse Triggers herself to help injured animals or needy people. Cogni-
tively oriented interventions included confronting her
276 Ball & Y o u n g

Table 2
Elective Topics for the Dual Focus Schema Therapy Manual

AXIS-I RELAPSE Methods

Topic 1: INTERNAL AND EXTERNAL TRIGGERS 1. Imagery Exercise Using Schema Modes
2. Changing Chairs for Disputing Maladaptive Modes
Goals
1. Identification of High-Risk Situations or Triggers Topic 8: COPING WITH THE ANGRY OR IMPULSIVE CHILD
2. Education about Intrapersonal and Interpersonal Relapse Goals
Precipitants 1. Imagery of Angry or Impulsive Child Modes
Methods 2. Expressing Strong Anger Toward Maladaptive Parent
l. Self-Monitoring Methods
2. Education about Relapse Precipitants 1. Imagery Exercise Using Schema Modes
2. Assertiveness Training
Topic 2: COPING WITH HIGH-RISK SITUATIONS
Goals THERAPY INTERFERENCE
1. Identifying High-Risk Situations for Focused Intervention Topic 9: THERAPEUTIC RELATIONSHIP
2. Identify Past and Planned Coping Strategies
Goals
3. Learn to Resist Social Pressures to Use
1. Provide Rationale for Here-and-Now Focus on Therapeutic
Methods Relationship
1. Review of Self-Monitoring Form 2. Provide Schema-Based Interpretation of Patient's In-topic or
2. Coping Skills Training Extra-topic Behaviors Related to Therapy
3. Assertiveness Role Plays 3. Use Difficult Topic Material as Opportunities for Limited
Reparenting
Topic 3: COPING WITH CRAVING
Methods
Goals
1. Review Techniques of Interpreting Therapeutic Relationship
1. Define Drug Craving 2. Therapist Completion of Schema Questionnaire and Review in
2. Review Method of Coping with Cravings Supervision
Method
Topic 10: TRAUMATIC MEMORIES OF ABUSE
1. Education and Coping Skills for Craving
Goals
Topic 4: ACTIVITY PLANNING 1. Recall Traumatic Memories of Abuse
Goals 2. Express Anger and Other Negative Emotions Toward
1. Discuss Importance of Pleasurable Activities and Avoiding Perpetrators and Those Who Did Not Protect
Boredom 3. Decrease Self-Blame and Responsibility
2. Identify 1-2 New/Old Activities to Engage In Methods
Method 1. Historical Recall of Abuse Through Imagery and Open-Eyed
1. Review of Pleasurable Activity List Discussion
2. Emotional Ventilation
MODE WORK 3. Assertive Communication About Wrongs and Lack of Protection
Topic 5: SCHEMA MODES Topic 11: SELF-INJURY
Goals Goals
1. Introduce Concept of Schema Modes 1. Ensure Patient Safety for Coming Week
2. Identify Major Modes Patient Uses and Give Names 2. Reestablish Sufficient Safety in Therapeutic Relationship to
3. Explore Origins, Functions, and Symptoms of Each Mode Resume Schema Work
Method 3. Explore Pros and Cons of Suicidal Ideation and Attempts
1. Discussion of Schema Modes Methods
1. Contracting for Safety
Topic 6: VULNERABLE CHILD AND DETACHED 2. Establishing Contingencies for Continued Attempts
PROTECTOR 3. Advantages/Disadvantages Analysis for Suicide
Goals 4. Mobilization of Support System
1. Imagery of Two Major Modes
2. Nurturing the Vulnerable Child and Reassuring the Detached Topic 12: MANAGING BOUNDARIES AND LIMITS
Protector Goals
1. Address Patient Acting Out Around Boundaries of Therapeutic
Method
Relationship
1. Imagery Exercise Using Schema Modes
2. Set Limits and Consequences for Continued Rule Violauons
Topic 7: CONFRONTING THE PUNITIVE PARENT Methods
Goals 1. Review Patient Behavior Inside or Outside of Session
1. Imagery of Punitive Parent 2. Explore Schema-Related Meaning and Establish Firm
2. Healthy Adult Challenges and Confronts Punitive Parent Boundary
 Dual Focus Schema Therapy
belief that all people eventually leave her and her ten-
dency to drive others away first through verbal or physical
abuse to avoid the abandonment. Attempts were made to
challenge her view of herself as ugly, undesirable, and un-
wanted (i.e., defectiveness). Her jealous beliefs and unre-
alistic expectation that her partner should always be avail-
able only for her also were examined, but her partner
increased his distance over the course of the treatment.
This event exacerbated Sally's depression and kept her
preoccupied with the termination of the therapeutic rela-
tionship. Several imagery exercises were used to reexperi-
ence memories and ventilate feelings related to her phys-
ically absent or verbally abusive parents. This material was
accompanied by in-session hopelessness and apathy and
episodic dissociative episodes, which were processed, but
not to full resolution. Sally appeared quite interested in
her therapy, although less committed to making behav-
ioral changes over the course of her 24-week (20-session)
treatment. She remained abstinent from heroin and co-
caine and reduced her marijuana use, but continued to
drink alcohol (2 to 3 drinks every other day) throughout
the study. She also demonstrated very gradual reductions
in BSI psychiatric symptoms and more dramatic de-
creases in her experiences of negative affect (MAACL).
Natalie (Cluster B)
Natalie is a 34-year-old single, unemployed, white
female mother of one child whose primary Axis-II diag-
nosis was borderline personality disorder (secondary:
negativistic, antisocial). H e r MCMMII personality code
indicated moderately elevated (base rate: 75 to 84) serf-
defeating, depressive, and schizoid scales. In addition to
drug dependence, her MCMMI1 syndrome code indi-
cated significantly elevated (BR > 85) major depression,
anxiety, and somatoform scales and a moderate elevation
on dysthymia. BSI elevations included somatization, anx-
iety, and obsessive-compulsive. She had several prior sub-
stance abuse and psychiatric treatments, and had been
on methadone (50 rag) for 3 years before beginning this
individual therapy study. She was regularly using benzodi-
azepines, which she felt were necessary to maintain her
emotional stability. However, the methadone clinical staff
had not approved her use of these medications, and her
referring clinician regarded it as a significant problem in
need of attention.
Natalie scored low on NEO Extraversion and high on
NEO Neuroticism and IIP-CX Cold, Domineering, Vin-
dictive, and Nonassertive scales. Her core early maladap-
tive schemas were abandonment and emotional depriva-
tion, which appeared to originate from relationships with
a very serf-centered mother and antisocial father who were
emotionally unavailable, deceived and lied to her, and left
her at home unsupervised. She developed compensatory
interpersonal schemas of enmeshment and subjugation
277
in which she would rapidly and strongly attach herself to
males and remain in relationships despite abuse and oc-
casional rapes. She also relied on anger suppression,
pseudopanic episodes, and numbing as methods of cop-
ing with distressing affect and regulating intimac)<
Natalie began therapy with a sense of urgency about
several pressing problems she was experiencing with her
ex-boyfriend (father of her daughter) and persistent
problems managing the boundaries of her relationship
with her mother, whom she feared losing. She wanted the
therapist to rapidly understand everything about her and
brought in 10 to 15 diaries she had kept for the past 5
years. Each session for the first 6 to 8 weeks began with
her replaying distressing events from the week, and it was
often difficult to integrate the schema-focused work into
the session. When this could happen, the work focused
on her feelings of abandonment related to her mother's
leaving the house for months at a time to be with her
lover (and later her involvement with Natalie's boy-
friend), leaving her children cared for by a highly antiso-
cial father who sexualized the relationship with Natalie,
who adored him. Therapeutic interventions focused pre-
dominantly on helping her avoid adult relationships (in-
cluding one with ex-boyfriend) where she was likely to be
physically assaulted or raped. However, she was unable to
do the experiential work necessary to attribute some of
her very early substance abuse (onset age 5) and experi-
ences of rape by neighborhood boys to an absent mother
or a father who failed to protect or provide adequate
boundaries. Most attempts at imagery or past origin work
were interrupted by disabling physical symptoms or
pseudopanic states. She was quite preoccupied with the
limited availability of the therapist and abruptly dropped
out at 4 months (17 weeks; 13 sessions). She later re-
ported that she was unable to tolerate the idea that the
therapist would end the relationship, so she decided to
take control over this outcome. She remained abstinent
from heroin and cocaine and significantly decreased her
benzodiazepine use through 4 months, but at the 6-
month termination research interview she had resumed
heavy daily benzodiazepine use. Her psychiatric symp-
toms (BSI) and negative affect ratings (M_AACL) re-
mained unchanged over the 6 months of the study.
Bill (Cluster C)
Bill is a 36-year-old single white male whose primary
Axis-II diagnosis was obsessive-compulsive personality dis-
order (secondary: antisocial, depressive). His MCMI-III
validity scales indicated an invalid profile, but BSI eleva-
tions included depression, obsessive-compulsive, and
paranoid ideation. He began using substances at the age
of 14, had several prior substance-abuse (but no psychiat-
ric) treatments, and had been on methadone (110 nag)
for 1 year before beginning this individual therapy study.
278 Ball & Young

His primary substance abuse problem at the beginning of
therapy was heroin, with more sporadic use of solvents
(high-grade paint stripper), cocaine, and alcohol.
Bill scored low on NEO Extraversion, Agreeableness,
and Conscientiousness, and high on NEO Neuroticism
and IIP-CX Exploitable, Domineering, and Vindictive
scales. His core early maladaptive schema was unrelent-
ing standards, which appeared to originate from the
seemingly contradictory combination of parental perfec-
tionism and defeat secondary to their both being Nazi
concentration camp survivors. His entitlement schema
seemed to be associated with the application of unrelent-
ing standards and expectations within his interpersonal
relationships. Bill put a great deal o f pressure on himself,
and any m i n o r deviation in his striving for perfection trig-
gered a massive substance relapse, irresponsible giving
up, and antisocial acting out.
Bill began therapy in a loud, challenging manner,
wanting to know for sure that therapy was going to help
him, and that he was going to get as m u c h out of therapy
as we were going to get out of him as a research partici-
pant. Because he continued to abuse heroin, cocaine,
and a high-potency inhalant for the first 3 months, ther-
apy necessarily remained more relapse-prevention fo-
cused while he struggled to grasp cognitively any of the
schema and coping style material presented. By m o n t h 4,
he had achieved complete abstinence from solvents and
was using heroin, alcohol, and cocaine m u c h less fre-
quently. He seemed like an entirely different person, ex-
cept that his unrelenting standards became even stronger.
Cognitively oriented interventions included a cost-benefit
analysis of his unrelenting standards and reducing the
perceived risks of imperfection in his relationships with
his wife, coworkers, and therapist. The therapy also fo-
cused on slowly lowering his standards and accepting
"good-enough" work and rekindling old leisure interests
and spontaneous activities with his wife. Much of the work
in his outside relationships and with that of the therapist
focused on helping him change his dichotomous view of
other people as well as his own recovery (i.e., all g o o d /
sober vs. all bad/relapsed). Despite a rather turbulent
course of treatment, Bill appeared genuinely interested
in improving himself and made some significant changes
over the course of his 24-week (18-session) treatment. In
addition to his reduced substance abuse, he also experi-
enced significant reductions in BSI psychiatric symptoms
and negative affect, although MAACL dysphoria in-
creased at termination almost to baseline levels.
Discussion
There has been significant growth recently in the de-
velopment and pilot testing of promising, time-limited
treatment approaches for personality disorders. The field

Table 3
Summary of Schema-Related Information for Three Case Examples

"NAME" Maladaptive Core Cognitive Schema Schema Schema

{Cluster} Schemas Distortions Maintenance Avoidance Compensation Core Memories

"Sally" Abandonment "People will always Giveup and Numbing Control, manipulate, Given up to multiple
{A} Social isolation leave me, so I am blame self Substance use possess others foster placements
Defectiveness better off alone." Remaining alone Identity flipping Take care of helpless Maternal blame for
Feel defective, Keep busy, on the and injured brother mental
unwanted move Act strong/ illness
Somatization independent Paternal
Drive others away first disengagement
"Natalie" Enmeshment "I must do anything Choose Suppress anger Clinging dependence Repeated maternal
{B} Subjugation to keep people unpredictable, Numbing Help others at all costs abandonment
Abandonment from leaving unavailable, Panic and deceit
Mistrust/Abuse me." abusive Somatization Multiple peer rapes
partners Substance use
Despondent when
others don't
reciprocate
"Bill" {C} Unrelenting "When I don't Expect much Suppress feelings Manipulate and lie Paternal alcoholism
standards accomplish or or compete Social withdrawal Assert freedom and physical/
Entitlement get what I want, with others Somatic symptoms Antisocial emotional abuse
I should get Pressure self Procrastinate, forget irresponsibility" Parental Holocaust
enraged, give up, Strivefor Give up on self and survivor memories
use drugs, and perfection others
be dejected." Keep busy Substance use
Avoid commitments
 Dual Focus Schema Therapy
of personality disorder treatment historically was divided
into groups that had either questioned the existence of
personality and its disordered expression (behavioral),
or had developed symptom-focused techniques that were
ineffective for "difficult-to-treat" patients in short-term
protocols (cognitive), or had viewed treatment as a very
long-term process with unclear outcomes for a fairly nar-
row functional range of character disturbance (psycho-
analytic). Limited clinical success combined with major
shifts in the delivery of psychotherapy under managed
care has stimulated each of these major individual ther-
apy models to consider seriously the need to adapt tradi-
tional methods to respond better to the needs of this
challenging, complex population. Shorter-term psycho-
dynamic approaches developed, focusing increasingly on
conscious thought processes, core conflicts or relational
themes, and confrontational techniques, while longer-
term cognitive-behavioral approaches began focusing on
the origins of maladaptive behavioral patterns and cogni-
tive themes, their expression in the therapeutic relation-
ship, and the importance of empathic understanding.
These are major theoretical and technical changes. M-
though the language used to describe psychopathology
and psychotherapy remains different, we have been
struck more by the underlying similarities of constructs
and approaches in the different theoretical and clinical
writing and videotaped demonstrations of cases.
Mthough there is now some excitement about con-
ducting personality disorder treatment research, it is not
a time for unrealistic optimism. Individuals previously
considered untreatable by psychotherapy are now consid-
ered challenging or difficult. Mthough many approaches
appear promising, empirical support for their efficacy is
almost nonexistent. The major exception to this is Line-
han's (1993) dialectical behavior therapy, which shows its
clearest effects on reducing parasuicidality and hospital-
ization (Linehan et al., 1991, 1993). For the field to con-
tinue its advance, it increasingly will need to value these
improvements in targeted life areas rather than expect-
ing deeper, structural change as the major outcome of in-
terest. Realistic goals are necessary when treating severe
personality disorders and substance dependence (e.g.,
improving self-esteem, emotional functioning, relation-
ships, psychiatric symptoms) through improved reten-
tion and outcome in a substance abuse treatment that ex-
plicitly addresses the personality functioning of the
patient. As we have discussed previously (Ball, 1998), re-
search in this area contends with a number of practical
problems, including diagnostic reliability and stability of
DSM-IV personality disorders, participant recruitment,
addressing the Axis-I symptoms that typically motivate
the individual to seek treatment, controlling for addi-
tional treatments, training therapists in a complex psy-
chotherapeutic approach, and the treatment time frame.
7_79
Six months is probably an inappropriately short period
of time within which to expect change in this complex
population, and yet it stretches the duration beyond that
of most clinical research and
managed care plans. Nearly
all patients in our study to Targeted change
date have expressed a wish
in substance use
that therapy could be longer-
term, and most had difficulty and core schemas
accepting termination. We can significantly
hope that relatively short-term
impact a broad
(6-month) approaches such as
ours will show enough prom- range of behaviors
ise that a more extended course by disrupting the
of therapy may be justified on
behavioral and
the basis of longer-term cost-
effectiveness or as an effective interpersonal chain
means to prevent relapse of of events that help
a presenting Axis-I disorder.
perpetuate the
Davidson and Tyrer (1996)
have reported positive results dual disorder in
in a series of single-case studies adulthood.
of personality-disordered pa-
tients using a 10-week cogni-
tive-behavioral treatment, and Fisher and Bentley" (1996)
found that a cognitive-behavioral group had better alco-
hol and psychosocial outcomes than a treatment-as-usual
group for personality-disordered substance abusers. Our
pilot results show similarly promising results.
In order for an empirically based treatment literature
to continue its evolution, clinicians and theoreticians will
need to articulate their approaches in ways that permit
independent investigators to replicate promising single-
case studies through controlled clinical trials. We pre-
sented a treatment model and some case study results for
the first well-specified, detailed treatment manual for the
full range of DSM-IV personality disorders, integrated
with a focus on a common, co-occurring Axis-I disorder
(substance abuse). DFST integrates a schema-focused ap-
proach (Young, 1994a) with relapse prevention tech-
niques (Marlatt & Gordon, 1985). Of the first 10 opioi&
dependent, personality-disordered individuals treated, 6
completed the 24-week DFST, 2 dropped out after several
months, and 2 individuals began in acute emotional dis-
tress and dropped out after one appointment. The 8 par-
ticipants who received a reasonable dose of the treatment
exhibited steady decreases in substance-use frequency,
psychiatric symptoms, and negative affect. We have suc-
cessfully trained doctoral-level psychotherapists, devel-
oped treatment manuals (Ball & Young, 1998) and ad-
herence/competence rating scales, and have recently
completed enrollment of 30 additional patients in a ran-
domized trial (comparing DFST versus 12-Step Drug
Counseling). These weekly individual therapies have very
280 Ball & Young

different hypothesized mechanisms of action and are Ball, S. A., &Young, J. E. (1998). DualFocus Schema Therapy: A treat-
ment manual for personality disorder and addiction. Unpublished
provided by doctoral-level clinical psychologists trained
manuscript.
by the originators of the two respective approaches. Beck, A. T., Freeman, A., & Associates. (1990). Cognitive therapy ofper-
Because this group of individuals rarely presents for sonality disorders. New York: Guilford.
Beck A. T., Wright, E D., Newman, C. E, & Liese, B. S. (1993). Cognitive
treatment for their personality disorders per se, re- therapy of substance abuse. New York: Guilford Press.
searchers invariably study and treat these disorders in Beck, J. S. (1994). Cognitive therapy: basics and beyond. New York: Guil-
the context of alleviating a ford Press.
Benjamin, L. S. (1993). Interpersonal diagnosis and treatment of personality
presenting Axis-I disorder or
disorders. NewYork: Guilford Press.
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sure within the patient's envi- and strategies for treatment development. Journal of Personality
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n e e d to value Psychiatry, 54, 923-928.
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An earlier stage in the pilot testing of this treatment approach was
presented at the 1997 annual meeting of the College on Problems of
Drug Dependence in Nashville, Tennessee, and the 1999 annual
convention of the American Psychological Association in Boston,
Massachusetts. The authors thank the study therapists (John Cecero,
Ph.D., Donna LaPaglia, Psy.D., Diane Johnson, Ph.D., and Helen
Sackler, Ph.D.) and research interviewers (William O'Neill and Laura
Randolph). This work was supported by a National Institute on Drug
Abuse behavioral therapy development grant R01 DA10012-01 to the
first author and psychotherapy center grant P50-DA09241 (Bruce
Rounsaville, PI). Copies of the Young questionnaires can be obtained
through the second author's website: http://www.schematherapy.com.
Correspondence concerning this article, including requests for the
treatment manual, should be addressed to Samuel A. Ball, Clinical
Research Unit, 1 Long Wharf Drive-Suite 10, New Haven, CT 06511;
e-mail: alemball@snet.net.
Received: January 14, 1999
Accepted: October29, 1999