• Introduction
• Review of Common Unsafe Behaviors
• Identifying Safe Behaviors to Aid in Recovery

For notes CLICK HERE 

CEU TRAINING: Schema Therapy Interventions – Dependence/Incompetence & Enmeshment/Undeveloped Self Schemas

DATE: 12-05-18

TIME: 11:00-1:00 PM CT

OUTSIDE STUDY: 1 Hour

DIDACTIC PRESENTATION: 2 Hours

EDUCATOR: Shaun Lotter MA, LPC #200631338

SOURCES: 

NLT study Bible (2nd ed.). (2008). Carol Stream, Ill.: Tyndale House.

Schema Therapy– Young, Klosko & Weishaar, The Guilford Press, New York 2003

DESCRIPTION:

The training is targeted at assisting mental and behavioral health professionals to grow in their understanding and counseling of Christian clients. Counselors will be taught the Schema Therapy conceptualization and treatment of clients who have dependence/incompetence & enmeshment/undeveloped self schemas. Therapists will also integrate theological/faith components on such matters critical to the Judeo-Christian client population while integrating sound clinical skills.

OUTLINE:

•  Introduction
•  Review of Impaired Autonomy & Performance Domain
•  Dependence/Incompetence Schema Treatment Goals & Interventions
•  Enmeshment/Undeveloped Self Schema Treatment Goals & Interventions

IMPAIRED AUTONOMY & PERFORMANCE DOMAIN (a quick review)

Expectations about oneself and the environment that interfere with one’s perceived ability to separate, survive, function independently, or perform successfully.  Typical family origin is enmeshed, undermining of the child’s confidence, overprotective, or failing to reinforce child for performing competently outside the family.

DEPENDENCE/INCOMPETENCE SCHEMA:

It is not uncommon to encounter clients in the Impaired Autonomy & Performance Domain.  These individuals present as childlike and helpless.  They see themselves as unable to take care of themselves on their own and experience life as overwhelming.  Life seems so tough and they are inadequate to the challenge.  There are 2 components to this particular schema:

1. Incompetence – these individuals lack faith in their decisions and judgements about everyday life.  They hate fear and facing change alone.  They feel unable to face new tasks on their own and believe they need someone to show them what to do.  These fears can range in severity from mild to severe, in which case the individual may not even believe they will be able to feed, clothe, and shelter themselves apart from a support figure (this individual is in a kind of parent role for the client).
2. Dependence – this feature flows naturally out of the first, incompetence.   Since the individual is unable to function on their own, their only options are to find others to take care of them or to not function at all.  These caretakers are usually parents or substitute parents such as partners, siblings, friends, bosses, even therapists.

These clients do not typically come into therapy looking to work on this schema.  Instead, they present as seeking advice from an expert who can tell them what to do in life.  Their symptoms are often anxious or depressive, and they identify these as needing work.  Although, these symptoms often stem from the schema, such as a wife who is anxious and depressed because she is unable to consider setting boundaries with or leaving a controlling/abusive spouse.  Such clients exhibit behaviors like:

• asking others for help
• constantly asking questions as they work on new tasks
• repeatedly seeking advice about decisions
• having difficulty traveling alone
• having difficulty managing finances on their own
• giving up easily
• refusing additional responsibilities (like a promotion at work)

*Please be aware, a small percentage of these individuals will overcompensate by becoming non-dependent, doing everything on their own and shunning any kind of support as a means of distancing themselves from the struggle.  

Treatment Goals:

• Increasing client’s sense of competence and decreasing dependence on other people.
• Build self-confidence via identity work and increasing skill level in managing life challenges.
• Recognition of avoidance behaviors and processing fear & other emotions underneath, which may be connected to childhood.
• Deliberately engaging in life challenges, managing the frustration this creates without giving up.
• Understanding mistakes and failures as an acceptable part of learning.

Cognitive Strategies:

It is the goal of the cognitive strategies to begin to ask the client to challenge their current perceptions of themselves and the benefits of their behaviors.  The cognitive portion of work is identified by schema researchers as particularly important with this schema, as the client struggles with deeply entrenched ways of thinking which highlight the benefits and safety of their dependence/incompetence while minimizing the costs.  Instead, therapists should challenge this thinking, pointing out the limitations of this way of operating, such as unfulfilled emotional needs, a lack of autonomy, and no self-expression.  Additionally, the clients must learn to question their struggle with identifying anxiety as a bad thing, not to be tolerated.

Behavioral:

This intervention is critical if the client is going to gain enough real evidence to refute the schema.  They must confront the anxiety producing situations in order to grow.  Therapist and patient work to assign managing daily life challenges, starting with the easiest, so anxiety can be brought up and managed, while the client has success in mastering tasks.  Role play with the therapist and problem solving are useful.  Additionally, the therapist equips the client with anxiety management techniques – such as flash cards, breathing exercises, relaxation techniques, and rational responding.  Finally, successes should be celebrated by the therapist, who also encourages the client to reward themselves outside of session.

Experiential:

This kind of work may be more limited with this client.  It is valuable to examine origin of the schema and address abuse, trauma, or simply poor parenting which resulted in the struggle.  Be aware you may find a significant trauma history, though not always.  Be aware, if there is trauma, it is important to begin stabilization work, including DBT, rather than moving strongly into working on the dependence/incompetence schema.

ENMESHMENT/UNDEVELOPED SELF SCHEMA:

These clients are often fused with a significant other, leaving difficulty seeing where the client’s identity begins and the enmeshed other ends.  This person is usually a parent or parental figure, such as a partner, sibling, boss, or best friend.  Clients feel an extreme emotional involvement and closeness with the parental figure, at the expense of fun individuation and normal social development.  There is often the sense that neither the client nor the enmeshed other could survive or function without the other.  Additionally, these clients struggle to have a sense of self, which they will often describe as a feeling of emptiness.  They have often surrendered their identity in order to maintain their connection to the parental figure.  It is possible for a client to have one of the traits, enmeshment or undeveloped self, without the other.  For example, a client who had very dominant parents may never have developed a sense of self but is not enmeshed.  However, a client with an enmeshed parent almost always lacks a sense of self.  Struggles with this schema may present as:

• copying the behaviors of the parental figure
• talking about or thinking about him/her
• staying in constant contact with the parental figure
• suppressing all thoughts, feelings, and behaviors that are discrepant from the parental figure
• feeling overcome with guilt in any attempts to separate from the parental figure, including having boundaries

Cognitive:

These strategies work to challenge the client’s view that it is preferable to be enmeshed with the parent figure than to have an identity of one’s own.  Therapist and client explore the advantages and disadvantages of developing a separate sense of self.  Clients identify how they are similar and different from the parental figure.  Identifying similarities is important, as it is unhelpful for the client to go to the extreme and deny any likeness to the parental figure, creating fantasy preferences which are simply opposition to them.  Finally, the client can conduct dialogue between the enmeshed part of self that wants to stay in this kind of relationship with the parental figure and the healthy side who sees value in having a sense of self.

Experiential:

Clients visualize separating from the parental figure in imagery.  For example, clients relive moments in childhood when they disagreed with or felt different from the parent.  They imagine saying what they truly felt and doing what they truly wanted to do.  They imagine telling past and current parental figures how they are different, and how they are alike.  They imagine setting boundaries with past and current parental figures, such as refusing to divulge information or to spend more time together.  The Healthy Adult, played first by the therapist and then by the patient, helps the enmeshed child accomplish the separation.

Behavioral:

These strategies emphasize the client finding their own preferences and natural inclinations.  The client begins to list experiences they find inherently enjoyable.  They may be asked to list their favorite music, movies, books, restaurants, etc.  Clients list what they like & dislike about the significant others.  Behavioral strategies include asserting oneself in the relationship with the parental other.  In the case of this person being the spouse, understand that these individuals often choose a very dominant spouse and become immersed in the spouse’s world.  As such, learning how to be fully themselves in the relationship, including expressing preferences and setting boundaries is critical.

1. Introduction  – Diagnosis & Treatment of Any Associated Mental Disorder
2. Cognitive Interventions
3. Experiential Interventions
4. Behavioral Interventions
5. Common Resistance

Introductory Counselor Insights:

• It is critical that the therapist validates the client’s schemas and coping styles as understandable conclusions based on their life histories.  This leaves the client feeling understood, and a client who feels more understood is more likely to accept the necessity of change.  They will be more receptive to healthy alternative perspectives offered by the counselor.  Further, clients experience the counselor as allying with them against the schema.  Rather than viewing the schema as a core part of who they are (ego-syntonic) they begin to view it as foreign (ego-dystonic).  The counselor explains to the client that given their life history, it makes sense they see things as they do and behave as they do.  However, in the end, the ways in which they see and behave have only served to perpetuate their schemas.  The counselor works to build a case in favor of fighting their schemas with new ways of behaving rather than persisting in the same self-defeating behaviors.

• Failure to intentionally do the above will likely lead to one of two negative extremes: being so empathetic we do not push the client to face reality, or too confrontational and causing the client to feel defensive and misunderstood.

COGNITIVE INTERVENTIONS

1.  Testing the validity of the schema.

The schema is viewed as a hypothesis to be tested via empirical facts.  Create two lists, one validating the schema view and the other refuting it. Compare and contrast.  The list against the schema is important, as it will be referred back to at future times in which the client is reverting back to old thinking.  Both lists can be enhanced periodically as therapy progresses.  For example, the evidence against list can be enhanced by adding new success or by spelling out ways the client negates gains (ex: My husband & others love me, but that is because they do not know the real me).  Finally, the evidence for the schema can be linked back to childhood experience and the therapist can work with client to explore more adult explanations for the experiences of the client.  (ex: the child concludes they were unlovable, the adult sees the parents were too consumed with their own pain to love the child as they should have.).  The client can then examine how they have self-perpetuated their schemas in life since childhood, such as choosing partners who are unloving.

Counselor Insights:

• It is often easy to create the list in support of the schema b/c the client has lived in such a way as to constantly validate it.  This may require the therapist to step in and assist.  The difference in ability to create each list is a valid therapy subject.  It is also helpful for the client to see this tangible example of how they accentuate information/experience in such a way as to arrive at schema driven conclusions while negating information which would challenge it.  

• If the person legitimately does not have evidence to refute the schema, respond with acknowledging this, but say “It doesn’t always have to be this way.”  Then, later point the client to the childhood origin of the difficulty.  It is not an excuse for them to acknowledge the past and its impact on their life.

• Bouts of the client wrestling with the list refuting the schemas is clinically significant.  It is helpful for the client to gain self-awareness of not only what they falsely believe, but how they go about dismantling productive thought gains when their schema is touched upon by life situations.  In other words, they can see how they are active in tearing down what they have just worked so hard to build.  

• The client will want to develop an awareness if part of how they sabotage themselves is by seeking out those who will reinforce their schemas (ex: a man with a defectiveness schema selecting critical people to be around).  In such a case they do not have unloving relationships because they are unlovable, but, because they choose unloving people.  

2. Evaluating the Advantages & Disadvantages of Schema Responses.

The ways in which a person handles their schemas are helpful in exploration, gaining meaningful insight and considering actionable options for change.  Remember, in schema therapy, the counselor seeks to grow client competence.  The client initially came to therapy confused, seeing their issues as mysterious & overwhelming.  Therapy serves to make the problems clearly defined and solvable.  Making a list of how the client has previously handled schemas will help them to discover their very influential role in continuing or changing these responses.  They can list out the advantages of such responses, as well as their disadvantages.  Next, the therapist and client can create a list of alternative responses, with possible advantages & disadvantages of each.  The therapist and client can then go about reality testing these new responses (take them on test drives throughout the week) and then process successes & obstacles.

Counselor Insights:

• Remember to normalize for the client the experience of anxiety with any form of change.  It is a normal response of the brain to be uncertain of what is new, even if what is currently done is ineffective or destructive.  Help the client to understand the experience of anxiety does not mean what they are doing is wrong or “a bad idea.”

• Also, help a client to understand they are in control as they attempt different responses.  They are not being asked to decide whether or not they want to walk off the edge of a cliff (though they may feel this way) with no chance of return if they realize it was a mistake.  Instead, they are walking and considering taking a step to the right or left.  They will be in control of that step, able to evaluate after they have taken it, and then free to decide to go back to where they were or continue another step in the new direction.

3. Conducting a Dialogue Between the Schema Side & the Healthy Side.

The technique is an adaptation of the Gestalt “empty chair” technique.  The therapist is asking the client to make the case for or against their schema as the “schema” or “healthy” side.  We are using this language to continue, in any manner possible, to foster an ego-dystonic stance from the client, as they are not simply arguing as themselves, they are arguing as this “part” of their dysfunctional thinking.  The client can argue both sides, or the therapist can take one of the sides.

Counselor Insights:

• Remember, even though the client speaks the “healthy” side words, they likely will respond that “I just don’t believe them.”  The therapist can respond, “Most people feel the way you do at this point in therapy.  Rationally, they understand the healthy side, but emotionally they do not believe it yet.  All I’m asking you to do now is say what you know to be logically true.  Later we’ll work on helping you take in what you’re saying on a more emotional level.”  In other words, “say what you know is true no matter how it feels.”

4. Schema Flash Cards or Diary.

Flash cards are a way the client can “carry the therapist with them.”  This is particularly comforting for more emotionally liable clients.  CLICK HERE for an example flash card.  On a note card, the client outlines:

• Current Feelings

• Trigger

• Schema Triggered

• Origin of Schema

• Old False Belief

• New True Belief & Evidence Supporting It

• Old Behavioral Response

• New Behavioral Response to be Carried Out

The diary is a way of processing, post-event, relevant daily experiences.  The client can use the following format:

• Trigger

• Emotions

• Thoughts

• Actual Behavioral Response

• Schemas & Origins

• New Healthy Views of Life

• Realistic Concerns (now that schema has been separated out)

• Overactions

• New Healthy Behavioral Options

EXPERIENTIAL INTERVENTIONS

Transitioning from the rational to the emotive- feeling the schema’s.  The schema goes from a “cold’ to a “hot” cognition when experienced.

Imagery for Assessment Rationale:

• To identify and trigger the patient’s schemas.
• To understand the childhood origins of the schemas.
• To link schemas to presenting problems.
• To help the patient experience emotions associated with the schemas.

Continued Imagery Work Rationale:

1)  To identify those schemas that are most central for the patient.

2)  To enable patients to experience schemas on an affective level.

3)  To help patients link emotionally the origins of their schemas in childhood and adolescence with problems in their current lives.

Imagery Work for Re-parenting:  Most helpful for patients in the Disconnection & Rejection domain (Abandonment, Mistrust/Abuse, Emotional Deprivation, and Defectiveness). 

• The therapist asks permission to enter the image and speak directly to the Vulnerable Child.
• The therapist re-parents the Vulnerable Child.
• Later, the patients Healthy Adult, modeled after the therapist, re-parents the Vulnerable Child.

Writing Letters:  Patient is assigned to write a letter to a parent or significant other who has hurt them.

Imagery Work for Pattern Breaking:  Imagining situations that might activate the client’s schemas or have done so in the past.  The client activates and addresses schemas, challenging them, encountering blocks, and working through resistance while practicing new techniques.  Therapist guides through this process, aiding the client to process the incident utilizing imagery questions.

Resistance Issues: 

Patient Response: “I’m already past this.  I’ve dealt with my anger.  I understand my parents.  I forgive them.”  Taking such claims at face value is almost always a mistake.  To move from being wronged to forgiveness and to make headway against your schema, most clients must pass through anger.  They are grieving, and grief is almost always mixed with anger.

Identify the Detached Protector and dialogue with it to gain access to the client.  Definition- Adopts a coping style of emotional withdrawal, disconnection, isolation, and behavioral avoidance.  Individuals in this mode detach from other people and shut off their emotions to protect themselves from the pain of being vulnerable.  The mode is like protective armor or wall, with the more vulnerable modes hiding inside.  You may feel numb or empty.  You may also adopt a cynical or aloof stance to avoid investing emotionally in people or activities.  Behavioral examples include social withdrawal, excessive self-reliance, addictive self-soothing, fantasizing, compulsive distraction, and stimulation seeking.

Imagery Work Session Structure: Explanation: 5 min, Imagery: 25 min, Processing: 20 min

• Close your eyes. Picture yourself in a safe place.  Use pictures, not words or thoughts.  Let the image come on its own.  Notice the details.  Tell me what you are picturing.  What do you feel?  Is there someone with you, or are you alone?  Enjoy the relaxing, secure feeling in your safe place.
• Keep your eyes closed and wipe out that image. Now picture yourself as a child with one of your parents in an upsetting situation.  What do you see?  Where are you?  Notice the details.  How old are you?  What’s happening in the image?
• What do you feel? What are you thinking?  What does your parent feel?  What is your parent thinking?
• Carry on a dialogue between you and your parent. What do you say?  What does your parent say (continue the dialogue until it reaches a natural conclusion).
• Consider how you would like your parent to change or be different in the image, even if it seems impossible. For example, do you wish your parent would give you more freedom?  More affection?  More understanding?  More acknowledgment?  Less criticism?  Be a better role model?  Now tell you parent in the image how you would like him or her to change, in the words of a child.
• How does your parent react? What happens next in the image?  Keep the image going until the scene ends.  How do you feel at the end of the scene?
• Keep your eyes closed. Now intensify the feeling you have in this image as a child.  Make the emotion stronger.  Now, keeping the emotion in your body, wipe out the image yourself as a child and picture an image of a situation in your current life in which you have the same or similar feelings.  Don’t try and force it; let it come on its own.  What’s happening in the image?  What are you thinking?  What are you feeling?  Say it out loud.  If there is someone else in the image, tell the person how you would like him or her to change.  How does the person react?
• Wipe out the image and return to your safe place. Enjoy the relaxed feeling.  Open your eyes.

Sample Imagery Questions:

What are you seeing?                                                                                   

What are you hearing?                                                                 

Can you see yourself in the image?                                                          

What is the look on your face?                                                  

Is the patient in the image?

What is the patient thinking?

What is the patient feeling?                       

Where in your body do you feel the emotions?

What does the patient have the impulse to do/say & could they do this?

Is anyone else in the image?

How do the characters feel about one another?

What do they wish they could get from one another?

What does that character want to do?

Ending/Post-Imagery Questions:

What did the images mean to you?

What were the themes?

What schemas are related to these

BEHAVIORAL PATTERN-BREAKING INTERVENTIONS

Introduction: In this stage, clients attempt to replace their schema-driven patterns of behavior with healthier coping styles.  Behavioral pattern-breaking is the longest, and in some ways, the most crucial part of schema therapy.  Without it, relapse is likely.  Even with insight into their early maladaptive schemas, cognitive work, and experiential intervention, their schemas will re-assert themselves if clients do not change their behavioral patterns.

Behavioral interventions, when following schema therapy strictly, are the last intervention, building on the insight the client has gained via the other interventions.  They have provided the client psychological distance from the schema, helping him or her to view the schema as an intruder rather than as a core truth about self.  The previous interventions have also bolstered and strengthened the healthy side of the client.

Behavioral Pattern-Breaking specifically targets coping styles, those maladaptive ways of doing life which include surrendering, avoiding & overcompensating.

Step #1: Defining the Behaviors to Target

• The counselor and client work together to create a clear, specific list of behaviors which need to be challenged. It is important to be specific on this list, as ambiguity leads to poorly defined behavioral goals.  Also, a schema coping style may manifest in one area of the client’s life but not in another, so targeting becomes specific to areas of life.  For example, a client may be warm and inviting with friends but cold and distant with a spouse.  Once the target behaviors are defined, the therapist and client work to create a “blow by blow” account of what happens in these moments.  Again, it is critical counselor and client work together to develop a clear vision of what has been happening.  If necessary, the counselor can use guided imagery with the client to help them remember details of such events very specifically.
• The schema therapy theorist’s approach is to encourage behavioral change in current circumstances rather than making major life decisions/changes. It is believed clients have a great deal to learn in working through the challenges of their current situation, learning to be more effective in their life.  After making such changes, the client is in a better place to make a clear, more informed decision about a life circumstance (ie: job, moving, marriage, etc).  If a client does decide to move on after addressing schema wounding and correcting these, the person will be able to move on knowing they did all they could in the circumstance, having better closure.

Step #2: Prioritize Behavior Patterns To Be Targeted

• Each client will present with numerous behavior patterns which need to be addressed and these cannot be tackled all at once. The client and counselor should work together to determine which behaviors are to be targeted first, creating an order for further intervention.  This list can be revisited as therapy continues.
• Noticing the Behaviors in Session: It should come as no surprise a client demonstrates some schemas in the counseling office.  A counselor can utilize this to make here and now observations for the client.  The two can also work together to begin changing the behavior in session while processing initial discomfort that arises from such changes.

Step #3 Connect The Target Behavior to Its Origins in Childhood:

• It is critical for the client to establish empathy for themselves in order to be adequately supportive. In a sense, they need to see themselves in a less critical way to encourage positive change.  To facilitate this, the counselor, helps the client connect the current behavior with its childhood origins.  For example, a patient trying to give up alcohol connects his drinking to not wanting to feel painful emotions.  He links this fear and avoidance to being a frightened child when his abusive father would come home.  Instead of viewing himself as weak, the client can understand why he developed this behavior, empathizing with the child.

Step #4 Review the Advantages and Disadvantages of Continuing the Behavior:

• To strengthen the motivation, client and counselor can take time to review the advantages of continuing and discontinuing the maladaptive behavior. Unless a client believes it is worth the effort, they are not going to undertake behavioral change.  The counselor will then be the only person in the relationship who is motivated.  Not a recipe for success, or therapeutic rapport.

Step #5 Homework & Preparation: 

• It is time to develop our behavioral homework. Therapist and client work together to define specific homework assignments for the week.  The assignment development is collaborative.  Once the homework is agreed upon, the counselor can assist the client by completing either guided imagery of the homework or role-play.  The counselor can serve as a prop to help the client practice interacting with the people they will be dialoguing with as part of the homework.

Step #6 Reviewing Progress & Understanding and Processing Blocks:

• It is important the client and therapist review progress on homework. The goal here is not to have the client “get an A” each week, but to deal with challenges & setback, while also celebrating victories.  In the event there are blocks, or obstacles to success on homework, the counselor can explore using the following questions & guided imagery:
  • Is the client afraid of the consequences of changing?
  • Is the client angry that change is necessary or so hard?
  • Is the client having trouble tolerating the discomfort or struggle involved in changing?
  • Did the client uncover beliefs or feelings that are difficult to overcome?
  • Does the client believe that a positive outcome is impossible?
  • Guided Imagery: The counselor can use guided imagery to have the client walk back through the situation, actively encountering the block.  The client and counselor then work to define what is being thought and felt at the time of the block.  The counselor can also explore:
    • What are the others thinking and feeling in the scene?
    • What does the client want to do?
    • Also, the counselor might have the client carry out the new behavior in the imagery. Then the counselor can explore:
      • Does the client feel guilty or incur the wrath of a family member?
      • Does the client foresee some dreadful outcome?
    • The counselor may have the client imagine what the block looks like and imagine pushing through it. For example, the block might look like a dark weight pressing down on the client.  Or, the counselor can then have the client tie the block to childhood, imagining a situation in which the client felt the same way.

Finally, refine and re-assign homework.  Continue to repeat this process until success.

Sources:

Schema Therapy– Young, Klosko & Weishaar, The Guilford Press, New York 2003

1. Introduction – Diagnosis & Treatment of Any Associated Mental Disorder
2. The Corrective Cycle
3. Coping Responses
4. Schema Modes
   • Mode Dimensions
   • Mode Types
5. YSQ-2 Questions (click here for questionnaire) 

SCHEMA THERAPY – THE CORRECTIVE CYCLE, COPING RESPONSES, MODES & QUESTIONS

Let’s continue our discussion of the Schema Therapy Model by introducing the client corrective cycle, coping responses, modes and questions.

THE CORRECTIVE CYCLE: Once an individual is wounded (think back to our discussion of core emotional needs & these needs not being met), there is a tendency to engage in a behavioral cycle which is maladaptive.  In other words, the person attempts to deal with the pain they have been through using ineffective ways.  This is particularly true of individuals who have “just tried to move forward” or “let the past go.”

The original wound was likely created in childhood or adolescence and not effectively dealt with.  However, from that point forward, the individual makes decisions, creates relationships, and behaves in such a way as to recreate the circumstances of the original wound on a continuing basis.  In other words, without even intending to, the client self-sabotages.

The person will also interpret all incoming information in such a way as to confirm the faulty belief system created by the wound.  Their unresolved past wounds become the lens through which they interpret life.  As Christian counselors, we can clearly see here the reason why God places such a high value on the truth, as ongoing lies are devastating.  As Jesus said, “³² And you will know the truth, and the truth will set you free.” – John 8:32 (NLT).

This troubling cycle serves two purposes.  The first is to maintain a kind of cognitive and emotional equilibrium.  In other words, while beliefs & behaviors may be maladaptive, they are congruent, and thus, in line with the individual’s belief system.  The second purpose is to correct the mistakes which occurred the first time around.  The person will “get it right” this time.

How does this look?  Here we will transition into Coping Responses.

Coping Responses: these are specific behaviors or strategies (fueled consciously or unconsciously by faulty beliefs) through which coping styles of avoidance, overcompensation, and surrender are expressed in response to a threat. They are unique, idiosyncratic ways in which clients manifest their coping styles. When the individual habitually adopts certain coping responses, these adhere over time into “coping styles.” Thus, coping style is a trait, whereas a coping response is a state. A coping style is a collection of coping responses that an individual characteristically utilizes to avoid, surrender, or overcompensate. A coping response is a specific behavior (or strategy) that the individual is exhibiting at a given point in time.

A word on Temperament: it is very likely that temperament plays a significantly greater role in determining a client’s coping response than in the actual schema manifested. For example: a more passive client is likely to utilize avoidance as a response, where a more aggressive client will overcompensate.

Defining 3 Types of Coping Styles:

Avoidance: When patients utilize avoidance, they attempt to arrange their lives, so the schema is never activated. They attempt to live without awareness, as though the schema does not exist. They avoid thinking about the schema. They block thoughts and images that are likely to trigger it.  When such thoughts or images loom, they distract themselves or put them out of their minds. They avoid feeling the schema. When feelings do surface, they reflexively push them back down. They may drink excessively, take drugs, have promiscuous sex, overeat, compulsively clean, seek stimulation, or become workaholics. When they interact with others, they may appear perfectly normal. They usually avoid situations that might trigger the schema, such as intimate relationships or work challenges. Many patients shun whole areas of life in which they feel vulnerable. Often, they avoid engaging in therapy. For example, these patients might “forget” to complete homework assignments, refrain from expressing affect, raise only superficial issues, come late to sessions, or terminate prematurely.

Example:  A college student presents for counseling, reporting dissatisfaction with life, including feelings of anxiety and loneliness.  Throughout counseling, the client expresses a desire for change and closeness.  However, the client often comes to session reporting instances of promiscuous sexual encounters with destructive other persons, with whom there is no chance of actual connection.

Surrender: Yielding to the schema. The patient does not try to avoid or fight it. They accept the schema is true. They feel the emotional pain of the schema directly. They act in ways that confirm the schema. Without realizing what they are doing, they repeat schema-driven patterns so, as adults, they continue to relive the childhood experiences that created the schema. When they encounter schema triggers, their emotional responses are disproportionate, and the experience their emotions fully and consciously. Behaviorally, they choose partners who are most likely to treat them as the “offending parent” did. They frequently relate to these parents in passive, compliant ways that perpetuate the schema. In the therapy relationship, these parents may also play out the schema with themselves in the “child” role and the therapist in the role of “offending parent.”

Example:  A woman is abused emotionally by a critical and controlling father as a child.  She grows-up and seeks out men who are critical and controlling.  She then actively seeks to gain the approval she could never get from her father, from men, like him, who are incapable or unwilling to give it.  When she is in yet another abusive relationship, she seeks the help of a male counselor.  The counselor is upset by what he hears regarding the way the client has been treated and quickly sets about trying to help the client by directing what she needs to do.  The client is drawn to this and begins responding to the therapist as an obedient child.)

Overcompensation: Patients fight the schema by thinking, feeling, behaving, and relating as though the opposite of the schema were true.  They endeavor to be as different as possible from the children they were when the schema was acquired.  Overcompensation can be viewed as a partially healthy attempt to fight back against the schema that unfortunately overshoots the mark, so the schema is perpetuated rather than healed. It is healthy to fight back against a schema so long as the response is proportionate to the situation, taking into account the feelings of others, and can reasonably be expected to lead to the desired outcome. But over-compensators typically get locked into counterattacking. Their behaviors is usually excessive, insensitive, or unproductive. Overcompensation develops because it offers an alternative to the pain of the schema. It is a means of escape from the sense of helplessness and vulnerability that the patient felt growing up.

Example:  A couple presents for marriage therapy, on the verge of possible divorce.  The husband is a very accomplished physician who is excelling in his career.  His wife complains of a lack of sensitivity to the needs of the family and his not having any energy for the marriage.  What has brought the two into counseling is “the last straw” as the husband has been considering the position of “chief medical officer” at his hospital.  He thought his wife would be thrilled that he had been approached for the position.  It was an honor, and, after all, they were on this “adventure” together.

Narcissism (a sub-set of overcompensation): These overcompensations typically serve to help patients cope with core feelings of emotional deprivation and defectiveness. Rather than feeling ignored and inferior, these patients can feel special and superior. However, though they may be successful in the outside world, narcissistic patients are not usually at peace with themselves. Their overcompensation isolates them and ultimately brings them unhappiness. They continue to overcompensate, no matter how much it drives away other people. In doing so, they lose their ability to connect deeply with others. They are so invested in appearing to be perfect they forfeit true intimacy. Further, no matter how perfect they try to be, they are bound to fail at something eventually, and they rarely know how to handle defeat constructively. They are unable to take responsibility for their failures or acknowledge their limitations and therefore have trouble learning from their mistakes. When the experience sufficiently powerful setbacks, their ability to overcompensate collapses, and the often decompensate by becoming clinically depressed. When their overcompensation fails, the underlying schemas reassert themselves with enormous emotional strength.  Thus, incentivizing the patient for continued overcompensation in future: “I can’t ever let myself feel that way again.”

Schema Modes:  Parts of self, existing on a spectrum of dissociation. The extent to which multiple modes are able to be experienced simultaneously, the level of dissociation is lower. Healthy individuals experience modes shifts as a part of any given day and may experience multiple modes at once (ex: a bittersweet event). A patient’s schemas and coping responses tend to group together into “parts of self.”

• Mode Dimensions: Dissociated vs. Integrated, Unacknowledged vs. Acknowledged, Maladaptive vs. Adaptive, Extreme vs. Mild, Rigid vs. Flexible, Pure vs. Blended.
  • Think of each of these as a continuum, with one descriptive word on one end and the other on the opposite end. A client can be placed somewhere along this line.
  • Unacknowledged ————————————————————Acknowledged
• Mode Types: Child Modes, Dysfunctional Parent Modes, Dysfunctional Coping Modes & Healthy Adult Modes.
  • Child Modes:
    • Vulnerable Child: experiences most of the core schemas (abandoned, abused, deprived, rejected child).
    • Angry Child: enraged about unmet emotional needs and acts in anger without regard to consequences. Often, protects vulnerable child & is a teenager.
    • Impulsive/Undisciplined Child: expresses emotions, acts on desires, and follows natural inclinations from moment to moment in a reckless manner, without regard for possible consequences for self or others.
    • Happy Child: the one whose core emotional needs are currently met.
  • Dysfunctional Parent Modes:
    • Punitive Parent: punishes the various child modes for being “bad.” The patient becomes like the parent who has been internalized.
    • Demanding Parent: continually pushes and pressures the child to meet excessively high standards.
  • Dysfunctional Coping Modes:
    • Compliant Surrenderer: submits to the schema, becoming, once again, the passive, helpless child who must give in to others.
    • Detached Protector: withdrawals psychologically from the pain of the schema by emotionally detaching, abusing substances, self-stimulating, avoiding people, or utilizing various other forms of escape.
    • Overcompensator: fights back either my mistreating others or by behaving in extreme ways in an attempt to disprove the schema in a manner that ultimately proves dysfunctional.
  • Healthy Adult Mode:
    • Healthy Adult: works to heal the schemas, modeled and bolstered by therapist.

Finally, let’s take a look at questions counselors can ask in session with clients to help zero in on possible schema wounds.  These questions are conversational and engaging to the client while being diagnostically significant to the clinician.  CLICK HERE to read some of the YSQ-L2 questionnaire.

Sources:

Schema Therapy– Young, Klosko & Weishaar, The Guilford Press, New York 2003

We will be doing case consult for this upcoming meeting!

1. Introduction to Schema Therapy
2. Phases of Treatment
3. Core Needs
4. Frustration of Needs
5. Unconditional vs. Conditional Wounds
6. 5 Schema Domains

Introduction to Schema Therapy

Schema Therapy (or more properly, Schema-Focused Cognitive Therapy) is an integrative approach to treatment that combines the best aspects of cognitive-behavioral, experiential, interpersonal and psychoanalytic therapies into one unified model. Schema-Focused Therapy has shown remarkable results in helping people to change negative (“maladaptive”) patterns which they have lived with for a long time, even when other methods and efforts they have tried before have been largely unsuccessful.

The Schema-Focused model was developed by Dr. Jeff Young, who originally worked closely with Dr. Aaron Beck, the founder of Cognitive Therapy. While treating clients at the Center for Cognitive Therapy at the University of Pennsylvania, Dr. Young and his colleagues identified a segment of people who had difficulty in benefiting from the standard approach. He discovered that these people typically had long-standing patterns or themes in thinking, feeling and behaving/coping that required a different means of intervention. Dr. Young’s attention turned to ways of helping patients to address and modify these deeper patterns or themes, also known as “schemas” or “life traps.”

The schemas that are targeted for treatment are enduring and self-defeating patterns that typically begin early in life. These patterns consist of negative/dysfunctional thoughts and feelings, have been repeated and elaborated upon, and pose obstacles to accomplishing one’s goals and getting one’s needs met. Some examples of schema beliefs are:

• I’m unlovable.
• I’m a failure.
• People don’t care about me.
• I’m not important.
• Something bad is going to happen.
• People will leave me.
• I will never get my needs met.
• I will never be good enough.

Although schemas are usually developed early in life (during childhood or adolescence), they can also form later, in adulthood. These schemas are perpetuated behaviorally through the coping styles of schema maintenance, schema avoidance, and schema compensation. The Schema-Focused model of treatment is designed to help the person to break these negative patterns of thinking, feeling and behaving, which are often very tenacious, and to develop healthier alternatives to replace them.

Schema-Focused Therapy consists of three stages.

1. The assessment phase, in which schemas are identified during the initial sessions. Questionnaires may be used as well to get a clear picture of the various patterns involved.
2. The emotional awareness and experiential phase, wherein patients get in touch with these schemas and learn how to spot them when they are operating in their day-to-day life.
3. The behavioral change stage becomes the focus, during which the client is actively involved in replacing negative, habitual thoughts and behaviors with new, healthy cognitive and behavioral options.

What is a Maladaptive Schema/Wound?

A broad, pervasive pattern or theme comprised of memories, emotions, cognitions, and bodily sensations regarding oneself and one’s relationships with others.  It is developed in childhood or adolescence, elaborated throughout one’s lifetime and dysfunctional to a significant degree.  Often inflexible/rigid & egosyntonic (problems are central to the patient’s identity and feel, to them, as a part of who they are/how they understand the world).  Self-defeating behaviors are a response to the underlying schema, not the schema itself.  Schemas/Wounds are not experienced as a constant state of being but can be activated and operate at certain points in time.    

How does a Maladaptive Schema/Wound Form?

1^st: People have Core Emotional Needs:

• Secure attachments to others (includes safety, stability, nurturance & acceptance).
• Autonomy, competence, and a sense of identity.
• Freedom to express valid needs and emotions.
• Spontaneity and play.
• Realistic limits & self-control.

2^nd: People’s Core Emotional Needs are not met:

Toxic childhood experiences are the primary origin of Early Maladaptive Schemas/Wounds.  The wounds created earliest are typically strongest and usually originate within the nuclear family.  To a large extent, the dynamics of a child’s family are the dynamics of that child’s entire early world.  The 4 types of early life experiences which foster the acquisition of wounds are:

• Toxic frustration of needs. The child experiences too little of a good thing such as love/stability/understanding. (Wounds: Emotional Deprivation, Abandonment).
• Traumatization/Victimization (Schemas: Mistrust/Abuses, Defectiveness/Shame, Vulnerability to Harm).
• Too much of a good thing. Parents give too much of something, that in moderation, is a good thing. (Schemas: Dependence/Incompetence & Entitlement/Grandiosity).
• Selective internalization or identification with significant others. The child selectively identifies with and internalizes the parent’s thoughts, feelings, experiences, and behaviors- the origins of identifying as the victim or the abuser.

2 Types of Wounds:

1^st Unconditional Wounds:  These are the core wounds at the heart of maladaptive behaviors which are disrupting a person’s life and relationships.  Typically, they are created in childhood, when the person was most vulnerable and consist of beliefs about oneself and others.  Unconditional Wounds are felt as absolute and unchanging.  They demand individuals operate in faulty ways, often without insight or awareness.  This is what you believe about yourself, others, and the world you live in.

2^nd Conditional Wounds:  In contrast with unconditional wounds, these hold out the possibility outcomes can be changed in a favorable manner, if the person will operate with these beliefs as a guidepost.  They are created as a faulty attempt to address unconditional wounds, which the individual sees as absolute and unchanging. These are behaviors you engage in because of what you believe to be true (ie: your unconditional wound/s listed previously).

Schema Domains:

#1 Disconnection & Rejection

(The expectation that one’s needs for security, safety, stability, nurturance, empathy, sharing of feelings, acceptance, and respect will not be met in a predictable manner.  Typical family of origin is detached, cold, rejecting, withholding, lonely, explosive, unpredictable, or abusive.)

1.  Abandonment/Instability

The perceived instability or unreliability of those available for support and connection.  Involves the sense that significant others will not be able to continue providing emotional support, connection, strength, or practical protection because they are emotionally unstable and unpredictable (e.g., have angry outbursts), unreliable, or present only erratically; because they will die imminently; or because they will abandon the individual in favor of someone better.

2.  Mistrust/Abuse

The expectation that others will hurt, abuse, humiliate, cheat, lie manipulate, or take advantage.  Usually, involves the perception that the harm is intentional or the result of unjustified and extreme negligence.  May include the sense that one always ends up being cheated relative to others or “getting the short end of the stick.”

3.  Emotional Deprivation

The expectation that one’s desire for a normal degree of emotional support will not be adequately met by others.  The three major forms of deprivation are:

A: Deprivation of Nurturance– Absence of attention, affection, warmth, or companionship.

B: Deprivation of Empathy– Absence of understanding, listening, self-disclosure, or mutual sharing of feelings from others.

C: Deprivation of Protection– Absence of strength, direction, or guidance from others.

4.  Defectiveness/Shame

The feeling that one is defective, bad, unwanted, inferior, or invalid in important respects or that one would be unlovable to significant others if exposed.  May involve hypersensitivity to criticism, rejection, and blame; self-consciousness, comparisons, and insecurity around others; or a sense of shame regarding one’s perceived flaws.  These flaws may be private (e.g., selfishness, angry impulses, unacceptable sexual desires) or public (e.g., undesirable physical appearance, social awkwardness).

5.  Social Isolation/Alienation

The feeling that one is isolated from the rest of the world, different from other people, and/or not part of any group or community.

#2 Impaired Autonomy and Performance

 (Expectations about oneself and the environment that interfere with one’s perceived ability to separate, survive, function independently, or perform successfully.  Typical family origin is enmeshed, undermining of the child’s confidence, overprotective, or failing to reinforce child for performing competently outside the family.)

6.  Dependence/Incompetence

The belief that one is unable to handle one’s everyday responsibilities in a competent manner, without considerable help from others (e.g., take care of oneself, solve daily problems, exercise good judgment, tackle new tasks, make good decisions).  Often presents as helplessness.

7.  Vulnerability to Harm or Illness

Exaggerated fear that imminent catastrophe will strike at any time and that one will be unable to prevent it.  Fears focus on one or more of the following:

A: Medical catastrophes (e.g., heart attacks, AIDS).

B: Emotional catastrophes (e.g., going crazy).

C: External catastrophes (e.g., elevators collapsing, victimization by criminals, airplane crashes, earthquakes).

8.  Enmeshment/Undeveloped Self

Excessive emotional involvement and closeness with one or more significant others (often parents) at the expense of full individuation or normal social development.  Often involves the belief that at least one of the enmeshed individuals cannot survive or be happy without the constant support of the other.  May also include feelings of being smothered by or fused with others or insufficient individual identity.  Often experienced as a feeling of emptiness and floundering, having no direction, or in extreme cases questioning one’s existence.

9.  Failure

The belief that one has failed, will inevitably fail, or is fundamentally inadequate relative to one’s peers in areas of achievement (school, career, sports, etc). Often involves beliefs that one is stupid, untalented, lower in status, less successful than others, and so forth.

#3 Impaired Limits

(Deficiency in internal limits, responsibility to others, or long-term goal orientation.  Leads to difficulty respecting the rights of others, cooperating with others, making commitments, or setting and meeting realistic personal goals.  Typical family origin is characterized by permissiveness, overindulgence, lack of direction, or a sense of superiority rather than appropriate confrontation, discipline, and limits in relation to taking responsibility, cooperating in a reciprocal manner, and setting goals.  In some cases, the child may not have been pushed to tolerate normal levels of discomfort or may not have been given adequate supervision, direction, or guidance.)

10.  Entitlement/Grandiosity

The belief that one is superior to other people; entitled to special rights and privileges; or not bound by the rules of reciprocity that guide normal social interaction.  Often involves insistence that one should be able to do or have whatever one wants regardless of what is realistic, what others consider reasonable, or the cost to others; or an exaggerated focus on superiority (ie: being among the most successful, famous, wealthy) in order to achieve power or control (not primarily for attention or approval).  Sometimes includes excessive competitiveness toward or domination of others: asserting one’s power, forcing one’s point of view, or controlling the behavior of others in line with one’s own desires without empathy or concern for others’ needs or feelings.

11.  Insufficient Self-Control/Self-Discipline

Pervasive difficulty or refusal to exercise sufficient self-control and frustration tolerance to achieve one’s personal goals or to restrain the excessive expression of one’s emotions and impulses.  In its milder form, the patient presents with an exaggerated emphasis on discomfort avoidance: avoiding pain, conflict, confrontation, responsibility, or overexertion at the expense of personal fulfillment, commitment, or integrity.

#4 Other-Directedness

(An excessive focus on the desires, feelings, and responses of others, at the expense of one’s own needs in order to gain love and approval, maintain one’s sense of connection, or avoid retaliation.  Usually involves suppression and lack of awareness regarding one’s own anger and natural inclinations.   The typical family of origin is based on conditional acceptance: Children must suppress important aspects of themselves in order to gain love, attention, and approval.  In many such families, the parents’ emotional needs and desires—or social acceptance and status—are valued more than the unique needs and feelings of each child.)

12.  Subjugation

Excessive surrendering of control to others because one feels coerced—submitting in order to avoid anger, retaliation, or abandonment.  The two major forms of subjugation are:

A:  Subjugation of needs: Suppression of one’s preferences, decisions, and desires.

B:  Subjugation of emotions: Suppression of emotions, especially anger.  Usually involves the perception that one’s own desires, opinions, and feelings are not valid or important to others.  Frequently presents as excessive compliance, combined with hypersensitivity to feeling trapped.  Generally, leads to a buildup of anger, manifested in maladaptive symptoms (e.g., passive-aggressive behavior, uncontrolled outbursts of temper, psychosomatic symptoms, withdrawal of affection, “acting out,” substance abuse).

13.  Self-Sacrifice

Excessive focus on voluntarily meeting the needs of others in daily situations at the expense of one’s own gratification.  The most common reasons are: to prevent causing pain to others; to avoid guilt from feeling selfish; or to maintain the connection with others perceived as needy.  Often results from an acute sensitivity to the pain of others.  Sometimes leads to a sense that one’s own needs are not being adequately met and to the resentment of those who are taken care of.  (Overlaps with the concept of codependency).

14.  Approval-Seeking/Recognition-Seeking

Excessive emphasis on gaining approval, recognition, or attention from the other people or on fitting in at the expense of developing a secure and true sense of self.  One’s sense of esteem is dependent primarily on the reactions of others rather than on one’s own natural inclinations.  Sometimes includes an overemphasis on status, appearance, social acceptance, money, or achievement as a means of gaining approval, admiration, or attention (not primarily for power or control).  Frequently results in major life decisions that are inauthentic or unsatisfying or in hypersensitivity to rejection.

#5 Overvigilance and Inhibition

(Excessive emphasis on suppressing one’s spontaneous feelings, impulses, and choices, or on meeting rigid, internalized rules and expectations about performance and ethical behavior, often at the expense of happiness, self-expression, relaxation, close relationships, or health.  Typical family origin is grim, demanding, and sometimes punitive: performance, duty, perfectionism, following rules, hiding emotions, and avoiding mistakes predominate over pleasure, joy, and relaxation.  There is usually an undercurrent of pessimism and worry that things could fall apart if one fails to be vigilant and careful at all times.)

15.  Negativity/Pessimism

A pervasive, lifelong focus on the negative aspects of life (pain, death, loss, disappointment, conflict, guilt, resentment, unsolved problems, potential mistakes, betrayal, things that could go wrong, etc.) while minimizing or neglecting the positive or optimistic aspects.  Usually includes an exaggerated expectation—in a wide range of work, financial, and interpersonal situations—that things will eventually go seriously wrong or that aspects of one’s life that seem to be going well will ultimately fall apart.  Usually involves an inordinate fear of making mistakes that might lead to financial collapse, loss, humiliation, or being trapped in a bad situation.  Because they exaggerate potential negative outcomes, these individuals are frequently characterized by chronic worry, vigilance, complaining, and indecision.

16.  Emotional Inhibition

The excessive inhibition of spontaneous action, feeling, or communication, usually to avoid disapproval by others, feelings of shame, or losing control of one’s impulses.  The most common areas of inhibition involve:

A:  Inhibition of anger and aggression.

B:  Inhibition of positive impulses (e.g., joy, affection, sexual excitement, play).

C:  Difficulty expressing vulnerability or communicating freely about one’s feelings, needs, and so forth.

D:  Excessive emphasis on rationality while disregarding emotions.

17.  Unrelenting Standards/Hypercriticalness

The underlying belief that one must strive to meet very high internalized standards of behavior and performance, usually to avoid criticism.  Typically results in feelings of pressure or difficulty slowing down and in hypercriticalness towards oneself and others.  Must involve significant impairment in pleasure, relaxation, health, self-esteem, sense of accomplishment, or satisfying relationships.  Unrelenting standards typically present as:

A:  Perfectionism, inordinate attention to detail, or an underestimate of how good one’s own performances is relative to the norm.

B:  Rigid rules and “shoulds” in many areas of life, including unrealistically high moral, ethical, cultural, or religious precepts.

C:  Preoccupation with time and efficiency, the need to accomplish more.

18.  Punitiveness

The belief that people should be harshly punished for making mistakes.  Involves the tendency to be angry, intolerant, punitive, and impatient with those people (including oneself) who do not meet one’s expectations or standards.  Usually includes difficulty forgiving mistakes in oneself or others because of a reluctance to consider extenuating circumstances, allow for human imperfection, or empathize with feelings.

Sources:

Schema Therapy– Young, Klosko & Weishaar, The Guilford Press, New York 2003

http://www.schematherapy-nola.com/what-is-schema-therapy