- Introduction – Diagnosis & Treatment of Any Associated Mental Disorder
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
- 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.
- 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.
- 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.”
- 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