In the behavioral pattern-breaking stage of treatment, patients 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 if patients have insight into their Early Maladaptive Schemas, and even if they have done the cognitive and experiential work, their schemas will re-assert themselves if patients do not change their behavioral patterns. The progress they have made will erode, and eventually they will fall back under the sway of their schemas. For patients to achieve and maintain full gains, it is essential that they change their behavioral patterns.
Of the four main change components in schema therapy, behavioral pattern-breaking is usually the final one that the therapist focuses on. If the patient has not progressed adequately through the cognitive and expe-riential stages, the patient is unlikely to achieve lasting changes in schema-driven behavior. The other parts of treatment prepare the patient for the task of behavioral change. They give the patient psychological distance from the schema, helping him or her to view the schema as an intruder rather than as a core truth about the self. The cognitive and experiential stages strengthen the healthy side of the patient, especially the ability of the healthy side to fight the patient’s schemas. Once the behavioral part of treatment is underway, they help the patient overcome blocks to behavior-al change.
Thus the behavioral stage of treatment takes place within the frame-work of the schema model and incorporates the other schema strategies, such as flash cards, imagery, and dialogues. Where relevant, the therapist also uses traditional behavioral techniques, such as relaxation training,
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sertiveness training, anger management, control strategies (i.e., self-monitoring, goal-setting, self-reinforcement) and graduated exposure to feared situations. (We assume that readers are familiar with these standard techniques from behavior therapy, so we will not elaborate on them in this book.)
COPING STYLES
Behavioral pattern-breaking targets coping styles: The behaviors that are the focus of change are the ones patients use in surrendering to, avoiding, and overcompensating for their Early Maladaptive Schemas. These are the self-defeating behaviors patients employ to cope when their schemas are triggered: the unfounded jealous accusations of the patient with an Aban-donment schema, the self-deprecatory comments of the patient with a De-fectiveness schema, the advice-soliciting of the patient with a Dependence schema, the obedience of the subjugated patient; the phobic avoidance of the patient who has a Vulnerability to Harm or Illness schema. These sur-render, avoidance, and overcompensatory behaviors ultimately serve to perpetuate schemas. Patients must change their coping styles in order to heal their schemas and thereby fill the unmet needs that brought them into therapy.
Case Illustration
A young woman named Ivy comes for schema therapy. She is feeling frus-trated and unhappy in many life areas. The pattern is the same: in her fam-ily, in her love life, at work, with her friends, she assumes a caretaking role while asking virtually nothing for herself. As she puts it, “I take care of ev-erybody, but nobody takes care of me.” She is depressed, overwhelmed, ex-hausted, and resentful. In the Assessment Phase, Ivy and the therapist agree that she has a Self-Sacrifice schema. Her main coping style is surren-dering to the schema. She takes care of others but does not allow others to take care of her.
Ivy meets her best friend Adam for dinner every few weeks. The din-ners follow the same pattern: Adam asks Ivy about her life, and Ivy gives short, positive answers, basically conveying, “Everything’s fine,” and then asks Adam about his life. Adam answers by raising a troubling issue in his own life, and the two spend the rest of dinner discussing the issue he has raised. Why does Ivy not share anything of importance about herself with her friend? The answer is that her friend’s questions trigger her Self-Sacrifice schema. Ivy feels guilty and selfish talking about herself. She copes with the triggering of her schema by giving quick nonanswers and shifting the focus back to Adam. Ivy ends up feeling emotionally deprived
(almost all patients with Self-Sacrifice schemas have linked Emotional De-privation schemas.)
In the behavioral part of treatment, Ivy decides to bring greater bal-ance into her intimate relationships. She decides to begin with her rela-tionship with Adam. To prepare her, the therapist asks her to close her eyes and picture an image of herself sitting at dinner with Adam and telling him about her life. In imagery, Ivy conducts a dialogue between her Self-Sacrifice schema, which tells her to switch the focus back to Adam, and her healthy side, which promulgates the wisdom of sharing a problem with her friend. Next, switching chairs between the “schema” and the “healthy side,” Ivy gets angry at her schema, asserting her right to be taken care of by others. In imagery she connects the situation to her childhood with her fragile, needy mother. She tells her mother, “It cost me too much to take care of you. It cost me my sense of self.”
Next, in imagery, she visualizes sharing a problem with Adam, dealing with all the obstacles that arise.
THERAPIST: So what do you want to tell Adam?
IVY: I want to tell him what it’s like to have my mother getting sick and needing so much from me.
THERAPIST: OK, so could you imagine telling him about that in the image?
About your mother getting sick, and your feelings about it?
IVY: I want to tell him, but I feel scared.
THERAPIST: And what is the scared side saying?
IVY: It’s saying, “It’s not supposed to be this way. Adam’s not supposed to be taking care of me, I’m supposed to be taking care of him.”
THERAPIST: What are you afraid will happen if you let Adam take care of you?
IVY: I’m afraid he won’t like me anymore.
THERAPIST: Are you afraid of anything else?
IVY: I’m afraid I’ll start crying, or something.
THERAPIST: And what would be so bad about that?
IVY: I’d be really embarrassed.
THERAPIST: Well, that’s your Self-Sacrifice schema talking, everything you’ve been saying: “You’re not supposed to let anyone take care of you. People won’t like you if you show your own vulnerability. You’re not supposed to cry.” What does the healthy side say to that? Could you answer as the healthy side in the image?
IVY: Well, yeah, the healthy side is saying, “It’s all right to let my friends take care of me. They’ll still like me. It’s okay to cry with a close friend.”
Finally, as a behavioral homework assignment, Ivy practices respond-ing more authentically to her friend when he asks about her life. The next time they meet for dinner, she shares an issue concerning her love rela-tionship. Adam responds warmly and supportively, countering Ivy’s Self-Sacrifice (and Emotional Deprivation) schemas.
Maladaptive Coping Styles Associated with Specific Schemas Each schema is associated with certain dysfunctional behavior patterns that tend to characterize the patient’s approach to partners and significant others (including the therapist). Table 5.1 gives an example of each coping style for each schema.
As Table 5.1 shows, behavioral pattern-breaking refers not only to how one behaves in specific situations but also to the types of situations one generally selects: whom one marries; the career one chooses; one’s cir-cle of friends. Behavioral pattern-breaking involves major life decisions, as well as everyday behaviors. Patients maintain their Early Maladaptive Schemas by making major life decisions that perpetuate their schemas.
Patients can often change discrete, situation-specific behaviors with standard cognitive-behavioral techniques, but lifelong behavioral pat-terns driven by Early Maladaptive Schemas require an integrative ap-proach. Assertiveness training might help a patient who has difficulty setting limits with his girlfriend, but assertiveness training alone will probably not be sufficient to change a broader life pattern of subjugation to significant others. Patients subjugate because they fear punishment, abandonment, or criticism, and they must work through these underly-ing issues in order to overcome the pattern. The linked schemas tied to these underlying issues—Punitiveness, Abandonment, Defectiveness—
block progress. If the patient has a Mistrust/Abuse schema, he is going to be afraid that, if he asserts himself, his girlfriend will become abusive.
If the patient has an Abandonment schema, he is going to be afraid that his girlfriend will leave him if he asserts himself. If the patient has a De-fectiveness schema, he is not going to feel he has the right to be asser-tive with his girlfriend, even if he knows the steps necessary for self-assertion. Skills training is frequently not the primary intervention. The schema has cognitive and emotional aspects that the treatment must ad-dress beforehand.
It is often easier for patients to change their cognitions and emotions than it is to break lifelong patterns of behavior. For this reason, the thera-pist must be patient but persistent throughout the behavioral stage, em-ploying the rule of empathic confrontation. The therapist expresses empa-thy for how hard it is to change deeply instilled patterns of behavior yet continually confronts the necessity for that change.
TABLE 5.1. Examples of Coping Styles Associated with Specific Schemas
Schema Surrender Avoidance Overcompensation
Abandonment/
Instability
Selects partners and significant others who are unavailable or unpredictable.
Avoids intimate relationships altogether out of fear of
abandonment.
Pushes partners and significant others away with clinging, possessive, or controlling behaviors.
Mistrust/Abuse Chooses
untrustworthy partners and significant others;
is overvigilant and suspicious of others.
Avoids close involvement with others in personal and business life; does not confide or self-disclose.
Mistreats or exploits others; acts in an overly trusting manner.
Emotional Deprivation
Chooses cold, detached partners and significant others;
discourages others from giving emotionally.
Withdraws and isolates; avoids close relationships.
Makes unrealistic demands that others meet all of his or her needs.
Defectiveness/
Shame
Chooses critical partners and
significant others; puts him- or herself down.
Avoids sharing
“shameful” thoughts and feelings with partners and significant others due to fear of rejection.
Behaves in a critical or superior way toward others; tries to come across as “perfect.”
Social Isolation/
Alienation
Becomes part of a group but stays on the periphery; does not fully join in.
Avoids socializing;
spends most of his or her time alone.
Puts on a false
“persona” to join a group, but still feels different and alienated.
Dependence/
Incompetence
Asks for an excessive amount of help;
checks decisions with others; chooses overprotective partners who do everything for him or her.
Procrastinates on decisions; avoids acting independently or taking on normal adult responsibilities.
Demonstrates excessive self-reliance, even when turning to others would be normal and healthy.
Vulnerability to Harm or Illness
Worries continually that catastrophe will befall him or her;
repeatedly asks others for reassurance.
Engages in phobic avoidance of
“dangerous” situations.
Employs magical thinking and compulsive rituals;
engages in reckless, dangerous behavior.
Enmeshment/
Undeveloped Self
Imitates behavior of significant other, keeps in close contact with
“enmeshed other”;
does not develop a separate identity with unique preferences.
Avoids relationships with people who stress individuality over enmeshment.
Engages in excessive autonomy.
(cont.)
TABLE 5.1. (cont.)
Schema Surrender Avoidance Overcompensation
Failure Sabotages work efforts by working below level of ability;
unfavorably compares his or her achievement with that of others in a biased manner.
Procrastinates on work tasks; avoids new or difficult tasks completely; avoids setting career goals that are appropriate to ability level.
Diminishes achievements of others; tries to meet perfectionistic standards to compensate for sense of failure.
Entitlement/
Grandiosity
Has unequal or uncaring relationships with partners and significant others;
behaves selfishly;
disregards needs and feelings of others; acts superior.
Avoids situations in which he or she cannot excel and stand out.
Gives extravagant gifts or charitable
contributions to make up for selfish behavior.
Insufficient Self- Control/Self-Discipline
Performs tasks that are boring or
uncomfortable in a careless way; loses control of emotions;
excessively eats, drinks, gambles, or uses drugs for pleasure.
Does not work or drops out of school;
does not set long-term career goals.
Makes short-lived, intense efforts to complete a project or to exercise self-control.
Subjugation Chooses dominant, controlling partners and significant others;
complies with their wishes.
Avoids relationships altogether; avoids situations in which his or her wishes are different from those of others.
Acts in a passive–
aggressive or rebellious manner.
Self-Sacrifice Engages in self-denial;
does too much for others and not enough for him- or herself.
Avoids close relationships.
Becomes angry at significant others for not reciprocating or for not showing appreciation; decides to do nothing for others anymore.
Negativity/
Pessimism
Minimizes positive events, exaggerates negative ones; expects and prepares for the worst.
Does not hope for too much; keeps
expectations low.
Acts in an
unrealistically positive, optimistic, “Pollyanna-ish” way (rare).
(cont.)
READINESS FOR BEHAVIORAL PATTERN-BREAKING
How does the therapist know when it is time to shift the focus of treatment to behavioral pattern-breaking? The answer is when patients have success-fully mastered the cognitive and experiential parts of treatment. If patients are able to label their Early Maladaptive Schemas when they are triggered, to understand the origins of their schemas in childhood, and to participate in schema dialogues in which they consistently defeat their schemas utiliz-ing their healthy sides—both cognitively and emotionally—then they are probably ready to begin behavioral pattern-breaking.
DEFINING SPECIFIC BEHAVIORS AS POSSIBLE TARGETS OF CHANGE
The first step is for the therapist and patient to develop an extensive list of specific behaviors to serve as potential targets of change. The therapist and patient can refer to many sources of information to develop this list: the case conceptualization developed in the Assessment Phase, detailed de-scriptions of problematic behaviors, imagery of problematic situations, the
TABLE 5.1. (cont.)
Schema Surrender Avoidance Overcompensation
Emotional Inhibition
Emphasizes reason and order over emotion; acts in a very controlled, flat manner; does not show spontaneous emotions or behavior.
Avoids activities involving emotional self-expression (such as expressing love or showing fear) or requiring uninhibited behavior (such as dancing).
Acts impulsively and without inhibition (sometimes under the influence of
disinhibiting substances such as alcohol).
Approval-Seeking/
Recognition-Seeking
Draws the attention of others to his or her accomplishments related to status.
Avoids relationships with admired individuals out of fear of not gaining their approval.
Acts flagrantly to gain the disapproval of admired individuals.
Punitiveness Acts in an overly punishing or harsh way with significant others.
Avoids situations involving evaluation to escape the fear of punishment.
Acts in an overly forgiving manner while being inwardly angry and punitive.
Unrelenting Standards/
Hypercriticalness
Attempts to perform perfectly; sets high standards for self and others.
Avoids taking on work tasks;
procrastinates.
Throws out high standards altogether and settles for below-average performance.
therapy relationship, relationships with significant others, and schema questionnaires.
Refining the Case Conceptualization
The therapist and patient can start by refining the case conceptualization they developed in the Assessment Phase, elaborating on the processes of schema surrender, avoidance, and overcompensation. Working with these coping styles, they can begin to develop a list of specific behaviors or life circumstances that require change. It is important for the therapist to cover each major life area separately, such as intimate relationships, work, and social activities, because the patient may have different schemas and coping styles linked to different life areas. For example, a patient with an Emotional Deprivation schema may be warm and nurturing with close friends but cold and distant with romantic partners; a patient with a Subju-gation schema may be passive with authority figures but domineering and controlling with younger siblings or children; or a patient may have a De-fectiveness schema that is activated when meeting strangers in a social sit-uation but not when meeting significant others one-to-one.
Detailed Descriptions of Problematic Behaviors
Perhaps the most important step in identifying self-defeating behavioral patterns is for the therapist and patient to develop detailed descriptions of problematic situations in the patient’s life. When the patient reports a situ-ation that is a consistent schema trigger, the therapist helps the patient clarify specific behaviors by asking questions. The goal is to get a blow-by-blow account of what happened. Sometimes the therapist encounters diffi-culty during this effort. As part of the schema perpetuation process, the pa-tient distorts what happened to fit the schema and ignores contradictory data. The therapist must push through the patient’s reluctance to recall what happened in an objective, rather than emotional, schema-driven fashion.
Case Illustration
A young female patient named Daphne comes to a session and reports that she had a fight with her husband the previous evening. Daphne has an Abandonment/Instability schema as a result of growing up in a household filled with strife. Her parents fought nearly every night, often to the point of threatening divorce. Daphne remembers watching them shouting at each other and feeling helpless to stop them, then hiding in her closet with her hands over her ears. Now she is married to Mark, a medical resident.
He works long hours and comes home haggard and depleted. His home-coming sparks a fight nearly every night.
Daphne tells the story of their latest fight:
DAPHNE: Mark and I had another fight last night.
THERAPIST: What started the fight?
DAPHNE: Oh, the same old thing. He was late. I don’t know. (Tosses her head.)
THERAPIST: How did the fight begin?
DAPHNE: The same way it always does. It doesn’t matter. All we do is argue.
We should probably get divorced.
THERAPIST: Daphne, I see how hopeless you feel, but it’s still important for us to understand what happened. Think back to the beginning of the fight. How did it start?
DAPHNE: I had a really hard day. I couldn’t seem to get any of my freelance work done. The baby was crying all day. Mark came home late again, and I let him have it.
THERAPIST: How did you let him have it?
DAPHNE: I told him I can’t possibly earn money for us when I have to take care of a screaming baby all day. How am I supposed to work? When the baby’s up I have to take care of him, and when’s he’s sleeping I’m so tired that I have to sleep, too. I mean, Mark gets to leave for the whole day, and I’m stuck here.
THERAPIST: What did Mark say?
DAPHNE: He said it wasn’t his fault that the baby was crying and that he works hard, too.
THERAPIST: What happened next?
DAPHNE: I told him, “You leave us alone all day and night. You’re a rotten husband and father.”
THERAPIST: How were you feeling at that point?
DAPHNE: Angry. Really angry and scared. I was scared that he didn’t care about me and the baby and might leave us forever.
THERAPIST: What about Mark? What do you think he was feeling?
DAPHNE: At the time I thought he couldn’t care less, because he left the room. Later he told me he was devastated that I said he was a rotten husband and father.
By recounting her interaction with her husband in such detail, Daphne and her therapist are able to identify her problematic behaviors.
Mark’s lateness triggers her Abandonment/Instability schema, and she be-comes panicked and angry. When he finally gets home, instead of express-ing her vulnerability and fear, she lashes out at him, tryexpress-ing to hurt him as much as she can. In coping with her schema by overcompensating,