After completing the Assessment and Education Phase described in the previous chapter, the therapist and patient are ready to begin the Change Phase. This phase incorporates cognitive, experiential, behavioral, and in-terpersonal strategies to modify schemas, coping styles, and modes. We usually begin the change process with cognitive techniques, which are the focus of this chapter.1
As part of the Assessment and Education Phase, the therapist has al-ready filled out the case conceptualization form and educated the patient about the schema model. The therapist and patient have identified the pa-tient’s dysfunctional life patterns and Early Maladaptive Schemas, explored the childhood origins of the schemas, and linked the schemas to the pre-senting problems. They have also identified the patient’s coping styles, emotional temperament, and modes.
Cognitive strategies help the patient articulate a healthy voice to dis-pute the schema, strengthening the patient’s Healthy Adult mode. The therapist helps the patient build a logical, rational case against the schema.
Usually patients have not questioned their schemas: They have accepted them as “givens” or as truths in their lives. In their internal psychological worlds, their schemas have reigned supreme. There has been no strong Healthy Adult mode to counter the schema. Cognitive strategies help pa-tients step outside the schema and evaluate its veracity. Papa-tients see that there is a truth outside of the schema and that they can fight the schema with a truth that is more objective and empirically sound.
91
1With patients with BPD, the therapist does not begin with cognitive work but focuses in-stead on forming a stable bond with the patient. This is discussed further in Chapter 9.
OVERVIEW OF COGNITIVE STRATEGIES
It is through the cognitive strategies that the patient first recognizes that the schema is inaccurate—either untrue or greatly exaggerated. The thera-pist and patient begin by agreeing to regard the schema as open to ques-tion. Rather than an absolute truth, it is a hypothesis to be tested. They then subject the schema to logical and empirical analyses. They examine the evidence supporting and refuting the schema in the patient’s life; they go through the evidence the patient has used to uphold the schema, and they find alternative interpretations of these same events; they conduct de-bates between the “schema side” and the “healthy side”; and they list the advantages and disadvantages of the patient’s current coping styles. Based on this work, the patient and therapist generate healthy responses to the schema. They write these responses on schema flash cards and read the flash cards whenever the schema is triggered. Finally, patients practice re-sponding to schemas on their own using the Schema Diary form.
When the cognitive strategies are effective, patients gain a heightened appreciation of how distorted the schema actually is. They have gained more psychological distance from the schema and no longer view it as an absolute truth. They have some insight into how the schema twists their perceptions. They begin to wonder whether the schema really has to run—
and ruin—their lives. They realize they might have a choice.
Successfully treated patients have internalized the cognitive work as part of a Healthy Adult mode that actively counters the schema with ratio-nal arguments and empirical evidence. After completing the cognitive component of schema therapy, patients are usually no longer dependent on the therapist’s assistance in challenging the schema. When a schema is triggered in their lives outside of therapy, they are able to fight the schema using the cognitive techniques. Even though patients may still feel as though the schema is true, they know that it is not factually true. They have a heightened intellectual awareness that the schema is false.
THERAPEUTIC STYLE
We call the primary stance that the schema therapist takes throughout treat-ment “empathic confrontation” or “empathic reality-testing.” In the cogni-tive stage of treatment, empathic confrontation means that the therapist em-pathizes with the reasons for patients having the beliefs that they do—
namely, that their beliefs are based on their early childhood experiences—
while simultaneously confronting the fact that their beliefs are inaccurate and lead to unhealthy life patterns that patients must change in order to im-prove. The therapist acknowledges to patients that their schemas seem right
to them because they have lived entire lives that seem to verify their schemas and that they adopted certain coping styles because it was the only way to survive adverse childhood circumstances. Consistent with constructivist models, the therapist validates patients’ schemas and coping styles as under-standable conclusions based on their life histories. At the same time, the therapist reminds patients about the negative consequences of their schemas and maladaptive coping styles. Their schemas and coping styles were adap-tive in early childhood but now are maladapadap-tive. A therapeutic stance of empathic confrontation acknowledges the past while distinguishing the re-alities of the past from the rere-alities of the present. It supports the patient’s ability to see and to accept what is.
Empathic confrontation requires constant shifting between empathy and reality-testing. Therapists often err in one direction or the other. Ei-ther they are so empathic that they do not push patients to face reality, or they are too confrontational and cause patients to feel defensive and mis-understood. Either way, patients are unlikely to change. With empathic confrontation, the therapist strives for the optimal balance between empa-thy and reality-testing that will enable patients to progress. When the ther-apist is successful in this endeavor, patients feel truly understood and af-firmed, perhaps for the first time in their lives. Feeling understood, they are more likely to accept the necessity of change, and they are more recep-tive to healthy alternarecep-tive perspecrecep-tives offered by the therapist. Further, patients experience the therapist as allying with them against the schema.
Rather than viewing the schema as a core part of who they are, they begin to view it as foreign.
The therapist explains to patients that, given their life histories, it makes sense that they see things as they do and behave as they do. How-ever, in the end, the ways in which they see and behave have only served to perpetuate their schemas. The therapist builds a case in favor of fighting their schemas with new ways of behaving rather than persisting in the same self-defeating patterns. The material gathered in the Assessment Phase enables the therapist to substantiate the destructiveness of the schemas and coping styles in their lives. The therapist encourages patients to respond to schema triggers in healthier ways. In so doing, they can eventually heal their schemas and meet their basic emotional needs. The following excerpt provides a brief example of empathic confrontation and is taken from the interview Dr. Young conducted with Marika, a patient whom we introduced in Chapter 2. Marika entered therapy to improve her marriage. Marika and her husband, James, are stuck in a repetitive, vicious cycle in which she becomes more and more aggressively demanding of at-tention and affection, and he becomes more and more withdrawn, indiffer-ent, and cold. After exploring her childhood relationship with her father, Dr. Young speaks to Marika about her approach to James.
“Marika, I know it feels natural to you to try to get James upset in order to get his attention. But, even though it’s the only way you think he’ll give you any caring, you still need to approach him in a more vulnerable way.
Let him know why you need his love and see if he responds before mov-ing so quickly to that other style of upsettmov-ing him. I understand it was the only way that got you any attention from your father, but it might not be the only way that works with James.”
Thus the therapist empathizes with Marika’s reason for approaching James in such an aggressive way—because that was the only way she got anything from her father—while still presenting the negative conse-quences of this approach and the wisdom of approaching James in a more vulnerable way.
COGNITIVE TECHNIQUES
Cognitive techniques in schema therapy include the following:
1. Testing the validity of a schema
2. Reframing the evidence supporting a schema
3. Evaluating the advantages and disadvantages of the patient’s coping styles
4. Conducting dialogues between the “schema side” and the “healthy side”
5. Constructing schema flash cards 6. Filling out Schema Diary forms
The therapist typically goes through the cognitive techniques with patients in the order we have listed them here, as the techniques build on one an-other.
Testing the Validity of the Schemas
The therapist and patient test the validity of a schema by examining the objective evidence for and against the schema. This process is similar to testing the validity of automatic thoughts in cognitive therapy, except that the therapist uses the patient’s whole life as empirical data and not just the present circumstances. The schema is the hypothesis to be tested.
The therapist and patient make a list of evidence from the past and present supporting the schema; then they make a list of evidence refuting the schema. Patients usually find it remarkably easy to compose the first list, evidence supporting the schema, because they already believe this evidence. They have been rehearsing it all their lives. Generating evidence
that supports the schema feels natural and familiar to them. In contrast, patients usually find it extremely difficult to compose the second list, evi-dence refuting the schema, and frequently require a good deal of input from the therapist, because they do not believe the evidence against the schema. They have spent their lives ignoring or downplaying this evi-dence. They do not have ready access to this evidence as a result of schema perpetuation, which has continuously induced them to accentuate infor-mation confirming the schema and negate inforinfor-mation contradicting the schema. The discrepancy between the patient’s ease at playing the schema side and difficulty playing the healthy side often proves highly instructive to the patient. The patient observes firsthand how the schema works to preserve itself.
To illustrate this technique, we examine one patient’s evidence regard-ing her Defectiveness schema. Shari is 28 years old, married with two chil-dren, and works as a psychiatric nurse. Her Defectiveness schema origi-nated in her childhood with her alcoholic mother. (Her father divorced her mother and left the family when Shari was 4 years old. Although he pro-vided money, Shari rarely saw him after that.) Throughout her childhood, her mother frequently humiliated her by appearing intoxicated in public places. She once came drunk to one of Shari’s school plays and disrupted the performance. Shari avoided bringing friends home out of fear of what her mother might do. Her home life was barren and chaotic.
Here is Shari’s list of evidence that she is defective:
1. I’m not like everyone else. I’m different and always have been.
2. My family was different from other families.
3. My family was shameful.
4. No one ever loved me or cared for me when I was a child. I never belonged to anyone. My own father didn’t care to see me.
5. I’m awkward, stilted, obsessive, afraid, and self-conscious with other people.
6. I’m inappropriate with other people. I don’t know the rules.
7. I’m fawning and pandering with other people. I need acceptance and approval too much.
8. I get too angry inside.
It is important to mention that, despite Shari’s critical appraisal of her cial ability, she is actually highly socially skilled. Her problem is one of so-cial anxiety, not one of soso-cial skills.
Not surprisingly, Shari found it extremely difficult to compose the second list, evidence refuting the schema. When it came to this part of the exercise, she could not think of anything to write down at all. She sat there bewildered and silent. Even though she is both personally and profession-ally successful and has a multitude of commendable traits, she could not
think of a single positive quality to ascribe to herself. The therapist had to suggest every one.
The therapist asks leading questions designed to draw from the pa-tient the evidence against the schema. For example, if a papa-tient has a De-fectiveness schema such as Shari does, the therapist might ask, “Has any-one ever loved you or liked you?” “Do you try to be a good person?” “Is there anything at all good about you?” “Is there anyone you care about?”
“What have other people told you is good about you?” Such questions—
often worded in an extreme manner—spur the patient to generate positive information. The therapist and patient gradually develop a list of the pa-tient’s good qualities. Later the patient can use this list to counter the schema.
Here is the list Shari compiled with the help of her therapist.
1. My husband and children love me.
2. My husband’s family loves me. (My sister-in-law asked me to take her children if she and my brother-in-law died.)
3. My friends Jeanette and Anne Marie love me.
4. My patients like and respect me. I get really good feedback from them pretty much all the time.
5. Most of the staff at the hospital likes me and respects me. I get good evaluations.
6. I’m sensitive to other people’s feelings.
7. I loved my mother, even if she cared about drinking more than she cared about me. I was the one who was there for her until the end.
8. I try to be good and do the right thing. When I get angry, it’s for good reason.
It is important for the therapist to write down the evidence against the schema, because patients tend to quickly dismiss or forget it.
Shari is fortunate, because there is an abundance of evidence against her Defectiveness schema. Not all patients have such good fortune. If there is not much evidence to contradict the schema, the therapist acknowl-edges it, but says, “It doesn’t have to be this way.” For example, a male pa-tient with a Defectiveness schema might actually have very few loving peo-ple in his life. Through surrendering to the schema (choosing significant others who are rejecting and critical), avoiding the schema (staying out of close relationships), or overcompensating for the schema (treating others arrogantly and pushing them away), the patient might look back on a whole life without love. The therapist says,
“I agree you haven’t developed loving relationships in your life, but it’s for a good reason. It’s because of what happened to you as a child that it’s been so hard for you. Because you learned very young to expect
criti-cism and rejection, you stopped reaching out to people. But we can change this pattern. We can work together to help you choose people who are warm and accepting and let them become part of your life. You can work on gradually getting close to some of these people and letting them gradually get close to you. You could try to stop denigrating your-self and others. If you take these steps, things could be different for you.
This is what we’ll work on in therapy.”
As therapy progresses and the patient develops a greater ability to form close relationships, the therapist and patient can add new information to the list of evidence against the schema.
As another step in this process of examining the evidence, patients look at how they discount the evidence against the schema. They write down how they negate evidence. For example, Shari listed the ways she discounts the evidence against her Defectiveness schema.
1. I tell myself that I’m fooling my husband and children, and that’s why they love me. They don’t know the real me.
2. I do more for my family and friends than they do for me, and then I feel like that’s the only reason they care about me.
3. When people give me good feedback, I don’t believe them. I think that there’s some other reason they’re saying it.
4. I tell myself that I’m only sensitive to people’s feelings out of weak-ness. I’m afraid to assert myself.
5. I get down on myself for getting angry and resentful while I was taking care of my mother.
After writing down how they negate evidence, patients “reclaim” the evi-dence against the schema. The therapist shows how invalidating the evidence against the schema is simply another form of schema perpetua-tion.
Reframing the Evidence Supporting the Schema
The next step is to take the list of evidence supporting the schema and to generate alternative explanations for what happened. The therapist takes events the patient views as proving the schema and reattributes them to other causes. The goal is to discredit the evidence supporting the schema.
Evidence from the Patient’s Early Childhood
The therapist discounts early childhood experiences as reflecting patho-logical family dynamics, including poor parenting, rather than the truth of the schema. The therapist points out any activities that occurred within
the family that would not have been acceptable in healthy families. In ad-dition, the therapist and patient consider the psychological health and character of the parents (and other family members) one by one. Did the parent truly have the patient’s best interests at heart? What role did the parent assign to the patient? The therapist points out that parents often as-sign roles to children that do not serve the children’s needs but the needs of the parents. These roles do not reflect inherent flaws in the children, but instead reflect flaws in the parents. Did the parent use the patient in any selfish way? The therapist goes on exploring in this fashion until patients shift to a more realistic perspective of their family history. They stop view-ing their early childhood experiences as proof of their schemas.
For example, one item on Marika’s list of evidence supporting her De-fectiveness schema was, “My father didn’t love me or pay attention to me.”
Marika attributed her father’s lack of love to her inherent unlovability: He did not love her because she was unworthy of love. In her view, she was too needy. The therapist spent time exploring the patterns in Marika’s fam-ily of origin. Then the therapist suggested an alternative explanation: Her father was incapable of loving his children. In fact, he did not love her brother, either. Her father did not show love for her because of his own psychological limitations, not because she was unlovable. Marika’s father was narcissistic and incapable of genuine love. He did not have the ability to be a good father. A good father would have loved her. She was an affec-tionate child who wanted a close relationship with her father, but he could not have this kind of relationship.
Evidence from the Patient’s Life Since Childhood
The therapist discounts experiences since childhood that support the schema by attributing them to schema perpetuation. The coping styles pa-tients learned in childhood have carried their schemas forward into their adult lives. The therapist notes that, because of their schema-driven behav-iors, patients have never given their schemas a fair test. For example, an-other item on Marika’s list of evidence supporting her Defectiveness schema was, “All the men in my life have treated me badly.” She reported that she had had three boyfriends. One of them abused her, one left her, and one frequently slept with other women.
Marika believes that her boyfriends treated her badly because she is undeserving of respect and love, and they knew it. The therapist suggests an alternative explanation: Since she started dating as an adolescent and continuing until the present day, her Defectiveness schema has caused her to keep choosing partners who were critical and rejecting and who would thus treat her badly. (Partner selection is frequently an important aspect of schema perpetuation.)