The schema therapist views the therapy relationship as a vital component of schema assessment and change. Two features of the therapy relationship are characteristic of schema therapy: the therapeutic stance of empathic confrontation and the use of limited reparenting. Empathic confrontation—
or empathic reality-testing—involves expressing understanding of the rea-sons that patients perpetuate their schemas while simultaneously con-fronting the necessity for change. Limited reparenting involves providing, within the appropriate boundaries of the therapy relationship, what pa-tients needed but did not get from their parents as children.
This chapter describes the therapy relationship in schema therapy. We focus on how the therapy relationship is helpful first in the assessment of schemas and coping styles and second as an agent of change.
THE THERAPY RELATIONSHIP IN THE ASSESSMENT AND EDUCATION PHASE
In the Assessment and Education Phase, the therapy relationship is a pow-erful means to assess schemas and to educate the patient. The therapist es-tablishes rapport, formulates the case conceptualization, decides what style of limited reparenting is appropriate for the patient, and determines whether the therapist’s own schemas are likely to interfere with therapy.
177
The Therapist Establishes Rapport
As in other forms of psychotherapy, the therapy relationship begins with establishing rapport with the patient. The therapist strives to embody the empathy, warmth, and genuineness identified by Rogers (1951) as the nonspecific factors of effective therapy. The goal is to create an environ-ment that is accepting and safe, in which the patient can form an emo-tional bond with the therapist.
Schema therapists are personal rather than detached and aloof, in their manner of relating to patients. They try not to appear as though they are perfect, nor as though they have knowledge they are withholding from the patient. They let their natural personalities come through. They share their emotional responses when they believe it will have a positive effect on the patient. They self-disclose when it will help the patient. They aim for a stance of objectivity and compassion.
Schema therapists ask patients for feedback about themselves and the treatment. They encourage patients to express negative feelings about therapy so that these feelings do not build up and create distance and resis-tance. The goal in responding to negative comments is to listen without becoming defensive and to try to understand the situation from the pa-tient’s point of view. (Of course, the therapist does not let the patient be-have abusively—by yelling or making personal attacks—without setting limits.) To the extent that the patient’s negative feedback is a schema-driven distortion, the therapist attempts to acknowledge the kernel of truth while helping the patient identify and fight the schema through empathic confrontation. To the extent that the patient’s negative feedback is accurate, the therapist acknowledges mistakes and apologizes.
Schema therapy is an approach that finds what is healthy and sup-ports it. The basic model is one of empowering the patient. The therapist forms an alliance with the patient’s healthy side against the patient’s schemas. The ultimate goal of treatment is to strengthen the patient’s Healthy Adult mode.
The Therapist Formulates the Case Conceptualization
The therapy relationship illuminates the patient’s (and the therapist’s) schemas and coping styles. When one of the patient’s schemas is triggered in the therapy relationship, the therapist helps the patient identify the schema. The therapist and patient explore what happened—what actions of the therapist triggered the schema and what the patient thought, felt, and did. What was the patient’s coping response? Was the style one of sur-render, avoidance, or overcompensation? The therapist uses imagery to help the patient link the incident to childhood—so that the patient realizes
who it was in childhood that promulgated the schema—and to current life problems.
When the therapy relationship triggers one of the patient’s Early Mal-adaptive Schemas, then the situation is similar to Freud’s concept of trans-ference: The patient is responding to the therapist as though the therapist were a significant figure from the patient’s past, usually a parent. In schema therapy, however, the therapist discusses the patient’s schemas and coping styles openly and directly, rather than tacitly working through the patient’s
“transference neurosis” (Freud, 1917/1963).
Case Illustration
We present an excerpt from an interview Dr. Young conducted with Dan-iel, a patient discussed in previous chapters. At the time of the interview, Daniel had been in schema therapy with another therapist, named Leon, for approximately 9 months. Daniel’s Mistrust/Abuse, Defectiveness, and Subjugation schemas had already been identified. He typically utilized schema avoidance as his coping style.
During the session, the therapist leads Daniel through a number of imagery exercises. In the final 20 minutes of the interview, Dr. Young asks Daniel about his therapeutic relationship with Leon. Next, Dr. Young ex-plores whether Daniel’s schemas were triggered during the current inter-view. The therapist begins by asking Daniel about his Mistrust/Abuse schema.
DR.YOUNG: When you first started working with your therapist, Leon, did you feel mistrust toward him?
DANIEL: I’ve always felt trusting and accepted by Leon. I get irritated at times when he tries to force me to get away from my avoidance, be-cause in therapy I avoid even talking about some of these things. So he tries to get me back on the track, and sometimes that bothers me, but I know that I’m wasting my time when I just ramble on about other things. He tries to get me to do the work at hand.
Next, the therapist asks about Daniel’s Subjugation schema.
DR.YOUNG: Do you ever feel controlled by Leon, like he’s pushing you and trying to control you. . . .
DANIEL: Yes.
DR. YOUNG: Because one of the schemas here (points to the Young Schema Questionnaire) is Subjugation. . . .
DANIEL: Yes.
Dr. Young moves on to his own relationship with Daniel. He inquires whether Daniel’s schemas were triggered during the interview. He begins by asking about Subjugation.
DR.YOUNG: Did you feel that at all in here—the issue of my trying to con-trol you?
DANIEL: No.
DR.YOUNG: There was nothing that irritated you at all or set you off . . . DANIEL: Well, when you were forcing the imagery, even though it seemed
to go smoother than it normally does, I resisted, because I felt a little controlled, like you were telling me what to do.
DR. YOUNG: I see. And did you feel angry or irritated with me?
DANIEL: Irritated.
DR.YOUNG: How did you override that? How did you keep going? Did you just ignore it, or. . . .
DANIEL: Um, it seemed to have a natural flow to it, so, even though there was a momentary feeling of irritation, it seemed to flow.
DR.YOUNG: So, once you could see that you could do it, the resistance was gone.
DANIEL: Yeah.
DR. YOUNG: But there was an initial resistance. . . .
DANIEL: And even a lack of faith in my ability to bring up the images.
DR.YOUNG: So it’s two things. One is feeling insecure that you can do it, the other is feeling that I’m controlling you.
DANIEL: Yes.
The therapist asks Daniel about other times his Subjugation and Defective-ness schemas were triggered during the session.
DR.YOUNG: Were there any other times during the session that you felt I controlled you, or that you wondered whether you could do it well enough?
DANIEL: During the time that you were trying to get me to think of images at the social setting and get to feel some of the feelings involved. It seemed hard for me to drum that up, to put into words.
DR. YOUNG: And you felt insecure, or you felt controlled, or both?
DANIEL: Um, a little of both.
DR. YOUNG: If you could have expressed the irritated side of you at the
time, what would it have said? Could you be the irritated side, just so I can hear what it would say?
DANIEL: (as the “irritated side,” speaking disdainfully) “I don’t like to be forced into this silly little game we’re playing here.”
DR. YOUNG: And what would the other side say? The healthy side . . . ? DANIEL: Um, it would say that (as the “healthy side”) “This is important
stuff, it’s important for your growth as a person to face your fears and face the things that are unpleasant, so that you might overcome them.”
DR. YOUNG: And what does the schema side say back to that?
DANIEL: (as the “schema side,” speaking coldly) “That’s a bunch of baloney, because it’s not going to work anyway. Obviously, you haven’t been too successful up to now, and who’s to say it’s going to be any more suc-cessful after this? And besides, who’s he to tell you what you need or what you need to do?”
The therapist makes explicit that Daniel’s Mistrust/Abuse schema has also been operating in their relationship during the session, along with his De-fectiveness and Subjugation schemas.
DR.YOUNG: Also, in the way you said, “silly little game,” there was a sense that I might be manipulating you, if I heard it right. Was there an ele-ment of feeling manipulated in that?
DANIEL: Yeah.
DR. YOUNG: Like it was a game. What would the game have been? Be the suspicious part of you for a second. . . .
DANIEL: The game would be artificially creating a social scene, which is not real.
DR. YOUNG: Was it as if it was for my benefit rather than for yours, or somehow it was to hurt you?
DANIEL: To uncover me.
DR. YOUNG: To expose you?
DANIEL: Yes.
DR. YOUNG: In a way that wasn’t going to help?
DANIEL: Yes. In a way that would hurt me by exposing me.
DR. YOUNG: Almost like humiliating you.
DANIEL: Yes.
The therapist links what Daniel felt during the session to other encounters in his life.
DR.YOUNG: So there was almost a momentary sense, when I started to ask you to do some imagery work, that I might be trying to expose you and humiliate you, even though it was just a fleeting feeling.
DANIEL: Yes.
DR.YOUNG: And then you were able to override that and say, “No, it’s for my own good,” but there’s still that part of you. . . .
DANIEL: Yes.
DR. YOUNG: And that’s what you’re having to deal with every day when you meet women or meet people, that schema side of you, that even in a few seconds mistrusts or feels controlled or feels insecure, and you’re not always sure how to respond to it.
DANIEL: Yes.
This excerpt provides a good example of how the therapist can utilize the therapy relationship to educate patients about their schemas. In addi-tion, it is noteworthy that Dr. Young specifically asked the patient about whether his schemas were triggered in the therapy relationship. The pa-tient would not have raised the subject without direct questioning on the therapist’s part.
There are typical session behaviors for each schema. For example, pa-tients who have Entitlement schemas might ask for extra time or special consideration in scheduling appointments; patients who have Self-Sacrifice schemas might try to take care of the therapist; patients who have Unrelenting Standards schemas might criticize the therapist for minor er-rors. The patient’s behavior with the therapist suggests hypotheses about the patient’s behavior with significant others. The same schemas and cop-ing styles that the patient exhibits with the therapist probably appear in other relationships outside the therapy.
The Therapist Assesses the Patient’s Reparenting Needs
Another task the therapist faces in the Assessment and Education Phase is assessing the patient’s reparenting needs. Throughout treatment, the thera-pist will use the therapy relationship as a partial antidote to the patient’s schemas. This “limited reparenting” provides a “corrective emotional ex-perience” (Alexander & French, 1946) specifically designed to counteract the patient’s Early Maladaptive Schemas.
The therapist uses a variety of sources to ascertain the patient’s reparenting needs: childhood history, reports of interpersonal difficulties, questionnaires, and imagery exercises. Sometimes the richest source of in-formation is the patient’s behavior in the therapy relationship. Whatever sheds light on the patient’s schemas and coping styles supplies clues about the patient’s reparenting needs.
Case Illustration
Jasmine is a young woman who begins therapy wary of becoming “depen-dent” on the therapist. She tells her therapist that she has just started col-lege and is accustomed to making her own decisions without relying on her parents or anyone else for guidance. She does not want that to change.
In the first few weeks of therapy, it becomes apparent that Jasmine’s core schema is Emotional Deprivation as a result of her childhood with emo-tionally cold parents who shamed her when she asked for help. “They pected me to deal with my problems by myself,” she says. Guidance is ex-actly what Jasmine needs from her therapist—it is one of her unmet emotional needs. For Jasmine, limited reparenting involves giving her some of the guidance she never got from her parents as a child. Recog-nizing her Emotional Deprivation schema helps the therapist know what form of reparenting she needs. (One of the barriers to reparenting Jasmine will be to help her accept help and caring, as she has learned that it is shameful to do so.)
Had Jasmine’s therapist taken her at her word and viewed her problem as one of preserving her independence, the therapist might have refrained from giving her the guidance she needed. Jasmine was not too dependent.
Rather, she had never been permitted to be dependent enough. Emo-tionally, she had always been alone. By reparenting her in accord with her core Early Maladaptive Schema, the therapist could help her recognize that her dependency needs were normal and that establishing autonomy was a gradual process.
Ideal Therapist Qualities in Schema Therapy
Flexibility is a key feature of the ideal schema therapist. Because the type of limited reparenting required depends on each patient’s unique child-hood history, therapists must adjust their styles to fit the emotional needs of the individual patient. For example, depending on the patient’s schemas, the therapist has to focus on generating trust, providing stability, giving emotional nurturance, encouraging independence, or demonstrat-ing forgiveness. The therapist must be able to provide in the therapy rela-tionship whatever is a partial antidote to the patient’s core Early Maladap-tive Schemas.
Like a good parent, the schema therapist is capable of partially meet-ing—within the limits of the therapy relationship—the patient’s basic emotional needs we described in Chapter 1: (1) secure attachment; (2) au-tonomy and competence; (3) genuine self-expression of needs and emo-tions; (4) spontaneity and play; and (5) realistic limits. The goal is for the patient to internalize a Healthy Adult mode, modeled after the therapist, that can fight schemas and inspire healthy behavior.
Case Illustration
Lily is 52 years old, and her children are grown and out of the house. She has an Emotional Deprivation schema. As a child, no one connected with her emotionally. She became increasingly withdrawn, preferring to study or play her violin rather than interact with others. She had few friends, and they were not really close. Lily has been married to her husband, Joseph, for 30 years. She has lost interest in her marriage and spends most of her time at home isolated with her books and her music. In the Assessment Phase, Lily and the therapist agree that her core schema is Emotional De-privation and that her main coping style is avoidance.
As the weeks pass, Lily begins to have sexual feelings for her male therapist. She becomes aware of how emotionally empty her life is. No lon-ger satisfied to read and play music alone, she begins to want more.
Alarmed and ashamed of her needs, she copes by withdrawing psychologi-cally from the therapist. The therapist observes her withdrawal. He theo-rizes that her Emotional Deprivation schema has been triggered in the therapy relationship and that she is responding with schema avoidance.
Knowing her core schema and main coping style points the way to under-standing for the therapist.
The therapist points out Lily’s withdrawal and helps her explore it. Al-though not able to talk about her sexual feelings, she is able to say that she is experiencing feelings of caring for the therapist and that this is making her extremely uncomfortable. She has not really cared about anybody for a long time. The therapist asks Lily to close her eyes and link the feeling of discomfort with him to times in the past that she had similar feelings. She connects the feeling first to her husband in the early days of their marriage and then to her father when she was a child. She remembers walking home from school and seeing a little boy run into his father’s arms and feeling a wave of longing to do the same with her own remote father. In her mem-ory, Lily went up to her room when she got home and spent the rest of the day practicing her violin.
The therapist helps Lily see the schema-driven distortion in her view of the therapy relationship. Unlike her father, the therapist welcomes her feelings of caring (when they are expressed within the appropriate limits of the therapy relationship). In the therapy relationship, she is allowed to care and to want caring; the therapist will not reject her for it. She is al-lowed to talk about her feelings directly and does not have to withdraw.
Although this kind of communication was not possible with her father, it is possible with the therapist and, by implication, with other people in the world. (We encourage patients to verbalize sexual feelings to the therapist as well, although we gently, in a nonrejecting way, indicate that acting on these feelings with the therapist is not possible. We emphasize that
pa-tients can eventually share these same feelings with someone in their lives who will be in a position to respond in kind)
When a patient engages in behaviors during the session that reflect overcompensation, the schema therapist responds objectively and ap-propriately, utilizing empathic confrontation. The therapist expresses un-derstanding of the reasons for the patient behaving in such a way but points out the consequences of the behavior in the therapy relationship and in the patient’s outside life. The following example illustrates this process.
Case Illustration
Jeffrey is 41 years old. He comes to therapy because Josie, his girlfriend of 10 years, has broken up with him. He is realizing that, this time, he is not going to get her back. Throughout their relationship, Jeffrey repeatedly cheated on Josie. She would break up with him, he would beg for her for-giveness and promise to reform, and she would take him back. But no more. Consequently, Jeffrey has fallen into a major depression.
Jeffrey has narcissistic personality disorder, a personality type that is discussed much more fully in Chapter 10. His core schema is Defective-ness, and his primary coping style is schema overcompensation. In his re-lationships with women, Jeffrey overcompensates for his feelings of defec-tiveness by winning them over sexually. Even though he loved Josie as much as he was capable of, he was not able to give up cheating on her (a major source of narcissistic gratification).
Jeffrey overcompensates in the therapy relationship by getting angry whenever the therapist evokes feelings of vulnerability. He is uncomfort-able being vulneruncomfort-able with the therapist because of his Defectiveness schema: Being vulnerable causes him to feel ashamed and exposed. In one session, Jeffrey relates a childhood incident concerning himself and his emotionally rejecting mother (from whom Jeffrey is currently estranged).
The therapist comments that, based on this incident, it seems that Jeffrey loved his mother, even though he was angry with her as a child. Jeffrey lashes out at the therapist, calling him a “momma’s boy.” In a serious tone, the therapist leans forward and asks Jeffrey why he just lashed out like that. What was he feeling underneath? When Jeffrey denies feeling any-thing underneath, the therapist suggests that Jeffrey may have felt vulnera-ble. “I understand,” says the therapist. “As a child you loved your mother.
I loved my mother as a child, too. It’s natural for children to love their mothers. It’s not a sign of weakness or inadequacy.” The therapist commu-nicates that Jeffrey does not have to feel inferior to anyone, including the therapist, for loving his mother. Next, the therapist conveys that Jeffrey’s overcompensation—lashing out at the therapist—has the effect of making