Autor: Julio Cesar Tafforelli | Publicado: 2011-09-02T09:41:00-07:00

A Client’s Guide to Schema TherapyDavid C. Bricker, Ph.D. and Jeffrey E. Young, Ph.D.Schema Therapy InstituteHARRY is a 45-year old middle -level manager. He has been married for 16 years, but hismarriage has been very troubled. He and his wife are often resentful of each other, theyrarely communicate on an intimate level, and they have few moments of real pleasure.Other aspects of Harry’s life have been equally unsatisfying. He doesn’t enjoy his work,primarily because he doesn’t get along with his co-workers. He is often intimidated by his boss and other people at the office. He has a few friends outside of work, but nonethat he considers close.During the past year Harry’s mood became increasingly negative. He was getting moreirritable, he had trouble sleeping and he began to have difficulty concentrating at work.As he became more and more depressed, he began to eat more and gained 15 pounds.When he found himself thinking about taking his own life, he decided it was time to get help. He consulted a psychologist who practices cognitive therapy.As a result of short-term cognitive therapy techniques, Harry improved rapidly. His mood lifted, his appetite returned to normal, and he no longer thought about suicide. In addition he was able to concentrate well again and was much less irritable. He also began to feel more in control of his life as he learned how to control his emotions for the first time.But, in some ways, the short-term techniques were not enough. His relationships withhis wife and others, while they no longer depressed him as much as they had, still failed to give him much pleasure. He still could not ask to have his needs met, and he had few experiences he considered truly enjoyable. The therapist then began schema therapy to help Harry change his long-term life patterns.This guide will present the schema therapy approach, developed by Dr. Jeffrey Young toexpand cognitive therapy for clients with more difficult long-term problems. Schematherapy can help people change long-term patterns, including the ways in which theyinteract with other people. This overview of schema therapy consists of six parts:1) A brief explanation of short-term cognitive therapy2) An explanation of what a schema is and examples of schemas;3) An explanation of the processes by which schemas function;4) An explanation of modes and how they function within schema therapy;5) Several case examples; and6) A brief description of the therapeutic processShort-Term Cognitive TherapyCognitive therapy is a system of psychotherapy developed by Aaron Beck and hiscolleagues to help people overcome emotional problems. This system emphasizeschanging the ways in which people think in order to improve their moods, such asdepression, anxiety and anger.Emotional disturbance is influenced by the cognitive distortions that people make indealing with their life experiences. These distortions take the form of negativeinterpretations and predictions of everyday events. For instance, a male college studentpreparing for a test might make himself feel discouraged by thinking: “This material is impossible” (Negative Interpretation) and “I’ll never pass this test” (Negative Prediction).The therapy consists of helping clients to restructure their thinking. An important step in this process is examining the evidence concerning the maladaptive thoughts. In the example above, the therapist would help the student to look at his past experiences and determine if the material was in fact impossible to learn, and if he knew for sure that he couldn’t pass the test. In all probability, the student would decide that these two thoughts lacked validity.More accurate alternative thoughts are then substituted. For instance, the student might be encouraged to think: “This material is difficult, but not impossible. I’ve learneddifficult material before” and “I’ve never failed a test before, so long as I’ve done enough preparation.” These thoughts would probably lead him to feel better and cope better.Often short-term cognitive therapy is enough to help people overcome emotionalproblems, especially depression and anxiety. Recent research has shown this to be so.However, sometimes this approach is not enough. Some clients in short-term cognitivetherapy find that they don’t get all the benefits they want. This has led us, as well as various other researchers (Beck, xxxx) to look at deeper and more permanent cognitive structures as a means to understand and treat problem moods and behaviors. Schematherapy was created as a result of these efforts.Schemas - What They AreA schema is an extremely stable, enduring negative pattern that develops duringchildhood or adolescence and is elaborated throughout an individual’s life. We view theworld through our schemas.Schemas are important beliefs and feelings about oneself and the environment whichthe individual accepts without question. They are self -perpetuating, and are veryresistant to change. For instance, children who develop a schema that they areincompetent rarely challenge this belief, even as adults. The schema usually does not goaway without therapy. Overwhelming success in people’s lives is often still not enoughto change the schema. The schema fights for its own survival, and, usually, quitesuccessfully.It’s also important to mention the importance of needs in schema formation andperpetuation. Schemas are formed when needs are not met during childhood and thenthe schema prevents similar needs from being fulfilled in adulthood. For instance a childwhose need for secure attachments is not fulfilled by his parents may go for many yearsin later life without secure relationships.Even though schemas persist once they are formed, they are not always in ourawareness. Usually they operate in subtle ways, out of our awareness. However, when aschema erupts or is triggered by events, our thoughts and feelings are dominated bythese schemas. It is at these moments that people tend to experience extreme negativeemotions and have dysfunctional thoughts.In our work with many patients, we have found eighteen specific schemas. Most clientshave at least two or three of these schemas, and often more. A brief description of eachof these schemas is provided below.Emotional DeprivationThis schema refers to the belief that one’s primary emotional needs will never be met byothers. These needs can be described in three categories: Nurturance – needs foraffection, closeness and love; Empathy – needs to be listened to and understood;Protection – needs for advice, guidance and direction. Generally parents are cold orremoved and don’t adequately care for the child in ways that would adequately meetthe above needs.Abandonment/InstabilityThis schema refers to the expectation that one will soon lose anyone with whom anemotional attachment is formed. The person believes that, one way or another, closerelationships will end imminently. As children, these clients may have experienced thedivorce or death of parents. This schema can also arise when parents have beeninconsistent in attending to the child’s needs; for instance, there may have beenfrequent occasions on which the child was left alone or unattended to for extendedperiods.Mistrust/AbuseThis schema refers to the expectation that others will intentionally take advantage insome way. People with this schema expect others to hurt, cheat, or put them down.They often think in terms of attacking first or getting revenge afterwards. In childhood,these clients were often abused or treated unfairly by parents, siblings, or peers.Defectiveness/ShameThis schema refers to the belief that one is internally flawed, and that, if others getclose, they will realize this and withdraw from the relationship. This feeling of beingflawed and inadequate often leads to a strong sens e of shame. Generally parents werevery critical of their children and made them feel as if they were not worthy of beingloved.Social Isolation/AlienationThis schema refers to the belief that one is isolated from the world, different from otherpeople, and/or not part of any community. This belief is usually caused by earlyexperiences in which children see that either they, or their families, are different fromother people.Dependence/IncompetenceThis schema refers to the belief that one is not capable of handling day-to-dayresponsibilities competently and independently. People with this schema often rely onothers excessively for help in areas such as decision-making and initiating new tasks.Generally, parents did not encourage these children to act independently and developconfidence in their ability to take care of themselves.Vulnerability to Harm and IllnessThis schema refers to the belief that one is always on the verge of experiencing a majorcatastrophe (financial, natural, medical, criminal, etc.). It may lead to taking excessiveprecautions to protect oneself. Usually there was an extremely fearful parent whopassed on the idea that the world is a dangerous place.Enmeshment/Undeveloped SelfThis schema refers to a pattern in which you experience too much emotionalinvolvement with others – usually parents or romantic partners. It may also include thesense that one has too little individual identity or inner direction, causing a feeling ofemptiness or of floundering. This schema is often brought on by parents who are socontrolling, abusive, or overprotective that the child is discouraged from developing aseparate sense of self.This schema refers to the belief that one is incapable of performing as well as one’speers in areas such as career, school or sports. These clients may feel stupid, inept oruntalented. People with this schema often do not try to achieve because they believethat they will fail. This schema may develop if children are put down and treated as ifthey are a failure in school and other spheres of accomplishment. Usually the parentsdid not give enough support, discipline, and encouragement for the child to persist andsucceed in areas of achievement, such as schoolwork or sportThis schema refers to the belief that one must submit to the control of others in order toavoid negative consequences. Often these clients fear that, unless they submit, otherswill get angry or reject them. Clients who subjugate ignore their own desires andfeelings. In childhood there was generally a very controlling parent.This schema refers to the excessive sacrifice of one’s own needs in order to help others.When these clients pay attention to their own needs, they often feel guilty. To avoid thisguilt, they put others’ needs ahead of their own. Often clients who self -sacrifice gain afeeling of increased self -esteem or a sense of meaning from helping others. In childhoodthe person may have been made to feel overly responsible for the well being of one orboth parents.Emotional InhibitionThis schema refers to the belief that you must suppress spontaneous emotions andimpulses, especially anger, because any expression of feelings would harm others orlead to loss of self -esteem, embarrassment, retaliation or abandonment. You may lackspontaneity, or be viewed as uptight. This schema is often brought on by parents whodiscourage the expression of feelings.Approval-Seeking/Recognition-SeekingThis schema refers to the placing of too much emphasis on gaining the approval andrecognition of others at the expense of one’s genuine needs and sense of self. It canalso include excessive emphasis on status and appearance as a means of gainingrecognition and approval. Clients with this schema are generally extremely sensitive torejections by others and try hard to fit in. Usually they did not have their needs forunconditional love and acceptance met by their parents in their early years.Unrelenting Standards/HypercriticalnessThis schema refers to the belief that whatever you do is not good enough, that youmust always strive harder. The motivation for this belief is the desire to meet extremelyhigh internal demands for competence, usually to avoid internal criticism. People withthis schema show impairments in important life areas, such as health, pleasure or self -esteem. Usually these clients’ parents were never satisfied and gave their children lovethat was conditional on outstanding achievement.Entitlement/GrandiosityThis schema refers to the belief that you should be able to do, say, or have whateveryou want immediately regardless of whether that hurts others or seems reasonable tothem. You are not interested in what other people need, nor are you aware of the long-term costs to you of alienating others. Parents who overindulge their children and whodo not set limits about what is socially appropriate may foster the development of thisschema. Alternatively, some children develop this schema to compensate for feelings ofemotional deprivation or defectiveness.Insufficient Self-Control/Self-DisciplineThis schema refers to the inability to tolerate any frustration in reaching one’s goals, aswell as an inability to restrain expression of one’s impulses or feelings. When ack oflself-control is extreme, criminal or addictive behavior rule your life. Parents who did notmodel self -control, or who did not adequately discipline their children, may predisposethem to have this schema as adults.Negativity/PessimismThis schema refers to a pervasive pattern of focusing on the negative aspects of lifewhile minimizing the positive aspects. Clients with this schema are unable to enjoythings that are going well in their lives because they are so concerned with negativedetails or potential future problems. They worry about possible failures no matter howwell things are going for them. Usually these clients had a parent who worriedexcessively.This schema refers to the belief that people deserve to be harshly punished for makingmistakes. People with this schema are critical and unforgiving of both themselves andothers. They tend to be angry about imperfect behaviors much of the time. Inchildhood these clients usually had at least one parent who put too much emphasis onperformance and had a punitive style of controlling behavior.How Schemas WorkThere are two primary schema operations: Schema healing and schema perpetuation.All thoughts, behaviors and feelings may be seen as being part of one of theseoperations. Either they perpetuate the schema or they heal the schema. In a latersection on the therapy process we will explain more about schema healing.Schema perpetuation refers to the routine processes by which schemas function andperpetuate themselves. This is accomplished by cognitive distortions, self -defeatingbehavior patterns and schema coping styles.Earlier we mentioned that cognitive distortions are a central part of cognitive therapy.These distortions consist of negative interpretations and predictions of life events. Theschema will highlight or exaggerate information that confirms the schema and willminimize or deny information that contradicts it. Likewise, unhealthy behavior patternswill perpetuate the schema’s existence. Someone who was abused in childhood anddeveloped a Mistrust/Abuse schema may seek out abusive relationships in adulthoodand remain in them, providing a constant stream of evidence for the schema.In order to understand how schemas work, there are three schema coping styles thatmust be defined. These styles are schema surrender, schema avoidance, and schemaovercompensation. It is through these three styles that schemas exert their influence onour behavior and work to insure their own survival.Schema surrender refers to ways in which people passively give in to the schema.They accept the schema as truth and then act in ways that confirm the schema. Forinstance, a young man with an Abandonment/Instability schema might choosepartners who are unable to commit to long-term relationships. He might then react toeven minor signs indications of abandonment, such as spending short times without hispartner, in an exaggerated way and feel excessive negative emotion. Despite theemotional pain of the situation, he might also passively remain in the relationshipbecause he sees no other possible way to connect with women.Schema avoidance refers to the ways in which people avoid activating schemas. Asmentioned earlier, when schemas are activated, this causes extreme negative emotion.People develop ways to avoid triggering schemas in order not to feel this pain. There arethree types of schema avoidance: cognitive, emotional and behavioral.Cognitive avoidance refers to efforts that people make not to think about upsettingevents. These efforts may be either voluntary or automatic. People may voluntarilychoose not to focus on an aspect of their personality or an event, which they finddisturbing. There are also unconscious processes which help people to shut outinformation which would be too upsetting to confront. People often forget particularlypainful events. For instance, children who have been abused sexually often forget thememory completely.Emotional or affective avoidance refers to automatic or voluntary attempts to blockpainful emotion. Often when people have painful emotional experiences, they numbthemselves to the feelings in order to minimize the pain. For instance, a man might talkabout how his wife has been acting in an abusive manner toward him and say that hefeels no anger towards her, only a little annoyance. Some people drink or abuse drugsto numb feelings generated by schemas.The third type of avoidance is behavioral avoidance. People often act in such a way asto avoid situations that trigger schemas, and thus avoid psychological pain. For instance,a woman with a Failure schema might avoid taking a difficult new job which would bevery good for her. By avoiding the challenging situation, she avoids any pain, such asintense anxiety, which could be generated by the schema.The third schema process is Schema overcompensation. The individual behaves in amanner which appears to be the opposite of what the schema suggests in order to avoidtriggering the schema. On the surface, it may appear that the overcompensators arebehaving in a healthy manner, by standing up for themselves. But when they overshootthe mark they cause more problem patterns, which then perpetuate the schema. Forinstance, a young man with a Defectiveness schema might overcompensate bypresenting himself as perfect and being critical of others. This would likely lead othersto criticize him in turn, thereby confirming his belief that he is defective.Working With ModesWhen treating clients with schema therapy one of the most important innovations is theconcept of mode. For our purposes we will define a mode as the set of schemas orschema operations that are currently active for an individual. Or you might think of amode simply as a mindset or state that you might be in temporarily. Most people canrelate to the idea that we all have these different parts of ourselves and we go in andout of them all the time. For instance, if a friend tells you she had a bad day becauseher boss (or her toddler) was in his raging bull mode, you’d know exactly what shemeans.There are often occasions when a therapist will choose to work with a client’s modes intherapy. If a client is extremely upset at the beginning of a session, the therapist mayinquire about what part of the person is feeling the emotional pain and attempt torecognize it and deal with it directly. For instance, for several sessions, Myra was verysad and hurt because she was unable to talk out some problems with her husband. Intalking with her therapist they focused on a mode, or part of her, that she called LonelyMyra, that seemed to be active after these failed attempts. By engaging this part ofMyra in this manner the therapist was able to give her an opportunity to express thefeelings and thoughts connected with her pattern of loneliness.The exact pattern of work with modes will vary from session to session. But some ofthe more common activities in mode work can be described. The history of the mode isoften discussed; the client will speak about when the mode started and what was goingon at the time. Connections are made between modes and current problems.Dialogues can be conducted between different modes when there is a conflict. Forinstance, a miser mode and a playboy mode might have it out over what type of car tobuy. And there is always an effort to link mode work with other aspects of the therapy.Case ExamplesIn this section six case examples are presented. In each one, the schema coping stylesare demonstrated. By reading through this section, you will get a better feel for howthese processes can operate in real life situations.Abby is a young woman whose main schema is Subjugation. She tends to see peopleas very controlling even when they are being appropriately assertive. She has thoughtssuch as “I can’t stand up for myself or they won’t like me’ and is likely to give in toothers (Schema surrender). At other times she decides that no one will get the betterof her and becomes very controlling (Schema overcompensation). Sometimes whenpeople make unreasonable demands on her she minimizes the importance of her ownfeelings and has thoughts like “It’s not that important to me what happens.’ At othertimes she avoids acquaintances with whom she has trouble standing u for herselfp(Schema avoidance).Stewart’s main schema is Failure. Whenever he is faced with a possible challenge, hetends to think that he is not capable. Often he tries half -heartedly, guaranteeing that hewill fail, and strengthening the belief that he is not capable (Schema surrender). Attimes, he makes great efforts to present himself in an unrealistically positive light byspending excessive amounts of money on items such as clothing and automobiles(Schema overcompensation). Often he avoids triggering his schema by staying awayfrom challenges altogether and convinces himself that the challenge was not worthtaking (Schema avoidance).Rebecca’s core schema is Defectiveness/Shame. She believes that there issomething basically wrong with her and that if anyone gets too close, they will rejecther. She chooses partners who are extremely critical of her and confirm her view thatshe is defective (Schema surrender). Sometimes she has an excessive defensivereaction and counterattacks when confronted with even mild criticism (Schemaovercompensation). She also makes sure that none of her partners get too close, sothat she can avoid their seeing her defectiveness and rejecting her (Schemaavoidance).Michael is a middle-aged man whose main schema is Dependence/Incompetence.He sees himself as being incapable of doing daily tasks on his own and generally seeksthe support of others. Whenever he can, he chooses to work with people who help himout to an excessive degree. This keeps him from developing skills needed to work aloneand confirms his view of himself as someone who needs others to help him out(Schema surrender). At times, when he would be best off taking advice from otherpeople, he refuses to do so (Schema overcompensation). He reduces his anxiety byprocrastinating as much as he can get away with (Schema avoidance).Ann’s core schema is Social Isolation/Alienation. She sees herself as being differentfrom other people and not fitting in. When she does things as part of a group she doesnot get really involved (Schema surrender). At times she gets very hostile towardsgroup members and can be very critical of the group as a whole (Schemaovercompensation). At other times she chooses to avoid group activities altogether(Schema avoidance).Sam’s central schema is Emotional Deprivation. He chooses partners who are notvery capable of giving to other people and then acts in a manner which makes it evenmore difficult for them to give to him (Schema surrender). At times he will act in avery demanding, belligerent manner and provoke fights with his partners (Schemaovercompensation). Sam avoids getting too close to women, yet denies that he hasany problems in this area (Schema avoidance).Therapeutic Process - Changing SchemasIn schema therapy the goal of the treatment is to engage in schema healing processes.These processes are intended to weaken the early maladaptive schemas and copingstyles as much as possible, and build up the person’s healthy side. An alliance is formedbetween the therapist and the healthy part of the client against the schemas. Any ofthe therapy activities described below may be seen as examples of schema healing.The first step in therapy is to do a comprehensive assessment of the client. The maingoal of this assessment is to identify the schemas and coping styles that are mostimportant in the client’s psychological makeup. There are several steps to this process.The therapist generally will first want to know about recent events or circumstances inthe clients’ lives which have led them to come for help. The therapist will then discussthe client’s life history and look for patterns which may be related to schemas.There are several other steps the therapist will take in assessing schemas. We use theYoung Schema Questionnaire, which the client fills out, listing many of the thoughts,feeling and behaviors related to the different schemas; items on this questionnaire canbe rated as to how relevant to the client’s life they are.There are also various imagery techniques which the therapist can use to assessschemas. One specific technique involves asking clients to close their eyes and create animage of themselves as children with their parents. Often the images that appear willlead to the core schemas.Jonathan is a 28 year old executive whose core schema is Mistrust/Abuse. He cameto therapy because he was having bouts of intense anxiety at work, during which hewould be overly suspicious and resentful of his co-workers. When asked to create animage of himself with his family, he had two different images. In the first he saw himselfbeing terrorized by his older brother. In the second he saw his alcoholic father cominghome and beating his mother, while he cowered in fear.There are many techniques that the therapist can use to help clients weaken theirschemas. These techniques can be broken down into four categories: emotive,interpersonal, cognitive and behavioral. Each of these categories will be brieflydiscussed, along with a few examples.Emotive techniques encourage clients to experience and express the emotional aspectsof their problem. One way this is done is by having clients close their eyes and imaginethey are having a conversation with the person to whom the emotion is directed. Theyare then encouraged to express the emotions as completely as possible in the imaginarydialogue. One woman whose core schema was Emotional Deprivation had severalsuch sessions in which she had an opportunity to express her anger at her parents fornot being there enough for her emotionally. Each time she expressed these feelings, shewas able to distance herself further from the schema. She was able to see that herparents had their own problems which kept them from providing her with adequatenurturance, and that she was not always destined to be deprived.There are many variations on the above technique. Clients may take on the role of theother person in these dialogues, and express what they imagine their feelings to be. Orthey may write a letter to the other person, which they have no intention of mailing, sothat they can express their feelings without inhibition.Mode work can be invaluable as an emotive technique. A client may be feeling a vaguesense of sadness which he can’t clarify. By looking at modes with his therapist he mayconnect with a mode that he labels as Unimportant. By dialoging with the therapistfrom the mode’s point of view many feelings can come out which can be worked onfurther. In this case the client might get in touch not only with the sadness, but alsowith anger at being ignored.Interpersonal techniques highlight the client’s interactions with other people so that therole of the schemas can be exposed. One way is by focusing on the relationship with thetherapist. Frequently, clients with a Subjugation schema go along with everything thetherapist wants, even when they do not consider the assignment or activity relevant.They then feel resentment towards the therapist which they display indirectly. Thispattern of compliance and indirect expression of resentment can then be explored to theclient’s benefit. This may lead to a useful exploration of other instances in which theclient complies with others and later resents it, and how they might better cope at thosetimes.Another type of interpersonal technique involves including a client’s spouse in therapy. Aman with a Self-Sacrifice schema might choose a wife who tends to ignore his wishes.The therapist may wish to involve the wife in the treatment in order to help the two ofthem to explore the patterns in their relationship and change the ways in which theyinteract.Cognitive techniques are those in which the schema-driven cognitive distortions arechallenged. As in short-term cognitive therapy, the dysfunctional thoughts are identifiedand the evidence for and against them is considered. Then new thoughts and beliefs aresubstituted. These techniques help the client see alternative ways to view situations.The first step in dealing with schemas cognitively is to examine the evidence for andagainst the specific schema which is being examined. This involves looking at the client’slife and experiences and considering all the evidence which appears to support or refutethe schema. The evidence is then examined critically to see if it does, in fact, providesupport for the schema. Usually the evidence produced will be shown to be in error, andnot really supportive of the schema.For instance, let’s consider a young man with an Emotional Deprivation schema.When asked for evidence that his emotional needs will never be met, he brings upinstances in which past girlfriends have not met his needs. However, when these pastrelationships are looked at carefully, he finds that, as part of the schema surrenderprocess, he has chosen women who are not capable of giving emotionally. Thisunderstanding gives him a sense of optimism; if he starts selecting his partnersdifferently, his needs can probably be metAnother cognitive technique is to have a structured dialogue between the client andtherapist. First, the client takes the side of the schema, and the therapist presents amore constructive view. Then the two switch sides, giving the client a chance toverbalize the alternative point of view.After having several of these dialogues the client and therapist can then construct aflashcard for the client, which contains a concise statement of the evidence against theschema.A typical flashcard for a client with a Defectiveness/Shame schema reads: “I knowthat I feel that there is something wrong with me but the healthy side of me knows thatI’m OK. There have been several people who have known me very well and stayed withme for a long time. I know that I can pursue friendships with many people in whom Ihave an interest.”The client is instructed to keep the flashcard available at all times and to read itwhenever the relevant problem starts to occur. By persistent practice at this, and othercognitive techniques, the client’s belief in the schema will gradually weaken.Behavioral techniques are those in which the therapist assists the client in changinglong-term behavior patterns, so that schema surrender behaviors are reduced andhealthy coping responses are strengthened.One behavioral strategy is to help clients choose partners who are appropriate for themand capable of engaging in healthy relationships. Clients with the EmotionalDeprivation schema tend to choose partners who are not emotionally giving. Atherapist working with such clients would help them through the process of evaluatingand selecting new partners.Another behavioral technique consists of teaching clients better communication skills.For instance, a woman with a Subjugation schema believes that she deserves a raiseat work but does not know how to ask for it. One technique her therapist uses to teachher how to speak to her supervisor is role -playing. First, the therapist takes the role ofthe client and the client takes the role of the supervisor. This allows the therapist todemonstrate how to make the request appropriately. Then the client gets an opportunityto practice the new behaviors, and to get feedback from the therapist before changingthe behavior in real life situations.IN SUMMARY, schema therapy can help people understand and change long-term lifepatterns. The therapy consists of identifying early maladaptive schemas, coping stylesand modes, and systematically confronting and challenging them.Young, J.E., and Klosko, J.S. (1993). Reinventing your life. New York:Young, J.E., Klosko, J.S., and Weishaar, M.E. Schema therapy: Apractitioner’s guide. New York: Guilford, 2003.