By Kenneth Rothbaum, MD
[Spring 2006; Vol. 32, No. 3; Pg 8, 11]
In
the last 30 years cognitive behavioral therapy (CBT) has revolutionized
psychotherapy. However, it is primarily effective for patients who have
acute disorders like depression and anxiety. Some patients do not respond to it
in its classical form. Some of them have chronic or recurrent Axis I
disorders and personality disorders, while others complain primarily of
interpersonal difficulties.
Schema therapy (ST) is designed to treat them. It represents the work of Jeffrey Young, PhD, who is a former director of Aaron Beck’s CBT Institute in Philadelphia. Therefore, his work developed in the context of CBT theory and practice, though some of its features come from psychodynamic, gestalt, and classical behavioral therapy. It is a relatively short-term therapy in which the therapist is highly active. It contains specific strategies to treat specific schemas.
A
schema is a broad theme in a person’s life, comprised of memories, behaviors,
and cognitions. Schema therapy is designed to resolve current problems
that are related to unmet early childhood needs like the need for autonomy or
nurturing. Schemas are deeply held, unquestioned dysfunctional beliefs
about the self, others, and the world. When something activates them, they
produce powerful, dysphoric affects and self-defeating responses. The 18
schemas are grouped into domains: some of them are concerned with disconnection
and rejection, impaired autonomy and performance, underdeveloped self, impaired
limits, other-directedness, over-vigilance, and inhibition. Domains
largely represent the needs of young children.
Unmet
childhood needs create what are called early maladaptive schemas (EMS), such as
emotional deprivation, abandonment/instability, mistrust/abuse, and
defectiveness/shame. For example, a child who has been insufficiently
nurtured may develop an “emotional deprivation” schema and will believe that
he or she will never get the affection, understanding, and closeness he or she
needs. It is “just how things are.”
In
response to an EMS, an individual must learn to cope. There are three
“schema coping styles”-–surrender, avoidance, and over-compensation,
corresponding to freeze, flight, or fight. For example, a patient with an
emotional deprivation schema might marry someone cold and aloof (surrender),
another might withdraw (avoidance) and a third might demand that others address
unmet emotional need (overcompensation).
Schema
therapy also takes temperament into consideration. A specific
temperament lies somewhere on a continuum, with extreme ones shaping the
formation of schemas and coping styles, and therefore contributing to problems.
The
initial evaluation and case conceptualization is conducted over several
sessions. The therapist takes note of self-defeating patterns, discusses
early development, and identifies schemas and coping strategies. The
identification of schemas evolves from interviews, imagery, and the answers to
two questionnaires. The “schema questionnaire” examines the patient’s
current attitudes, while the “Young parental inventory” looks at the
patient’s impressions of parental attitudes. The presenting problem
should be conceptualized in terms of schemas. Coping styles, temperament, and
the goals of treatment should be explored.
The
therapist then employs cognitive, experiential(imagery, role-playing, etc.),
behavioral (testing patients’ hypotheses), and relational (limited
re-parenting) strategies. Schema “flash cards” can be used when a
schema is activated; they can help mitigate the extreme affect and maladaptive
behavior that can follow activation. The therapist teaches the patient how
schemas contribute to current problems. During treatment of an
“emotional deprivation” schema the therapist will ask the patients to
diminish their exaggerated beliefs that others are selfishly depriving them of
what they need. Patients learn that caring exists on a continuum and they
learn how to see which of their needs are not being met. Because schemas
develop so early, the patient is largely unaware of them, but the therapist can
use experiential strategies like role-playing or imagery to bring them to
awareness. The therapeutic relationship is utilized to guide patients to
choose more nurturing partners and to help them avoid over-reacting with anger
when their needs are thwarted.
Here
is the case of a 40-year-old lawyer who reported that his wife had been angry
with him for years because he was dependent on her and was enmeshed with his
mother. Because he allowed his mother to act like a dictator towards him
his entire family had to comply with her demands. When he was a child he
had been taught that expressing needs was “bad”. He has had difficulty
asserting himself at work and he therefore was failing to live up to his
potential. He was expecting that others were trying to control him. His
wife was talking of a separation because he appeared to be unwilling to change.
He had been in conventional psychotherapy intermittently for years.
His
questionnaire revealed several schemas–-enmeshment, self-sacrifice,
subjugation, approval-seeking, and dependence. To determine which one was
most connected to the presenting problem, he was asked to do an imagery
exercise. With his eyes closed, he was asked to bring up a childhood image
of struggling with his mother. He had to describe the image in
detail—his mother’s demands, how he felt and how the struggle was resolved.
He was then asked to tell his
mother what he wanted and how he
wished to
resolve the struggle.
Subjugation
was the relevant schema for him. It is an excessive surrendering of
control to others because one feels coerced, usually for fear of the other’s
anger, retaliation, or abandonment. It can take two forms–-subjugation
of needs(the suppression of one’s preferences, decisions, and desires) and
subjugation of emotions (the suppression of emotions, especially anger). It
involves the perception that one’s opinions and desires are not valid or are
unimportant to others. These patients are usually overly compliant, but
they may periodically have a buildup of anger that can lead to acting-out,
passive-aggressive behavior, or psychosomatic symptoms. An alternate
presentation is rebelliousness, which represents over-compensation.
This
patient was groomed to be an obedient child and he remained that way,
capitulating to his mother and wife and others in order to avoid confrontation.
He was afraid, so he acted on his maladaptive beliefs by suppressing his true
self. He was surrendering to his schema. One of the goals of
treatment was for him to learn that he has a right to express his needs and to
ask for what he wants. The therapist challenged him to consciously
diminish his exaggerated belief that he would suffer negative consequences if he
asserted his needs. He had been using a cognitive style of thinking in
terms of “all or nothing” and over-generalizing when confronted with others
who were in position (real or perceived) of authority. His cognitive
schema style was immature and rigid, providing evidence that he developed it
early in his life.
He
was asked to test his exaggerated beliefs and to alter his behavior.
First, the therapist used role-playing to teach him to appropriately identify
when he was angry and what his needs were. He used imagery to express his
anger at the controlling parent, to identify his needs, and then to ask for them
to be met. On a behavioral level, he was encouraged to assert his needs
with others and to learn more about himself. Because a patient like this
often gravitates towards people who like to control others, he was guided to
identify them and to avoid them.
Within
a few months this man was able to tentatively assert himself with his mother,
since he was no longer inappropriately frightened that she would retaliate and
he was no longer controlled by a sense of guilt. He took more
responsibility at home by planning meals and outings. His wife noticed these
changes, which improved their relationship. It was clear that his
attitudes and behaviors would require more work, lest he revert to his former
ways, but his prognosis was excellent.