This brief overview of the treatment process presents the steps in assessing and changing schemas. Each of these procedures is described in detail in later chapters. The two phases of treatment are the Assessment and Education Phase and the Change Phase.
In this first phase, the schema therapist helps patients to identify their schemas and to understand the origins of the schemas in childhood and adolescence. In the course of the assessment, the therapist educates the patient about the schema model. Patients learn to recognize their maladaptive coping styles (surrender, avoidance, and overcompensation) and to see how their coping responses serve to perpetuate their schemas. We also teach more severely impaired patients about their primary schema modes and help them observe how they flip from one mode to another. We want patients both to understand their schema operations intellectually and to experience these processes emotionally.
The assessment is multifaceted, including a life history interview, several schema questionnaires, self-monitoring assignments, and imagery exercises that trigger schemas emotionally and help patients make emotional links between current problems and related childhood experiences. By the end of this phase, the therapist and patient have developed a complete schema case conceptualization and have agreed on a schema-focused treatment plan that encompasses cognitive, experiential, and behavioral strategies, as well as the healing components of the therapist-patient relationship.
Throughout the Change Phase, the therapist blends cognitive, experiential, behavioral, and interpersonal strategies in a flexible manner, depending on the needs of the patient week by week. The schema therapist does not adhere to a rigid protocol or set of procedures.
As long as patients believe that their schemas are valid, they will not be able to change; they will continue to maintain distorted views of themselves and others. Patients learn to build a case against the schema. They disprove the validity of the schema on a rational level. Patients list all the evidence supporting and refuting the schema throughout their lives, and the therapist and patient evaluate the evidence.
In most cases, the evidence will show that the schema is false. The patient is not inherently defective, incompetent, or a failure. Rather, through a process of indoctrination, the schema was taught to the patient in childhood, much as propaganda is taught to the populace. But sometimes the evidence alone is not sufficient to disprove the schema. For example, patients might in fact be failures at work or at school. As a result of procrastination and avoidance, they have not developed the relevant work skills. If there is not enough existing evidence to challenge the schema, then patients evaluate what they can do to change this aspect of their lives. For example, the therapist can guide them to fight expectations of failure so they can learn effective work skills.
After this exercise, the therapist and patient summarize the case against the schema on a flash card that they compose together. Patients carry these flash cards with them and read them frequently, especially when they are facing schema triggers.
Patients fight the schema on an emotional level. Using such experiential techniques as imagery and dialogues, they express anger and sadness about what happened to them as children. In imagery, they stand up to the parent and other significant childhood figures, and they protect and comfort the vulnerable child. Patients talk about what they needed but did not receive from the parents when they were children. They link childhood images with images of upsetting situations in their current lives. They confront the schema and its message directly, opposing the schema and fighting back. Patients practice talking back to significant people in their current lives through imagery and role-playing. This empowers powers patients to break the schema perpetuation cycle at an emotional level.
The therapist helps the patient design behavioral homework assignments in order to replace maladaptive coping responses with new, more adaptive patterns of behavior. The patient comes to see how certain partner choices or life decisions perpetuate the schema, and begins to make healthier choices that break old self-defeating life patterns.
The therapist helps the patient plan and prepare for homework assignments by rehearsing new behaviors in imagery and role-playing in the session. The therapist uses flash cards and imagery techniques to help the patient overcome obstacles to behavioral change. After carrying out assignments, the patient discusses the results with the therapist, evaluating what was learned. The patient gradually gives up maladaptive coping styles in favor of more adaptive patterns.
Most of these dysfunctional behaviors are, in fact, coping responses to schemas, and they are often the main obstacles to schema healing. Patients must be willing to give up their maladaptive coping styles in order to change. For example, patients who continue surrendering to the schema—by remaining in destructive relationships or by not setting limits in their personal or work lives -perpetuate the schema and are not able to make significant progress in therapy. Overcompensators may fail to make progress in treatment because, rather than acknowledging their schemas and taking responsibility for their problems, they blame others. Or they may be too preoccupied with overcompensating—by working harder, improving themselves, impressing others—to clearly identify their schemas and apply themselves to changing.
Avoiders may fail to progress because they keep escaping from the pain of their schemas. They do not allow themselves to focus on their problems, their pasts, their families, or their life patterns. They cut off their emotions or dull them. It takes motivation to overcome avoidance as a coping style. Because avoidance is rewarding in the short run, patients must be willing to endure discomfort and to continually confront themselves with the long-term negative consequences.
The therapist assesses and treats schemas, coping styles, and modes as they arise in the therapeutic relationship. The therapist-patient relationship serves as a partial antidote to the patient’s schemas. The patient internalizes the therapist as a “Healthy Adult” who fights against schemas and pursues an emotionally fulfilling life.
Two features of the therapy relationship are especially important elements of schema therapy: the therapeutic stance of empathic confrontation and the use of limited reparenting. Empathic confrontation involves showing empathy for the patients’ schemas when they arise toward the therapist, while showing patients that their reactions to the therapist are often distorted or dysfunctional in ways that reflect their schemas and coping styles. Limited reparenting involves supplying, within the appropriate bounds of the therapeutic relationship, what patients needed but did not receive from their parents in childhood. We discuss these concepts at greater length later.