Schema therapy emphasizes individualized case conceptualization. Several cognitive therapists have provided excellent examples of case formulation from a cognitive perspective (e.g., Beck et al., 1990; Persons, 1989). Schema-focused case conceptualization is broader: It provides an integrative framework that includes self-defeating life patterns, early developmental processes, and coping styles, as well as schemas. Thus each patient has a unique conceptualization, based on both the patient’s Early Maladaptive Schemas and his or her coping styles.
By the end of the Assessment Phase, the therapist completes the Schema Therapy Case Conceptualization Form (see Figure 2.1).1The form includes the patient’s schemas, links to the presenting problems, schema triggers, hypothesized temperamental factors, developmental origins, core memories, core cognitive distortions, coping behaviors, modes, the effects of schemas on the therapeutic relationship, and change strategies.
FIGURE 2.1. Schema Therapy Case Conceptualization Form for Annette
Background Information
Therapist’s name: Rachel W. Patient’s name: Annette G.* Age: 26
Marital status: Single
Children (Ages): None Occupation: Receptionist Ethnic background: Caucasian Education: Completed High School
Relevant Schemas
1. Emotional Deprivation (of nurturance, empathy, and protection)
2. Self-Sacrifice 3. Mistrust/Abuse 4. Defectiveness/Shame
5. Entitlement/Grandiosity 6. Insufficient Self-Control/Self-Discipline
Current Problems
Problem 1: Depression
Schema links: Emotional Deprivation, Defectiveness, Self-Sacrifice
Problem 2: Alcohol abuse
Schema links: Coping response for Emotional Deprivation, Mistrust/Abuse, Defectiveness
Problem 3: Relationship problems: dates inappropriate men, has difficulty becoming intimate
Schema links: Emotional Deprivation, Mistrust/Abuse, Defectiveness, Self-Sacrifice
Problem 4: Work problems: does not complete tasks, moves from job to job
Schema links: Insufficient Self-Control/Self-Discipline, Entitlement/Grandiosity
Schema Triggers (Specify M-F if limited to men or women)
1. Choosing a boyfriend (M) 2. Trying to get close to a boyfriend (M)
3. Feeling alone 4. Thinking about her problems and her need for therapy
5. Being asked to do something boring, routine, or uninteresting
Severity of Schemas, Coping Responses, and Modes; Risk of Decompensation
Schemas are moderately strong. Coping responses and modes are very strong. No suicidal ideation. Low risk of decompensation.
Possible Temperamental/Biological Factors
None
Developmental Origins
Mother was helpless and needy. Neither parent fulfilled Annette’s emotional needs as a child.
Father was angry and explosive. Annette was put in the role of protecting her mother from her father.
Annette had no limits or discipline as a child. Could do and have whatever she wanted.
Family members never shared feelings or discussed their problems.
Core Childhood Memories or Images
Father was very angry. Annette and her mother were frightened. Mother turned to Annette for help but did not offer any support, empathy, or protection for her.
Core Cognitive Distortions
No one will ever be there to take care of my needs. I have to be the strong one all the time.
There’s something fundamentally wrong with me for having so many emotional problems and being so needy.
Most men are unpredictable, angry, and explosive.
I should be able to do and have whatever I want.
I shouldn’t have to stick with tasks, activities, or relationships that are boring or uninteresting.
Surrender Behaviors
Does not ask others to nurture or protect her.
Takes care of her mother and asks little in return.
Does not talk about vulnerable feelings with other people.
Avoidance Behaviors
Abuses alcohol to block out painful feelings.
Seeks stimulation and novelty to avoid emotions.
Tries to avoid focusing on painful thoughts and feelings.
Avoids intimacy with men.
Overcompensating Behaviors
Acts tough and in control, even though she feels vulnerable and needy.
Relevant Schema Modes (in addition to the Healthy Adult)
1. Tough Annette (Detached Protector) 2. Little Annette (Lonely, Frightened
Child) 3. “Spoiled Annette”
Therapy Relationship (Impact of schemas and modes on in-session behavior; personal reactions and/or countertransference)
Annette acts tough much of the time in session. She is reluctant to admit strong attachment, neediness, or vulnerability toward me, even though she seems engaged and connected. She tries to avoid imagery exercises and doesn’t like to talk about painful emotions or events. She often doesn’t follow through on written homework assignments because she says they’re boring or upsetting to her.
Despite these problems, I find Annette engaging to work with and think we have a very good therapy relationship. I get somewhat frustrated by her lack of discipline and concern for others in the “Spoiled Annette” mode.
Copyright 2002 by Jeffrey Young. Unauthorized reproduction without the written consent of the author is prohibited. For permission and more information, write to Schema Therapy Institute, 36 West 44th Street, Suite 1007, New York, NY 10036.
To develop an effective case conceptualization, the therapist must make an accurate assessment of the patient’s Early Maladaptive Schemas and coping styles. The case conceptualization has a large impact on the course of treatment, providing tactical considerations and practical recommendations for choosing targets of change and implementing treatment procedures. Correct schema identification guides interventions, enhances the therapeutic alliance by helping the patient feel understood, and anticipates likely areas of difficulty during the Change Phase.
It is important that the therapist not jump to conclusions about which schemas are operating based solely on DSM-IV diagnosis, life history, or responses to a single assessment modality. The same Axis I diagnosis could be the outward manifestation of different schemas in different people. Almost all the schemas can result in depression, anxiety, substance abuse, psychosomatic symptoms, or sexual dysfunction. Even in a specific personality diagnosis such as BPD, patients may share some schemas and not others.
In addition, the therapist cannot assume the presence of a schema solely on the basis of simplistic analysis of a patient’s childhood experiences: Patients might share similar painful childhood circumstances, yet end up with different schemas. For example, two female patients both grew up with fathers who were rejecting. The first patient developed schemas of Abandonment and Defectiveness, both relatively severe. Her father treated her older sister with affection, but ignored her. She concluded that there was something wrong with her that made her unlovable to her father. Because she felt, from a young age, that anyone who liked her would eventually leave, she avoided romantic relationships entirely to escape future pain.
In contrast, the second patient had a father who was rejecting toward all the children in the family. Furthermore, her mother (unlike the first patient’s mother) was a warm and loving parent who compensated for her father’s coldness by providing affection and acceptance. The second patient attributed her father’s rejection to limitations in her father’s capacity to love, as he was equally cold to her and to her siblings. She came to believe that some men would not love her but that others would—she had to find the right ones. She later sought out loving men who further healed the damage done by her father. Although this patient had an Abandonment schema of low to moderate severity, she did not develop a Defectiveness schema. Thus two patients with rejecting fathers ended up with quite different schemas and coping styles as a result of more complex elements in their childhood experiences.
Other factors also influence which schemas a patient develops and the strength of those schemas. Many patients, such as the second woman just described, have other people in their lives who counteract a schema by providing what the patient needs, thereby preventing the schema from developing or weakening it. Patients might also have subsequent life experiences that modify or heal the schema. For example, patients might form healthy love relationships or establish close friendships and thereby partially heal schemas in the Disconnection and Rejection realm. Sometimes a patient’s temperament works against the formation of a schema. Some people appear to be more psychologically resilient and do not develop strong Early Maladaptive Schemas, even under conditions of considerable adversity, whereas other people seem more psychologically vulnerable and develop maladaptive schemas with relatively mild levels of mistreatment.
Accurate identification of schemas is important because there are specific, individualized treatment interventions for each schema. For example, a patient repeatedly asks her therapist to give her advice about problems with her boyfriend. On the basis of these and similar statements, her therapist mistakenly concludes that the patient has a Dependence schema. Because the treatment strategy for the Dependence schema is to increase the patient’s self-reliance by having her make her own decisions, the therapist declines to give her advice. In fact, however, the patient has an Emotional Deprivation schema. She has never had someone strong to whom she could go for guidance. The treatment strategy for Emotional Deprivation is to reparent the patient by providing nurturance, empathy, and guidance— to meet, in a limited way, the patient’s unmet emotional needs. Viewing the patient in this way, the therapist offers direct advice. Thus correct schema identification points the way to the correct intervention.
Accurate identification of the patient’s coping styles is equally important to the case conceptualization. Does the patient primarily surrender to, avoid, or overcompensate for schemas? Most patients use a mixture of coping styles. A patient with a Defectiveness schema might overcompensate in the workplace by overachieving and competing but avoid intimate relationships in his personal life and engage in solitary activities. Coping styles are not schema-specific: They generally cut across schemas and can serve as coping mechanisms for distressing emotions generated by many different schemas. For example, individuals who gamble compulsively in order to escape emotional upset might do so because they feel abandoned, abused, rejected, or subjugated. They could gamble to avoid the pain of almost any schema that produces psychological suffering for them.
It is important for the therapist to validate the early adaptive value of the patient’s coping style. The patient developed the coping style for a good reason, in order to cope with a difficult childhood situation. However, the coping style is probably maladaptive in the adult world, in which the patient has more choices and is no longer at the mercy of the parents’ mistreatment or neglect. If the coping style is avoidance or overcompensation, then it is likely to be problematic in the patient’s therapy because it is a barrier to schema work. One purpose of these coping styles is to block the schema from awareness, and the patient has to become aware of a schema in order to fight it. The coping style is also problematic if it lowers the patient’s quality of life, such as when the patient procrastinates, alienates others, is cut off emotionally, overspends, or abuses drugs.
Patients may respond to therapeutic interventions that trigger their schemas with the same coping styles that they use in their outside lives. It is important to recognize coping styles, because behavior that looks healthy might, in fact, represent a maladaptive coping style. The calm detachment of a patient with an avoidant coping style might resemble the demeanor of a healthy adult, but it actually indicates a dysfunctional approach to emotions.
Viewing problematic behaviors as coping styles helps us understand why patients persist in self-defeating behaviors. The resistance of these patients to change indicates their continued reliance on responses that have worked, at least to some degree, in the past.