We now discuss the specific steps in the assessment and education process in greater detail.
The task of the initial evaluation is to identify the patient’s presenting problems and therapy goals and to assess the suitability of the patient for schema therapy.
It is important for the therapist to identify the presenting problems clearly and to stay focused on them as the patient moves through the assessment. Sometimes therapists become caught up in exploring the patient’s schemas and forget to link the schemas back to the presenting problems. Framing the problems in schema terms and developing a treatment plan that addresses them help the patient feel focused and hopeful.
The therapist is specific in defining the presenting problems and treatment goals. For example, when stating a presenting problem, instead of saying, “The patient is having trouble choosing a career,” the therapist says, “The patient negates potential career options and procrastinates looking for work”; or, instead of saying, “The patient has relationship difficulties,” the therapist says, “The patient repeatedly chooses partners who are withholding and aloof.” Operationalizing presenting problems in this manner helps the therapist formulate appropriate therapy goals.
Case Illustration. Marika is 45 years old. She has sought therapy for help with marital problems she is having. The following excerpts are taken from an interview with her conducted by Dr. Young. At the time of the interview, Marika had been in schema therapy with another therapist for 8 weeks.
In the first excerpt, Marika describes her relationship with her husband, James.
“I’ve been married to James for 7 years. I married at age 38. We have no children. My husband and I both work. I manage an art gallery, he owns a construction company. We have two frenetic careers, two ‘you can never do it quite right enough’ personalities and busy careers.
“I feel like when I was first married, I could bounce back from fights. He is, I think, verbally and emotionally abusive. I was going to make it right. Now I feel like I have no time and no patience, but I love him and want to save the marriage.”
All the ways Marika has tried to improve her marriage have stopped working, and she cannot summon the energy to keep trying. She feels that her emotional needs are not being met and that her husband is verbally abusive. Her goal for treatment is to improve the quality of the marital relationship so that she will feel satisfied and so that she will no longer be treated in a demeaning manner. In the course of the assessment, the therapist will try to understand her marital problems in terms of her schemas and coping styles and in terms of her husband’s schemas and coping styles.
Schema therapy is not appropriate for all patients; for some patients it will become appropriate later in therapy, after acute crises and symptoms have improved, but not earlier. The following list gives some of the indications that schema therapy either may not be suitable or may need to be postponed.
The patient is in major crisis in some life area.
The patient is psychotic.
The patient has an acute, relatively severe, untreated Axis I disorder requiring immediate attention.
The patient is currently abusing alcohol or other drugs at a moderate to severe level.
The presenting problem is situational or does not seem to be related to a life pattern or schema.
If the patient is in crisis, then the therapist works to resolve the crisis before beginning schema therapy. If the patient has an acute, severe, untreated Axis I disorder, then the therapist first directs treatment to symptom relief through cognitive-behavioral therapy or psychotropic medication. For example, if the patient has severe panic attacks, major depression, insomnia, or bulimia, then the therapist addresses the acute disorder before undertaking schema work. If the patient is currently a serious substance abuser, then the therapist first directs treatment toward stopping the substance abuse. Once the patient has stopped or significantly reduced the addictive behavior, then the therapist turns to the schema work. It is rarely possible to do schema work effectively while the patient is seriously abusing substances because the drugs numb the very emotions the patient has to confront in order to progress. This is especially true when the patient is under the influence of drugs or alcohol during sessions.
We initially developed schema therapy as a treatment for personality disorders, but it is now being utilized for many chronic Axis I disorders as well, often in conjunction with other modalities. Treatment-resistant or relapsing anxiety and depression are often appropriate targets for schema therapy. When a patient seems to have no clear Axis I disorder or has been unresponsive to previous therapy for an Axis I disorder, then schema therapy is often indicated. For example, a 31-year-old male patient in cognitive-behavioral therapy for depression repeatedly fails to comply with homework assignments. The therapist frames the problem in terms of the patient’s Subjugation schema. The homework assignments remind the patient of his school years, when he resented being controlled by parents and teachers and rebelled against authority. Just as he did then, the patient is overcompensating for his schema by not doing his homework. Because the patient wants to make progress, the therapist can ally with the patient in fighting the schema in order to complete the cognitive-behavioral work.
Other difficulties in therapy that might benefit from a schema approach include attendance problems and problems in the therapy relationship. When there are blocks to change, a schema approach can assist the therapist and patient in conceptualizing the block and generating potential solutions. It is often helpful to present the block to the patient as a mode and then to ally with the patient in responding to this mode in a healthy way.
The therapist tries to determine whether the patient’s presenting problems are situational or whether they reflect a pattern in the patient’s life. For example, a 64-year-old man enters therapy following the death of his wife. He is deeply depressed and has not responded to pharmacological nor psychological treatment. Does his depression represent the workings of a schema, or is it merely the consequence of his grief? His depression could flow from either source.
The therapist takes a focused life history in order to answer this question, beginning with the current problem and moving back through time, tracking the problem as far back as possible. The therapist looks for periods of schema activation in the past, delving into them with the patient. Did the patient experience any traumatic losses in childhood? Patterns emerge as the same triggering events, cognitions, emotions, and behaviors repeat over time and across situations. Relationship histories, school or work difficulties, and periods of strong affect provide clues to schemas. For example, if a patient is having trouble managing her anger at her boss, it may well be that her boss is triggering one of her schemas. Further inquiry can shed light on the matter.
The therapist also works to identify the patient’s coping styles of surrender, avoidance, and overcompensation. The therapist explores how patients have coped with their schemas in the past.
When patients surrender to a schema, they reenact it, just as it happened in childhood, with themselves in the same childhood role. They experience the same thoughts and feelings they did as children, and they behave the same way as they did then. In contrast, schema avoidance looks like flight from the schema, entailing the use of cognitive, emotional, or behavioral strategies to deny, escape, minimize, or detach from the schema. With schema overcompensation, the patient appears to be fighting back: He or she uses cognitive, emotional, or behavioral tactics to counterattack, compensate for, or externalize the schema.
The therapist introduces the idea of coping styles to patients by explaining that these are strategies they developed in childhood in order to adapt to distressing events. Their individual coping styles are the result of both their temperaments and parental modeling. Over time, these strategies have become generalized ways of dealing with the world. Coping styles are especially visible when schemas are triggered. The therapist tells patients that coping styles can prevent access to schemas and block therapy progress. In addition, some coping styles, such as substance abuse or emotional detachment, are problematic in themselves. This introduction to coping styles provides a rationale for administrating self-report questionnaires and prompts patients to volunteer information about how they coped during difficult times in the past.
In his interview with Marika (the patient first described on p. 70), Dr. Young takes a focused life history to determine whether her difficulties with James are unique to their relationship or part of a larger pattern in her life. In the following brief excerpt, Dr. Young asks about previous relationships. He starts with the present and works backward, staying with the information relevant to the presenting problem.
THERAPIST: What was your previous relationship like prior to James?
MARIKA: It’s almost like a mirror image of the one with James. Both men were alcoholics. I was verbally abused in both. Where James abandons me emotionally, Chris abandoned me physically—he stayed out at night. Both men were generous with money and said they loved me a lot.
At this point a pattern appears to be emerging in Marika’s romantic relationships. Both partners “verbally abused” and “abandoned” her. Both were generous materially. The therapist hypothesizes that she has schemas in the Disconnection and Rejection realm—perhaps Abuse or Abandonment—and inquires about her reactions to men who treated her well.
THERAPIST: What were you like with someone who was nice to you? What about the nice guys? There must have been some who treated you well.
MARIKA: They didn’t last long. I ended it. They were just awful.
THERAPIST: Were they too nice?
MARIKA: One guy was very nice; he was solicitous and would give me presents.
THERAPIST: Was he critical?
MARIKA: No, he dripped all over my words. We had real conversations.
THERAPIST: What was wrong with that relationship?
MARIKA: He was European and was too “old world.”
Marika’s response supports the hypothesis that her problems with James are schema-driven rather than situational. A pattern is emerging in her history in which she has been attracted to men who treat her badly and uninterested in men who treat her well. This pattern fits well with our model: We believe that the triggering of schemas generates sexual chemistry in romantic relationships. Marika’s explanation of why she was not attracted to the nice guy does not ring true as a satisfactory explanation but rather seems more like a rationalization for the absence of chemistry. In selecting men for romantic relationships, her coping style appears to be primarily one of surrendering to her schemas. Other coping styles are apparent in Marika’s interactions with James. To overcompensate for her feelings of emotional deprivation, she becomes angry and demanding. This provokes arguments with James, just as it provoked negative responses from her father when she was a child. The result of overcompensating in this way is that she ends up feeling even more deprived. Her attempt to over-compensate ultimately serves to perpetuate her schema. This is almost always the case: The final outcome of schema avoidance and overcompensation is perpetuation of the schema.
While developing hypotheses about schemas and coping styles, the therapist notes whether some schemas are interrelated. Are there any schemas that seem to get triggered together? We call these “linked schemas.” For example, Marika has the linked schemas of Emotional Deprivation and Defectiveness. When she feels deprived of love, she blames herself. She attributes James’s neglect of her to her own flaws. She is not “good enough” to be loved unconditionally. Her feelings of deprivation are inextricably linked to her feelings of defectiveness.