The life history assessment forms provide a comprehensive assessment of the patient’s current problems, symptoms, family history, images, cognitions, relationships, biological factors, and significant memories and experiences. The inventory is lengthy and can be given as homework. Having the patient complete the inventory outside the session can save much therapy time. For example, the inventory asks the patient to list childhood memories, and these memories are clues to Early Maladaptive Schemas. (Sometimes patients who do not report abuse in the interview will do so on this questionnaire. They cannot bring themselves to tell the therapist face to face, but they are able to tell the therapist in writing when they are home.) The therapist can use the material to form hypotheses about life patterns, schemas, and coping styles.
The Young Schema Questionnaire (YSQ-L2; Young & Brown, 1990, 2001) is a self-report measure to assess schemas.2 Patients rate themselves on how well each item describes them on a 6-point Likert scale. The therapist usually gives the YSQ to the patient to take home and complete after the first or second session.
Questionnaire items are grouped by schema. A two-letter code appears after each set of items to indicate to the therapist which schema is being measured. However, the name of the schema is not on the questionnaire itself. A key to the abbreviations appears on the scoring form.
The therapist does not usually compute the patient’s total score or mean score for each schema in order to interpret the results. Rather, the therapist looks at the items for each schema separately, circling high scores (usually 5’s and 6’s) and drawing attention to patterns. The therapist reviews the completed questionnaire with the patient, asking questions about those items that the patient rated highly. We have observed clinically that, if a patient has three or more high scores (rated 5 or 6) on a particular schema, that schema is usually relevant to the patient and worthy of exploration.
The therapist uses the high-scoring items to prompt the patient to talk about each relevant schema by asking, “Can you tell me more about how this statement relates to your life?” Exploring two high-scoring items for each relevant schema with the patient in this way usually suffices to convey the essence of the schema. The therapist teaches the patient the name of each high-scoring schema and the meaning of the schema in everyday words and encourages the patient to read more about the schema in Reinventing Your Life (Young & Klosko, 1994).
By this point in the assessment, the therapist knows the patient’s presenting problems and has explored patterns in the focused life history. The therapist has formed hypotheses about the patient’s schemas. Responses on the Young Schema Questionnaire may support or refute these hypotheses, and they may contradict previous information. The therapist asks questions about inconsistencies. Sometimes patients misread questions, rewrite them, or interpret them in highly personal or idiosyncratic ways. The therapist clarifies discrepancies in order to ensure correct schema identification.
Some patients find that just filling out the questionnaire triggers their schemas. Fragile patients, such as those with BPD who have experienced severe early trauma, may experience strong emotions while answering items and therefore need to proceed slowly. The therapist can ask these patients to fill out a certain number of items each week, or the patient can work on the questionnaire with the therapist in the session. Some patients may respond to upsetting questions by avoiding the questionnaire. They leave items blank, they keep “forgetting” to fill out the questionnaire, or they rate items cursorily with low scores. They avoid the questionnaire in order to avoid facing their schemas. These kinds of responses point to a coping style of schema avoidance. If patients exhibit persistent difficulty completing the questionnaire, the therapist does not insist. Rather, the therapist explores reasons for not completing the questionnaire with the patient. If we cannot overcome these obstacles relatively quickly, we usually view this as a sign that the patient has significant avoidance problems and rely more on other facets of the assessment process to determine which schemas apply.
We generally spend one or two sessions going over the completed questionnaire with the patient, depending on the number of high-scoring schemas. Because patients are permitted to change the wording of questions, there is often a great deal the therapist and patient can discuss. Talking about questionnaire items usually leads patients to explore important material quickly. As the therapist and patient review the questionnaire, the therapist continually formulates and revises hypotheses about the patient’s schemas and links schemas to the patient’s presenting problems and life history.
The Young Parenting Inventory (YPI; Young, 1994) is one of the primary means of identifying the childhood origins of schemas. The YPI is a 72-item questionnaire in which respondents rate their mothers and fathers separately on a variety of behaviors that we hypothesize contribute to the development of schemas. Like the YSQ, the YPI uses a 6-point Likert scale, and the items are grouped by schemas. We generally give the YPI to patients as homework a few weeks after the YSQ—typically around the fifth or sixth session when we discuss the origins of the patient’s schemas.
If patients had stepparents, grandparents, or other parent substitutes at home when they were children, they can adapt the questionnaire by adding columns for additional parents or parent substitutes with whom they lived as children or adolescents. For example, one patient lived with her mother and father, then, after her father died when she was 5 years old, with her mother and stepfather. She added a column and rated the items on the YPI for her mother, father, and stepfather.
The inventory is a measure of the most common origins we have observed for each Early Maladaptive Schema. It reflects childhood environments that, from our observation, are likely to shape the development of specific schemas. However, it is possible that the patient experienced the childhood environment commonly associated with a particular schema but nevertheless did not develop the expected schema. This could happen for a number of reasons: (1) the patient’s temperament prevented the schema from developing; (2) one parent or a significant other in the child’s life compensated for the other; or (3) the patient, a significant person, or an event later in life healed the schema.
The therapist scores the YPI in a similar fashion to the YSQ. The therapist circles all items rated 5 or 6 for either parent. (We assume that scores of 5 or 6 have a high chance of being clinically significant as origins for a particular schema.) The only exceptions are items 1 through 5, which assess the origins of Emotional Deprivation and are scored in reverse: low scores signify the relevance of that origin for Emotional Deprivation. Unlike the YSQ, it is not necessary to have more than one high score on a particular schema for an item to be potentially significant. Although it is true that the more high scores there are for a given schema, the more certain we can be that the schema is relevant for the patient, any high-scoring item on the YPI can be meaningful as a schema origin. For example, if a patient indicates on a YPI item that she was sexually abused by a parent, it is very likely that the patient has a Mistrust/Abuse schema, even if the patient rated the other origins for that schema very low.
In the next session, after the therapist has reviewed the patient’s scores, the patient and the therapist together discuss any high-scoring items. The therapist encourages the patient to expand on each origin by giving examples from childhood or adolescence that illustrate how the parent manifested the behavior. This discussion continues until the therapist has a full and accurate picture of how each parent contributed to the development of the patient’s schemas. The therapist explains to the patient the relationship between each origin and the corresponding schema, and also how the childhood origin and schema may be linked to the patient’s presenting problems.
Although the YPI was not designed to measure which schemas patients have but rather to identify likely origins for schemas that score high on the YSQ, the YPI has nevertheless proven to be a valuable indirect measure of schemas. If a patient strongly endorses items on the YPI that reflect the typical origins of a schema, we frequently observe that the patient has that schema, even if the patient rated the same schema low on the YSQ. The most likely explanation for this is that patients are often able to identify accurately what their parents were like even though they are out of touch with their own emotions. Thus, for patients with high schema avoidance, the YPI may sometimes prove to be a better measure for identifying schemas than the YSQ.
The therapist compares responses on the YPI to those on the YSQ. If high-scoring schemas on one questionnaire match high-scoring schemas on the other questionnaire, this adds to the likely significance of the schemas. Inconsistencies also yield important information. As with the YSQ, scores on the YPI might also be low as a result of schema avoidance or overcompensation. If a response is unexpectedly low, the therapist might say something like, “On your schema questionnaire, you say that throughout your life people have tried to control you, yet on your parenting inventory you indicate that your mother and father did not try to rule your life. Can you help me understand how these two statements fit for you?” Trying to resolve apparent inconsistencies like this proves very useful both in clarifying a patient’s schemas and their origins and in helping patients face feelings and events that they have been avoiding or blocking.
The Young-Rygh Avoidance Inventory (Young & Rygh, 1994) is a 41-item questionnaire that assesses schema avoidance. It includes such items as, “I watch a lot of television when I’m alone,” “I try not to think about things that upset me,” and “I get physically ill when things aren’t going well for me.” Individuals rate responses on a 6-point scale.
As with the other inventories, the therapist is not especially concerned with the total score but rather discusses high-scoring items with the patient. However, a high total score does indicate a general pattern of schema avoidance. The inventory is not schema-specific: An avoidant coping style is often a pervasive trait that can be utilized to avoid any schema.
The Young Compensation Inventory (Young, 1995) is a 48-item questionnaire that assesses schema overcompensation. Items include such statements as, “I often blame others when things go wrong,” “I agonize over decisions so I won’t make a mistake,” and “I dislike rules and get satisfaction from breaking them.” The inventory uses a 6-point scale.
The therapist uses the overcompensation inventory as a clinical tool and discusses high-scoring items with the patient. For example, if the patient endorses blaming as a coping style, the therapist asks for an example. The therapist explores whether the blaming overcompensates for other, more painful feelings—perhaps feelings of shame. The therapist might ask, “Is it possible that blaming was a way for you to deal with your own feelings of shame in the situation?” As therapy progresses, patients self-monitor their use of the coping styles identified on these two inventories.