At this point in the assessment process, the therapist has taken a focused life history and reviewed completed questionnaires with the patient. The therapist and patient are building an intellectual understanding of the patient’s schemas and coping styles.
The next step is to trigger the patient’s schemas in the therapy session so that both the therapist and the patient can feel them. The therapist usually accomplishes this with imagery. Imagery is a powerful assessment tool for most patients. With its frequently immediate and dramatic revelations of core material, it can often be the most effective way to identify schemas. A detailed description of how to do imagery work with patients is given in Chapter 4. Here we present a brief overview of the use of imagery for assessment.
The goals of imagery for assessment are:
To identify and trigger the patient’s schemas
To understand the childhood origins of the schemas
To link schemas to presenting problems
To help the patient experience emotions associated with the schemas
We begin by providing patients with a convincing rationale for imagery work: that imagery will help them to feel their schemas, understand the childhood origins of their schemas, and connect their schemas to their current problems.
After giving patients this brief rationale, we ask them to close their eyes and let an image float to the top of their minds. We ask them not to force the image but to let it come on its own. Once patients picture an image, we ask them to describe it to us, out loud and in the present tense. We help them make it vivid and emotionally real.
The following exercise is an introduction to imagery that readers might wish to try themselves. It is based on a group training exercise we developed for therapists attending workshops on schema therapy (Young, 1995).
1. Close your eyes. Picture yourself in a safe place. Use pictures, not words or thoughts. Let the image come on its own. Notice the details. Tell me what you are picturing. What do you feel? Is there someone with you, or are you alone? Enjoy the relaxing, secure feeling in your safe place.
2. Keep your eyes closed and wipe out that image. Now picture yourself as a child with one of your parents in an upsetting situation. What do you see? Where are you? Notice the details. How old are you? What’s happening in the image?
3. What do you feel? What are you thinking? What does your parent feel? What is your parent thinking?
4. Carry on a dialogue between you and your parent. What do you say? What does your parent say? (Continue until dialogue reaches a natural conclusion.)
5. Consider how you would like your parent to change or be different in the image, even if it seems impossible. For example, do you wish your parent would give you more freedom? More affection? More understanding? More acknowledgment? Less criticism? Be a better role model? Now tell your parent in the image how you would like him or her to change, in the words of a child.
6. How does your parent react? What happens next in the image? Keep the image going until the scene ends. How do you feel at the end of the scene?
7. Keep your eyes closed. Now intensify the feeling you have in this image as a child. Make the emotion stronger. Now, keeping the emotion in your body, wipe out the image of yourself as a child and picture an image of a situation in your current life in which you have the same or a similar feeling. Don’t try to force it; let it come on its own. What’s happening in the image? What are you thinking? What are you feeling? Say it out loud. If there is someone else in the image, tell that person how you would like him or her to change. How does the person react?
8. Wipe out the image and return to your safe place. Enjoy the relaxed feeling. Open your eyes.
The imagery assessment we conduct with patients is similar to this exercise. We start and end with a safe place. We ask patients to picture separate images of upsetting childhood situations with each parent and any other significant figures from their childhoods or adolescences. Then we instruct patients to speak to these people in their images, expressing what they are thinking and feeling and what they wish they could get from the other person. We then ask patients to switch to an image from their current lives that feels the same as the childhood situation. Once again, patients carry on a dialogue with the person from their adult life, saying aloud what they are thinking and feeling and what they want from the other. We repeat this process until we have covered all the significant others in childhood who contributed to the formation of the patient’s schemas. (Chapter 4, on experiential techniques, provides an extended transcript of Dr. Young conducting this exercise with a patient.)
When doing imagery work with patients, it is important for the therapist to begin early in the session so that there is enough time to discuss what happens afterward. In this discussion, the therapist helps patients explore the images in order to identify schemas, understand their origins in childhood, and link them to the presenting problems. In addition, the therapist helps the patient integrate the imagery work with information from previous assessment modalities.
Sometimes patients are distraught after an imagery session. Starting imagery work early in the session helps ensure that there is enough time for patients to recover before they have to leave. When patients are afraid of the imagery work, the therapist attempts to set them at ease. The therapist tells them that they are in control of the imagery and, although the therapist is asking them to close their eyes to enhance their concentration, they may open their eyes if they become overwhelmed. Because of traumatic histories, feelings of mistrust, or anxiety, some patients participate in imagery exercises with downcast, rather than closed, eyes. Some request that the therapist not watch them during the exercises. The therapist makes the necessary accommodations. After the exercise, the therapist may need to ground these patients in the present moment before the session ends, using a mindfulness exercise.
Typically we start with an upsetting image from the patient’s childhood and then work forward by linking this image to an upsetting image from the patient’s current life. However, imagery exercises may proceed in other ways. For example, if the patient comes into the session already upset about a current situation, we can use an image of this situation as the starting place: We can ask the patient to picture an image of the current situation and then work back in time, asking him or her to picture an image from childhood that feels the same way. We can use an image of a specific symptom in the patient’s body as the starting place. For example, we might say, “Can you picture an image of your back when you’re in pain? What does it look like? What is the pain saying?” We can use strong emotions the patient experiences but does not understand as the starting place. Some examples follow.
Nadine is 25 years old. She has sought therapy for depression. Nadine works as an office manager in a large company. She has been consistently promoted at work because she is an excellent mediator of office disputes and because she frequently offers to take on tasks that others prefer to avoid. Although she functions at a high level, the therapist has determined that her depression is a sign that her work behavior is schema-driven and detrimental to her.
In her life history, Nadine described growing up in a religious family in which everyone was forbidden to express anger except her father. Nadine was the oldest of five children. Although her mother was ill and Nadine had a lot of responsibility for her younger siblings, she was not permitted to complain. It was her obligation to sacrifice for the sake of her parents and siblings, who were more needy than she was.
Doing imagery work about her childhood, Nadine recounted an incident in which she was falsely accused by her father of giving her mother the wrong medicine. Actually, it was Nadine’s younger sister who had given the medicine, but Nadine felt it was wrong to implicate her sister and so took the blame herself. She stood before her irate father, suppressing her anger at her self-sacrifice. When the therapist asked her to picture an image of a current situation that felt the same way, Nadine came up with an image of taking the blame for a subordinate’s mistake at work.
Nadine’s Self-Sacrifice schema makes her well suited for exploitation at work. As in her family of origin, Nadine mediates disputes by absorbing blame and volunteering for unwanted tasks. She suppresses her anger, but her depression grows. Driven by her self-sacrifice, she helps ensure her emotional deprivation. (This is almost always true: Patients who have Self-Sacrifice schemas have Emotional Deprivation schemas as well, because they focus on meeting the needs of others rather than their own needs.) At home and at work, Nadine takes care of others, but no one takes care of her. Imagery helps Nadine recognize the origin of her Self-Sacrifice schema in her childhood and connect the schema to her depression.
Diane is a 50-year-old divorced woman who runs her own successful business. She reports a history of anxiety that has not responded to previous therapy. She arrived at her third session of schema therapy feeling anxious and stating that she was not sure why. When she reviewed the events of the week, she said that her 17-year-old daughter had been late picking her up at work the night before. Rationally, she had known there was no cause for alarm, but emotionally she had felt frightened. Her anxiety had persisted until that moment.
The therapist asked Diane to close her eyes and picture an image of the previous night, waiting for her daughter to pick her up. Once Diane had a vivid image and could recall the feeling of fear, the therapist asked her to picture an image of a time when she felt the same way as a child. Diane saw an image of herself as a child at summer camp, waiting for her parents to pick her up on the last day. Because her mother was manic-depressive and unable to care for her in a consistent manner and her father was a salesman who was frequently away from home, Diane was scared that no one would come for her. As she saw other children leaving with their parents, she began frantically pacing back and forth. Eventually she was the only child left. This image expressed Diane’s Abandonment schema.
The therapist then asked Diane to continue the exercise by returning to the current image in which she was waiting for her daughter to pick her up. Now Diane understands why she was so frightened: Her Abandonment schema was triggered by her daughter’s lateness. The imagery work helped her identify the schema underlying her anxiety. When patients have strong emotions they cannot understand, imagery can often help them discover the schema that is hidden underneath.
Somatic symptoms are frequently signs of schema avoidance. When patients have somatic symptoms, imagery can often help them overcome their cognitive and emotional avoidance in order to identify the underlying schemas. Paul is a 46-year-old physician. Altogether, he has spent more than 20 years in therapy trying to rid himself of his fear that he has a “migrating tumor” in his body. Despite his medical knowledge that tells him that this is not possible and despite years of medical tests that have failed to detect any biological abnormality, Paul persists in fearing he is terminally ill and will be killed by the tumor at any time.
In imagery, the therapist asks Paul to identify where the tumor is in his body at that moment. The therapist asks him to picture an image of the tumor and describe its size, texture, shape, and color. The therapist instructs him to talk to the tumor and ask why it is in his body and then to take the role of the tumor and answer. Speaking as the tumor, Paul says that he has not been doing his best work and is very bad. The tumor is in his body to punish him. Paul had better work more conscientiously or the tumor will strike him dead.
The therapist then asks Paul to picture an image of someone who made him feel the same way when he was a child. Paul pictures an image of himself as a child with his exacting father. His father is telling him that his school grades are unacceptable and that he must work harder. Like the tumor, the father embodies Paul’s Unrelenting Standards schema. The imagery helps Paul access the schema underlying his somatic symptom and understand the origins of the schema in his childhood relationship with his father.
Schema avoidance is the most common obstacle to imagery assessment work. Schema avoidance may manifest itself in a number of ways. Patients might refuse to do the exercise, stating disdainfully that it will not be helpful. (This is a likely response from a narcissistic patient.) Patients might stall by asking questions or bring up unrelated topics in order to distract the therapist. Patients might keep opening their eyes or insist that they only see a “blank screen.” Their images may be too vague to make out, or they may see only “stick figures.”
There are many possible causes for schema avoidance. Some can be easily overcome: The patient may be self-conscious about “performing,” worried about doing the exercise “right,” or too nervous to concentrate. Often the therapist can resolve these difficulties simply by restating the rationale for the imagery work and reassuring the patient that the difficulties can be overcome. The therapist can also begin with less threatening material: For example, the therapist might begin with pleasant or neutral images and then gradually introduce more upsetting images.
We have several methods for overcoming schema avoidance of imagery work. We describe them more fully in the chapter on experiential techniques (Chapter 4), but we list them briefly here. They include:
Educate the patient about the rationale for imagery work.
Examine the pros and cons of doing the exercise.
Start with soothing imagery and gradually introduce more anxiety-provoking material.
Conduct a dialogue with the avoidant side of the patient (mode work).
Use affect regulation techniques such as mindfulness or relaxation training.
Initiate psychotropic medication.
Some patients have trouble visualizing themselves as children. When this happens, it can be helpful to have patients picture themselves in the present, then work backward to early adulthood, adolescence, and then finally to childhood. It can also be helpful to ask patients to picture their parents or siblings as they were when the patients were children. Sometimes patients cannot visualize themselves, but they can visualize other people and places from childhood. In addition, patients can bring in photographs of themselves as children to stimulate imagery. The therapist and patient can look at the photographs together, and the therapist can ask questions such as, “What might the child be thinking? What is the child feeling? What does the child want? What happens next in the picture?”
Another method for overcoming schema avoidance is conducting a dialogue with the avoidant side of the patient. We call this side the “Detached Protector” mode (see Chapter 8). The Detached Protector protects the patient by cutting off feelings. The therapist negotiates with the Detached Protector to gain access to the vulnerable part of the patient where the core schemas are—the Vulnerable Child mode.
However, sometimes it is not so easy for the therapist to deal with schema avoidance. Persistent schema avoidance may indicate that the patient’s schemas are severe. For example, patients who have been abused may be too mistrustful to make themselves emotionally vulnerable. Very fragile patients may be too frightened to experience the affect connected to their schemas because of the possibility of decompensation. Severe schema avoiders and overcompensators have trouble with imagery because they cannot tolerate the negative affect. All of these patients may need to form a more stable and trusting bond with the therapist before attempting imagery work. Imagery work often becomes possible as the therapeutic relationship grows over time.
Some patients have great difficulty with childhood imagery because something traumatic happened to them and they are blocking it; or, at the other extreme, they experienced neglect and deprivation so great that the atmosphere was empty and flat. They have few memories of childhood. In these cases, the therapist must obtain knowledge of the schemas through other assessment methods. However, it is possible for traumatized or neglected patients to report sensations and emotions that give clues to schemas. For example, patients may feel trapped when they close their eyes, or they may report feeling alone. These sensations and emotions can help the therapist build hypotheses about the patient’s schemas.
The patient’s schemas also appear in the therapy relationship. (Of course, this is true of the therapist’s schemas as well: The therapist’s own schemas are triggered. We discuss this issue of countertransference in Chapter 6 on the therapeutic relationship.) The triggering of the patient’s schemas in the therapy relationship represents an opportunity for the therapist to gather more assessment material. The therapist and patient can discuss what transpired, working to identify schemas, triggers, and associated thoughts and feelings, covering both the current circumstance and related events in the past. The therapist asks patients to remember other people who have prompted them to feel the same way.
Early Maladaptive Schemas produce characteristic behaviors in therapy. For example, a patient with a Dependence schema might repeatedly ask for help with questionnaires and homework assignments; a patient with a Self-Sacrifice schema might be overly solicitous of the therapist and frequently inquire about the therapist’s health or mood; a patient with an Entitlement schema might repeatedly make requests for special treatment, such as scheduling changes or extra time; a patient with an Abandonment schema might resist relying on the therapist out of fear of being deserted; a patient with a Mistrust/Abuse schema might ask suspiciously about the therapist’s note taking or adherence to confidentiality; a patient with a Defectiveness schema might avoid making eye contact or have difficulty accepting compliments; a patient with an Enmeshment schema might copy aspects of the therapist’s appearance or style. The therapist can learn about the patient’s schemas by observing how the patient behaves in the therapy relationship. The therapist shares this information with the patient, speaking about it empathically in schema terms.