Our primary experiential assessment technique is imagery. This section describes how to introduce imagery work to patients and how to conduct an assessment imagery session, moving from a relaxing image to upsetting images of childhood to upsetting images from the patient’s current life. We show how schema therapists utilize experiential strategies to identify schemas, understand the childhood origins of schemas, and relate schemas to the patient’s presenting problems.
It is best to plan to devote almost the whole therapy hour to the first imagery assessment session with a patient. We generally allot about 5 minutes to presenting the rationale and answering any questions; do imagery work for about 25 minutes; then take about 20 minutes more to process with the patient what happened during the imagery session. Later imagery assessment sessions may only require the first half of a session.
At this point in treatment, patients have completed a life review and have filled out and discussed the Young Schema Questionnaire and the Young Parenting Inventory. Patients are starting to build an intellectual understanding of their schemas. The therapist and patient have discussed hypotheses about the patient’s core schemas and how they developed in childhood.
Imagery work is a powerful technique with which to continue this hypothesis testing because it triggers schemas in the office—often in a way that allows both the patient and the therapist to feel them. It is one thing for patients to see rationally that they might have certain schemas from their childhood and another thing for them to feel the schemas, to remember what it was like when they were children, and to connect this feeling to their current problems. Imagery work moves the understanding of the schema from the intellectual to the emotional realm. It turns the idea of the schema from a “cold” into a “hot” cognition. Discussing what happened during an imagery session helps to further educate patients about schemas and their own unmet needs as children.
The rationale for imagery assessment work is thus threefold:
To identify those schemas that are most central for the patient.
To enable patients to experience schemas on an affective level.
To help patients link emotionally the origins of their schemas in childhood and adolescence with problems in their current lives.
We generally present a brief rationale to patients for doing the imagery assessment work. Most patients do not require more. We explain that the purpose of doing imagery is to enable them to feel their schemas and to understand how their schemas began in childhood. Imagery thus deepens the intellectual understanding they derived from the cognitive work with emotional understanding.
When doing imagery work with patients, one guiding principle is to give the least amount of instruction necessary for the patient to produce a workable image. We want the images that patients produce to be totally their own. The therapist avoids making suggestions and gives as few prompts as possible. The aim is to capture as accurately as possible the patient’s experience, rather than inserting the therapist’s own ideas or hypotheses. The goal is to elicit core images—those connected with such primary emotions as fear, rage, shame, and grief—that are linked to the patient’s Early Maladaptive Schemas.
The therapist generally instructs the patient as follows: “Now close your eyes and let an image float to the top of your mind. Don’t force the image; just let an image come into your mind and tell me what you see.” The therapist asks the patient to describe the image out loud in the present tense and in the first person, as though it were happening right now. The therapist tells the patient to use pictures to make the image, not words or thoughts: “Imagery is not like thinking or free association, in which one thought leads to another; rather, imagery is like watching a movie inside your mind. But more than just watching the movie, I want you to experience it—to become part of the movie and live through all the events that unfold.” With this goal in mind, the therapist helps the patient to elaborate on the image, to make it vivid, and to become absorbed in the image.
The therapist can help the patient by asking questions such as, “What are you seeing?”; “What are you hearing?”; “Can you see yourself in the image? What is the look on your face?” Once the image is distinct, the therapist explores the thoughts and emotions of all the “characters” in the image. Is the patient in the image? What is the patient thinking? What is the patient feeling? Where in the body does the patient feel these emotions? What does the patient have the impulse to do? Is anyone else in the image? What is that person thinking and feeling? What does that person want to do? The therapist tells the patient to speak out loud and have the characters tell one another what they are feeling. How do the characters feel about each other? What do they wish they could get from one another? Could they say it out loud?
The therapist ends the imagery session by asking patients to open their eyes and then asking such questions as, “What was the experience like for you?”; “What did the images mean to you?”; “What were the themes?”; “What schemas are related to those themes?”
In addition to helping patients feel their schemas more intensely, the therapist’s goal is to experience the image with the patient in order to understand it on an emotional level. This kind of empathic experiencing of the patient’s imagery is a powerful way to diagnose schemas.
Initially, we start and end imagery sessions with an image of a safe place. This is especially important for fragile patients and traumatized patients. Starting with a safe-place image is a simple, nonthreatening way to introduce imagery work. Starting this way also provides the patient with a chance to practice doing imagery before getting into more significant, emotionally laden material. At the end of an imagery session, returning to the safe place gives patients a refuge when the imagery material has left them upset.
In this example, the therapist and patient generate a safe-place image. Hector is 42 years old and entered therapy at the insistence of his wife, Ashley, who is threatening to divorce him. Her main complaints are that he is detached, cold, and prone to angry outbursts. As the excerpt begins, the therapist has already given Hector the rationale for doing imagery and is moving into constructing a safe-place image.
THERAPIST: Would you like to do an imagery exercise now?
HECTOR: OK.
THERAPIST: Please close your eyes and picture yourself in a safe place. Just let an image of a safe place come into your mind, and tell me what it is.
HECTOR: I see a photograph (long pause).
THERAPIST: What is it a photograph of?
HECTOR: It’s a photograph of my brother and I looking out the window of our tree house. My uncle built it for us.
THERAPIST: Tell me what you see when you look at the photograph.
HECTOR: I see the two of us.… (Opens eyes.) This really is a photograph, I remember this photograph. (Closes eyes.) I see the two of us, and we’re smiling.
THERAPIST: OK, keeping your eyes closed, can you see yourself?
The therapist helps the patient stay focused on the image. When he wanders, the therapist leads him back into the imagery.
HECTOR: Yeah.
THERAPIST: How old are you?
HECTOR: Oh, I’m about 7.
THERAPIST: What season is it?
HECTOR: It’s fall. The leaves are changing, they’re falling and blowing around.
THERAPIST: Good. Now, keeping your eyes closed, I’d like you to become the little boy in the photograph. I’d like you to look around you, from the boy’s perspective, and tell me what you see.
HECTOR: OK. I’m next to my brother, looking out the window of my tree house.
THERAPIST: What else do you see?
HECTOR: I see my grandfather standing on the side of our house taking our picture. I see the street, and the trees, and my neighborhood. All the houses are the same, and they’re close together, each with its little piece of lawn.
THERAPIST: What sounds do you hear?
HECTOR: (pause) I hear traffic, and people’s voices. And birds chirping.
THERAPIST: Now I’d like you to turn and look around the inside of the tree house. What do you see?
HECTOR: Well, I see this little wooden room. It’s built out of these uneven planks, and there are gaps where I can see out. It’s in the middle of a big tree, and the branches go all the way down to the ground. It’s a little dark inside. Outside it’s daylight, but no one can see in. And if we’re quiet, no one can tell that we’re here.
THERAPIST: And what do you hear in there?
HECTOR: It’s very, very quiet. I only hear the leaves rustling once in a while, and the wind whistling.
THERAPIST: And does it have a smell?
HECTOR: Yeah. It smells like pine. And like earth.
THERAPIST: And how do you feel in there?
HECTOR: Good. I feel good. I feel like it’s a secret place, a special, secret place. It feels very peaceful here.
THERAPIST: How does your body feel?
HECTOR: Relaxed. My body feels relaxed.
The therapist helps Hector elaborate on the image and experience it as though it were happening in the present moment.
Certain stylistic concerns are important when doing safe-place imagery. Unlike other imagery, which has the goal of triggering negative emotions, the goal of safe-place imagery is to calm the patient. The therapist tries to soothe and relax the patient, avoiding negative elements. The therapist phrases ideas in positive terms: for example, instead of saying, “There is no danger,” the therapist says, “You are safe”; instead of saying, “You are free of anxiety,” the therapist says, “You feel calm.” The therapist guides the patient away from psychologically charged themes, striving for images that are warm, uplifting, and comforting.
Some patients—usually those who have had traumatic experiences of being abused or neglected as children—are unable to generate safe-place images on their own. They may never have had a safe place. The therapist helps these patients construct safe-place images. Beautiful natural scenes such as beaches, mountains, meadows, or forests sometimes work well. However, even with our help, some patients cannot imagine anyplace where they feel safe. When this happens, the therapist can try using the office as the safe place: The therapist orients patients to the surroundings in the office at the beginning and end of imagery sessions. The therapist asks patients to look around and describe everything they see, hear, feel—until they report feeling calm. We sometimes have to postpone imagery until later in therapy, when the patient feels safe with the therapist and can view the office as a safe place.
The therapist ends the first imagery session by bringing patients back to the safe-place image and then asks them to open their eyes. In most cases, this is enough to calm and center the patient, and the therapist can move on to discussing the imagery.
In cases in which the patient is fragile or the imagery was traumatic, then more soothing is required on the part of the therapist. When patients seem intensely agitated following an imagery session, the therapist works to ground them in the present moment, where they are safe. The therapist asks them to open their eyes and to look around the office, describing what they see and hear, and talks with them about mundane matters—where they are going and what they will be doing right after the session. The therapist allows time for the affect stirred up by the images to subside. These measures help patients make the transition from upsetting imagery material back to ordinary life.
It is important to leave enough time for patients to calm down and to fully discuss imagery sessions. If it can be avoided, the therapist does not allow patients to leave the session extremely depressed, frightened, or angry as a result of imagery, because these feelings can occasionally spill over into their lives outside the session in undesirable ways. If necessary, the therapist suggests that patients sit in the waiting room until they feel ready to leave. The therapist can talk briefly with the patient between sessions. The therapist can also follow up with a phone call at night to check up on the patient’s progress.
Now that we have provided a rationale and presented safe-place imagery to patients so that they feel comfortable, we move into childhood imagery. Our purpose is to observe the patient’s affect and the themes that emerge, in order to identify schemas and understand their origins.
We generally elicit the following images from patients in the order presented (we typically work on only one image in a given session).
Any upsetting childhood image.
One upsetting image with each parent (i.e., an image with the mother and an image with the father).
Upsetting images of any other significant others, including peers, who may have contributed to the formation of a schema.
The therapist starts with an unstructured image, simply instructing the patient to picture an upsetting image from childhood. This gives patients the opportunity to communicate whatever they feel was most difficult about their childhoods. Moving into structured images ensures that the therapist covers all significant others who contributed to the patient’s schemas.
The following excerpt is taken from an imagery session Dr. Young conducted with Marika, a patient introduced in the previous chapter, who sought therapy for help with marital problems. She states that there is a lack of intimacy in the marriage and that her husband, James, is aloof, critical, and emotionally abusive.
On her questionnaires, Marika wrote that her father was “aloof” and “sarcastic” and that, with him, “crumbs would have to do.” She had already practiced a safe-place image with her therapist. In this excerpt, the therapist asks Marika to picture an upsetting image of her father when she was a child.
THERAPIST: Would you like to do an exercise now?
MARIKA: Yes.
THERAPIST: Good, maybe you could close your eyes for a while.
MARIKA: OK.
THERAPIST: What I’m going to ask you to do is just keep your eyes closed, and I want you to get an image of yourself with your father when you were a child. And don’t try to force it, let it come on its own.
THERAPIST: What are you seeing?
MARIKA: (Suddenly starts to cry.) It’s just me, and he’s sitting down, and he’s reading his paper, and he has on a white shirt, and he has lots of pens in his shirt pocket. And I go up and I just tap on the paper, like, “tap, tap,” and he looks at me like, you know, like, “you’re bothering me.” But I know he’s going to let me crawl up on his lap. (Cries quietly.)
THERAPIST: So it’s like he doesn’t really want you to be there.
MARIKA: But I know he’ll let me get up on his lap, you know, and then, and then I sit on his lap and he might read to me, but he always reads the stories that he wants to read, not the ones I want.
And then I start taking his pens out of his pen holder, and stuff like that, and he always makes me put them back, ’cause he wants them back. And then, if I go too far, he takes my fingers and he bends them back. And it hurts, and then I have to say “uncle,” and then I go away. Or sit there and try to make nice again, so he… (long pause).
THERAPIST: So he’ll like you again?
MARIKA: So he’ll like me again.
THERAPIST: So it seems like you have to do everything he wants to do and it’s always on his terms?
MARIKA: Yeah.
THERAPIST: And you have to take the crumbs, whatever he’ll give you, even though it’s not what you really want.
MARIKA: Yeah.
THERAPIST: Can you, in this image now, tell your father what you would have liked him to be like?
MARIKA: All right.
THERAPIST: And what he doesn’t give you that you need. Tell him what you need, all right?
MARIKA: Well, I wouldn’t have minded if we went outside and walked down the street and just got out of the house. And I wouldn’t have minded if you’d laughed a little more. And, I wouldn’t have minded if you could have taken my brother and me and gone somewhere and played with us. But you never wanted to play with us.
The first thing one notices about this imagery session with Marika is how quickly her affect shifts. As soon as she closes her eyes and pictures her father, she begins to cry. This rapid shifting of the patient’s affect is common when doing imagery work.
The predominant emotion Marika expresses in the session is grief: Her crying expresses grief for the emotional needs not met by her father. The core theme is Emotional Deprivation—her father is reluctant to pay attention to her and to give her physical affection, and he lacks empathy for her feelings. He seems uninterested in her. This is the essence of Emotional Deprivation: The parent is emotionally disconnected from the child. The child keeps trying to get the parent to connect, but the parent rarely does.
Two other related schemas are Subjugation and Mistrust/Abuse. Everything is on the father’s terms: He deigns to let Marika climb up on his lap; they read the stories he wants to read. When she is with him, she must do what he wants to do. He is in control; she has no power to get the attention and affection she wants from him. She has to “make nice” to be accepted, even after her father bends her fingers back—she has to accept mistreatment if she wants attention from her father.
A more subtle but still important theme is Defectiveness. Most neglected children have the feeling that the reason their parent is not paying attention to them is that they are somehow unworthy. Marika’s father’s indifference to her is rejecting, and the theme of rejection is part of the Defectiveness schema. Marika wants to be worthy of his love, and, when faced with her father’s inability to give her love, she feels that she must be the one who is to blame. She feels unlovable. (This theme emerges more clearly as the session progresses.)
After exploring a significant childhood image—one that elicits negative affect related to an Early Maladaptive Schema—the therapist asks the patient to switch to an image of a current or adult situation that feels the same. In this way, the therapist forges a direct link between the childhood memory and the patient’s adult life.
The following example is a continuation of the imagery session with Marika. Dr. Young asks Marika to picture an image of herself with her husband, James, that feels the same as the image with her father. The therapist then asks Marika to talk to James in the image, to tell James what she wants from him.
THERAPIST: Can you tell James what you want from him now in this image? Just say it out loud.
MARIKA: (to James) James, I want you to stop yelling at me. And I want you to ask me every single day how my day was. And to listen to me when I tell you all my silly stories. And to not look at me when I talk like you wish I would either hurry up or shut up.
And I wish we would go out and have a little bit more fun together. Like just to laugh or, even if you don’t want to laugh, you could just laugh at the silly things I do or something, just so I know that you’re enjoying being with me, just a little. (Cries.)
THERAPIST: You just want to feel that he enjoys you a little bit.
MARIKA: I know there’s got to be a reason that we’re married.
THERAPIST: What does he say to you when you say that? Be him now. Have him answer you.
MARIKA: Well, he just starts to tell me all the reasons why: We do a lot, and he has a very important job. And you know it takes a lot of hours. And he’s very tired and, you know, “I can only do so much.” And, you know, almost like, “How dare you have any demands,” because he’s doing the best he can.
THERAPIST: Sort of like your father, feeling that because he works hard and gives you material things, you should be happy?
MARIKA: Uh-huh.
THERAPIST: The same thing. If they’re working and giving you money, you should be satisfied?
MARIKA: Yes.
Almost everything Marika says to James in this image, she might have said to her father. The themes are the same. There is the Emotional Deprivation: Marika wants James to pay attention to her, listen to her, have fun with her. There is the Subjugation: James sets the terms of the relationship. Because he works so hard, he gets to determine when he shows affection. Marika has no right to make any demands. And there is the Defectiveness: Marika wants James to find her appealing and enjoy being with her, instead of behaving in a rejecting way.
The therapist helps the patient conceptualize what happened in the imagery session in schema terms. This provides an intellectual context for what happened during the session and helps the patient develop greater insight into the meaning of the imagery. In the following excerpt, the therapist and Marika discuss the implications of the imagery session for the understanding of her schemas. Conceptualizing the imagery session in schema terms helps the patient integrate what happened during the imagery session with the assessment material that preceded it.
The therapist focuses on the core schemas of Emotional Deprivation, Defectiveness, and Subjugation. He begins by describing Marika’s Emotional Deprivation schema. As often happens with this schema, Marika is only dimly aware of her emotional deprivation.
THERAPIST: It’s interesting that on your questionnaire that you filled out, the Schema Questionnaire, the ones that scored highest were, I think, Unrelenting Standards—let’s see, I wrote them down here… Self-Sacrifice.…
MARIKA: Yeah, all the ones I don’t think apply to me. (Laughs.)
THERAPIST: Yeah, I have a feeling that the ones that are more painful for you aren’t the ones you scored highest on. But maybe sometimes you’re not aware of some of the deeper things going on with you.
MARIKA: Yes.
THERAPIST: Let me tell you some of the ones that occur to me that might be your schemas, judging from what you’ve said here today so far. One of them I call Emotional Deprivation, which is the feeling that you’re not going to get your normal needs met for emotional support—that there are not going to be people who love you, who are strong, who understand you and listen to you and take your needs into account, that there’s no one to nurture you and really try to take care of you and pay attention to you. Does that feel right, that that might be one of the issues?
MARIKA: Well, certainly you have to qualify it for men, because with my women friends.…
THERAPIST: Yes, right. Your mother was different. Your mother was very loving. But at least as it relates to men, emotional deprivation seems like it’s a very big issue. Your father wasn’t very emotionally nurturing or giving.
MARIKA: Right.
THERAPIST: And neither is James, right?
MARIKA: Yeah.
THERAPIST: And yet that’s what you want. That’s what you ask them both for. You ask them to just give you some attention, give you some emotional caring.
The therapist points out the core theme in Marika’s relationships with her father and husband. Both men reinforce her sense of emotional deprivation. The therapist continues by describing Marika’s Defectiveness schema.
THERAPIST: Let’s go to another one that I thought might be an issue. There’s one called Defectiveness, which is the sense that you’re inwardly defective in some way, or unlovable. And it seems to me that a lot of what you’ve described with your father would have to lead to that feeling. He would have made you feel that there’s something wrong with you that makes it so that you can never get his attention, something about you that makes it so that he doesn’t want to be with you, that makes him give you that disdainful look. That must create inside of you, I would think, a deeper feeling of being somehow inadequate or not up to what he needs, to his expectations. Does that feel right?
MARIKA: (Cries.) Yeah. Well, and it’s also a woman’s issue, ’cause there hasn’t been one day in my life that I haven’t criticized what I look like. My hair is too straight, I’m overweight, I’m not pretty enough, you know, on and on and on, since the time I can remember, because that’s what my mother did.
THERAPIST: And, implicitly, that’s what your father was doing, too, by not giving you attention, ignoring you, he was leading you to feel that you were not good enough—that there were flaws in you that made it so he didn’t want to pay attention to you. So, between your mother being critical and your father ignoring you, you would have had the feeling that you deserve to be criticized, do you know what I mean?
MARIKA: (Sighs deeply.) Yeah.
The therapist points out that Marika acts to reinforce her Defectiveness schema.
THERAPIST: And I wonder if that’s the feeling, the Defectiveness feeling, that you have. You keep doing it to yourself, you keep finding fault, you keep finding more evidence, your weight or your appearance, that you can use to put yourself down, to keep you feeling defective. Do you know what I’m saying?
MARIKA: Yeah. It’s automatic. If I weighed 120 pounds, there’s something still wrong.
THERAPIST: And that’s the schema talking.
MARIKA: Yeah, I realized that, finally, when I did lose a lot of weight, my problems weren’t over.
THERAPIST: The Defectiveness feeling was still there, even when the weight was low. And then, of course, again you’ve chosen a husband who reinforces it, who’s criticizing you.
MARIKA: Yes.
THERAPIST: Who contributes to your sense of feeling defective. And then you try to fight back by defending yourself, but deep down some part of you believes him, and that’s the schema.
As the therapist describes the themes that emerged during the imagery session, he relates these themes to examples from Marika’s current life. In doing so, he helps Marika see the workings of her schema in her day-to-day life.
Like Marika, most patients have schemas that are connected to childhood experiences with parents, and images of parents are almost always the most significant. However, we also explore other relevant childhood images: We explore whatever images we hypothesize as most central to the development of the patient’s schemas. Most often these involve parents, but sometimes they involve siblings, extended family members, peers, teachers, or even strangers. If we believe from obtaining the life history that some other individual from the patient’s childhood or adolescence played a significant role in the development of a schema, then we include imagery of the patient with that person as well. For example, if we know a patient was abused by his brother as a child, we also say, “Close your eyes now and picture an image of yourself as a child with your brother”; or, if we know a patient was teased by her peers at school, we say, “Close your eyes and picture an image of yourself as a child in the school yard.”
Doing imagery work for assessment helps both the therapist and the patient to identify and feel core schemas, to understand their origins in childhood, and to link these origins to the patient’s current problems. Further, imagery work enriches both the therapist’s and the patient’s understanding of the patient’s schemas, helping them move from recognizing the patient’s schemas intellectually to experiencing them emotionally.