Experiential Strategies for Change

Several sessions pass between the use of experiential techniques for assessment and the use of experiential techniques for change. After conducting the imagery assessment, we move to conceptualizing the patient’s schemas and then to the cognitive techniques for battling schemas described in the preceding chapter, such as examining the evidence for and against schemas and using flash cards. It is at that point that we introduce experiential techniques for change.

This section on experiential change techniques presents the following: (1) the rationale for including such techniques in treatment; (2) how to conduct imagery dialogues; (3) “reparenting” imagery work; (4) imagery of traumatic memories; (5) writing letters as homework assignments; and (6) imagery for pattern-breaking.

Rationale

The rationale for experiential work is to fight schemas affectively. At this point in treatment, the therapist and patient have already examined the evidence for and against the schema and built a rational case against it. After completing this cognitive stage, the patient often says something like, “I understand on a rational level that my schema isn’t true, but I still feel the same way. I still feel like my schema is true.” It is primarily the experiential work (in combination with limited reparenting) that helps the patient fight the schema on this emotional level.

Imagery Dialogues

Imagery dialogues are one of our primary experiential change techniques. We instruct patients to conduct dialogues in imagery, both with the people who caused their schemas in childhood and with the people who reinforce their schemas in their current lives. The imagery dialogues we describe in this section are a simplified form of mode work, which we elaborate on in a later chapter. We utilize three modes in this simplified version: the Vulnerable Child, the Healthy Adult, and the Dysfunctional Parent.

As we have noted, most often the significant childhood figures are parents, and parents are the first characters we use for imagery dialogues. We ask patients to close their eyes and to picture themselves with a parent in an upsetting situation. Often these images are the same as or similar to memories that arose in the imagery for assessment. We then focus on helping patients to express strong affect toward the parent, particularly anger. We help patients identify the needs that were not met by their parent, and we help them get angry with the parent in the image for not meeting these needs.

Why do we want the patient, the child in the image, to get angry at the parent whose behavior caused the schema? The rationale is not simply getting the patient to vent, although venting anger is in itself cathartic and of some value. Our main goals are to empower the patient to fight back against the schema and to distance the patient from the schema. It is empowering for patients to express anger and stand up for their rights with the offending parent. Anger provides emotional strength to fight the schema. The schema represents a world gone wrong, and anger sets the world right again. When patients say, “I won’t let you abuse me anymore,” “I won’t let you criticize me,” “I won’t let you control me,” “I needed love and you didn’t give it to me,” “I had a right to feel angry,” or “I had a right to a separate identity,” they feel revived and worthwhile. They validate their own rights as human beings. They assert that they deserved better than what happened to them as children.

What we are trying to convey to the patient is a feeling of entitlement to basic human rights. The therapist educates patients about what we believe to be the universal needs and basic rights of children. For example, we teach the patient with a Defectiveness schema that all children are entitled to be treated with respect. We teach the patient with Emotional Deprivation that all children are entitled to affection, understanding, and protection. We teach the patient with a Subjugation schema that all children are entitled to express their feelings and needs (within reasonable limits). We tell them that, as children, they were entitled to these things, too. Our hope is that, when patients leave the session and go out into the world, they will take with them some of this healthy entitlement that they did not learn as children.

Expressing anger at the parent in sessions is of foremost importance in this stage of the experiential work. Sometimes patients try to talk the therapist out of doing this work. They say they have resolved their anger already in prior therapy. They say, “I’m already past this. I’ve dealt with my anger. I understand my parents. I forgive them.” However, we have found that when we take such claims at face value, we usually are mistaken. Later we realize that the patient has never really experienced genuine anger toward the parent. If patients have not done this part of the experiential work—if they have not gotten angry at the parent in a meaningful way, either in therapy or in their actual lives—then they have not gone through this stage. (We generally discourage patients from expressing anger directly at their parents “in real life” unless we have carefully weighed the pros and cons with the patient.) Later in treatment the therapist and patient will speak about whether or not the patient can forgive the parent. Later the therapist will help the patient see the good aspects of the parent and accept the parent’s limitations. However, in order to move from being wronged to forgiveness and to make headway against the schema, most patients must first go through anger. For most patients, expressing the anger in therapy is crucial. Without it, patients still believe emotionally that the schema is true, even though they might know intellectually that it is not.

Sometimes patients say that they feel too guilty to do this exercise. They believe that it is wrong to get angry at their parents. They believe that somehow their anger will hurt the parents, that they are betraying their parents by doing the exercise, or that their parents do not deserve the anger because “they did the best they could.” When this happens, we tell patients that it is only an exercise. Furthermore, we are not condemning the parents as bad people by getting angry at them in imagery; we are getting angry at particular errors in their parenting.

It is also important that patients express grief about what happened to them in childhood. Grief is almost always mixed in with the anger. Going through the process of grieving helps patients differentiate the past, when the schema was true, from the present, when it no longer has to be true. Grieving helps patients let go of unrealistic expectations that the parent will change and helps them acknowledge the parent’s good qualities. It also helps them accept the fact that their childhood was painful and that they cannot undo that, but that it is possible to focus on the future and make it as gratifying as possible.

Patients often realize that, despite everything, they still love the parent. They become able to negotiate a workable relationship with the parent. When all reasonable efforts to do so have failed, however, grieving helps patients let go of the parent, leaving them more open to forming other, healthier attachments. Finally, grieving helps patients build compassion for their childhood selves, replacing their more typical attitudes of scorn or indifference toward themselves. Grieving helps patients forgive themselves.

The second purpose we mentioned for venting anger at the parent was to help the patient gain emotional distance from the schema. One reason it is so hard for patients to fight their schemas is that their schemas feel ego-syntonic. Patients have internalized the messages their parents gave them, and now they say to themselves what the parent used to say (or imply through their behavior): “Your feelings don’t matter,” “You deserve to be abused,” “You are unlovable,” “You will always be alone,” “No one will ever meet your needs,” “You must always do what the other person wants.” The parent’s voice has become the patient’s own voice, and it feels right. When patients vent anger at a parent in imagery, they help reverse this process. They externalize the schema as the “parent’s voice.” In this way, the patients achieve a sense of distance from what feels like their own voice. Now it is the parent who criticizes, controls, deprives, or hates them—and not a core part of themselves. The schema becomes ego-dystonic. The therapist allies with the patient to fight the schema, represented by the parent.

Case Illustration

The following excerpts are from an interview Dr. Young conducted with Daniel, a patient we introduced in Chapter 3. Daniel had been in traditional cognitive therapy with another therapist for about 9 months for social anxiety and anger-management problems. He is 36 years old and is the single father of a young son. Five years ago he divorced his wife after discovering she had been secretly having affairs with other men. Except for his child, he has been alone since then. Daniel’s long-term therapy goal is to establish a successful intimate relationship with a woman.

Daniel’s childhood was traumatic. His father was an alcoholic who drank at neighborhood bars every night. Daniel can remember even as a small child walking through town alone at night to find his father and bring him home. While his father was out drinking, Daniel’s mother stayed at home entertaining her boyfriends, drinking and having sex with them while Daniel was there. When there was no boyfriend available, Daniel’s mother displayed her naked body to him in a sexually provocative way, under the guise of educating him about sex. In addition, Daniel’s mother was physically and verbally abusive to him.

As one might expect from his history, Daniel’s core schema—particularly in regard to intimate relationships with women—is Mistrust/Abuse. Daniel’s mother sexually, physically, and verbally abused him, and both parents used him for their own purposes. As Daniel said himself, “People will use and abuse me.” This is his basic belief. A number of other schemas cluster around this core. Like most abuse victims, Daniel feels defective. His mother’s abuse and his father’s neglect left him feeling inadequate, ashamed, worthless, and unlovable. In addition to Defectiveness, Daniel also has strong Subjugation and Emotional Inhibition schemas.

In this excerpt, Dr. Young instructs Daniel to carry on imagery dialogues with his mother and then his ex-wife. Dr. Young’s purpose is to help Daniel express anger toward the people in his past who have hurt him and to assert his rights. As the excerpt begins, Daniel is describing an image of an upsetting childhood situation with his mother.

Having determined what the mother did that was hurtful and how Daniel felt about it, the therapist moves on to exploring the patient’s unmet needs. He asks Daniel what he wished he could have gotten from his mother.

Up until this point, the patient’s affect has been somewhat flat. The therapist helps him vent with greater emotional intensity by exaggerating the mother’s behavior. (As we demonstrate in later chapters, to do this the therapist uses mode work: He introduces the “Angry Child” mode as a character in the imagery.)

The therapist, playing the part of Daniel’s mother in the imagery dialogue, is deliberately being provocative and inflammatory. We often adopt this tactic when playing the part of the parent in role-plays with emotionally inhibited patients. In order to increase the patient’s level of affect, we say whatever will most enrage the patient, so long as what we say is “in character,” based on what we have already learned about the parent. Note that the therapist, playing the part of the patient’s mother, virtually quotes verbatim what the patient himself said when he played the part of his mother earlier in the dialogue and uses information that the patient has already provided, such as the fact that his mother pulled his hair to punish him when he was a child.

The therapist moves on to Daniel’s first wife, who cheated on him, and continues to help him vent anger at the people who have hurt and betrayed him in the past.

In encouraging Daniel to vent anger at his mother and ex-wife, the therapist helps him feel both more empowered in regard to his abusers and more distant from his childhood sense of helplessness.

Imagery Work for Reparenting

Imagery work for reparenting is especially helpful for patients with most of the schemas in the Disconnection and Rejection domain (Abandonment, Mistrust/Abuse, Emotional Deprivation, and Defectiveness). When these patients were children, their ability to relate to others and feel safe, loved, nurtured, or worthy was largely destroyed. Through reparenting in imagery work, the therapist helps patients go back into that child mode and to learn to get from the therapist, and later from themselves, some of what they missed. This approach is a form of “limited reparenting.”

As with the imagery dialogues we have described thus far, the reparenting work in imagery that we describe here is a simplified form of mode work. We use the same three modes of the Vulnerable Child, Maladaptive Parent, and Healthy Adult, but now we bring the Healthy Adult into the image to defend the child against the Dysfunctional Parent and to nurture the Vulnerable Child.

The three steps in this process are as follows: (1) The therapist asks permission to enter the image and speak directly to the Vulnerable Child; (2) the therapist reparents the Vulnerable Child; and (3) later, the patient’s Healthy Adult, modeled after the therapist, reparents the Vulnerable Child.

Step 1: The Therapist Asks Permission to Enter the Image and Speak Directly to the Vulnerable Child

First, the therapist must access the patient’s Vulnerable Child mode. To do this, the therapist asks patients to close their eyes and picture an image of their little child mode, either now or in some past situation. The therapist then carries on a dialogue with the patient’s Vulnerable Child, using the patient as an intermediary. Rather than speaking directly to the child, the therapist asks the patient to relay messages.

Here is an example with Hector, the patient we described earlier who entered therapy at the insistence of his wife, who was threatening to leave him. Hector generally presented in a detached manner and had some trouble adjusting to imagery work. Even after several imagery practice sessions, he found it difficult to stay focused on negative childhood images.

Hector’s mother is schizophrenic, and she was in and out of mental hospitals throughout his childhood. He and his younger brother spent time in foster homes. This image expresses his Abandonment and Mistrust/Abuse schemas.

The therapist asks the patient for permission to speak directly to “Little Hector,” the patient’s Vulnerable Child.

The patient is protecting the Vulnerable Child from being hurt. This is understandable for patients with core schemas in the Disconnection and Rejection realm. They are detached from the affect connected to their schemas, and they have difficulty opening up to the pain involved in doing this work. Patients who were abused as children are literally afraid of the therapist.

At this point, the therapist begins a dialogue with the part of the patient that is being avoidant (the “Detached Protector” mode). The therapist tries to persuade the patient that it is safe to let the therapist talk to the Vulnerable Child.

The therapist continues in this way until the patient grants the therapist permission to talk directly to the Vulnerable Child. With a severely damaged patient, it may take the therapist many sessions to get to this point.

Step 2: The Therapist Reparents the Vulnerable Child

Once the therapist has permission to speak directly to the patient’s Vulnerable Child, the therapist enters the image and reparents the child.

The therapist says to the child, “What do you want from me? What can I do to help you?” Sometimes patients say, “I just want you to play with me. Would you play a game with me?” Or they say, “I want you to hold me,” or “Tell me I’m a good child.” Whatever the patient wants (if it is appropriate behavior for a parent with a child, of course), we try to provide in the image. For patients who want us to play a game with them, we ask, “What game do you want to play?” For patients who want to be held, we say, “Why don’t I put my arm around you in the image?” As the Healthy Adult in the image, the therapist provides the antidote to the patient’s core schemas.

Step 3: The Patient’s Healthy Adult, Modeled after the Therapist, Reparents the Vulnerable Child

After we reparent the Vulnerable Child, we ask patients to access a nurturing part of themselves, modeled after the therapist, that can do the same. Often we wait until a later session to do this, when the patient’s healthy side is stronger.

The goal is for the patient’s Healthy Adult to meet the emotional needs of the Vulnerable Child in the imagery. Doing this exercise helps patients build up a part of themselves that can satisfy their unmet emotional needs and thus fight their schemas.

The reparenting imagery work also serves an important purpose for the therapy sessions that come later. Once the therapist has spoken directly to the patient’s Vulnerable Child, the therapist can appeal to this mode in later sessions whenever the patient is cut off in an avoidant or compensatory mode. The therapist can reach the vulnerable part of the patient hiding behind the avoidance or compensation. Following is an example with Hector, who often came to therapy sessions in a detached mode.

Often when patients say they do not know what they are feeling, they are out of touch with their Vulnerable Child. When the therapist asks them to close their eyes and picture their Vulnerable Child, they suddenly can recognize what it is they are feeling. The therapist then has something to work on in the session that was inaccessible a moment before.

Once the therapist has established a link with the patient’s Vulnerable Child, the therapist has a strategy for the remainder of therapy for tapping in to what the patient is feeling at the core, even when the adult side of the patient does not seem to know. Whenever the patient says, “I don’t know what I’m feeling right now,” or “I feel scared and I don’t know why,” or “I feel angry and I don’t know why,” the therapist can say, “Close your eyes and picture your little child.” Accessing the Vulnerable Child mode almost always provides us with information about what the patient is feeling and why.

Traumatic Memories

This section presents a discussion of imagery dialogues for patients dealing with traumatic memories, usually of abuse or abandonment. Imagery of traumatic memories differs from other imagery in the following ways: It is more difficult for patients to endure; the affect it generates is more extreme; the psychological damage is more severe; and the memories are more often blocked.

We have two goals when conducting imagery of traumatic memories. The first goal is getting the patient to release blocked affect—the “strangulated grief” associated with the experience of trauma. The therapist helps the patient relive the trauma, feeling and expressing all of the associated emotions. Our second goal is to provide protection and comfort to the patient in the image by bringing in the Healthy Adult. As with the other imagery dialogues we have described, the dialogues we describe in this section are a form of mode work, using the three main characters of the Vulnerable Child, the Abusive or Abandoning Parent, and the Healthy Adult.

When doing nontraumatic imagery work, typically we persuade avoidant patients to persist. We push them to work past the point at which they feel comfortable. We encourage them to vent fully the emotions connected to the image. However, when dealing with memories of abuse or other trauma—especially blocked memories—we do not push the patient. Rather, we go slowly, letting patients set their own pace. The goal of helping the patient to feel safe takes precedence over all other considerations. More often than not, imagery work with traumatic memories is terrifying for patients. The therapist tries to maximize the patient’s sense of control over the work. If blocked memories of abuse are coming to the surface, then the therapist takes the admonition to go slowly even more seriously and deals with the patient’s memories in small increments. The therapist gives the patient plenty of time to absorb new information and to work through all the implications before moving on.

There are many steps the therapist can take to help the patient maintain a sense of control during and after traumatic imagery sessions. The therapist can agree on a signal patients can use during the session—for example, raising their hands—whenever they want to stop the imagery. The therapist can begin and end with a safe-place image. Framing the imagery in this way can help patients contain the affect evoked by the work.

Another way in which the therapist can help patients contain affect is to discuss the imagery session thoroughly after it is over. In this discussion, the therapist gives patients the opportunity to talk through everything that happened—what they thought, felt, needed, learned. For example, the therapist might go through 15 minutes of traumatic imagery with a patient and then wait several weeks before doing related imagery again. During those weeks, the patient would spend a lot of time processing with the therapist all that took place during the previous imagery session.

During the imagery itself, we have found that it is generally best for the therapist to remain quiet. The therapist just listens, without reality-testing or confronting, gently asking open-ended questions—”What’s happening now in the image?” or “What happens next?”—when the patient appears stuck. Later in therapy, once the patient has understood the full extent of the trauma and relived it fully, the therapist can intervene more actively. When the patient becomes too frightened to work on an image, the therapist can provide the child in the image with some kind of barrier or weapon against the perpetrator, hopefully allowing the patient to feel safe enough to continue working on the image. We discuss this further in Chapter 9, on borderline personality disorder. (As we explain in that chapter, we do not suggest bringing weapons into the images of patients who have a history of violence.)

One important principle is for the therapist to refrain from making any suggestions about what happened to the patient. It is not the therapist’s place to make pronouncements about what “really happened,” nor to make inferences about what happened. Rather, patients are left free to discover their own stories. If the therapist suspects that the patient has been sexually abused but the patient is neither talking about it nor raising it in imagery work, the therapist does not bring it up. The therapist just waits silently and hopes the patient will eventually bring it up. Generally we have found that, if we work long enough with patients, over time they feel safe enough and they trust us enough to finally bring up abuse if it has occurred. Particularly in light of the current debate about false memories, we believe it is essential for therapists to err on the side of caution. Therefore we say nothing; we just schedule regular imagery sessions and we wait.

After completing traumatic imagery sessions about their childhoods, patients sometimes will deny that the image was true. They will say, “That never really happened. That was not really a memory. I made it up.” We feel that the proper response to this assertion is that, in terms of the therapy, it does not matter whether the image is literally true. What we are addressing in therapy is the theme of the image, not the accuracy. The image has an emotional truth, and the therapist and patient are working together to find that truth and to help the patient heal from it. We can work with the image without deciding about its accuracy or validity. Even though a memory may be false in the sense that certain details might be inaccurate, the theme of the image—the theme of being deprived, controlled, abandoned, criticized, abused—is usually on target. We try not to get caught up in worrying about whether an image is accurate or not, and we do not behave with patients as though the image is necessarily accurate. We focus on the theme of the image—the schema—and work with that.

With extremely fragile patients, particularly patients with BPD, a risk exists of their dissociating or decompensating during and after experiential work. We elaborate on this in Chapter 9.

Letters to Parents

Another experiential technique that we often give patients as a homework assignment is to write letters to their parents or to other significant people who hurt them when they were children or adolescents. Patients bring the letters to subsequent sessions and read them aloud to the therapist. (Patients do not actually send the letters to their parents, except in rare instances, as we discuss shortly.)

The rationale for writing letters to parents is to summarize what the patient has learned about the parent as a result of doing the cognitive and experiential work. Patients can use the letters as opportunities to state their feelings and assert their rights. The therapist can suggest that they address certain topics: what the parent did (or did not do) that was damaging in the patient’s childhood; how the patient felt about it; what the patient wished for at the time from the parent; what the patient wants from the parent now.

In most cases, we recommend to patients that they not actually send the letters. Occasionally, patients do decide to send them, but only after we have spent a lot of time going over all the possible repercussions. For example, patients might enrage their parents; parents might become depressed; patients might feel guilty later; or patients might alienate siblings and end up excluded from their families. The therapist is careful to cover all possible scenarios thoroughly before a patient actually sends a letter.

This is an example of a letter written by a patient named Kate, a 26-year-old young woman who writes copy for an advertising agency. Kate sought treatment for depression and anorexia nervosa. Her core schema is Defectiveness. Kate wrote this letter to her mother, who was critical and rejecting when she was a child.

This letter summarizes the essential elements of the cognitive and experiential work Kate had done thus far in the treatment regarding her mother. The letter expresses how Kate’s mother hurt her as a child. It asserts Kate’s right to feel and express her anger about what happened and to expect her mother to behave appropriately from now on. Although Kate never sent her mother the letter, writing it helped Kate fight her schemas and clarify the issues in their relationship.

Imagery for Pattern-Breaking

We also use imagery techniques to help patients push through their coping styles of avoidance and overcompensation to discover new ways of relating. Patients imagine behaving in healthy ways, rather than retreating into their typical coping styles. For example, a patient with a Failure schema imagines something he would ordinarily avoid, like asking his boss for an important assignment; or a patient with a Defectiveness schema imagines relating in a vulnerable way to her spouse rather than overcompensating by adopting a superior stance. Imagery helps these patients face their schemas and fight them directly.

The following excerpt involves Daniel, the patient described previously whose father was alcoholic and whose mother was sexually and physically abusive. In the excerpt, he practices imagery for pattern-breaking. Daniel’s long-term therapy goal is to establish an intimate relationship with a woman. In this excerpt, the therapist asks Daniel to close his eyes and imagine being at a dance with single women. He then instructs Daniel to carry on a dialogue between his Mistrust/Abuse and Defectiveness schemas, which are pressuring him to leave the situation, and his Healthy Adult, which is encouraging him to stay and master the situation. Dr. Young then instructs Daniel to imagine staying at the dance and breaking through his avoidance.

Daniel has shifted into an avoidant mode at the dance. If this were “real life” rather than an imagery exercise, he would probably remain frozen in this mode for the remainder of the dance, or he would leave. The therapist pushes Daniel to imagine overcoming his avoidance and connecting with a woman.

Note that the therapist is not asking Daniel to rehearse what he would actually say to a woman at a dance. Rather, the therapist is asking Daniel to fight his schemas and avoidant coping style. Rather than shutting down emotionally and withdrawing into himself as he would normally do—thus perpetuating his Mistrust/Abuse and Defectiveness schemas—the therapist helps Daniel imagine approaching women and speaking in a more genuine and vulnerable way. The assumption of a more open attitude toward women opposes his schemas and leads to a better outcome. The exercise helps Daniel build up the part of himself that is able to behave constructively in social situations with women. The imagery also helps Daniel see that his fears about women are not realistic but are schema-driven. This reduces some of his shame and thus his avoidance.

Having given a voice to Daniel’s Defectiveness schema, the therapist moves on to his Mistrust/Abuse schema.

The therapist discusses the imagery exercise with the patient.

Once again, the therapist’s aim was not for Daniel to practice what he actually would say in a social situation with a woman. Rather, his aim was for Daniel to fight his schemas by recognizing that his schema-driven fears are unrealistic.