Behavioral pattern-breaking targets coping styles: The behaviors that are the focus of change are the ones patients use in surrendering to, avoiding, and overcompensating for their Early Maladaptive Schemas. These are the self-defeating behaviors patients employ to cope when their schemas are triggered: the unfounded jealous accusations of the patient with an Abandonment schema, the self-deprecatory comments of the patient with a Defectiveness schema, the advice-soliciting of the patient with a Dependence schema, the obedience of the subjugated patient; the phobic avoidance of the patient who has a Vulnerability to Harm or Illness schema. These surrender, avoidance, and overcompensatory behaviors ultimately serve to perpetuate schemas. Patients must change their coping styles in order to heal their schemas and thereby fill the unmet needs that brought them into therapy.
A young woman named Ivy comes for schema therapy. She is feeling frustrated and unhappy in many life areas. The pattern is the same: in her family, in her love life, at work, with her friends, she assumes a caretaking role while asking virtually nothing for herself. As she puts it, “I take care of everybody, but nobody takes care of me.” She is depressed, overwhelmed, exhausted, and resentful. In the Assessment Phase, Ivy and the therapist agree that she has a Self-Sacrifice schema. Her main coping style is surrendering to the schema. She takes care of others but does not allow others to take care of her.
Ivy meets her best friend Adam for dinner every few weeks. The dinners follow the same pattern: Adam asks Ivy about her life, and Ivy gives short, positive answers, basically conveying, “Everything’s fine,” and then asks Adam about his life. Adam answers by raising a troubling issue in his own life, and the two spend the rest of dinner discussing the issue he has raised. Why does Ivy not share anything of importance about herself with her friend? The answer is that her friend’s questions trigger her Self-Sacrifice schema. Ivy feels guilty and selfish talking about herself. She copes with the triggering of her schema by giving quick nonanswers and shifting the focus back to Adam. Ivy ends up feeling emotionally deprived (almost all patients with Self-Sacrifice schemas have linked Emotional Deprivation schemas.)
In the behavioral part of treatment, Ivy decides to bring greater balance into her intimate relationships. She decides to begin with her relationship with Adam. To prepare her, the therapist asks her to close her eyes and picture an image of herself sitting at dinner with Adam and telling him about her life. In imagery, Ivy conducts a dialogue between her Self-Sacrifice schema, which tells her to switch the focus back to Adam, and her healthy side, which promulgates the wisdom of sharing a problem with her friend. Next, switching chairs between the “schema” and the “healthy side,” Ivy gets angry at her schema, asserting her right to be taken care of by others. In imagery she connects the situation to her childhood with her fragile, needy mother. She tells her mother, “It cost me too much to take care of you. It cost me my sense of self.”
Next, in imagery, she visualizes sharing a problem with Adam, dealing with all the obstacles that arise.
THERAPIST: So what do you want to tell Adam?
IVY: I want to tell him what it’s like to have my mother getting sick and needing so much from me.
THERAPIST: OK, so could you imagine telling him about that in the image?
About your mother getting sick, and your feelings about it?
IVY: I want to tell him, but I feel scared.
THERAPIST: And what is the scared side saying?
IVY: It’s saying, “It’s not supposed to be this way. Adam’s not supposed to be taking care of me, I’m supposed to be taking care of him.”
THERAPIST: What are you afraid will happen if you let Adam take care of you?
IVY: I’m afraid he won’t like me anymore.
THERAPIST: Are you afraid of anything else?
IVY: I’m afraid I’ll start crying, or something.
THERAPIST: And what would be so bad about that?
IVY: I’d be really embarrassed.
THERAPIST: Well, that’s your Self-Sacrifice schema talking, everything you’ve been saying: “You’re not supposed to let anyone take care of you. People won’t like you if you show your own vulnerability. You’re not supposed to cry.” What does the healthy side say to that? Could you answer as the healthy side in the image?
IVY: Well, yeah, the healthy side is saying, “It’s all right to let my friends take care of me. They’ll still like me. It’s okay to cry with a close friend.”
Finally as a behavioral homework assignment, Ivy practices responding more authentically to her friend when he asks about her life. The next time they meet for dinner, she shares an issue concerning her love relationship. Adam responds warmly and supportively countering Ivy’s Self-Sacrifice (and Emotional Deprivation) schemas.
Each schema is associated with certain dysfunctional behavior patterns that tend to characterize the patient’s approach to partners and significant others (including the therapist). Table 5.1 gives an example of each coping style for each schema.
As Table 5.1 shows, behavioral pattern-breaking refers not only to how one behaves in specific situations but also to the types of situations one generally selects: whom one marries; the career one chooses; one’s circle of friends. Behavioral pattern-breaking involves major life decisions, as well as everyday behaviors. Patients maintain their Early Maladaptive Schemas by making major life decisions that perpetuate their schemas.
Patients can often change discrete, situation-specific behaviors with standard cognitive-behavioral techniques, but lifelong behavioral patterns driven by Early Maladaptive Schemas require an integrative approach. Assertiveness training might help a patient who has difficulty setting limits with his girlfriend, but assertiveness training alone will probably not be sufficient to change a broader life pattern of subjugation to significant others. Patients subjugate because they fear punishment, abandonment, or criticism, and they must work through these underlying issues in order to overcome the pattern. The linked schemas tied to these underlying issues—Punitiveness, Abandonment, Defectiveness—block progress. If the patient has a Mistrust/Abuse schema, he is going to be afraid that, if he asserts himself, his girlfriend will become abusive. If the patient has an Abandonment schema, he is going to be afraid that his girlfriend will leave him if he asserts himself. If the patient has a Defectiveness schema, he is not going to feel he has the right to be assertive with his girlfriend, even if he knows the steps necessary for self-assertion. Skills training is frequently not the primary intervention. The schema has cognitive and emotional aspects that the treatment must address beforehand.
It is often easier for patients to change their cognitions and emotions than it is to break lifelong patterns of behavior. For this reason, the therapist must be patient but persistent throughout the behavioral stage, employing the rule of empathic confrontation. The therapist expresses empathy for how hard it is to change deeply instilled patterns of behavior yet continually confronts the necessity for that change.
TABLE 5.1. Examples of Coping Styles Associated with Specific Schemas
| Schema | Surrender | Avoidance | Overcompensation |
| Abandonment/Instability | Selects partners and significant others who are unavailable or unpredictable. | Avoids intimate relationships altogether out of fear of abandonment. | Pushes partners and significant others away with clinging, possessive, or controlling behaviors. |
| Mistrust/Abuse | Chooses untrustworthy partners and significant others; is overvigilant and suspicious of others. | Avoids close involvement with others in personal and business life; does not confide or selfdisclose. | Mistreats or exploits others; acts in an overly trusting manner. |
| Emotional Deprivation | Chooses cold, detached partners and significant others; discourages others from giving emotionally. | Withdraws and isolates; avoids close relationships. | Makes unrealistic demands that others meet all of his or her needs. |
| Defectiveness/Shame | Chooses critical partners and significant others; puts him- or herself down. | Avoids sharing “shameful” thoughts and feelings with partners and significant others due to fear of rejection. | Behaves in a critical or superior way toward others; tries to come across as “perfect.” |
| Social Isolation/Alienation | Becomes part of a group but stays on the periphery; does not fully join in. | Avoids socializing; spends most of his or her time alone. | Puts on a false “persona” to join a group, but still feels different and alienated. |
| Dependence/Incompetence | Asks for an excessive amount of help; checks decisions with others; chooses overprotective partners who do everything for him or her. | Procrastinates on decisions; avoids acting independently or taking on normal adult responsibilities. | Demonstrates excessive self-reliance, even when turning to others would be normal and healthy. |
| Vulnerability to Harm or Illness | Worries continually that catastrophe will befall him or her; repeatedly asks others for reassurance. | Engages in phobic avoidance of “dangerous” situations. | Employs magical thinking and compulsive rituals; engages in reckless, dangerous behavior. |
| Enmeshment/Undeveloped Self | Imitates behavior of significant other, keeps in close contact with “enmeshed other”; does not develop a separate identity with unique preferences. | Avoids relationships with people who stress individuality over enmeshment. | Engages in excessive autonomy. |
| Failure | Sabotages work efforts by working below level of ability; unfavorably compares his or her achievement with that of others in a biased manner. | Procrastinates on work tasks; avoids new or difficult tasks completely; avoids setting career goals that are appropriate to ability level. | Diminishes achievements of others; tries to meet perfectionistic standards to compensate for sense of failure. |
| Entitlement/Grandiosity | Has unequal or uncaring relationships with partners and significant others; behaves selfishly; disregards needs and feelings of others; acts superior. | Avoids situations in which he or she cannot excel and stand out. | Gives extravagant gifts or charitable contributions to make up for selfish behavior. |
| Insufficient Self-Control/Self-Discipline | Performs tasks that are boring or uncomfortable in a careless way; loses control of emotions; excessively eats, drinks, gambles, or uses drugs for pleasure. | Does not work or drops out of school; does not set long-term career goals. | Makes short-lived, intense efforts to complete a project or to exercise self-control. |
| Subjugation | Chooses dominant, controlling partners and significant others; complies with their wishes. | Avoids relationships altogether; avoids situations in which his or her wishes are different from those of others. | Acts in a passive–aggressive or rebellious manner. |
| Self-Sacrifice | Engages in self-denial; does too much for others and not enough for him- or herself. | Avoids close relationships. | Becomes angry at significant others for not reciprocating or for not showing appreciation; decides to do nothing for others anymore. |
| Negativity/Pessimism | Minimizes positive events, exaggerates negative ones; expects and prepares for the worst. | Does not hope for too much; keeps expectations low. | Acts in an unrealistically positive, optimistic, “Pollyannaish” way (rare). |
| Emotional Inhibition | Emphasizes reason and order over emotion; acts in a very controlled, flat manner; does not show spontaneous emotions or behavior. | Avoids activities involving emotional self-expression (such as expressing love or showing fear) or requiring uninhibited behavior (such as dancing). | Acts impulsively and without inhibition (sometimes under the influence of disinhibiting substances such as alcohol). |
| Approval-Seeking/Recognition-Seeking | Draws the attention of others to his or her accomplishments related to status. | Avoids relationships with admired individuals out of fear of not gaining their approval. | Acts flagrantly to gain the disapproval of admired individuals. |
| Punitiveness | Acts in an overly punishing or harsh way with significant others. | Avoids situations involving evaluation to escape the fear of punishment. | Acts in an overly forgiving manner while being inwardly angry and punitive. |
| Unrelenting Standards/Hypercriticalness | Attempts to perform perfectly; sets high standards for self and others. | Avoids taking on work tasks; procrastinates. | Throws out high standards altogether and settles for belowaverage performance. |