The first step is for the therapist and patient to develop an extensive list of specific behaviors to serve as potential targets of change. The therapist and patient can refer to many sources of information to develop this list: the case conceptualization developed in the Assessment Phase, detailed descriptions of problematic behaviors, imagery of problematic situations, the therapy relationship, relationships with significant others, and schema questionnaires.
The therapist and patient can start by refining the case conceptualization they developed in the Assessment Phase, elaborating on the processes of schema surrender, avoidance, and overcompensation. Working with these coping styles, they can begin to develop a list of specific behaviors or life circumstances that require change. It is important for the therapist to cover each major life area separately, such as intimate relationships, work, and social activities, because the patient may have different schemas and coping styles linked to different life areas. For example, a patient with an Emotional Deprivation schema may be warm and nurturing with close friends but cold and distant with romantic partners; a patient with a Subjugation schema may be passive with authority figures but domineering and controlling with younger siblings or children; or a patient may have a Defectiveness schema that is activated when meeting strangers in a social situation but not when meeting significant others one-to-one.
Perhaps the most important step in identifying self-defeating behavioral patterns is for the therapist and patient to develop detailed descriptions of problematic situations in the patient’s life. When the patient reports a situation that is a consistent schema trigger, the therapist helps the patient clarify specific behaviors by asking questions. The goal is to get a blow-by-blow account of what happened. Sometimes the therapist encounters difficulty during this effort. As part of the schema perpetuation process, the patient distorts what happened to fit the schema and ignores contradictory data. The therapist must push through the patient’s reluctance to recall what happened in an objective, rather than emotional, schema-driven fashion.
A young female patient named Daphne comes to a session and reports that she had a fight with her husband the previous evening. Daphne has an Abandonment/Instability schema as a result of growing up in a household filled with strife. Her parents fought nearly every night, often to the point of threatening divorce. Daphne remembers watching them shouting at each other and feeling helpless to stop them, then hiding in her closet with her hands over her ears. Now she is married to Mark, a medical resident. He works long hours and comes home haggard and depleted. His homecoming sparks a fight nearly every night.
Daphne tells the story of their latest fight:
DAPHNE: Mark and I had another fight last night.
THERAPIST: What started the fight?
DAPHNE: Oh, the same old thing. He was late. I don’t know. (Tosses her head.)
THERAPIST: How did the fight begin?
DAPHNE: The same way it always does. It doesn’t matter. All we do is argue. We should probably get divorced.
THERAPIST: Daphne, I see how hopeless you feel, but it’s still important for us to understand what happened. Think back to the beginning of the fight. How did it start?
DAPHNE: I had a really hard day. I couldn’t seem to get any of my freelance work done. The baby was crying all day. Mark came home late again, and I let him have it.
THERAPIST: How did you let him have it?
DAPHNE: I told him I can’t possibly earn money for us when I have to take care of a screaming baby all day. How am I supposed to work? When the baby’s up I have to take care of him, and when’s he’s sleeping I’m so tired that I have to sleep, too. I mean, Mark gets to leave for the whole day, and I’m stuck here.
THERAPIST: What did Mark say?
DAPHNE: He said it wasn’t his fault that the baby was crying and that he works hard, too.
THERAPIST: What happened next?
DAPHNE: I told him, “You leave us alone all day and night. You’re a rotten husband and father.”
THERAPIST: How were you feeling at that point?
DAPHNE: Angry. Really angry and scared. I was scared that he didn’t care about me and the baby and might leave us forever.
THERAPIST: What about Mark? What do you think he was feeling?
DAPHNE: At the time I thought he couldn’t care less, because he left the room. Later he told me he was devastated that I said he was a rotten husband and father.
By recounting her interaction with her husband in such detail, Daphne and her therapist are able to identify her problematic behaviors. Mark’s lateness triggers her Abandonment/Instability schema, and she becomes panicked and angry. When he finally gets home, instead of expressing her vulnerability and fear, she lashes out at him, trying to hurt him as much as she can. In coping with her schema by overcompensating, Daphne perpetuates her schema. She ends up feeling even more afraid that Mark will leave her, recreating just the kind of unstable atmosphere that frightened her so much when she was a child.
If patients have difficulty remembering details of a problematic situation, the therapist can help them use imagery to replay the situation. The therapist asks them to close their eyes and picture an image of the situation. The therapist asks questions about what is happening in the image, coaxing patients to remember the details of their behavior. The therapist says, “What are you thinking? What are you feeling? What do you wish you could do? What do you do next?” Through imagery, patients can often access thoughts, feelings, and behaviors that were previously inaccessible.
Henry is a college student at a competitive school. His presenting problem is that he procrastinates doing his schoolwork and thus is performing below his ability level.
Henry is the only child of professional parents who value achievement above all else. He was the valedictorian of his small high school class—a feat he achieved without exerting much effort. He was also a star athlete in high school, but he realized in his freshman year of college that he was not talented enough to pursue a career in professional sports. “I felt like a failure,” he said, “but I figured that my academic success was guaranteed.” Henry expected his schoolwork to replace sports as the main source of his self-esteem. Now, however, he was not doing his schoolwork, and his grades were mediocre.
In the Assessment Phase of treatment, Henry identified Unrelenting Standards and Insufficient Self-Control/Self-Discipline as the principal schemas that interfered with his studying. After battling these schemas with cognitive and experiential strategies, the therapist and Henry turned to behavioral pattern-breaking. In the following excerpt, the therapist uses imagery to help Henry identify his behaviors while he was putting off doing his schoolwork.
THERAPIST: Do you want to do an imagery exercise to help you pinpoint the problem?
HENRY: OK.
THERAPIST: Good, then close your eyes and get an image of yourself sitting down to work last night.
HENRY: OK. (Closes eyes.)
THERAPIST: What do you see?
HENRY: I’m in my room. It’s pretty messy, with papers all over the place. I have my books in front of me and my computer to the side. (Pause.)
THERAPIST: What happens when you start to think about doing your work?
HENRY: Well, it’s kind of late. I told myself all day I could work later. Now I have a paper due and I haven’t even started.
THERAPIST: What are you thinking?
HENRY: I don’t want to do my paper. I’m too wound up to focus. I don’t know where to start. Just thinking about it gives me a stomachache. I’d rather play computer games, so I do.
THERAPIST: What happens next?
HENRY: I play computer games for a while, and then I listen to music. By then it’s really late and I know I have to work.
THERAPIST: What are you feeling?
HENRY: Anxious and depressed. The more anxious I get, the harder it is to concentrate.
THERAPIST: What goes through your mind?
HENRY: It’s too late.
THERAPIST: It’s too late to write the paper?
HENRY: No, it’s too late to get an A. I could have gotten an A if I had done the work. What’s the use? I’ve failed already.
THERAPIST: What do you do?
HENRY: I set my alarm for four in the morning, thinking I’ll get up then and write the paper. I sleep through the alarm and through all my classes the next day.
Henry uses avoidant behavioral strategies such as distraction to cope with his mounting anxiety. Note that, while investigating Henry’s behaviors, the therapist also elicits information about his cognitions and emotions. The more vividly the patient recalls the image, the more clearly he is able to recall specific behaviors.
The patient’s behavior in the therapy relationship is a further source of information about behaviors that require change, especially concerning relationships with significant others. This source of information is particularly advantageous because the therapist can observe the behaviors directly, perceiving subtleties that might be lost if the patient were merely reporting about relationships outside of therapy.
The therapist can observe the patient’s schemas, as well as the patient’s coping styles. Each set of schemas and coping styles has its own presentation. For example, a young female patient demonstrates her Emotional Deprivation schema and avoidant coping style by leaving sessions early. Unwilling to face the fact that she shares the therapist with other patients, she leaves the session before the next patient arrives in the waiting room.
A young male patient demonstrates his Defectiveness schema and his coping style of overcompensation by repeatedly correcting the therapist’s manner of speech. A young female patient shows her Enmeshment schema and her coping style of surrender by imitating the therapist’s style of dress. (In the Chapter 6, we elaborate further on the presentation of schemas and coping styles within the therapy relationship.)
The case of Alicia illustrates how schemas and coping styles manifest themselves in the therapy relationship and how they can subvert therapy. Alicia grew up in a strict, moralistic family. Her mother taught her that people were inherently evil and weak and that, to be good, one must watch oneself vigilantly. Forsaking family members in their time of need was the worst transgression. Alicia was dutiful and responsible and tried to fill her mother’s wishes. “I wanted to please her but I never could,” she says. Her father was an alcoholic, and her mother taught her that it was her duty to help him maintain self-control. Alicia tried to be very good so that she would not upset her father and “make him drink.” She emptied his whiskey bottles, begged and cajoled him not to go out at night, and got him into bed when he was drunk.
Alicia’s primary schemas were Defectiveness and Punitiveness. She could not forgive herself for having “bad” impulses and wishes. She also had schemas of Emotional Deprivation (from the cold emotional atmosphere of the family), Self-Sacrifice (from her mother’s demands that she serve the needs of family members, especially her father), and Unrelenting Standards (from the impossibility of being “good enough” to please her mother). As she grew up, Alicia lived in ways that perpetuated her schemas. She chose troubled partners and friends. She chose one boyfriend after another who was a substance abuser. She stayed in these relationships because she felt it was her moral obligation to do so. As her mother taught her, one does not desert loved ones in their time of need. In addition, as with her father, Alicia felt it was her fault when her boyfriends abused drugs. Somehow she had failed to prevent them.
Among other therapy goals, Alicia wanted to lose weight. She began reporting to the therapist during sessions how much she had eaten the previous week. At first it seemed as though Alicia wanted attention for her weight-loss efforts, and the therapist tried to give it (hoping to counter the patient’s Emotional Deprivation schema). However, it soon became clear that Alicia assumed that the therapist condemned her for the extra weight. Her Defectiveness and Punitiveness schemas were being triggered. Alicia was confessing to the therapist as she had confessed her “bad” behavior to her mother as a child. When she realized this, Alicia burst into tears, saying that she had been considering dropping out of therapy. Weight loss was not her goal, it was her mother’s goal. Alicia believed that, if she did not do what her mother said she should do, she was a bad person. Weight loss was a promise to her mother that she had to keep. Another side of her, however—her Vulnerable Child—felt that eating was her only pleasure, and she could not bear to limit herself. (Eating was a form of overcompensation for her Emotional Deprivation and Self-Sacrifice schemas.) Reporting her eating to the therapist, Alicia turned the therapist into another punitive figure in her mind, one she had to labor endlessly to please.
The therapist helped Alicia uncover other areas of her life in which she “confessed” her “bad” behavior under the assumption that the other person was judging her negatively. Changing this pattern became one of her goals in behavioral pattern-breaking.
Sometimes the therapist does not rely solely on patients’ self-reports to identify their problematic behaviors. There are bound to be flaws and gaps in patients’ self-observations. This is especially true when patients are overcompensating for their schemas. For example, narcissists are notoriously poor observers of their own behavior and its impact on others. Consultations with partners, family members, and friends can supply additional perspectives. When it is workable for the therapist to meet with them, significant others can often provide information that the patient cannot provide. The therapist explores the points of view of these significant others and asks them for specific examples that shed light on the patient’s maladaptive behavior patterns. If the therapist is unable to meet with significant others, the patient can ask them for feedback and then discuss their responses in therapy.
Taking careful histories of relationships with significant others can also furnish information. The therapist focuses on problematic behaviors. What schemas were triggered in these relationships? How did the patient cope? What exactly did the patient do? What were the self-defeating behaviors that perpetuated the schemas?
Monique presents for therapy, complaining that her husband, Lawrence, will not have sex with her.
MONIQUE: I don’t know.
THERAPIST: If you had to guess?
MONIQUE: I don’t know. He’s just not a sexual person.
Monique says that she pleads with her husband: “I tell him I’m lonely. I tell him I miss him.” Further inquiry determines that the two of them had a good sex life before they were married. She is certain that there is no one else: Neither she nor her husband is having an affair. As far as she knows, her husband is not angry with her. In fact, she is the one who is angry with him for abandoning their sexual life. Monique is wrestling with the temptation to cheat on Lawrence. The therapist is unable to learn from her why Lawrence appears so uninterested in sex with her.
The therapist asks if Lawrence can come in for a session alone. Monique agrees, and her husband comes in. Lawrence reports that Monique criticizes his sexual performance and compares his skill as a lover unfavorably to other lovers she had before they were married. Over the years, this has made him feel increasingly anxious and inadequate as a lover. He has thus taken the route of avoiding sex with her. Thus the therapist learns what problematic behaviors on Monique’s part are contributing to the break in their sexual relationship.
The Young Schema Questionnaire is an excellent source of problematic “surrender” behaviors tied to schemas. In addition, the Young-Rygh Avoidance Inventory and the Young Compensation Inventory list other forms of schema coping behaviors.