Once the therapist and patient have made a list of problematic behaviors and life patterns, they deliberate about which are the most important and which should be targets of change. Looking at the most significant problematic behaviors, they explore what the healthy behavior would be for the patient in each case. Often patients are not aware that their behaviors are problematic, and they do not know what healthy behaviors are. The therapist and patient generate alternative behaviors, discussing the advantages and disadvantages of each one. They come up with healthy responses to replace maladaptive ones, and these become the behavioral goals for treatment.
The therapist helps the patient select one specific behavior to change first. The patient works on one behavior at a time, not the whole pattern at once. How do the therapist and patient select this first behavior to change? We present some rules of thumb.
Our general approach in schema therapy is to attempt to change behaviors within a current life situation before recommending major life changes, such as leaving a marriage or job. (This, of course, does not apply to dangerous or intolerable situations, such as an abusive spouse.) Changing behaviors entails staying in a situation and learning to respond more appropriately. We believe patients have a lot to gain by first learning how to handle a difficult situation before deciding whether to leave it. Rather than jumping to conclusions about the impossibility of change, patients first make sure they cannot get what they want from the current state of affairs by improving their own behavior. In addition, they build skills for future difficult situations. If, after improving their behavior, patients eventually decide to leave the current situation, they can do so knowing they have done their part in trying to make it work.
We believe that the therapist should start with the most problematic behavior. This is the behavior that causes the patient the most distress and that most interferes with the patient’s interpersonal or occupational functioning. The exception is cases in which the patient feels too overwhelmed to proceed. In that case, the therapist picks the most problematic behavior that the patient feels capable of changing.
Our approach contrasts with cognitive-behavioral therapy, which typically begins with the easiest behavior. In cognitive-behavioral therapy, patients only gradually approach their most difficult behaviors. The therapist and patient construct hierarchies of behaviors ranked in order of increasing difficulty, and the patient starts from the bottom and works up. For example, if a patient comes to treatment because she cannot say “no” to her boss at work, a cognitive-behavioral therapist might have her start by practicing assertiveness with strangers and service people and gradually work her way up through friends and family members, finally addressing the problem with her boss.
In schema therapy, however, the therapist begins with core schemas and coping styles. Our goal is to help patients feel substantially better as quickly as possible. Only if patients are unable to make changes in their primary presenting problem do we shift to a secondary problem.