A Case Illustration of Behavioral Pattern-Breaking

Alec is a 35-year-old attorney. He was recently divorced from Kay after 7 years of marriage. Although he was unhappy in his marriage and had been struggling with a sexual attraction to a coworker, Alec was completely surprised when Kay told him she wanted a divorce. She would not tell him why she wanted the divorce other than to say she was unhappy. She refused his request to try marital therapy and moved out of the house that same day. The couple had no children. After a year’s separation, their divorce was finalized, and Kay dropped out of his life entirely. A few months later, Alec came to therapy.

Alec’s presenting problem was his difficulty initiating a relationship with a woman, particularly one that would lead to marriage and a family. He was finding it difficult to enter the dating scene. In addition, he did not understand why Kay had ended their marriage, nor why the woman he was attracted to at work refused to date him. He was obsessed with this woman and devoted a large part of each workday to thinking about her and trying to see her, so that his performance at work was steadily declining.

Alec is the youngest of three brothers. His mother died when he was 8 years old, and his grief-stricken father raised him. His brothers grew up and left home to go to college, leaving Alec to take care of his father. (He has felt estranged from his brothers ever since.) Outside of the home, Alec felt like a “social misfit.” He excelled at his schoolwork but had trouble making friends. His grim life seemed so different from the seemingly carefree lives of the other children. Whereas they seemed to have happy homes, his home life was empty and bleak. His father was chronically depressed. Alec says, “My father slept most of the time, or watched television. He pretty much was in bed or on the couch. He never went out, wouldn’t see anyone. And except to say, you know, ‘Pass the salt,’ he hardly ever spoke to me.”

In the Assessment Phase of treatment, Alec and his therapist identify his schemas as Abandonment/Instability (from the death of his mother and the fact that his brothers left home); Emotional Deprivation (from his distant, apathetic father and unconcerned brothers); Social Isolation/Alienation (from his unusual home life that led him to feel different from peers); and Self-Sacrifice (from taking care of his father).

His primary coping style is schema avoidance: Early in life, he became a workaholic. He threw himself into his schoolwork and, later, into his law career; he is highly successful. He met Kay at law school and married her a few years later. Although he was not in love with her, she was steady and sensible, and he was afraid to face the world alone. Like his father, Kay was chronically depressed. Although Alec wanted children, she refused. Their life together was stable but monotonous and without passion. (Alec’s marriage to Kay represented his surrender to his Emotional Deprivation schema. In his marriage to her, he replicated the emotionally vacant family life of his childhood.)

In recent years, Alec had become sexually attracted to Joan, his coworker. She flirted with him while he was still married, but she would not date him after his divorce. Although Alec asked her to go out with him a number of times, she always said no. Although Joan accepted gifts and favors from Alec, she clearly was not interested in him romantically, and he was having a great deal of trouble accepting this fact. When asked what was so alluring about Joan, Alec said: “When we’re alone, she makes me feel like I’m the only one in the world. She’s very intense and attentive. But when other people are around, she’s distant.” Alec finds Joan’s inconsistency toward him exciting. The therapist speculates that Alec’s attraction to Joan is schema-driven—that is, generated largely by his Abandonment/Instability schema. In addition, it seems likely that Self-Sacrifice is a linked schema driving the attraction, as Alec has given a lot to Joan and gotten little in return.

Alec and his therapist agree that the first target of behavioral pattern-breaking should be his “Joan-centered” activities at work, such as daydreaming about her, calling her on the phone, thinking up e-mails to send her, grilling other people about her, looking for newspaper articles of interest to her and bringing them to her, and arranging to “accidentally” run into her. Alec was spending virtually his entire workday obsessed with these activities, even though the activities were torturous for him and he regretted them afterward. Moreover, as we have noted, his performance at work was seriously impaired.

The therapist begins by helping Alec link the target behavioral pattern to its origins in childhood. The therapist asks him to close his eyes and picture an image of being at work and missing Joan.

Missing Joan at work triggers Alec’s Abandonment schema, evoking feelings connected to his mother’s death. To escape these feelings, Alec goes in search of Joan. The therapist and Alec compose a flash card for Alec to read when his schema is triggered at work. Rather than seeking out Joan, the flash card advises him to give the child part of him a voice by writing out a dialogue between his Abandoned Child and Healthy Adult modes (Alec calls his Healthy Adult mode his “Good Mother.”) If the Healthy Adult in Alec can partially meet the unmet emotional needs of the Abandoned Child, then his Vulnerable Child will not have to go in search of Joan to meet these needs.

To further prepare Alec for behavioral change, the therapist asks him to conduct a dialogue between the schema side, which wants him to stay focused on Joan, and his healthy side, which wants him to forget Joan, focus on his work, and attempt to meet new available women. Alec plays both sides, switching chairs to signify the change. As the excerpt starts, the therapist has asked Alec to imagine being at work, fighting the desire to look for Joan.

The dialogue continues until Alec feels that the healthy side has defeated the schema side.

Alec’s first homework assignment for behavioral pattern-breaking is to stop his “Joan-centered” activities, replacing them with reading his flash card and writing out dialogues. He has moderate success with this homework assignment. At his next session, he reports that he was able to stop many of the activities he was doing from his desk, such as calling and e-mailing Joan. However, although every morning Alec promised himself that he would not seek her out, by the end of almost every day, he had gone back on this promise and arranged some pretext for seeing her. The therapist helps Alec work through his block to changing this behavior. Alec lists the advantages and disadvantages of continuing to seek her out. The main advantage is that, as long as he continues to see her, there is a chance he might win her over and get what he wants. The main disadvantage is that the behavior keeps him stuck in a place of hurt and loss.

Another behavior Alec and his therapist select for pattern-breaking is overworking. They agree that Alec should spend weekends engaged in activities through which he might meet available women, rather than working all weekend in his office, as was his usual custom. In the following excerpt, Alec and his therapist design a behavioral homework assignment with this purpose in mind.

The patient writes out the homework assignment, with instructions to self-monitor thoughts, feelings, and behaviors. At the next session, Alec reports the results. The therapist praises Alec for doing the homework and displays interest in the outcome. In addition, the therapist reiterates the benefits of completing the assignment.