Changing schema-driven behaviors is difficult, and, despite a patient’s desire to change, the process has many pitfalls. Early Maladaptive Schemas are deeply rooted and drive entire life patterns. They fight for survival in both obvious and subtle ways. We have developed several approaches to overcoming blocks to behavioral change.
Once patients have made a commitment to behavioral pattern-breaking, they may still have difficulty initiating new behaviors. When patients do not follow through on behavioral homework assignments, the first step is to understand why. Is the patient aware of the nature of the block? Sometimes patients know what is blocking them from complying with the homework, and they can say it directly. If not, the therapist can ask questions. Is the patient afraid of the consequences of changing? Is the patient angry that change is necessary or so hard? Is the patient having trouble tolerating the discomfort or struggle involved in changing? Did the patient uncover beliefs or feelings that are difficult to overcome? Does the patient believe that a positive outcome is impossible? Although the patient and therapist have gone over the advantages and disadvantages of changing the behavior, the patient may have minimized the power of a deterrent, or a new deterrent may have arisen once the patient attempted to change.
If the patient cannot state what the block is, or the patient’s answer appears implausible, then the therapist uses other methods to explore the nature of the block.
In the previous chapter, we discussed the use of imagery for behavior change in considerable detail. Here we review some of those strategies to highlight their importance in behavioral pattern-breaking.
The therapist can use imagery to investigate the block. The therapist asks the patient to visualize the problematic situation and to describe what happens when he or she attempts the new behavior. The therapist and patient explore the point at which the patient becomes stuck. What is the patient thinking and feeling at that moment? What are the other “characters” thinking and feeling? What does the patient want to do? In this way, the therapist and patient can often discern the nature of the block.
The therapist can use imagery in other ways. For example, the therapist might ask the patient to imagine carrying out the new behavior and investigate what happens afterward. Does the patient feel guilty or incur the wrath of a family member? Does the patient foresee some dreadful outcome? Alternatively, the therapist can ask the patient to picture an image of the block and imagine pushing through it. For example, the block might look like a dark weight pressing down on the patient. On questioning, the patient reveals that the block conveys the same message as a pessimistic parent. The patient pushes this message away by pushing away the block. Or the therapist might tie the moment of the block back to childhood by asking the patient to picture an image of feeling the same way as a child. The therapist can then use the opportunity to reparent the patient’s Vulnerable Child. Thus imagery can be used both to discover the nature of blocks and to overcome them.
The therapist can help the patient conduct dialogues between the side of the patient that wants to avoid the new behavior and the side that is willing to try the new behavior. The patient can conduct the dialogue in imagery or role-play the two sides by switching chairs. The therapist coaches the healthy side when necessary.
The therapist works to identify the mode that is blocking change. It could be a child mode, too timid or furious to attempt change. Or it could be a Maladaptive Coping mode, tempting the patient to resort to the old mal-adaptive coping behavior. Or it could be a Dysfunctional Parent mode, breaking the patient’s spirit by punishing the patient or demanding too much. Once the therapist knows which mode is interfering with the new behavior, he or she can start a dialogue with this mode and try to resolve its specific concerns. We discuss this kind of mode work in later chapters.
The therapist and patient can write a flash card addressing the block. In the flash card, they fight the relevant schemas and maladaptive coping styles. For example, if the patient’s block consists of anger, the flash card might read: “Right now I feel too angry to practice being less aggressive in my close relationships, as I agreed to do in my therapy sessions.” The flash card summarizes the advantages and disadvantages of continuing the maladaptive coping style, spells out the healthy behavior, and provides solutions to practical problems. For anger, the flash card could suggest self-control techniques: “I’ll take slow, deep breaths until I feel calm, and then I’ll envision doing the healthy behavior.” Reading the flash card gives the patient the opportunity to work through the anger before responding in the situation.
Once the therapist and patient have identified the block and attempted to work through it, then the patient tries the new behavior again as a homework assignment. The therapist may consider reducing the difficulty of the assignment or breaking the assignment into smaller, graduated steps. If, after reassigning the homework, the patient is still unable to comply, the therapist may shift the focus to another behavioral pattern and come back to this one later. However, it is important for the therapist not to become sidetracked in the pursuit of behavioral change. Whatever happens, the therapist continues to use empathic confrontation to push for behavioral change. Sometimes it can be quite challenging for the therapist to keep empathically confronting the patient’s difficulty in making behavioral changes.
If the preceding strategies do not work, the therapist can consider setting contingencies that reward the new behavior. For example, patients could reward themselves for carrying out the new behavior as part of the homework assignment. What serves as a reward varies from patient to patient, depending on what the patient views as pleasurable. Some possibilities in-elude buying oneself a small gift, engaging in a fun activity or doing something self-nurturing. One especially powerful reinforcer for many patients is calling the therapist and leaving a message on the answering machine reporting that the homework is complete.
If the patient seems unalterably resistant to behavioral change over a long period of time, the ultimate contingency is for the therapist to suggest a break from therapy. For example, the therapist might introduce the idea of a time-limited effort: The therapist and patient decide how much longer to work on behavioral change, and, if no change is forthcoming during that period, they agree to cease therapy temporarily. The therapist lets the patient know that therapy can resume as soon as the patient is ready to attempt behavioral change. The therapist presents this as an issue of “readiness”—the therapist will wait for the patient to signal readiness for change. This is an extreme measure for the therapist to take and is meant for extremely resistant cases. Sometimes patients are simply not ready to change. They need time to pass or life circumstances to change before risking new behaviors. Sometimes they need to experience a greater level of distress. Staying stuck must feel worse than changing before some patients can summon enough motivation to change.
It is important to point out that we carefully weigh whether there are other benefits of remaining in therapy—such as reparenting a patient with BPD—that might outweigh the absence of behavioral change. Thus we sometimes continue treatment for a considerable period of time without behavioral change if there is a compelling rationale for doing so with a particular patient.
The therapist could introduce the idea of a time-limited effort followed by a break as follows:
“I think you’re trying very hard, but your schemas are very powerful. Perhaps at this point we’ve gone about as far as we can go in terms of change. Sometimes life events occur that enable people to change their behavior. How would you feel about this idea: We could continue to meet for one more month to see if you’re able to make any changes. If not, we could discontinue meeting for a while, and you could call me when you feel ready to resume treatment and work on these behavioral changes. What do you think about this as a possible plan?”
Spencer is 31 years old. He has come to therapy because he is dissatisfied with his job. Although he has a master’s degree in fine arts, since leaving school he has held a job as a graphic designer that is far below his level of competence. Although he feels bored and unappreciated at his job, he finds himself unable to look for other work. No job seems quite right: Either the job does not seem good enough or he does not feel qualified enough. In the Assessment Phase, Spencer identifies his Defectiveness and Failure schemas. He goes through the cognitive and experiential stages of treatment and undertakes behavioral change. Week after week, he is unable to carry through with behavioral homework assignments. Time passes, and he stays frozen where he is. However, something unexpected happens: Spencer loses his job. Even though he finds his financial reserves dwindling, he is still unable to look actively for work. His survival is threatened.
The therapist theorizes that Spencer’s paralysis points to a conflict in modes. When patients must take steps to ensure their very survival, yet still find themselves unable to act, then conflicting modes is a likely hypothesis. The therapist helps Spencer identify the two modes locked in conflict: the Defective Child, who feels too helpless and hopeless to proceed, and the Healthy Adult, who wants to find more fulfilling work. Conducting dialogues between these two modes helps Spencer resolve the conflict. The Healthy Adult assuages the fears of the Vulnerable Child and promises to handle whatever difficulties arise.
Patients feel at one with their Early Maladaptive Schemas: Their schemas are part of who they are. They believe in the truth of their schemas to such an extent that many times they cannot grasp the possibility of change. In some cases, the patient has not yet gotten sufficiently angry at the schema. In other cases, such as often happens with patients with narcissistic personality disorder, the disadvantages of the dysfunctional behaviors are not sufficiently motivating. Many narcissistic behaviors upset significant others far more than they upset the patients themselves, and patients are not motivated to change until a significant other does something drastic, such as threatening to end the relationship. The therapist addresses this problem by emphasizing the long-term negative consequences of maintaining the narcissistic behavior.
Rina has an Entitlement schema. Having been spoiled as a child, she believes she deserves special treatment. Among the privileges she accords to herself but not to others is to explode in anger whenever she does not get her way. She comes to therapy because her fiancé, Mitch, is threatening to call off their engagement unless she learns to control her temper. Rina experiences difficulty carrying through on behavioral homework assignments. For example, she and the therapist agree that she will take a “time out” when she is about to lose her temper with Mitch, but each time she decides that what she wants in that instance is more important. “I want what I want,” she says, and “giving in just isn’t me.” Hence, she continues to lose her temper. Rina does not have an Insufficient Self-Control/Self-Discipline schema, because the problem of self-control only arises when she cannot get her own way.
The therapist helps her overcome her block. Rina lists the advantages and disadvantages of continuing to lose her temper. She conducts dialogues between her healthy side and her entitled side. She and the therapist compose a flash card reminding her why it is important to learn to control her temper: She is endangering her relationship with Mitch every time she loses control of her anger, and keeping Mitch is more important to her than momentarily getting her way. Rina practices controlling her anger in imagery and role-plays. She gradually learns to control her anger and express herself more appropriately in her relationship with Mitch.