The Therapy Relationship in the Assessment and Education Phase

In the Assessment and Education Phase, the therapy relationship is a powerful means to assess schemas and to educate the patient. The therapist establishes rapport, formulates the case conceptualization, decides what style of limited reparenting is appropriate for the patient, and determines whether the therapist’s own schemas are likely to interfere with therapy.

The Therapist Establishes Rapport

As in other forms of psychotherapy, the therapy relationship begins with establishing rapport with the patient. The therapist strives to embody the empathy, warmth, and genuineness identified by Rogers (1951) as the nonspecific factors of effective therapy. The goal is to create an environment that is accepting and safe, in which the patient can form an emotional bond with the therapist.

Schema therapists are personal rather than detached and aloof, in their manner of relating to patients. They try not to appear as though they are perfect, nor as though they have knowledge they are withholding from the patient. They let their natural personalities come through. They share their emotional responses when they believe it will have a positive effect on the patient. They self-disclose when it will help the patient. They aim for a stance of objectivity and compassion.

Schema therapists ask patients for feedback about themselves and the treatment. They encourage patients to express negative feelings about therapy so that these feelings do not build up and create distance and resistance. The goal in responding to negative comments is to listen without becoming defensive and to try to understand the situation from the patient’s point of view. (Of course, the therapist does not let the patient behave abusively—by yelling or making personal attacks—without setting limits.) To the extent that the patient’s negative feedback is a schema-driven distortion, the therapist attempts to acknowledge the kernel of truth while helping the patient identify and fight the schema through empathic confrontation. To the extent that the patient’s negative feedback is accurate, the therapist acknowledges mistakes and apologizes.

Schema therapy is an approach that finds what is healthy and supports it. The basic model is one of empowering the patient. The therapist forms an alliance with the patient’s healthy side against the patient’s schemas. The ultimate goal of treatment is to strengthen the patient’s Healthy Adult mode.

The Therapist Formulates the Case Conceptualization

The therapy relationship illuminates the patient’s (and the therapist’s) schemas and coping styles. When one of the patient’s schemas is triggered in the therapy relationship, the therapist helps the patient identify the schema. The therapist and patient explore what happened—what actions of the therapist triggered the schema and what the patient thought, felt, and did. What was the patient’s coping response? Was the style one of surrender, avoidance, or overcompensation? The therapist uses imagery to help the patient link the incident to childhood—so that the patient realizes who it was in childhood that promulgated the schema—and to current life problems.

When the therapy relationship triggers one of the patient’s Early Maladaptive Schemas, then the situation is similar to Freud’s concept of transference: The patient is responding to the therapist as though the therapist were a significant figure from the patient’s past, usually a parent. In schema therapy, however, the therapist discusses the patient’s schemas and coping styles openly and directly, rather than tacitly working through the patient’s “transference neurosis” (Freud, 1917/1963).

Case Illustration

We present an excerpt from an interview Dr. Young conducted with Daniel, a patient discussed in previous chapters. At the time of the interview, Daniel had been in schema therapy with another therapist, named Leon, for approximately 9 months. Daniel’s Mistrust/Abuse, Defectiveness, and Subjugation schemas had already been identified. He typically utilized schema avoidance as his coping style.

During the session, the therapist leads Daniel through a number of imagery exercises. In the final 20 minutes of the interview, Dr. Young asks Daniel about his therapeutic relationship with Leon. Next, Dr. Young explores whether Daniel’s schemas were triggered during the current interview. The therapist begins by asking Daniel about his Mistrust/Abuse schema.

Next, the therapist asks about Daniel’s Subjugation schema.

Dr. Young moves on to his own relationship with Daniel. He inquires whether Daniel’s schemas were triggered during the interview. He begins by asking about Subjugation.

The therapist asks Daniel about other times his Subjugation and Defectiveness schemas were triggered during the session.

The therapist makes explicit that Daniel’s Mistrust/Abuse schema has also been operating in their relationship during the session, along with his Defectiveness and Subjugation schemas.

The therapist links what Daniel felt during the session to other encounters in his life.

This excerpt provides a good example of how the therapist can utilize the therapy relationship to educate patients about their schemas. In addition, it is noteworthy that Dr. Young specifically asked the patient about whether his schemas were triggered in the therapy relationship. The patient would not have raised the subject without direct questioning on the therapist’s part.

There are typical session behaviors for each schema. For example, patients who have Entitlement schemas might ask for extra time or special consideration in scheduling appointments; patients who have Self-Sacrifice schemas might try to take care of the therapist; patients who have Unrelenting Standards schemas might criticize the therapist for minor errors. The patient’s behavior with the therapist suggests hypotheses about the patient’s behavior with significant others. The same schemas and coping styles that the patient exhibits with the therapist probably appear in other relationships outside the therapy.

The Therapist Assesses the Patient’s Reparenting Needs

Another task the therapist faces in the Assessment and Education Phase is assessing the patient’s reparenting needs. Throughout treatment, the therapist will use the therapy relationship as a partial antidote to the patient’s schemas. This “limited reparenting” provides a “corrective emotional experience” (Alexander & French, 1946) specifically designed to counteract the patient’s Early Maladaptive Schemas.

The therapist uses a variety of sources to ascertain the patient’s reparenting needs: childhood history, reports of interpersonal difficulties, questionnaires, and imagery exercises. Sometimes the richest source of information is the patient’s behavior in the therapy relationship. Whatever sheds light on the patient’s schemas and coping styles supplies clues about the patient’s reparenting needs.

Case Illustration

Jasmine is a young woman who begins therapy wary of becoming “dependent” on the therapist. She tells her therapist that she has just started college and is accustomed to making her own decisions without relying on her parents or anyone else for guidance. She does not want that to change. In the first few weeks of therapy, it becomes apparent that Jasmine’s core schema is Emotional Deprivation as a result of her childhood with emotionally cold parents who shamed her when she asked for help. “They expected me to deal with my problems by myself,” she says. Guidance is exactly what Jasmine needs from her therapist—it is one of her unmet emotional needs. For Jasmine, limited reparenting involves giving her some of the guidance she never got from her parents as a child. Recognizing her Emotional Deprivation schema helps the therapist know what form of reparenting she needs. (One of the barriers to reparenting Jasmine will be to help her accept help and caring, as she has learned that it is shameful to do so.)

Had Jasmine’s therapist taken her at her word and viewed her problem as one of preserving her independence, the therapist might have refrained from giving her the guidance she needed. Jasmine was not too dependent. Rather, she had never been permitted to be dependent enough. Emotionally, she had always been alone. By reparenting her in accord with her core Early Maladaptive Schema, the therapist could help her recognize that her dependency needs were normal and that establishing autonomy was a gradual process.

Ideal Therapist Qualities in Schema Therapy

Flexibility is a key feature of the ideal schema therapist. Because the type of limited reparenting required depends on each patient’s unique childhood history, therapists must adjust their styles to fit the emotional needs of the individual patient. For example, depending on the patient’s schemas, the therapist has to focus on generating trust, providing stability, giving emotional nurturance, encouraging independence, or demonstrating forgiveness. The therapist must be able to provide in the therapy relationship whatever is a partial antidote to the patient’s core Early Maladaptive Schemas.

Like a good parent, the schema therapist is capable of partially meeting—within the limits of the therapy relationship—the patient’s basic emotional needs we described in Chapter 1: (1) secure attachment; (2) autonomy and competence; (3) genuine self-expression of needs and emotions; (4) spontaneity and play; and (5) realistic limits. The goal is for the patient to internalize a Healthy Adult mode, modeled after the therapist, that can fight schemas and inspire healthy behavior.

Case Illustration

Lily is 52 years old, and her children are grown and out of the house. She has an Emotional Deprivation schema. As a child, no one connected with her emotionally. She became increasingly withdrawn, preferring to study or play her violin rather than interact with others. She had few friends, and they were not really close. Lily has been married to her husband, Joseph, for 30 years. She has lost interest in her marriage and spends most of her time at home isolated with her books and her music. In the Assessment Phase, Lily and the therapist agree that her core schema is Emotional Deprivation and that her main coping style is avoidance.

As the weeks pass, Lily begins to have sexual feelings for her male therapist. She becomes aware of how emotionally empty her life is. No longer satisfied to read and play music alone, she begins to want more. Alarmed and ashamed of her needs, she copes by withdrawing psychologically from the therapist. The therapist observes her withdrawal. He theorizes that her Emotional Deprivation schema has been triggered in the therapy relationship and that she is responding with schema avoidance. Knowing her core schema and main coping style points the way to understanding for the therapist.

The therapist points out Lily’s withdrawal and helps her explore it. Although not able to talk about her sexual feelings, she is able to say that she is experiencing feelings of caring for the therapist and that this is making her extremely uncomfortable. She has not really cared about anybody for a long time. The therapist asks Lily to close her eyes and link the feeling of discomfort with him to times in the past that she had similar feelings. She connects the feeling first to her husband in the early days of their marriage and then to her father when she was a child. She remembers walking home from school and seeing a little boy run into his father’s arms and feeling a wave of longing to do the same with her own remote father. In her memory, Lily went up to her room when she got home and spent the rest of the day practicing her violin.

The therapist helps Lily see the schema-driven distortion in her view of the therapy relationship. Unlike her father, the therapist welcomes her feelings of caring (when they are expressed within the appropriate limits of the therapy relationship). In the therapy relationship, she is allowed to care and to want caring; the therapist will not reject her for it. She is allowed to talk about her feelings directly and does not have to withdraw. Although this kind of communication was not possible with her father, it is possible with the therapist and, by implication, with other people in the world. (We encourage patients to verbalize sexual feelings to the therapist as well, although we gently, in a nonrejecting way, indicate that acting on these feelings with the therapist is not possible. We emphasize that patients can eventually share these same feelings with someone in their lives who will be in a position to respond in kind)

When a patient engages in behaviors during the session that reflect overcompensation, the schema therapist responds objectively and appropriately, utilizing empathic confrontation. The therapist expresses understanding of the reasons for the patient behaving in such a way but points out the consequences of the behavior in the therapy relationship and in the patient’s outside life. The following example illustrates this process.

Case Illustration

Jeffrey is 41 years old. He comes to therapy because Josie, his girlfriend of 10 years, has broken up with him. He is realizing that, this time, he is not going to get her back. Throughout their relationship, Jeffrey repeatedly cheated on Josie. She would break up with him, he would beg for her forgiveness and promise to reform, and she would take him back. But no more. Consequently, Jeffrey has fallen into a major depression.

Jeffrey has narcissistic personality disorder, a personality type that is discussed much more fully in Chapter 10. His core schema is Defectiveness, and his primary coping style is schema overcompensation. In his relationships with women, Jeffrey overcompensates for his feelings of defectiveness by winning them over sexually. Even though he loved Josie as much as he was capable of, he was not able to give up cheating on her (a major source of narcissistic gratification).

Jeffrey overcompensates in the therapy relationship by getting angry whenever the therapist evokes feelings of vulnerability. He is uncomfortable being vulnerable with the therapist because of his Defectiveness schema: Being vulnerable causes him to feel ashamed and exposed. In one session, Jeffrey relates a childhood incident concerning himself and his emotionally rejecting mother (from whom Jeffrey is currently estranged). The therapist comments that, based on this incident, it seems that Jeffrey loved his mother, even though he was angry with her as a child. Jeffrey lashes out at the therapist, calling him a “momma’s boy.” In a serious tone, the therapist leans forward and asks Jeffrey why he just lashed out like that. What was he feeling underneath? When Jeffrey denies feeling anything underneath, the therapist suggests that Jeffrey may have felt vulnerable. “I understand,” says the therapist. “As a child you loved your mother. I loved my mother as a child, too. It’s natural for children to love their mothers. It’s not a sign of weakness or inadequacy.” The therapist communicates that Jeffrey does not have to feel inferior to anyone, including the therapist, for loving his mother. Next, the therapist conveys that Jeffrey’s overcompensation—lashing out at the therapist—has the effect of making, the therapist want to pull away from Jeffrey, instead of giving him the understanding that he needs.

Schema therapists can also tolerate and contain a patient’s strong affect—including panic, rage, and grief—and provide appropriate validation. They have realistic expectations of the patient. They can set limits on their own behavior and on the patient’s behavior. They can handle therapeutic crises appropriately. They can maintain appropriate boundaries between themselves and the patient, neither too distant nor too close.

Another task of the therapist in the Assessment Phase is to determine whether his or her own schemas and coping styles have the potential to be destructive to the therapeutic relationship.

The Therapist’s Own Schemas and Coping Styles

Ted comes to his first therapy session saying he wants help in his career as a broker in the financial district. He wants to develop the focus and discipline he believes are necessary for him to succeed. Ted is friendly and talkative. He tells amusing stories about his life. He compliments the therapist and does not complain, even when the therapist mispronounces his last name twice. The therapist feels it is all “too much”: Ted is too friendly, too talkative, too complimentary. (This sense of “too muchness” is often a sign of schema overcompensation.) Instead of feeling warm and close to Ted as one might expect with a friendly person, the therapist feels taken aback. The therapist hypothesizes that underneath Ted’s amiable style is an Early Maladaptive Schema. As the weeks progress, it becomes clear that the therapist’s hypothesis is correct. Underneath Ted’s friendliness, he feels insecure and alone. He has a Social Isolation schema, for which he overcompensates with “hyperfriendliness.”

The therapist’s reactions to the patient can be a valuable resource in assessing the patient’s schemas. However, therapists must be able to distinguish their valid intuition about a patient from the triggering of their own schemas. Early in therapy, it is important for therapists to become aware of their schemas in regard to the individual patient. Knowledge of one’s own schemas and coping styles can help therapists avoid mistakes. Therapists can ask themselves basic questions about the patient. Does the therapist genuinely care about the patient? If not, why not? Is working with the patient triggering any of the therapist’s schemas? Which ones? How is the therapist coping? Is the therapist doing anything that is potentially damaging to the patient? How would the therapist feel about doing imagery work with the patient? How would the therapist feel about dealing with the patient’s raw emotions, such as panic, rage, and grief? Can the therapist empathically confront the patient’s schemas as they appear? Can the therapist provide the kind of limited reparenting the patient needs?

In the following pages, we provide several examples of scenarios in which the therapist’s schemas have a negative impact on the therapy relationship. Each example is followed by one or more case illustrations.

1. The patient’s schemas clash with the therapists schemas. One risk is that the patient’s schemas might clash with the therapist’s schemas in such a way that they trigger each other in a self-perpetuating loop. Here are some examples of schema clashes between therapist and patient.

Case Illustration

Maddie has a core Emotional Deprivation schema. She copes with her schema by becoming overly demanding; that is, she overcompensates through her Entitlement schema.

Maddie begins therapy with a male therapist with a Subjugation schema. Maddie is a demanding patient in many ways. She calls frequently between sessions, keeps changing her appointment time, and makes other requests for special treatment. The therapist accedes to her demands, his Subjugation schema preventing him from setting limits. Inwardly he feels a burgeoning sense of resentment. In sessions with Maddie, he becomes distant and withdrawn (employing a coping style of schema avoidance). This further triggers Maddie’s Emotional Deprivation schema, and she becomes even more demanding; the therapist’s Subjugation schema becomes reactivated, and so on, in a reciprocal triggering of schemas with the potential to demolish the therapeutic alliance.

If the therapist recognizes that his Subjugation schema is being triggered in his sessions with Maddie and preventing him from responding to her therapeutically, then he can work to correct the problem. He can set appropriate limits and transform his maladaptive coping response of avoidance into one of empathic confrontation. He can tell Maddie he understands that, underneath, she feels emotionally deprived in her relationship with him, just as she did in childhood; nevertheless, the way she is expressing her feelings is having the opposite effect from the one she wants. It is making it more difficult for the therapist to give her the nurturance she needs.

Case Illustration

An older male patient, Kenneth, has an Unrelenting Standards schema, and his younger female therapist has a Defectiveness schema (resulting from her childhood with her critical father). When the therapist makes even a minor mistake, Kenneth devalues her. “I’m really disappointed in you,” he tells her sternly, triggering her Defectiveness schema and making her blush.

Depending on the therapist’s coping style, at that moment her performance as a therapist becomes impaired by schema surrender, avoidance, or overcompensation. She either denigrates herself (schema surrender), retreats from the issue by changing the subject (schema avoidance), or becomes defensive and blaming (schema overcompensation). Noticing any of these “imperfect” behaviors further triggers Kenneth’s Unrelenting Standards schema, provoking him to disparage her more, and so on. Eventually, convinced of the therapist’s ineptitude, Kenneth leaves therapy.

Case Illustration

Alana, a younger female patient, begins therapy with an older female therapist. Alana has a Mistrust/Abuse schema, which began in childhood as a result of contacts with her sexually abusive uncle. Her main coping style is schema surrender: She repeatedly assumes a victim role with others. Her therapist has a Subjugation schema. As a therapist, her main coping style is overcompensation. She dominates patients in order to cope with underlying feelings of being overly controlled in other areas of her life, such as her marriage and family of origin.

As therapy progresses, Alana assumes an increasingly passive role, and the therapist increasingly comes to dominate her. The therapist gets pleasure from controlling Alana, and Alana, who never learned how to resist, submits to whatever the therapist demands. The therapist unknowingly uses Alana to reduce her own feelings of subjugation, ultimately reinforcing Alana’s Mistrust/Abuse schema.

Numerous variations of schema clashes arise in the therapy relationship. The patient might have a Dependence schema and the therapist a Self-Sacrifice schema. The therapist does too much for the patient, maintaining the patient’s dependence. Alternatively, the patient might have a Failure schema and the therapist an Unrelenting Standards schema. The therapist has unrealistic expectations of what the patient should accomplish, subtly communicates impatience, and confirms the patient’s sense of failure. Or the patient might adopt an obsessive and controlling coping style in order to overcompensate for an underlying Negativity/Pessimism schema, whereas the therapist has an Insufficient Self-Control/Self-Discipline schema. The therapist appears disorganized and impulsive, causing the patient to worry. The patient eventually leaves therapy even more demoralized and downcast.

2. A mismatch exists between the patient’s needs and the therapist’s schemas or coping styles. The patient might have needs that the therapist is not able to meet. Because of the therapist’s own schemas or coping styles, the therapist cannot give the patient the right kind of reparenting. (Often the therapist resembles the parent who originally engendered the schema in the patient.) Here are several examples.

Case Illustration

Neil enters therapy for depression and marital problems. Although it is not immediately apparent, Neil’s core schema is Emotional Deprivation, based on his childhood with neglectful, self-involved parents and his marriage to a self-involved woman. It is Neil’s emotional deprivation that is keeping him depressed. In terms of limited reparenting, Neil needs caring and empathy from his therapist.

Unfortunately, his therapist has an Emotional Inhibition schema and is unable to provide emotional warmth. As therapy progresses, Neil, now emotionally deprived by his therapist as well, becomes even more depressed.

Case Illustration

Edward has a Dependence/Incompetence schema. Rather than going to college after graduating from high school 6 years ago, Edward went to work for his domineering father, who owns a successful textile business. His father makes all the business decisions, and, as he had done before Edward came to work for him, he exerts a large influence on Edward’s personal life.

Edward enters therapy for help with his chronically high anxiety. Even the small decisions he makes on his own torment him. Faced with a decision, he becomes frozen with anxiety and usually opts to reduce the anxiety by consulting his father.

In terms of reparenting, Edward needs a therapist who will promote gradually increasing levels of autonomy. However, Edward’s therapist has an Enmeshment schema and becomes overly involved. Edward ends up weaning himself from his father’s input, only to become dependent on the therapist.

Case Illustration

Max has an Insufficient Self-Control/Self-Discipline schema. He comes to therapy because his schema is holding him back in his career as a journalist. Because he is generally not accountable for his time, Max is having trouble getting his stories done. He needs a therapist who will confront him empathically and provide structure.

Max begins therapy with a female therapist who has a Subjugation schema in regard to men based on her childhood with her strict father. When she did something “bad” as a child, her father often flew into an un-controlled rage. As with her father, the therapist assumes an avoidant coping style with Max. When Max fails to follow through on homework assignments or drifts away from difficult session material, she keeps quiet. In order to avoid conflict, she fails to confront him and set limits. She cannot give him the structure he needs and thus perpetuates, rather than heals, his schema.

3. Overidentification takes place when the patient’s and therapist’s schemas overlap. If the patient and therapist have the same schema, the therapist might overidentify with the patient and lose objectivity. The therapist colludes with the patient in reinforcing the schema.

Case Illustration

Richie, the patient, and his female therapist both have Abandonment schemas. Richie’s parents divorced when he was 5 years old. He stayed with his father, and his mother became a distant figure in his life. He comes for therapy after his girlfriend leaves him. He is in a major depression and experiencing panic attacks.

The therapist lost her own mother in an automobile accident when she was 12 years old. When Richie talks about the loss of his mother, the therapist is filled with grief. When Richie mourns the end of his relationship with his girlfriend, the therapist feels overcome by his pain. She becomes too involved in his life and cannot set proper boundaries. She tells him to call her anytime, day or night, that he feels overwhelmed, and she spends hours on the phone talking to him each week. She is slow to recognize his cognitive distortions, agreeing with him rather than encouraging reality-testing when he interprets minor separations from his friends as instances of major abandonment. She supports his maladaptive coping responses rather than helping him change.

Self-Sacrifice is perhaps the most common schema among therapists. When working with patients who share this schema, therapists must be careful not to collude with the patients’ schemas. These therapists must make a conscious effort to model appropriate levels of “give and take,” neither giving too much to nor taking too much from their self-sacrificing patients. Unrelenting Standards is another schema common among therapists. When treating patients who share the schema, therapists must deliberately set reasonable expectations, both for themselves and for their perfectionistic patients.

4. The patient’s emotions trigger the therapist’s avoidance behavior. Sometimes the intensity of the patient’s emotions overwhelms the therapist and prompts him or her to become avoidant. The therapist withdraws psychologically or changes the subject, or otherwise communicates to the patient that it is not acceptable to have intense emotions.

Case Illustration

Leigh comes to therapy following the death of her father. She tells the therapist that she was her father’s “pride and joy” and that he was the only one who ever loved her. Leigh feels crushed by the loss and has stopped functioning. She has taken a leave of absence from work and spends her nights drinking at bars and her days sleeping or watching television. Since the death of her father, she has had sex with several men, all while she was drunk. She blacked out during some of these encounters and thus does not remember them.

Leigh’s male therapist has a Self-Sacrifice schema. The therapist has added Leigh to an already overcrowded schedule of patients. In addition, he is doing almost all of the housework, shopping, and cooking for his pregnant wife. Confronted with the fierceness of Leigh’s grief and the enormity of her emotional needs, he feels overwhelmed. He is too depleted to be there for her. He shuts down emotionally. He cannot bear to experience Leigh’s neediness, so he ignores it. He denies her the forum she needs to express her pain. Feeling he does not care about her, Leigh leaves therapy after a few months.

Case Illustration

Hans is 55 years old. He has just lost his job as an executive in a small corporation. Although he made hundreds of thousands of dollars each year for the 3 years he held the position, he did not save any money. In fact, he is in debt. Hans has a history of getting fired from jobs. His main problem is managing his anger. Hans has a Defectiveness schema, and whenever he feels criticized, he overcompensates by making loud, cutting remarks. Because he often perceives slights where none are intended, almost everyone he encounters eventually falls prey to his sarcastic and insulting comments.

Hans comes to therapy for help in working through his anger over getting fired and in settling down to find a new job. In his sessions, he goes on long tirades about the series of events that led up to his getting fired and about the people at work who betrayed and plotted against him. His anger seems boundless.

When time passes and he is not able to settle down and look for work, he becomes angry with the therapist as well. He begins to spend sessions raging at the therapist for not helping him. The therapist, who has a Subjugation schema, cannot withstand the force of Hans’s anger and becomes defensive. The more defensive the therapist becomes, the more angry Hans becomes.

When a patient is very vulnerable or angry a lot of the time, the therapist is at risk for engaging in some form of avoidance behavior. This is especially prone to happen with patients with BPD when the therapist cannot tolerate the patient’s intense affect and suicidality. The therapist withdraws, triggering the patient’s Abandonment schema, and thus further increases the intensity of the patient’s affect and suicidality in a vicious cycle that can quickly spiral into crisis. This issue is discussed further in Chapter 9.

5. The patient triggers the therapist’s schemas, and the therapist overcompensates. When the patient’s emotions alarm the therapist, some therapists overcompensate. For example, when patients with BPD are very emotional or suicidal, some therapists become avoidant and withdraw, as we just described. Other therapists, however, who tend to overcompensate, may retaliate. They become angry with the patient; they attack and blame the patient. What these patients need is a sign that the therapist truly cares about them, and such a sign will almost always calm them down. Neither the therapist who avoids nor the therapist who overcompensates gives patients with BPD what they need in times of crisis, and both thus tend to respond in ways that make matters worse.

Case Illustration

Victor, the patient, and his male therapist have Defectiveness schemas, and both tend to overcompensate under perceived attack. Victor begins treatment by saying that his childhood was “blissful” and that both his parents were “totally supportive.” In imagery of childhood, however, Victor recalls feeling that his father’s support was fake and that he never really pleased his father at all. “My father wanted me to be like him, athletic. But sports was my weakest area. I did well at school, I got straight A’s, I was Phi Beta Kappa in college, but that really didn’t matter to my father.”

Victor asks his therapist whether he was a good athlete in high school. The therapist, feeling envious that Victor was apparently a better student than he was, cannot resist bragging inappropriately about his own athletic record. He tells Victor that he was a state champion in wrestling. Feeling put down, Victor makes a disparaging remark about “jocks,” and the therapist retorts with a hostile comment about Victor’s “jealousy.” Thus, rather than healing the patient’s feeling of defectiveness, the therapist perpetuates it.

If the patient has an Entitlement schema and the therapist has a Self-Sacrifice schema, the therapist might give too much extra support for too long, and then, when the patient makes some entitled request, suddenly overcompensate by lashing out in anger against the patient.

6. The patient triggers the therapist’s Dysfunctional Parent mode. The patient behaves like a “bad child,” triggering a Disapproving Parent mode in the therapist. The therapist reprimands the patient like a scolding parent.

Case Illustration

Dan comes to therapy because he is failing in college. After going through the assessment, Dan and his female therapist agree that he has an Insufficient Self-Control/Self-Discipline schema. The therapist gives Dan homework assignments to self-monitor, but he does not comply. She sets up one assignment after another to foster discipline, but all of them fail. The therapist, who has a Defectiveness schema, begins to feel inadequate. She overcompensates by assuming the role of a “punitive parent.” She loses empathy and chastises Dan, just as his parents did when he was a child (and, we might add, just as her parents did when she was a child). Dan feels bad about himself but still finds himself unable to complete homework assignments or adhere to agreements. Feeling punished but not getting any better, Dan leaves therapy.

Case Illustration

Lana has a Defectiveness schema. She comes to therapy because, even though she is a highly successful actress, inside she feels worthless and unlovable. Unfortunately, her male therapist has an Unrelenting Standards schema. Like her father when Lana was a child, he assumes the attitude of a “demanding parent.” He sets ever higher standards for her to reach. Lana stays in therapy for years, striving to become “good enough” to win his approval.

7. The patient satisfies the therapist’s schema-driven needs. Therapists who do not monitor their own schemas are at risk to inadvertently exploit patients. Rather than focusing on the patient’s welfare, these therapists unintentionally use patients to fill their own unmet emotional needs.

Case Illustration

The female therapist has an Emotional Deprivation schema (another schema common among therapists). Throughout her life, she has received little nurturing. One of the ways she copes with her schema is by nurturing others in her work life. In this way, she symbolically nurtures her own inner child.

The patient, Marcie, has a Self-Sacrifice schema. She comes to therapy because she is depressed and does not know why. It becomes apparent that Marcie is so swept up in taking care of the members of her family, especially her mother, that she has little time for herself.

Like most people with Self-Sacrifice schemas, Marcie is empathic, self-denying, and solicitous. She notices when the therapist is looking fatigued or dejected. Even though she is bursting with things to say, she suppresses her own needs and asks the therapist what is wrong. Rather than pointing out what Marcie is doing, as she should, the therapist answers her, telling Marcie her troubles. Marcie is sympathetic. Over time the therapist increasingly allows Marcie to become her caretaker. With another person to care for, Marcie becomes even more depressed.

There are endless possibilities. Consider a patient who has an Enmeshment schema and fuses with a therapist who has a Social Isolation schema and who likes the closeness so much that she cannot help the patient individuate. Or consider an approval-seeking patient who, eager to please, compliments the therapist frequently and a therapist with a Defectiveness or Dependence schema who responds to the praise with obvious enjoyment. Unfortunately, the therapist’s positive response to the patient’s behavior reinforces it.

8. The therapist’s schemas are triggered when the patient fails to make “sufficient progress.” Often therapists with Defectiveness, Failure, or Dependence/Incompetence schemas respond improperly to patients who do not improve in therapy. Such therapists express anger or impatience toward the patient, often perpetuating the patient’s schemas.

Case Illustration

A male therapist is treating Beth, a young patient with BPD who is depressed about her relationship with her boyfriend, Carlos. Beth is obsessed with Carlos. When the relationship first started, Beth and Carlos were inseparable. Gradually Carlos began to want more “space,” and Beth became frantic. She became clingy and controlling, getting upset whenever Carlos wanted to separate and demanding an accounting of all his time away from her. By the time she started therapy, it was clear that Carlos wanted out of the relationship, but Beth was not letting him go. Rather, she was calling him repeatedly—crying, promising to change, begging him to reconsider. Carlos spoke to her, but he steadfastly refused to go back with her and started dating other women

The therapist has a Dependence/Incompetence schema. Nervously, he tries to help Beth let go of her boyfriend. He points out how self-destructive it is to try to hold onto Carlos, and Beth agrees. He teaches her thought-stopping and distraction techniques to use when she is obsessing about Carlos. He helps her identify alternative activities when she has urges to call Carlos. However, no matter what he does, nothing changes. Beth is still just as obsessed with Carlos and is still calling him and begging him to take her back. The therapist begins to feel inept and resentful. When Beth expresses feelings of hopelessness, he blames her. He insinuates that she does not want to get better. When she talks about calling Carlos, he berates her. Beth ends up feeling that she is not good enough for Carlos and not good enough for her therapist, either.

Therapists with Defectiveness, Failure, or Dependence/Incompetence schemas might respond to a patient’s lack of progress in other destructive ways. Therapists who surrender as a coping style might appear agitated and lacking in confidence, thus undermining the patient’s faith in therapy. Therapists who avoid might impulsively propose that the patient seek another, better therapist.

9. The therapist’s schemas are triggered when the patient has crises, such as high suicidality. Crises have a high likelihood of triggering the therapist’s schemas. They test the therapist’s ability to cope in positive ways.

Case Illustration

The female therapist has a Subjugation schema based on her childhood with a controlling mother. Starting when she was a young child, her mother threatened to abandon her if she was “bad”—”bad” meaning not doing what her mother wanted.

Jessica, the patient, begins therapy. Jessica gives a confusing account of her childhood: At one point she says her aunt and uncle sexually abused her and her little brother; at another point she says it never happened. Jessica’s boyfriend is a substance abuser. His drugs of choice are cocaine and alcohol. When he is on a binge, he disappears, often for days. The last time it happened, Jessica cut her ankles with a razor.

A few weeks into therapy, the boyfriend has a date to meet Jessica for dinner, but he never shows up. Jessica goes home, cuts her ankles, and calls the therapist, waking her up. “How could he do this to me?” Jessica wails over the phone. Jessica tells the therapist that she cut her ankles. Rather than feeling empathic, the therapist is furious. She thinks Jessica is trying to manipulate and control her, just as her own mother did in her childhood. “That was a very hostile thing to do!” she exclaims, throwing Jessica into a panic.

In order to handle crises effectively, the therapist must remain empathic and objective and not become critical or punitive. (We discuss the management of acute suicidality and other crises in Chapter 9.

10. The therapist envies the patient on an ongoing basis. If the therapist is narcissistic, the therapist might envy the patient. In such cases, the patient has access to a source of gratification that the therapist has longed for but never had, such as beauty, wealth, or success. Or, as in the following example, the patient fulfills in her own life one of the therapist’s unmet needs.

Case Illustration

Jade, the patient, is 19 years old. She comes to therapy because her mother is dying of cancer. Her father brings her to her first session. It is obvious that her father loves her. Jade is soft and sweet. She talks to the therapist about her dying mother and cries.

The female therapist tells Jade she will help her cope with her mother’s illness. But, despite these kind words, inside she feels jealous of Jade. The therapist grew up in a state of almost total emotional deprivation. Even though Jade’s mother is dying, she still has so much more than the therapist ever had. The therapist is especially jealous of Jade’s relationship with her father. Jade’s father is the kind of father the therapist always dreamed of having—loving and kind, not at all like her own unapproachable father. Thus envious of Jade, the therapist is unable to be genuinely caring, open, and empathic. Sensing that something is wrong, Jade leaves therapy after a short time.

Envy might prompt the therapist to focus on the relevant material and behave in a jealous manner (schema surrender), to avoid talking about important material (schema avoidance), or to try to live vicariously through the patient (schema overcompensation).

Therapists must struggle to know their own limits. When patients trigger their Early Maladaptive Schemas, they must decide whether they can cope well with anticipated challenges and continue to behave in a therapeutic and professional manner. Therapists can use the techniques of schema therapy to address the problem, either on their own or in supervision. They can conduct dialogues between the schema and the healthy side. What is the schema saying in the therapy with the patient? What is the schema directing the therapist to do? How does the healthy side—the “good therapist”—respond? In addition, the therapist can use experiential techniques to explore and remediate the problem. For example, the therapist can recall an image of a moment during the session in which the therapist’s own schemas were triggered. When in childhood did the therapist feel the same way? What does the therapist’s Vulnerable Child say in the image? How does the Healthy Adult answer? The therapist can carry out dialogues between modes. Finally, the therapist can practice behavioral pattern-breaking. Rather than acting out maladaptive coping responses with the patient, the therapist can delineate homework assignments that entail the use of empathic confrontation and limited reparenting.

If there are problems that cannot be resolved through consultation or supervision, then the therapist should consider referring the patient to another therapist.

The Role of the Therapy Relationship in Educating the Patient

The therapist tailors the educational material to the patient’s personality. Some patients want to learn as much as possible, whereas others tend to feel overwhelmed. Some want to read books, and others prefer to watch films or plays. Some want to show the therapist photographs from their childhoods, whereas others find this prospect unappealing. However, the therapy relationship plays an important role in educating almost all patients about their schemas and coping styles. Patients often derive great benefit from recognizing instances of schema activation right there in the session with the therapist. Such immediate examples are especially instructive. Current thoughts, feelings, and behaviors are vivid and clear and are more readily processed by patients due to the presence of affect.

In accord with the collaborative nature of schema therapy, the therapist tells the patient that, when the patient’s schemas are triggered in the therapy relationship, the therapist will confront the patient empathically. In addition, the therapist will try not to reinforce the patient’s maladaptive coping styles. The therapist says this in a way that communicates to the patient that it is a sign of caring.

Case Illustration

Bruce begins therapy with a therapist named Carrie. Bruce has a Mistrust/Abuse schema, based on his childhood with a sadistic older brother. When Bruce was vulnerable as a child, his brother took the opportunity to torture and humiliate him. Now, whenever Bruce feels vulnerable in the session with Carrie, he starts to joke. He is funny, and he makes Carrie laugh. However, as time goes on, Bruce continues to avoid becoming vulnerable in therapy. At last Carrie tells him that she is going to try not to laugh at his jokes anymore in session when he is using them to avoid important material. Although she appreciates his jokes, and although she understands why it is hard for him to be vulnerable, she also knows that the vulnerable child in him deserves a chance to speak.

Case Illustration

A 52-year-old patient named Clifford comes to his first session. He says that he wants the therapist to restore his self-confidence so that he can achieve even greater success in his career. In the course of the interview it becomes clear that Clifford has lost his most important relationships— with his wife, his children, his siblings, his best friend—but his aggressively upbeat manner does not permit appreciation of these losses. Ed, the therapist, attempts to reframe the presenting problem to include interpersonal relationships, but Clifford balks. “I’m paying the bills here,” he says, “I’ll pick what we talk about.” In the second session, Ed again raises the issue of interpersonal relationships, including examples of how Clifford treated him in the first session. Ed says directly to the patient, “Although you think what you have is a self-confidence problem, what you have is a deeper problem. It is called narcissism, and it keeps you from getting close to others and from knowing your true emotions.” For this patient, use of the diagnostic term “narcissism” was helpful. In fact, Clifford said that other therapists had stopped working with him without ever telling him why. (For other patients who are less well defended, a diagnosis might feel pejorative and be harmful rather than helpful.)

Later in treatment, Ed found it necessary to tell Clifford that he was not going to allow him to spend session time recounting his career accomplishments. He understood that Clifford’s accomplishments were important to him, but because the focus of therapy was intimate relationships, this kind of self-aggrandizing was not a productive use of session time.