During the Change Phase, the therapist continues to confront the patient’s Early Maladaptive Schemas and coping styles within the context of the therapy relationship. Empathic confrontation and limited reparenting are the two primary ways in which the therapy relationship fosters change.
Empathic confrontation is the therapeutic stance of schema therapy. The therapist takes this stance throughout the Change Phase to promote the patient’s psychological growth. However, empathic confrontation is not a technique; rather, it is an approach to the patient that involves a true emotional bond. The therapist must genuinely care about the patient for the approach to work.
In empathic confrontation, the therapist empathizes with the patient and confronts the schema. The therapist expresses understanding of the reasons the patient has the schema and how hard it is to change, while simultaneously acknowledging the importance of that change, striving for the optimum balance between empathy and confrontation that will enable the patient to change. The therapist uses empathic confrontation whenever the patient’s schemas are triggered in the context of the therapy relationship. The triggering of a schema is apparent in the patient’s over-reactions, misinterpretations, and nonverbal behaviors.
The first step is allowing patients to freely express their “truth.” The therapist encourages patients to state their points of view, fully sharing their thoughts and feelings. To help the patient, the therapist asks questions: What is the patient thinking and feeling? What does the patient have the urge to do? What actions on the therapist’s part triggered the schema? Which schema is it? Who else makes the patient feel this way? Who in the patient’s past made the patient feel this way? What happened? With whom did the patient feel this way in childhood? The therapist can use imagery to help the patient link the incident to past events.
Next, the therapist empathizes with the patient’s feelings, given the patient’s perspective on the situation, and acknowledges the realistic component of the patient’s point of view. If it is appropriate, the therapist apologizes for anything he or she has said or done that was hurtful or insensitive. Once the patient feels understood and validated, the therapist moves on to reality-testing. The therapist confronts flaws in the patient’s viewpoint, using logic and empirical evidence. The therapist offers an alternative interpretation, often using self-disclosure about the interaction. The therapist and patient evaluate the patient’s reactions to the therapy situation. This process usually yields a kernel of truth combined with a schema-driven distortion.
Lysette is a 26-year-old woman who comes to therapy following the breakup of a love relationship. Her core schema is Emotional Deprivation, which originated in her childhood with wealthy but emotionally unavailable parents. Her father and mother traveled throughout her childhood, leaving her with nannies or at boarding schools. Lysette remembers once throwing herself down the stairs to prevent her parents from leaving on a trip. In the course of a therapy session, Lysette feels that the therapist is not getting the point she is making. This triggers her Emotional Deprivation schema, and she rails at the therapist. “You never understand me,” she says with rage.
The therapist utilizes empathic confrontation. First, the therapist helps Lysette express her view of what just happened. Lysette tells the therapist how angry she is and says that, underneath the anger, she is afraid the therapist will never understand her. At bottom she is afraid that she will always be alone. The therapist expresses understanding of Lysette’s reason for feeling as she does and apologizes for misunderstanding her. Once Lysette feels heard, they move on to reality-testing. It is true that the therapist did not understand Lysette perfectly; however, the therapist does understand her most of the time and does genuinely care about her. When Lysette covers up her fear with anger, however, it has the effect of pushing the therapist away and making it harder for the therapist to give her what she needs.
When employing empathic confrontation in the context of the therapy relationship, therapists use appropriate self-disclosure. They share their own thoughts and feelings about the interaction when it is likely to benefit the patient. If the patient has attributed judgments, motives, or emotions to the therapist that are false, then the therapist can choose to tell the patient so outright.
For example, a young woman comes to therapy. She has an Abandonment schema and asks her therapist: “Am I too needy for you? Are you going to stop seeing me because I’m too needy?” The therapist answers directly: “No, you’re not too needy for me. I don’t feel that way.” The therapist uses the therapy relationship to contradict the schema. (Of course, the therapist only says this if it is true.) The therapist thus assures the patient that normal expressions of neediness are fine.
As another example, a young man with a Defectiveness schema says to his therapist, “The people in my family see me as selfish. Do you see me as selfish?” The therapist answers truthfully, “No. I don’t see you as selfish. I see you as very giving.” Thus the therapist’s self-disclosure provides a partial antidote to the patient’s schemas.
Bill, the patient, has a Failure schema. He comes to therapy to work on his career as a corporate manager, which is not advancing as he had hoped. At the end of the first session, Eliot, the therapist, gives Bill the homework assignment of filling out the Young Schema Questionnaire. Bill comes to the next session with the assignment undone. He enters the session with a belligerent attitude, angrily pacing about and making excuses.
Eliot waits a while until Bill calms down enough to take part in a discussion. They analyze what just happened. “I thought you were going to yell at me,” Bill explains. Eliot then explores the origins of this expectation in Bill’s childhood and its effects on his work life. Bill grew up on a farm, and, as a child, his father punished him harshly for not completing his chores quickly enough. (Bill also has a Punitiveness schema.) The therapist sympathizes with Bill’s childhood experience. Underneath his angry exterior, there is a vulnerable child who is afraid of failing and getting punished. Eliot then helps Bill trace the effects of his schemas on his work life. It emerges that Bill has a history of antagonizing coworkers and bosses, thus hindering the growth of his career. Once Bill understands his underlying schemas (Failure and Punitiveness) and his maladaptive coping style (he overcompensates by behaving angrily), Eliot moves onto reality-testing. He self-discloses about the effects of Bill’s angry behavior: When Bill behaved that way, Eliot wanted to distance himself from Bill.
By analyzing their schemas as they are triggered naturally in the therapy relationship, patients gain insight into how they perpetuate their schemas and set the stage for their difficulties in their lives outside therapy.
Therapists can anticipate schema activation, and they can teach patients to do the same. One might easily predict that a patient’s Abandonment schema will be triggered when the therapist goes on vacation. Such knowledge enables the therapist to address the patient’s fears ahead of time and to help the patient develop a healthy coping response. For example, the therapist and patient could construct a flash card for the patient to read in the therapist’s absence.
Similarly, one might predict that a patient with a Subjugation schema will be reluctant to follow directions from the therapist. The therapist can prepare for this eventuality and give the patient suggestions rather than directions on such matters as session exercises and homework assignments. Instead of instructing the patient, the therapist asks the patient to choose the exercise or design the homework.
Limited reparenting is especially valuable for patients who have schemas in the Disconnection and Rejection domain; that is, patients who were abused, abandoned, emotionally deprived, or rejected in childhood. The more severe the trauma, the more important the reparenting aspect of therapy becomes. Nevertheless, patients with schemas in other domains also benefit from limited reparenting. With these patients, limited reparenting focuses on such issues as autonomy, realistic limits, self-expression, reciprocity, and spontaneity.
The reparenting is “limited” in that the therapist offers an approximation of missed emotional experiences within ethical and professional boundaries. The therapist does not actually try to become the parent, nor does he or she regress the patient to childlike dependency. Rather, limited reparenting is a consistent way of interacting with a patient that is designed to heal that patient’s specific Early Maladaptive Schemas.
In order to fit the reparenting style to the individual patient, the therapist needs to take into account the patient’s developmental stage. Patients with BPD have more childlike needs. Losing object constancy, they frequently require extra contact in the form of additional appointments or phone calls between sessions. Therapists must balance the patient’s needs with their own limits and model healthy limit-setting. We discuss limit-setting further in Chapter 9.
Like empathic confrontation, limited reparenting includes genuine self-disclosure on the part of the therapist. In order to be helpful, the self-disclosure must be sincere and truthful. For example, praise for a patient with a Defectiveness schema is appropriate reparenting only if it is based on realistic positive qualities of the patient that the therapist authentically appreciates. Sometimes, with hostile or negative patients, it is difficult for the therapist to find positive qualities. In such instances, a statement that conveys understanding can counteract a schema. Such a statement to a mistrustful patient, for example, might be, “When you feel safe, you let me get closer to you.” Thus the therapist acknowledges how hard it is for the patient to get close to others but explains the patient’s guardedness as a form of avoidance and not as the patient’s “true self.”
Another type of therapist self-disclosure is answering the patient’s questions directly if they are not too personal. For example, a patient with a Mistrust/Abuse schema wants to know about the therapist’s record-keeping. The therapist answers her questions directly, rather than interpreting them or questioning them. Limited reparenting in this case involves being forthright with the patient about the contents of her file.
In another case, a patient with a Defectiveness schema notices that the therapist has a scale in her office and asks why. The therapist replies that she treats patients with eating disorders. Rather than weighing themselves daily (or several times a day), these patients have agreed to weigh themselves only at weekly therapy sessions with her. The patient replies, “Oh, I thought you were trying to tell me I was fat.” A direct answer on the part of the therapist increases the patient’s sense of trust. The therapist is not sending her indirect negative messages.
In contrast, however, patients with Dependence schemas tend to ask the therapist’s opinions when they could be making decisions for themselves. In such cases, the therapist combines limited reparenting with empathic confrontation and gently declines to answer. The therapist says, for example, “I know you feel anxious deciding on your own. Your Dependence schema is preventing you from trying to figure things out for yourself, but you can do it. Instead of telling you what to do, I’ll support you while you find your own answer.”
It is important for therapists to remember that it is not their job to avoid activating the patient’s schemas in the therapy relationship. First of all, it is probably impossible to avoid doing so, especially when working with fragile patients. The therapist’s task is to work on the patient’s schemas when they are triggered. Rather than minimizing the importance of what is happening, the therapist uses the activation of schemas as an opportunity to maximize the patient’s potential for psychological growth.
Limited reparenting is interwoven throughout the experiential work, especially imagery. When the therapist enters patients’ images to serve as the “Healthy Adult” and allows patients to say aloud what they needed but did not get from their parents as children, then the therapist is reparenting. The therapist is teaching patients that there are other ways a parent might have treated them. As children, they had needs that were not met, and other parents might have met them. By first modeling the Healthy Adult in imagery, then bringing patients into the imagery to serve as the Healthy Adult, the therapist teaches patients to reparent their own inner child.
We have elaborated specific limited reparenting strategies for each Early Maladaptive Schema. The strategies take into account the coping styles that typically characterize the schema. The limited reparenting strategies are designed to provide a partial antidote to the schema within the therapy relationship.
1. Abandonment/Instability. The therapist becomes a transitional source of stability, eventually helping the patient to find other stable relationships outside of therapy. The therapist corrects distortions about how likely the therapist is to abandon the patient. The therapist helps the patient accept the therapist’s departures, vacations, and unavailability without shutting down or behaving self-destructively
2. Mistrust/Abuse. The therapist is completely trustworthy, honest, and genuine with the patient. The therapist asks about trust and intimacy regularly and discusses any negative feelings the patient has toward him or her. The therapist asks about vigilance in sessions. In order to build up the patient’s trust, when necessary the therapist postpones the experiential work and proceeds through traumatic memories slowly.
3. Emotional Deprivation. The therapist provides a nurturing atmosphere, with warmth, empathy, and guidance. The therapist encourages patients to ask for what they need emotionally and to feel entitled to have emotional needs. The therapist helps the patient express feelings of deprivation without lashing out or remaining silent. The therapist helps the patient accept the therapist’s limitations and tolerate some deprivation while appreciating the nurturing that is available.
4. Defectiveness. The therapist is accepting and nonjudgmental. The therapist cares about the patient despite the patient’s flaws. The therapist is willing to be imperfect, sharing minor weaknesses with the patient. The therapist compliments the patient as often as possible without seeming phony.
5. Social Isolation. The therapist highlights ways in which the patient and therapist are similar and ways in which the patient and therapist are different yet compatible.
6. Dependence/Incompetence. The therapist resists attempts by patients to take on a dependent role with the therapist. He or she encourages patients to make their own decisions. The therapist praises the patient’s good judgments and progress.
7. Vulnerability to Harm or Illness. The therapist increasingly discourages the patient’s dependence on the therapist for reassurance about the dangerousness of moving about in the world. The therapist expresses calm confidence in the patient’s ability to handle phobic situations and feared illnesses.
8. Enmeshment/Undeveloped Self. The therapist helps the patient by setting appropriate boundaries that are neither too close nor too distant. The therapist encourages the patient to develop a separate sense of self.
9. Failure. The therapist supports the patient’s work or school successes. The therapist provides structure and sets limits.
10. Entitlement. The therapist supports the patient’s vulnerable side and does not reinforce the patient’s entitled side. The therapist empathically confronts entitlement and sets limits. The therapist supports emotional connectedness more than status or power.
11. Insufficient Self-Control/Self-Discipline. The therapist is firm in setting limits. The therapist models appropriate self-control and self-discipline and rewards patients for gradually developing these abilities.
12. Subjugation. The therapist is relatively nondirective rather than controlling. He or she encourages patients to make choices about therapy goals, treatment techniques, and homework assignments. The therapist points out deferential or rebellious behavior and helps patients recognize anger, vent it, then learn to express it appropriately.
13. Self-Sacrifice. Therapists help patients to set appropriate boundaries and to assert their own rights and needs. The therapist encourages the patient to rely on the therapist, thereby validating the patient’s dependency needs. The therapist discourages the patient from taking care of the therapist, pointing out the pattern with an empathic confrontation.
14. Negativity/Pessimism. The therapist avoids playing the positive side to the patient’s negative side. Rather, the therapist asks the patient to play both the positive and negative roles. The therapist models healthy optimism.
15. Emotional Inhibition. The therapist encourages the patient to express affect spontaneously in the sessions. The therapist models the appropriate expression of affect.
16. Unrelenting Standards. Therapists model balanced standards in their approach to therapy and their own lives. Rather than maintaining an atmosphere of unbroken seriousness, therapists reward patients for playfulness. Therapists value the therapy relationship more than “getting things done” and encourage imperfect behavior.
17. Punitiveness. Therapists assume a forgiving attitude toward the patient and toward themselves and acknowledge the patient for forgiving others.
18. Approval-Seeking. The therapist emphasizes the patient’s core self over such superficial attainments as status, appearance, or wealth.
The same patient behavior requires different therapist responses, depending on the underlying schema. The following scenario is an example:
A young female patient repeatedly comes inordinately late to therapy sessions (i.e., she arrives when there are only 10 minutes left to the session).
If the patient has a Mistrust/Abuse schema and is coming late because she is afraid the therapist is going to abuse her, then reparenting entails empathizing with the “Abused Child” and helping the child mode to feel safe. The therapist might say, “I know that it’s hard for you to come to sessions, that underneath you’re scared of me. I also know there’s a reason you feel this way, because of the way people you trusted treated you when you were a child. I’m glad you’re able to come at all, and I hope that, gradually, you’ll trust me enough to come for the whole session.”
If the patient has an Abandonment/Instability schema and is coming late because she is afraid to attach to the therapist, only to inevitably lose him or her, then reparenting involves reassuring the Abandoned Child about the stability of the therapeutic relationship. The therapist might say: “I know you think I’m mad at you for coming late. I want you to know that I’m not mad and that I know there’s a reason you’re coming late that has to do with your childhood. Even when you come late, I still feel a bond with you.”
If the patient has an Emotional Deprivation schema and is late as a result of an overcompensatory feeling of entitlement, then reparenting consists of empathizing with the Deprived Child, who now will miss the support of a full session, but insisting, nevertheless, on ending the session on time. The therapist might say: “I regret that you’re late and we’ll only get to spend a few minutes together. I want to give you the opportunity to express your feelings about that. Let’s spend the rest of the session talking about it.”
If the patient has a Defectiveness schema and is late because she is afraid that the therapist will see her “true” self and despise her, then reparenting concerns empathizing with the Rejected Child, emphasizing that the therapist accepts her whether she is late or not. The therapist might say, “I want to acknowledge you for coming, even though it’s so difficult for you. It’s important to me that you know I accept you and value our relationship, even when you come late.”
If the patient has a Failure schema and is late because she is sure she will fail in therapy, then reparenting encompasses empathizing with the underlying expectation of failure but confronting the consequences of the behavior. The therapist might say: “I know it’s hard for you to believe therapy’s going to work because a lot of things haven’t worked for you in the past. But let’s look at what’s going to happen if you don’t come on time, compared to what could happen if you do.”
If the patient has a Dependence/Incompetence schema and is late because she cannot plan and navigate on her own, then reparenting involves building strengths and teaching skills. The therapist might say, “Let’s look at what you did right to get here and where you went wrong. That way we can plan together how you might get here on time next week.”
If the patient has a Self-Sacrifice schema and is late because she was waylaid by an acquaintance on the way to therapy and could not break away, then reparenting consists of pointing out the negative consequence to the patient of her self-sacrifice and building assertiveness skills. The therapist might say: “It cost you most of your therapy session to stay in that conversation, and you gained nothing. Let’s talk about how you might have broken out of the conversation. Would you like to do some imagery about it? Close your eyes and picture an image of meeting your friend and getting stuck in the conversation.”
Knowledge of the patient’s underlying schemas helps the therapist reparent the patient in the most effective way.