These patients constantly expect to lose the people closest to them. They believe these people will abandon them, get sick and die, leave them for somebody else, behave unpredictably, or somehow suddenly disappear. Therefore, they live in constant fear and are always vigilant for any sign that someone is about to leave their lives.
The common emotions are chronic anxiety about losing people, sadness, and depression when there is an actual or perceived loss, and anger at the people who have left them. (In more intense forms, these emotions become terror, grief, and rage.) Some patients even become upset when people leave them for short periods of time. Typical behaviors include clinging to significant others, being possessive and controlling, accusing others of abandoning them, jealousy, competitiveness with rivals—all to prevent the other person from leaving. Some patients with an Abandonment schema avoid intimate relationships altogether, in order to avoid experiencing what they anticipate to be the inevitable pain of loss. (One patient with this schema, when asked why he could not make a commitment to the woman he loved, answered: “What if she dies?”) Consistent with the schema perpetuation process, these patients typically choose unstable significant others, such as uncommitted or unavailable partners, who are a highly likely to abandon them. They usually have intense chemistry with these partners, and often fall obsessively in love.
The Abandonment schema is frequently linked with other schemas. It can be linked with the Subjugation schema. Patients believe that if they do not do what the other person wants, then he or she will leave them. It can also be linked with the Dependence/Incompetence schema. Patients believe that if the other person leaves, they will be unable to function in the world on their own. Finally, the Abandonment schema can be linked with the Defectiveness schema. Patients believe the other person will find out how defective they are and will leave.
One goal of treatment is to help patients become more realistic about the stability of relationships. Patients who have been successfully treated for an Abandonment schema no longer worry all the time that reliable significant others are about to disappear. In object relation terms, they have learned to internalize significant others as stable objects. They are far less likely to magnify and misinterpret behaviors as signs that other people are going to abandon them.
Their linked schemas are usually diminished as well. Because they feel less subjugated, or dependent, or defective, abandonment is not as frightening to them as it used to be. They feel more secure in their relationships, so they do not have to cling, control, or manipulate. They are less angry. They select significant others who are consistently there for them, and no longer avoid intimate relationships. Another sign of improvement in patients with this schema is that they are able to be alone for extended periods of time without becoming anxious or depressed, and without having to reach out immediately and connect to somebody.
The more severe the Abandonment schema, the more important the therapy relationship is to the treatment. Patients with BPD typically have Abandonment as one of their core schemas, and, therefore, the therapy relationship is the primary source of healing. According to our approach, the therapist becomes a transitional parent figure—a stable base from which the patient can venture into the world and form other stable bonds. First, the patient learns to overcome the schema within the therapy relationship, and then transfers this learning to significant others outside of therapy. Through “limited reparenting,” the therapist provides the patient with stability, and the patient gradually learns to accept the therapist as a stable object. Mode work is especially helpful (see Chapter 9). Through empathic confrontation, the therapist corrects the patient’s distorted sense that the therapist is constantly about to abandon the patient. The therapist helps the patient accept the therapist’s departures, vacations, and unavailability without catastrophizing and overreacting. Finally, the therapist helps the patient find someone to replace the therapist as the primary relationship—someone stable, who is not going to leave—so the patient is not dependent forever on the therapist to be the stable object.
Cognitive strategies focus on altering the patient’s exaggerated view that other people will eventually leave, die, or behave unpredictably. Patients learn to stop catastrophizing about temporary separations from significant others. Additionally, cognitive strategies focus on altering the patient’s unrealistic expectation that significant others should be endlessly available and totally consistent. Patients learn to accept that other people have the right to set limits and establish separate space. Cognitive strategies also focus on reducing the patient’s obsessive focus on making sure the partner is still there. Finally, cognitive strategies address the cognitions that link to other schemas—for example, changing the view that patients must do what other people want them to do or else they are going to be left; that they are incompetent, and need other people to take care of them; or that they are defective, and other people will inevitably find out and leave them.
In terms of experiential strategies, patients relive childhood experiences of abandonment or instability in imagery. Patients reexperience through imagery memories of the parent who left them, or of the unstable parent who was sometimes there and sometimes not. The therapist enters the image and becomes a stable figure for the child. The therapist expresses anger at the parent who acted irresponsibly, and comforts the Abandoned Child; then, patients enter the image as Healthy Adults and do the same. They express anger at the parent who abandoned them and comfort the Abandoned Child. Thus, patients gradually become able to serve as their own Healthy Adults in the imagery.
Behaviorally patients focus on choosing partners who are capable of making a commitment. They also learn to stop pushing partners away with behaviors that are too jealous, clinging, angry, or controlling. They gradually learn to tolerate being alone. Countering their schema-driven attraction to instability, they learn to walk away from unstable relationships quickly and to become more comfortable in stable relationships. They also heal their linked schemas: They stop letting other people control them; they learn to become more competent in handling everyday affairs, or they work on feeling less defective.
Abandonment often comes up as an issue in therapy when the therapist initiates a separation—such as ending a session, going on vacation, or changing an appointment time. The schema is triggered, and the patient becomes frightened or angry. These situations provide excellent opportunities for the patient to make progress with the schema. The therapist helps the patient do so through empathic confrontation: Although the therapist understands why the patient is so scared, the reality is that the therapist is still bonded to the patient while they are apart, and the therapist is going to return and see the patient again.
Alternatively, patients may be overly compliant in therapy to make sure the therapist does not ever leave them. They are “good patients,” but they are not authentic. Patients may also overwhelm the therapist by constantly seeking reassurance or calling between sessions in order to reconnect. Avoidant patients may miss sessions, be reluctant to come on a regular basis, or drop out of therapy prematurely because they do not want to become too attached to the therapist. Patients with the Abandonment schema may also repeatedly test the therapist—for example, by threatening to stop therapy or accusing the therapist of wanting to stop. We address these issues in detail in our chapter on treating patients with borderline disorder (see Chapter 9). Briefly, the therapist approaches the problem through a combination of setting limits and empathic confrontation.
Another risk is that patients with the Abandonment schema may make the therapist the central figure in their lives permanently, instead of forming stable, primary connections with other people. The patient never terminates therapy, but just continues to let the therapist be the stable connection. Becoming dependent upon the therapist becomes the unhealthy solution to the schema. The ultimate goal of therapy is for patients to connect with others in the outside world who can meet their emotional needs.
Patients with the Mistrust/Abuse schema expect others to lie, manipulate, cheat, or in other ways to take advantage of them, and in the most extreme form of the schema, try to humiliate or abuse them. These patients do not trust other people to be honest and straightforward, and to have their best interests at heart. Rather, they are guarded and suspicious. They sometimes believe that other people want to hurt them intentionally. At best, they feel that people care only for themselves and do not mind hurting others to get what they need; at worst, they are convinced that people are malevolent, sadistic, and get pleasure from hurting others. In the extreme form, patients with this schema may believe that other people want to torture and sexually abuse them. (Isaac Bashevis Singer [1978] wrote about the holocaust—a mass expression of the Mistrust/Abuse schema—in his book Shosha: “The world is a slaughterhouse and a brothel” [p. 266].)
Therefore, patients with this schema tend to avoid intimacy. They do not share their innermost thoughts and feelings or get too close to others; and, in some cases, they end up cheating or abusing other people in a sort of preemptive strike (“I’ll get them before they get me”). Broadly speaking, typical behaviors include victim and abuser behaviors. Some patients choose abusive partners and allow themselves to be physically, sexually, or emotionally abused, whereas other patients behave abusively toward others. Some patients become the “savior” of other abused people, or express outrage against people they perceive as abusers. Patients with this schema often come across as paranoid: They are perpetually setting up tests and gathering evidence to determine whether other people are worthy of trust.
The main goal of treatment is to help patients with the Mistrust/Abuse schema to realize that, whereas some people are not trustworthy, many others are trustworthy. We teach them that the best way to live is to stay away from abusive people as much as possible, stand up for themselves when necessary, and focus on having trustworthy people in their personal life.
Patients who have healed a Mistrust/Abuse schema have learned to distinguish between people who are trustworthy and those who are not. They have learned that there is a spectrum of trustworthiness: People worthy of trust do not have to be perfect; they just have to be “trustworthy enough.” With trustworthy people, patients learn to behave in a different way. They are willing to give them the benefit of the doubt, they are less guarded and suspicious, they stop setting up tests, and they no longer cheat others because they expect to be cheated. With individuals who become their partners or close friends, patients become more authentic. They share many of their secrets and are willing to be vulnerable. They eventually find that, if they behave openly, trustworthy people will generally treat them well in return.
When dealing with childhood abuse, the therapy relationship is crucial to the success of the therapy. At the core of the experience of childhood abuse are feelings of terror, helplessness, and isolation. Ideally, the therapist provides the patient with the antidote to these feelings. At the core of the experience of therapy are feelings of safety, empowerment, and reconnection.
With patients who were abused as young children, the therapist must work to establish emotional safety. The goal is to provide a safe place for patients to tell their story of abuse. Most abuse survivors are intensely ambivalent about telling their story. One part of the patient wants to discuss what happened, whereas another part wants to hide it. Many of these patients alternate between the two—just as they alternate between feeling overwhelmed and feeling numb (a common characteristic of posttraumatic stress disorder). We hope that, by the end of therapy, most of the patients ’ traumatic secrets will have been uncovered, discussed, and understood. (The therapist is careful throughout this process to avoid suggesting or subtly pushing for memories of abuse that may never have happened.)
Cognitively, the therapist helps to reduce patients ’ overvigilance to abuse. Patients learn to recognize a spectrum of trustworthiness. In addition, patients work to alter the extremely common view of themselves as worthless and to blame for the abuse (a blending of the Mistrust/Abuse and Defectiveness schemas). They stop making excuses for the abuser and place blame where it belongs.
Experientially, patients relive childhood memories of abuse through imagery. Because this is usually an upsetting process, patients need a good deal of preparation and time before undertaking it. The therapist waits until the patient is ready. Venting anger is of primary importance in the experiential work. It is especially important for patients to vent anger at the people who abused them during childhood, rather than continually direct anger at the people in their current lives, or at themselves. In imagery of childhood abuse, patients express all the emotions that were strangulated at the time. The therapist enters the images of abuse to stand up to the perpetrator, and protect and comfort the Abused Child. This helps the patient internalize the therapist as a trustworthy and effective caretaker. Eventually, the patient enters the imagery as the Healthy Adult and does the same, standing up to the perpetrator, and protecting and comforting the child. Patients also work in imagery to find a safe place, away from the abuser. This could be an image from the patient’s past, or an image the therapist and patient construct together, perhaps of a beautiful natural scene or of soothing lights and colors. Finally, patients visualize themselves being open and authentic with trustworthy significant others. Once again, the thrust of treatment is first to help patients make the sharp distinction between the people in the past who deserve the anger, and people in the present who do not; then, to help patients express anger in therapy sessions toward the people in the past who deserve it, while treating well those people in their current lives who treat them well.
Behaviorally, patients gradually learn to trust honest people. They increase their level of intimacy with appropriate significant others. When appropriate, they share their secrets and memories of abuse with their partner or close friends. They consider joining a support group for abuse survivors. They choose nonabusive partners. Patients stop mistreating others and set limits with abusive people. They are less punitive when other people make mistakes. Rather than avoiding relationships and remaining alone, or avoiding intimate encounters and staying emotionally distant from people, they allow people to get close and become intimate. They stop gathering evidence and keeping score about the things other people have done to hurt them. They stop constantly testing other people in relationships to see if they can be trusted. They stop taking advantage of other people, thus prompting others to respond in kind.
The patient’s intimate relationships are an important focus of treatment. He or she learns to become more trusting and behave more appropriately with significant others, such as lovers, friends, and coworkers (assuming the other person is trustworthy). Patients become more selective, both in whom they choose and whom they trust in their lives outside sessions. It is often helpful to bring the partner into therapy as well, so the therapist can give the patient examples of how the patient is misconstruing the partner. Some patients with this schema have become so abusive that they are seriously mistreating others. These patients need the therapist to serve as a model of morality and to set limits. Getting patients to stop mistreating others is an important behavioral goal.
In terms of the therapy relationship, the therapist tries to be as honest and genuine as possible with the patient. He or she asks about trust issues regularly, discussing any negative feelings the patient has toward the therapist. The therapist moves slowly, postponing the experiential work, while building sufficient trust. The empowerment of the patient is a core principle of treating this schema. The therapist aims to restore to the patient the sense of a strong, active, and capable self that was broken by the abuse. The therapist encourages independence and gives the patient a large measure of control over the course of treatment.
Abuse severs the bond between the individual and other human beings. The person is torn out of the world of ordinary human relationships and thrown into a nightmare. During abuse, the victim feels utterly alone, and, after it is over, feels detached and estranged from others. The real world of current relationships seems hazy and unreal, whereas the memories of the relationship with the perpetrator are sharp and clear. (In The Bell Jar, Sylvia Plath [1966] wrote: “To the person in the bell jar, blank and stopped as a dead baby, the world itself is the bad dream” [p. 278].) The therapist is an intermediary between the abuse survivor and the rest of humanity: he or she serves as a vessel through which the patient reconnects to the ordinary world. By connecting to the therapist, the patient reconnects symbolically to the rest of humanity.
Adapting a term from Alice Miller, the therapist strives to become an “enlightened witness” to the patient’s experience of abuse (Miller, 1975). As the patient tells the story, the therapist listens with a presence that is strong and nonjudgmental. The therapist is willing to share the emotional burden of the trauma, whatever it is. Sometimes the therapist must witness the patient’s vulnerability and disintegration under extreme conditions, or the perpetrator’s capacity for evil. Additionally, most survivors of abuse struggle with moral issues. They are haunted by feelings of shame and guilt about what they did and felt during the abuse. They want to understand their own responsibility for what happened to them, and to reach a fair, moral judgment of their own conduct. The therapist’s role is not to provide the answers, but to provide a safe place for patients to find their own answers (correcting negative distortions along the way).
Through “limited reparenting,” the therapist strives for a personal connection to the patient. Rather than relating as an impersonal expert, the therapist is a real person who cares about the patient and whom the patient can trust. The fact that the therapist strives for a close emotional bond with the patient does not mean that the therapist exceeds the limits of the therapist-patient relationship. Rather, the limits of the relationship provide a safe place for both therapist and patient to undertake the work of healing. Staying within these limits is essential for therapists when working with abuse survivors, because the work can be emotionally overwhelming. To treat survivors of abuse is to face dark truths about human fragility in the world and the human potential for evil.
Treating survivors of trauma can itself be traumatizing. Sometimes therapists even start experiencing the same feelings of fear, rage, and grief that the patient feels. Therapists may experience posttraumatic stress symptoms such as intrusive thoughts, nightmares, or flashbacks (Pearlman & Maclan, 1995). Therapists may fall into the patients ’ feelings of helplessness and hopelessness. Caught in all of these symptoms and feelings, a therapist might be tempted to exceed the limits of the therapist-patient relationship and become the patient’s “rescuer.” However, this would be a mistake: In exceeding limits, the therapist implies that the patient is helpless and runs the risk of becoming exhausted and resentful. (As we discussed in Chapter 2, schema therapy does exceed “typical” therapist-patient boundaries. However, although we extend the typical boundaries somewhat in order to provide limited reparenting, we are careful not to violate boundaries in ways that would be damaging to patients. For example, while we do provide trauma survivors with overt comforting, we do not push them to work faster on traumatic material than they want to go.)
In severe cases, it can take a long time for patients with a Mistrust/Abuse schema to trust the therapist—to trust that he or she is not going to hurt, cheat, humiliate, abuse, or lie to them. A good deal of therapy time is devoted to helping patients observe all the ways they misconstrue the therapist’s intentions, keep important facts secret, and avoid vulnerability. The goal is for patients to internalize the therapist as someone they can trust—perhaps the first close person in their lives who is both good and strong.
If the Mistrust/Abuse schema developed out of early childhood trauma, it often takes a long time to treat—only the Abandonment schema usually takes as long to treat. Occasionally, the damage is so severe that the patient can never trust the therapist enough to open up and change. No matter what the therapist does, the patient keeps twisting the therapist’s behavior in such a way that it seems malevolent or reflects some underlying negative motive. When the patient has strong compensatory behaviors, this can be a very difficult schema to overcome.
On a less serious level, patients may not want the therapist to take notes, may be unwilling to fill out forms, or may withhold important information because they are afraid that somehow the material will be used against them. We believe the therapist should accommodate these requests as much as possible, but also point them out to patients as examples of schema perpetuation.
This is probably the most common schema we treat in our work, although patients frequently do not recognize that they have it. Patients with this schema often enter treatment feeling lonely, bitter, and depressed, but usually not knowing why; or they present with vague or unclear symptoms that later prove to be related to the Emotional Deprivation schema. These patients do not expect other people—including the therapist—to nurture, understand, or protect them. They feel emotionally deprived, and may feel that they do not get enough affection and warmth, attention, or deep emotions expressed. They may feel that no one is there who can give them strength and guidance. Such patients may feel misunderstood and alone in the world. They may feel cheated of love, invisible, or empty.
As we have noted, there are three types of deprivation: deprivation of nurturance, in which patients feel that no one is there to hold them, pay attention to them, and give them physical affection, such as touch and holding; deprivation of empathy, in which they feel that no one is there who really listens or tries to understand who they are and how they feel; and deprivation of protection, in which they feel that no one is there to protect and guide them (even though they are often giving others a lot of protection and guidance). The Emotional Deprivation schema is often linked to the Self-Sacrifice schema. Most patients with a Self-Sacrifice schema are also emotionally deprived.
Typical behaviors exhibited by these patients include not asking significant others for what they need emotionally; not expressing a desire for love or comfort; focusing on asking the other person questions but saying little about oneself; acting stronger than one feels underneath; and in other ways reinforcing the deprivation by acting as though they do not have emotional needs. Because these patients do not expect emotional support, they do not ask for it; consequently, usually they do not get it.
Another tendency we see in patients with an Emotional Deprivation schema is choosing significant others who cannot or do not want to give emotionally. They often choose people who are cold, aloof, self-centered, or needy, and therefore likely to deprive them emotionally. Other, more avoidant, patients become loners. They avoid intimate relationships because they do not expect to get anything from them anyway. Either they stay in very distant relationships or avoid relationships entirely.
Patients who overcompensate for emotional deprivation tend to be overly demanding and become angry when their needs are not met. These patients are sometimes narcissistic: Because they were both indulged and deprived as children, they have developed strong feelings of entitlement to get their needs met. They believe they must be adamant in their demands to get anything at all. A minority of patients with the Emotional Deprivation schema were indulged in other ways as children: They were spoiled materially, not required to follow normal rules of behavior, or adored for some talent or gift, but they were not given genuine love.
Another tendency in a small percentage of patients with this schema is to be overly needy. Some patients express so many needs so intensely that they come across as clinging or helpless, even histrionic. They may have many physical complaints—psychosomatic symptoms—with the secondary gain of getting people to pay attention to them and take care of them (although this function is almost always outside their awareness).
One major goal of treatment is to help patients become aware of their emotional needs. It may feel so natural to them to have their emotional needs go unmet that they are not even aware that something is wrong. Another goal is to help patients accept that their emotional needs are natural and right. Every child needs nurturance, empathy, and protection, and, as adults, we still need these things. If patients can learn how to choose appropriate people and then ask for what they need in appropriate ways, then other people will give to them emotionally. It is not that other people are inherently depriving; it is that these patients have learned behaviors that either lead them to choose people who cannot give, or discourage people who can give from meeting their needs.
There is a strong emphasis on exploring the childhood origins of this schema. The therapist uses experiential work to help patients recognize that their emotional needs were not met in childhood. Many patients never realized they were missing something, even though they had symptoms of missing something. Through imagery work, patients get in touch with the Lonely Child part of themselves and connect this mode to their presenting problems. In imagery, they express their anger and pain to the depriving parent. They list all their unmet emotional needs in childhood, and what they wish the parent had done to meet each one. The therapist enters images of childhood as the Healthy Adult, who comforts and helps the Lonely Child; then, the patient enters the image as the Healthy Adult, and comforts and helps the Lonely Child. Patients write a letter to the parent, for homework (which they do not send), about the deprivation uncovered through imagery work.
As with most of the schemas in the Disconnection and Rejection domain, the therapy relationship is central to the treatment of the schema. (The exception is the Social Isolation schema, which usually involves less emphasis on the patient-therapist relationship and more on the patient’s outside relationships.) The therapy relationship is often the first place these patients have ever allowed anyone to take care of, understand, and guide them. Through “limited reparenting,” the therapist provides a partial antidote to their emotional deprivation: a warm, empathic, and protective environment, where they can get many of their emotional needs met. If the therapist cares about and reparents the patient, then this will ease the patient’s sense of deprivation. As with the Abandonment schema, the therapy relationship provides a model that patients can then transfer to others in their lives outside therapy (a “corrective emotional experience” (Alexander, 1956). Like the Abandonment schema, there is a great deal of emphasis on the patient’s intimate relationships. The therapist and patient carefully study the patient’s relationships with significant others. Patients work on choosing appropriate partners and close friends, identifying their own needs, and asking to have these needs met in appropriate ways.
Cognitively, the therapist helps patients change their exaggerated sense that significant others are acting selfishly or depriving them. To counter the “black or white” thinking that fuels overreactions, the patient learns to discriminate gradations of deprivation—to see a continuum rather than just two opposing poles. Even though other people set limits on what they give, they still care about the patient. Patients identify the unmet emotional needs in their current relationships.
Behaviorally, patients learn to choose nurturing partners and friends. They ask their partners to meet their emotional needs in appropriate ways and accept nurturance from significant others. Patients stop avoiding intimacy. They stop responding with excessive anger to mild levels of deprivation and withdrawing or isolating when they feel neglected by others.
In the therapy relationship, the therapist provides a nurturing atmosphere with attention, empathy, and guidance, making special attempts to demonstrate emotional involvement (e.g., remembering the patient’s birthday with a card). The therapist helps the patient express feelings of deprivation without overreacting or remaining silent. The patient learns to accept the therapist’s limitations and to tolerate some deprivation, while appreciating the nurturing the therapist does provide. The therapist helps the patient connect feelings in the therapy relationship with early memories of deprivation, and to work on those memories experientially.
The most common problem is that patients with this schema are so frequently unaware of it. Even though Emotional Deprivation is one of the three most common schemas we work with (Subjugation and Defectiveness schemas are the others), people often do not know that they have it. Because they never got their emotional needs met, patients often do not even realize that they have unmet emotional needs. Thus, helping patients make a connection between their depression, loneliness, or physical symptoms on the one hand, and the absence of nurturing, empathy, and protection on the other is very important. We have found that asking patients to read the Emotional Deprivation chapter of Reinventing Your Life (Young & Klosko, 1993) can often help them recognize the schema. They can identify with some of the characters or recognize the behavior of a depriving parent.
Patients with this schema often negate the validity of their emotional needs. They deny that their needs are important or worthwhile, or they believe that strong people do not have needs. They consider it bad or weak to ask others to meet their needs and have trouble accepting that there is a Lonely Child inside them who wants love and connection, both from the therapist and from significant others in the outside world.
Similarly, patients may believe that significant others should know what they need, and that they should not have to ask. All of these beliefs work against the patient’s ability to ask others to meet his or her needs. These patients need to learn that it is human to have needs, and healthy to ask others to meet them. It is human nature to be emotionally vulnerable. What we aim for in life is a balance between strength and vulnerability, so that sometimes we are strong and other times we are vulnerable. To only have one side—to only be strong—is to be not fully human and to deny a core part of ourselves.
Patients with this schema believe that they are defective, flawed, inferior, bad, worthless, or unlovable. Consequently, they often experience chronic feelings of shame about who they are.
What aspects of themselves do they view as defective? It could be almost any personal characteristic—they believe that they are too angry, too needy, too evil, too ugly, too lazy, too dumb, too boring, too strange, too overbearing, too fat, too thin, too tall, too short, or too weak. They might have unacceptable sexual or aggressive desires. Something in their very being feels defective: It is not something they do, but something they feel they are. They fear relationships with others because they dread the inevitable moment when their defectiveness will be exposed. At any moment, other people might suddenly see through them to the defectiveness at their core, and they will be filled with shame. This fear can apply to the private or public worlds: Patients with this schema feel defective in their intimate relationships or in the wider social world (or both).
Typical behaviors of patients with this schema include devaluing themselves and allowing others to devalue them. These patients may allow others to mistreat or even verbally abuse them. They are often hypersensitive to criticism or rejection, and react very strongly, either by becoming sad and downcast or angry, depending upon whether they are surrendering to the schema or overcompensating for it. They secretly feel that they are to blame for their problems with other people. Often self-conscious, they tend to make a lot of comparisons between themselves and others. They feel insecure around other people, particularly those perceived as “not defective,” or those who might see through to their defectiveness. They may be jealous and competitive, especially in the area of their felt defectiveness, and sometimes view interpersonal interactions as a dance of “one up, one down.” They often choose critical and rejecting partners, and may be critical of the people who love them. (Groucho Marx expressed the latter sentiment when he said, “I wouldn’t want to belong to a club that would have me as a member.”) Many of the characteristics of narcissistic patients—such as grandiosity and unrelenting standards—can be manifestations of a Defectiveness schema. In many cases, these characteristics serve to compensate for underlying feelings of defectiveness and shame.
Patients may avoid intimate relationships or social situations, because people might see their defects. In fact, we believe that avoidant personality disorder is a common manifestation of the Defectiveness schema, with avoidance as the primary coping style. This schema can also lead to substance abuse, eating disorders, and other serious problems.
The basic goal of treatment is to increase the patient’s sense of self-esteem. Patients who have healed this schema believe that they are worthy of love and respect. Their feelings of defectiveness were either mistaken or greatly exaggerated: Either the trait is not really a defect, or it is a limitation that is far less important than it feels to them. Furthermore, the patient is often able to correct the “defect.” But, even if patients cannot correct it, it does not negate their value as human beings. It is the nature of human beings to be flawed and imperfect. We can love each other anyway.
Patients who have healed this schema are more at ease around other people. They feel much less vulnerable and exposed, and are more willing to enter relationships. They are no longer so prone to feelings of self-consciousness when other people pay attention to them. These patients regard other people as less judgmental and more accepting, and put human flaws into a realistic perspective. Becoming more open with people, they stop keeping so many secrets and trying to hide so many parts of themselves, and can maintain a sense of their own value, even when others criticize or reject them. They accept compliments more naturally and no longer allow other people to treat them badly. Less defensive, they are less perfectionistic about themselves and other people, and choose partners who love them and treat them well. In summary, they no longer exhibit behaviors that surrender to, avoid, or overcompensate for their Defectiveness/Shame schema.
Once again, the therapy relationship is central to the treatment of this schema. If the therapist, knowing about the perceived defect, is able to still care about the patient, then the patient will know it and feel more worth-while. It is important for the therapist to give a lot of direct affirmation and praise, and point out the patient’s positive attributes.
Cognitive strategies aim to alter patients ’ view of themselves as defective. Patients examine the evidence for and against the schema, and they conduct dialogues between the critical schema and the healthy side that has good self-esteem. They learn to highlight their assets and to reduce the significance they assign to their flaws. Rather than being inherent, most of their flaws are behaviors they learned in childhood that can be changed, or they are not flaws at all, but rather manifestations of overcriticalness. We have found that most patients with this schema do not really have serious flaws, just extremely critical or rejecting parents. And even if the patient does have flaws, most of them can be addressed in therapy or through other means; if they cannot, they are not as profound as the patient considers them. Cognitive techniques help the patient reattribute feelings of defectiveness and shame to the criticalness of significant others in childhood. Flash cards listing the patient’s good qualities are very helpful with this schema.
Experientially, it is important for patients to vent anger at their critical, rejecting parents in imagery and dialogues. The therapist enters childhood images of the parent criticizing and rejecting the patient, and the therapist confronts the parent and comforts, protects, and praises the Rejected Child. Eventually, patients are able to play this role themselves: They enter the image as the Healthy Adult who stands up to the critical parent and comforts the Rejected Child.
Behavioral strategies—particularly exposure—are important to treatment, especially for avoidant patients. As long as patients with Defectiveness schemas avoid intimate human contact, their feelings of defectiveness remain intact. Patients work on entering interpersonal situations that hold the potential to enhance their lives. Behavioral strategies can also help patients correct some legitimate flaws (i.e., lose weight, improve their style of dress, learn social skills). In addition, patients work on choosing significant others who are supportive rather than critical. They try to select partners who love and accept them.
Behaviorally, patients also learn to stop overreacting to criticism. They learn that, when someone gives them a valid criticism, the appropriate response is to accept the criticism and try to change themselves; when someone gives them a criticism that is not valid, the appropriate response is simply to state their point of view to the other person and affirm internally that the criticism is false. It is not appropriate to attack the other person; it is not necessary to respond in kind or to fight to prove the other person wrong. Patients learn to set limits with hypercritical people and stop tolerating maltreatment. Patients also work on self-disclosing more to significant others whom they trust. The more they can share themselves and still be accepted, the more they will be able to overcome the schema. Finally, patients work on decreasing compensatory behaviors. They stop trying to overcompensate for their inner sense of defectiveness by appearing perfect, achieving excessively, demeaning others, or competing for status.
It is especially important for the therapist to be accepting and nonjudgmental toward patients with this schema. It is also important that the therapist not come across as perfect. Like every human being, the therapist makes mistakes and acknowledges flaws.
Many patients who have this schema are unaware of it. A lot of patients are avoiding or overcompensating for the pain of this schema, rather than feeling that pain. Patients with narcissistic personality disorder are an example of a group with a high probability of having the Defectiveness schema and a low probability of being aware of it. Narcissistic patients often get caught up in competing with or denigrating the therapist rather than working on change.
Patients with a Defectiveness schema might hold back information about themselves because they are embarrassed. A long time may pass before these patients are willing to share fully their memories, desires, thoughts, and feelings.
This schema is difficult to change. The earlier and more severe the criticism and rejection from parents, the more difficult it is to heal.
Patients with this schema believe that they are different from other people. They do not feel that they are part of most groups and feel isolated, left out, or “on the outside looking in.” Anyone who grows up feeling different might develop the schema. Examples include gifted people, those from famous families, people with great physical beauty or ugliness, gay men and women, members of ethnic minorities, children of alcoholics, trauma survivors, people with physical disabilities, orphans or adoptees, and people who belong to a significantly higher or lower economic class than those around them.
Typical behaviors include staying on the periphery or avoiding groups altogether. These patients tend to engage in solitary activities: Most “loners” have this schema. Depending upon the severity of the schema, the patient may be part of a subculture but still feel alienated from the larger social world; he or she may feel alienated from all groups but have some intimate relationships, or be disconnected from virtually everyone.
The basic goal of treatment is to help patients feel less different from other people. Even if they are not part of the mainstream, there are other people similar to them. Furthermore, at the core, we are all human beings, with the same basic needs and desires. Even though we have many differences, we are more alike than different. (“Nothing human is alien to me,” [Terrence, trans. 1965, I, i].) There may be a segment of society in which the patient probably will never fit—such as a gay patient in a fundamentalist religious group—but there are other places where the patient will fit. The patient should walk away from unwelcoming groups and find people who are more similar or accepting. Often, the patient must make major life changes and overcome extensive avoidance in order to accomplish this.
Unlike the other schemas in the Disconnection and Rejection realm, the focus is less on working experientially with childhood origins of the schema and more on improving the patient’s current relationships with peers and groups. Thus, cognitive and behavioral strategies take precedence. Group therapy may be helpful for many patients with this schema, especially those who avoid even friendships. The more isolated the patient, the more important the therapy relationship is to the treatment, because it will be one of the patient’s only relationships.
The aim of the cognitive strategies is to convince patients that they really are not as different from other people as they think. They share many qualities with all people, and some of the qualities that they regard as distinguishing them are in fact universal (e.g., sexual or aggressive fantasies). Even if they are not part of the mainstream, there are other people like them. Patients learn to focus on their similarities with other people, as well as their differences. They learn to identify subgroups of people who are like them—who share the ways they are different; they learn that many people can accept them even though they are different. They learn to challenge the automatic negative thoughts that block them from joining groups and connecting to the people in them.
Experiential strategies can help patients who were excluded as children and adolescents remember what it was like. (Some patients with this schema were not excluded as children. Rather, they chose solitude due to some preference or interest.) In imagery, patients relive these childhood experiences. They vent anger at the peers who excluded them; and they express their loneliness. Patients fight back against social prejudice toward people who are different. (This is one advantage of consciousness-raising groups: They teach group members to fight back against the hatred of others.) Patients can also use imagery to picture groups of people with whom they could fit in.
Behavioral strategies focus on helping patients overcome their avoidance of social situations. The goal is for patients gradually to start attending groups, connect to the people there, and cultivate friendships. In order to work toward this goal, patients undergo graduated exposure through a series of homework assignments. Anxiety management can help patients cope with their usually considerable social anxiety. Social skills training can help them work to correct any deficits in interpersonal skills. Where necessary, medication might be added to decrease the patient’s anxiety.
Of course, it is positive when patients with this schema have a close relationship with the therapist. However, unless patients also focus on cognitive and behavioral strategies to overcome their avoidance of social situations, the therapy relationship is probably not going to help them sufficiently. Sometimes patients with this schema can connect to the therapist, yet still continue to feel different from everyone else. It depends on the severity of the schema: For patients on the extreme end, the therapy relationship can counter their feelings of utter aloneness and be important. But to the extent that patients can already connect to individuals but cannot connect to groups, the therapy relationship by itself will probably not be especially valuable as a corrective emotional experience. Group therapy can be extremely helpful if the group is accepting of the patient; for this reason, “special interest” groups—containing members who are similar to the patient in some significant way (i.e., children of alcoholics, incest survivors, support groups for overweight patients)—can be most valuable.
The most common problem is that patients have difficulty overcoming their avoidance of social situations and groups. In order to confront the situations that they fear, patients must be willing to tolerate a high level of emotional discomfort. For this reason, their pattern of avoidance is resistant to change. When avoidance blocks progress in treatment, mode work can often help patients build up the part of themselves that wants the schema to change and talk back to the schema. For example, patients might imagine a group situation in which they recently felt alienated. The therapist enters the image as the Healthy Adult, who advises the Isolated Child (or Adolescent) about how to integrate with the group. Later, patients enter their images as their own Healthy Adult, to help the Isolated Child master and enjoy social situations.