These patients present as childlike and helpless. They feel unable to take care of themselves on their own, experience life as overwhelming, and themselves as inadequate to cope. The schema has two elements. The first is incompetence: These patients lack faith in their decisions and judgments about everyday life. They hate and fear facing change alone; they feel unable to tackle new tasks on their own and believe they need someone to show them what to do. These patients feel like children too young to survive on their own in the world: Without parents they might die. In the extreme form of the schema, patients believe they will not be able to feed, clothe, and shelter themselves, navigate from one place to another, or fulfill the simple, everyday tasks of life.
The second element—dependence—follows from the first. Because these patients feel unable to function on their own, their only options are to find other people to take care of them or not to function at all. The people they find to take care of them are usually parents or substitute parents, such as partners, siblings, friends, bosses—or therapists. The parent figure either does everything for them or shows them what to do at new each step along the way. The core idea is “I am incompetent; therefore, I must depend on others.”
Typical behaviors include asking others for help; constantly asking questions as they work on new tasks; repeatedly seeking advice about decisions; having difficulty traveling alone and managing finances on their own; giving up easily; refusing additional responsibilities (i.e., a promotion at work); and avoiding new tasks. Difficulty driving is often a metaphor for the schema. People with the Dependence/Incompetence schema often fear and avoid driving alone: They might get lost; their car might break down, and they would not know what to do. Something unforeseen might happen, and they would not be able to handle it. They would not be able to come up with a solution on their own. Thus, they need someone with them who can either give them the solution or handle the problem for them.
These patients usually do not come into therapy with the goal of becoming more independent or more competent. Rather, they come looking for a magic pill, or for an expert who will tell them what to do. Their presenting problems are often Axis I symptoms such as anxiety, phobic avoidance, or stress-induced physical problems. They may be depressed because they are afraid to leave an abusive, depriving, or controlling partner or parent figure, often a person resembling the parent who induced the schema, because they do not believe they can survive on their own. Their goal is typically to get rid of these symptoms rather than change their core sense of dependence and incompetence.
A small percentage of patients with the Dependence/Incompetence schema overcompensate for the schema by becoming counterdependent. Even though underneath they feel incompetent, they insist on doing everything on their own. They refuse to rely on anyone for anything. They will not be dependent, even in situations where it is normal to be dependent. Like pseudomature children who have had to grow up too soon, they manage alone, but they do it with a tremendous amount of anxiety. They take on new tasks and make their own decisions, and they may perform well and make good decisions, but inside, they always feel that, this time, they are not going to be able to pull it off.
The goals of treatment are to increase the patient’s sense of competence and decrease dependence on other people. Increasing the patient’s sense of competence usually involves building both confidence and skills; decreasing his or her dependence involves overcoming avoidance of trying tasks alone. Ideally, these patients become able to stop relying on other people to an unhealthy degree.
Giving up the dependence is the key to treatment. The therapist guides patients through a kind of response prevention: Patients stop themselves from turning to others for help, handle tasks on their own, accept that making mistakes is how they will learn, persevere until they are successful, and prove to themselves that they can eventually generate their own solutions to problems. Through trial and error, they can learn to trust their own intuition and judgments rather than disregarding them.
The cognitive-behavioral element of treatment is usually the most important with this schema. The focus is on helping patients change cognitions, build skills, and undergo graduated exposure to making decisions and functioning independently.
Cognitive strategies help patients alter the view that they need constant assistance in order to function. The techniques are the usual ones: flash cards, dialogues between the schema side and the healthy side, problem-solving to make decisions, and challenging negative thoughts. The therapist questions the patient’s view that depending on others is a desirable way to live. Excessive dependence on others has costs, such as unfulfilled emotional needs for autonomy and self-expression, which the therapist and patient can elucidate together. Using cognitive strategies to build motivation is essential because, in order to overcome the schema, patients will have to be willing to tolerate anxiety. The therapist can graduate the tasks from low to high anxiety to decrease the patient’s distress, and teach the patient relaxation, meditation, or other anxiety-reducing techniques.
As we have noted, experiential techniques are usually less important with this schema. At times, it is useful for patients to confront in imagery the parent who overprotected and undermined them in childhood, for example, if the parents are still treating them this way and they are angry about it. If patients are angry with the parent, the therapist helps them express it. However, patients with this schema often are not angry with the parent. Because the parent was often trying to help, mobilizing anger can be difficult. Nevertheless, even if the parent’s intentions were good, what he or she did was damaging to the patients ’ independence and sense of competence. Because the parent made so many decisions for them, patients were unable to develop confidence in their own judgment; because their parent did so many tasks for them, they were unable to develop basic living skills.
The therapist conducts imagery sessions in which the patient remembers childhood situations that created the schema. The patient enters the image as the Healthy Adult, who helps the Incompetent Child cope and solve problems. When the patient is unable to come up with a healthy response, the therapist acts as coach. The therapist also conducts imagery sessions in which the patient imagines current situations that require practicing basic living skills. Again, the patient enters the image as the Healthy Adult to help the Incompetent Child. (Many patients with this schema see themselves as little children when they picture themselves—little children in a world of big adults). The Healthy Adult says to the child, “I know you are young and too scared to made decisions. But you don’t have to make them. I will make them for you. I am an adult even though you are a child. I can make decisions and I can do things on my own.”
The behavioral part of treatment helps patients overcome their avoidance of independent functioning. This is crucial to the success of the treatment: If patients do not change their behavior, they will not gather enough evidence to fight the schema. Because avoidance maintains a conditioned fear indefinitely, patients will not be able to heal the schema until they are willing to confront anxiety-arousing situations. Therapists help patients to set up graded assignments in which they handle everyday tasks on their own. Starting with the easiest one, they practice handling these tasks as homework assignments.
Therapists can carry out behavioral rehearsals with patients during sessions to help them prepare for homework assignments. Patients imagine or role-play themselves successfully completing the tasks, solving any problems that arise. It is helpful for patients to reward themselves whenever they complete homework assignments. Anxiety management techniques—such as flash cards, breathing exercises, relaxation techniques, and rational responding—can help patients tolerate the anxiety of functioning independently.
Sometimes the therapist involves family members in the treatment if they are still fostering dependence in the patient, especially when the patient is living with them. Family members can be an important part of the both the problem and the solution to the schema. If the patient is able to handle family members adequately alone, then the therapist does not meet with them. However, as more often happens, if the patient is unable to stop family members from reinforcing the schema, then the therapist considers intervening.
In the therapy relationship, it is important to resist attempts by patients to take on a dependent role with the therapist. Rather, the therapist should encourage patients to make their own decisions, giving them help only when necessary. The therapist should also remember to acknowledge patients whenever they make progress on their own.
One of the greatest risks is that the patient might become dependent on the therapist rather than overcoming the schema. The therapist mistakenly assumes the role of parent figure and runs the patient’s life. The amount of dependence the therapist allows is a delicate balancing act. If the therapist does not allow any dependence, the patient will probably not stay in treatment. Realistically, the therapist has to start by allowing some dependence and then gradually withdrawing. The therapist should strive to allow the least possible amount of dependence that will keep the patient in treatment.
One of the greatest challenges in treating patients with this schema is overcoming their avoidance of independent functioning. Patients have to become willing to trade short-term pain for long-term gain and tolerate the anxiety of functioning as adults in the world. As we have noted, building motivation is an important aspect of treatment. Mode work can help patients strengthen the healthy part of themselves that wants independence and competence. This Independence Seeker can carry out dialogues with the dysfunctional parent, and with the coping modes in the patient that are blocking motivation.
These patients live their lives believing that catastrophe is about to strike at any moment. They are convinced that something terrible is going to happen to them that is beyond their control. They will suddenly be struck with a medical illness; there will be a natural disaster; they will become victims of crime; they will get into a terrible accident; they will lose all their money; or they will have a nervous breakdown and go crazy. A bad thing is going to happen, and they are not going to be able to prevent it. The predominant emotion is anxiety, ranging from low-level dread to fullblown panic attacks. These patients are not afraid of handling everyday situations, like patients who have Dependence schemas; rather, they are afraid of catastrophic events.
Most of these patients rely on avoidance or overcompensation to cope with the schema. They become phobic, restrict their lives, take tranquilizers, engage in magical thinking, perform compulsive rituals, or rely on “safety signals,” such as a person they trust, a bottle of water, or tranquilizers. All of these behaviors have the goal of stopping the bad thing from happening.
The goals of treatment are to get patients to lower their estimations of the likelihood of catastrophic events and to raise their evaluations of their ability to cope. Ideally, patients come to recognize that their fears are greatly exaggerated and, even if a catastrophe did occur, they would be able to deal with it adequately. The ultimate goal of treatment is to convince patients to stop avoiding and overcompensating for the schema, and to face most of the situations they fear. (Of course, we do not encourage patients to confront truly dangerous situations, such as driving in heavy storms or swimming in the ocean too far from the shore.)
Patients explore the childhood origins of the schema and trace its pattern through their lives. They count the costs of the schema. Patients explore the changes they would make in their current lives if they were not overly afraid. It is important to spend time building the patient’s motivation to change. The therapist helps the patient stay focused on the long-term negative consequences of living a phobic lifestyle, such as lost opportunities for fun and self-exploration; and on the positive benefits of moving more freely in the world, such as a richer, fuller life. Mode work is especially helpful in battling the patient’s resistance to change, helping the patient build a Healthy Adult who wants to progress, and who can guide the Frightened Child through challenging situations. Without sufficient motivation, patients will be unwilling to endure the anxiety of giving up their maladaptive coping devices. Cognitive and behavioral strategies for overcoming anxiety and avoidance are the central focus of treatment.
Cognitive strategies help patients lower their estimation of the probability of catastrophic events and raise their estimation of their capacity to cope. Patients counter their exaggerated perceptions of danger. Challenging catastrophic thoughts—or “decatastrophizing”—helps them manage panic attacks and other anxiety symptoms. Cognitive strategies also help patients build motivation by highlighting the advantages of changing.
Similarly, behavioral strategies help patients give up their magical rituals and safety signals, and face the situations they fear. Patients undergo graduated exposure to phobic situations in homework assignments between sessions. In order to prepare for these exposures, patients use imagery rehearsal in sessions: They picture themselves entering specific phobic situations and, with the assistance of the “Healthy Adult,” coping well. Anxiety-management techniques such as breathing exercises, meditation, and flash cards, help patients cope with the exposures as they go through them.
Experiential strategies are important, especially imagery for rehearsal and mode work. If the schema is the internalization of a parent (having a parent who models the schema is one of the most common origins), then the patient can conduct dialogues with this parent in imagery. The patient can enter images of childhood or current situations as the Healthy Adult to reassure the Frightened Child, and to confront the parent about the negative consequences of catastrophizing. Additionally, patients can visualize the Healthy Adult leading the Frightened Child to safety in phobic situations.
The therapy relationship is not the crucial aspect of treatment with these patients. What is most important is that the therapist consistently adopt an attitude of empathic confrontation toward the patient’s reliance on avoidance and overcompensation, and provide calm reassurance that the patient will be able to cope in healthier ways. In addition, the therapist models nonphobic ways of viewing and handling situations containing acceptable levels of risk.
The greatest problem is that patients are too afraid to stop avoiding and overcompensating. They resist giving up these protections against the anxiety of the schema. As we mentioned earlier, mode work can help patients strengthen the healthy part of them that yearns for a fuller life.
When patients with an Enmeshment schema enter treatment, they are often so fused with a significant other that neither they nor the therapist can say clearly where the patient’s identity begins and the “enmeshed other” ends. This person is usually a parent or a parental figure, such as a partner, sibling, boss, or best friend. Patients with this schema feel an extreme emotional involvement and closeness with the parental figure, at the expense of full individuation and normal social development. (One such patient, enmeshed with his mother, told his therapist how his mother, trying to dissuade him from getting married, said: “I know what’s best for you, son. After all, I’ve been in and out of a lot of women with you.”)
Many of these patients believe that neither they nor the parental figure could survive emotionally without the constant support of the other, that they need each other desperately. They feel an intense bond with this parental figure, almost as though, together, they are one person. (Patients may feel that they can read the other person’s mind, or sense what the other person wants without the other having to ask.) They believe it is wrong to set any boundaries with the parental figure, and feel guilty whenever they do. They tell the other person everything and expect the other person to tell them everything. They feel fused with this parental figure and may feel overwhelmed and smothered.
The characteristics discussed thus far represent the “Enmeshment” part of the schema. There is also the “Undeveloped Self”, a lack of individual identify, which patients often experience as a feeling of emptiness. These patients often convey a sense of an absent self, because they have surrendered their identity in order to maintain their connection to the parental figure. Patients who have an undeveloped self feel as though they are drifting in the world without direction. They do not know who they are. They have not formed their own preferences or developed their unique gifts and talents, nor have they followed their own natural inclinations—what they naturally are good at and love to do. In extreme cases, they may question whether they really exist.
The “Enmeshment” and “Undeveloped Self” parts of the schema often, but not always, go together. Patients can have an undeveloped self without enmeshment. The undeveloped self can develop for reasons other than enmeshment, such as subjugation. For example, patients dominated as children may never have developed a separate sense of self, because they were forced to do whatever their parents demanded. However, patients who are enmeshed with a parent or parental figure almost always have an undeveloped self as a consequence. Their opinions, interests, choices, and goals are merely reflections of the person with whom they are merged. It is as though the parental figure’s life is more real to them than their own: The parental figure is the star and they are the satellite. Similarly, patients with undeveloped selves might seek out charismatic group leaders with whom they can become enmeshed.
Typical behaviors include copying the behaviors of the parental figure, talking and thinking about him or her, staying in constant contact with the parental figure, and suppressing all thoughts, feelings, and behaviors that are discrepant from the parent figure. When patients do try to separate from the enmeshed person in any way, they feel overcome with guilt.
The central goal of treatment is to help patients express their spontaneous, natural selves—their unique preferences, opinions, decisions, talents, and natural inclinations—rather than suppressing their true selves and merely adopting the identity of the parent figures with whom they are enmeshed. Patients who have been treated successfully for enmeshment issues are not focused to an unhealthy degree on a parental figure. They are at the center of their own lives. They are no longer fused with a parental figure and are aware of how they are similar to the parental figure and how they are different. They set boundaries with the parental figure and have a full sense of their own identity.
For patients who have avoided closeness as adults in order to avoid enmeshment, the goal of treatment is for the patient to establish connections with others that are neither too distant nor too enmeshed.
Treatment focuses on patients ’ current lives. Cognitive and experiential techniques to help patients identify their preferences and natural inclinations, and behavioral techniques to help them enact their true self, are most important.
Cognitive strategies challenge the patient’s view that it is preferable to be enmeshed with a parent figure than to have an identity of one’s own. The therapist and patient explore the advantages and disadvantages of developing a separate self. Patients identify how they are both similar to and different from the parental figure. It is important to identify the similarities: The goal is not for patients to go to the opposite extreme and deny all similarities with the parental figure. Sometimes enmeshed patients say that they do not want to be like the parental figure at all now; and they cannot acknowledge even the similarities that exist. In this form of overcompensation for enmeshment, the patient does the opposite of the parental figure. In addition, patients conduct dialogues between the enmeshed side that wants to be fused with a parental figure, and the healthy side that wants to develop an individual identity.
Experientially patients visualize separating from the parental figure in imagery. For example, patients relive moments in childhood when they disagreed with or felt different from the parent. They imagine saying what they truly felt, and doing what they truly wanted to do. They imagine telling past and current parental figures how they are different, and how they are alike. They imagine setting boundaries with past and current parental figures, such as refusing to divulge information or to spend more time together. The Healthy Adult, played first by the therapist and then by the patient, helps the Enmeshed Child accomplish the separation.
Behavioral strategies help patients identify their preferences and natural inclinations. Patients begin listing experiences they find inherently enjoyable as a behavioral experiment. They refer to their basic bodily sense of pleasure as a way of identifying what they enjoy. For homework, they may be asked to list their favorite music, movies, books, restaurants, or activities. Patients list what they like and dislike about significant others. Behavioral strategies also help patients act on their preferences even when they differ from those of a parental figure. Additionally, behavioral strategies help patients select partners and friends who do not foster enmeshment. Typically, patients with this schema select strong partners, and then submerge themselves in the partners ’ lives. The partner becomes the parental figure. Patients become a satellite in the orbit of their partner, another star.
The therapist sets appropriate boundaries, regulating the therapy relationship so that it is neither too merged nor too distant. If the therapist and patient are too merged, it will recreate the enmeshment of the patient’s childhood; if it is too distant, the patient will feel disconnected and unmotivated to change.
The most obvious potential problem is that the patient might enmesh with the therapist, so that the therapist becomes the new parental figure in the patient’s life. The patient is able to give up the old parental figure, but only to replace the other person with the therapist. As with the Dependence/Incompetence schema, the therapist might have to allow some enmeshment at the beginning of treatment but should quickly begin encouraging the patient to individuate.
Patients who have a Failure schema believe that they have failed relative to their peers in areas of achievement such as career, money, status, school, or sports. They feel that they are fundamentally inadequate compared to others at their level—that they are stupid, inept, untalented, ignorant, or unsuccessful, and that they inherently lack what it takes to succeed.
Typical behaviors or these patients include surrendering to the schema by sabotaging themselves or performing halfheartedly, avoidance behaviors such as procrastinating or not doing the task at all, and overcompensating behaviors such as working nonstop or otherwise overachieving. Over-compensators with Failure schemas believe that they are not as smart or talented as other people, but they can make up for it by working extra diligently. They are often quite successful, yet still feel fraudulent. These patients appear successful to the outside world but feel underneath that they are on the brink of failing.
It is important to distinguish between the Failure and Unrelenting Standards schemas. Patients with the Unrelenting Standards schema believe they have failed to meet their own (or their parents ’) high expectations, but they will acknowledge that they have done as well or better than the average person in their same occupation. Patients with the Failure schema believe they have done worse than most others in their occupation, and very often they are right. Most patients with the Failure schema have not accomplished as much as the average person in their peer group. Failure has become a self-fulfilling prophecy in their lives. It is also important to distinguish between the Failure schema and the Dependence/Incompetence schema, which has more to do with daily functioning than with achievement. The Failure schema involves money, status, career, sports, and school; the Dependence/Incompetence schema involves everyday decision-making and taking care of oneself in daily life. The Failure schema often leads to a linked Defectiveness schema. Feeling like a failure in areas of achievement, the person feels defective.
The central goal of treatment is to help patients feel and become as successful as their peers (within the limits of their abilities and talents). This usually involves one of three scenarios. The first is increasing their level of success by building skills and confidence. Second, if they are, in fact, successful relative to their potential, it involves raising their appraisals of their level of success or changing perceptions of their peer group. The third scenario involves patients accepting unchangeable limitations in their abilities, while still feeling they have value.
It is important to assess carefully the origin of the Failure schema for each patient, because the strategies the therapist emphasizes will depend on this assessment. Some patients have failed due to an innate lack of talent or intelligence. In these cases, the therapist tries to help the patient build skills and set realistic goals. Other patients have the talent and intelligence to succeed but have never applied themselves fully. Perhaps they have lacked direction or focused on the wrong areas. In these cases, the therapist aims to provide direction or to shift their focus to areas in which they have more natural talents. Perhaps patients have another disorder that has interfered with their development (such as attention deficit disorder), in which case the therapist needs to treat the other disorder. Perhaps they lack discipline: Many patients with the Failure schema also have the Insufficient Self-Control/Self-Discipline schema. In these cases, the therapist allies with the patient to fight the Insufficient Self-Control/Self-Discipline schema. Perhaps patients are flooded with negative affect from another schema, such as Defectiveness or Emotional Deprivation, which they spend a lot of time and effort trying to avoid—by abusing drugs, drinking alcohol, playing the stock market, surfing the Internet, gambling, viewing pornography, or having sexual affairs—and the avoidance interferes with their dedication to work. In these cases, treatment involves working on the underlying schemas. It is important to assess why the patient has failed, in order to design the proper treatment for the problem. In most cases, the cognitive and behavioral aspects of the treatment take precedence.
If patients actually have failed relative to peers, then the most important cognitive strategy is to challenge the view that they are inherently inept and to reattribute their failure to schema perpetuation. These patients have not failed because they are inherently inept, but rather because they have inadvertently acted to defeat their attempts to succeed. It is the schema itself that has caused them to fail. Their coping styles—the ways they surrender to and avoid the schema—are the problem, not their basic ability. Patients conduct dialogues between the Failure schema and the healthy side that wants to fight the schema.
Another cognitive strategy is to highlight patients’ successes and skills. Typically, patients with this schema have ignored their accomplishments and accentuated their failures. The therapist helps correct this bias by teaching patients to notice each time they are successful. The therapist also helps patients identify skills, utilizing cognitive techniques such as examining the evidence. Finally, the therapist helps patients set realistic long-term goals. Patients whose long-term goals are unrealistically high might have to lower their expectations for success, find a different comparison group, or switch to a different field.
Experiential techniques can be helpful in preparing patients to undertake behavioral change. In imagery, patients relive failure experiences from the past and express anger at the people who discouraged them, or mocked and devalued them for failing. Often, the person was a parent, older sibling, or teacher. Doing this helps patients reattribute the failure to the other person’s criticalness rather than to their own lack of ability. Patients with attention-deficit/hyperactivity disorder are an example of a group often scolded as children for behaviors they usually could not control. Their parents viewed them as intentionally not learning, when, in fact, they could not learn normally. Naturally unathletic patients were often told they were not trying hard enough or practicing enough, when, in fact, they lacked the ability to perform at the expected level. Getting angry at parents and others for not recognizing and accepting their strengths and limitations is an important part of the process of letting go of the schema emotionally.
Alternatively, the patient’s parents may not have wanted the patient to succeed. Although the parents may have been unaware of it, they did not want the child to become too successful. They were afraid that the child would surpass or abandon them. The parents gave the child subtle messages that they would reject him or her or withdraw emotionally if the child became too successful. The child developed a “fear of success.” Experiential techniques help the patient identify this theme and relate to it emotionally. Getting angry with the Undermining Parent helps the patient understand that this was an unhealthy message, and one that the patient need no longer believe. Healthy parents do not punish their children for succeeding. Getting angry can help patients fight the view that people will reject them if they are too successful. Mode work helps patients develop a Healthy Adult mode that can encourage and guide the Failed Child. First the therapist, then the patient, plays the Healthy Adult in images of past and current achievement situations.
The behavioral part of the treatment is usually the most important. No matter how much progress patients make in the other areas, if they do not stop their maladaptive coping behaviors, they are going to keep reinforcing the schema. The therapist helps patients replace behaviors that surrender to, avoid, or overcompensate for the schema, with more adaptive behaviors. Patients set goals, set graded tasks to meet them, and then carry out the tasks as homework assignments. The therapist helps patients overcome blocks to completing the homework. If it is a skills problem, the therapist helps the patient develop skills. If it is an aptitude problem, the therapist helps the patient switch to more appropriate work. If it is an anxiety problem, the therapist teaches the patient anxiety management. If it is a problem with self-discipline, the therapist helps the patient create a structure to overcome procrastination and to build discipline. The therapist can help patients overcome blocks with behavioral rehearsal. Using imagery or role-playing techniques, they can work through whatever blocks naturally emerge.
In terms of the therapy relationship, the therapist models behaviors that are contrary to the schema: If the therapist sets realistic goals, works steadily to reach them, thinks through problems in advance, persists despite failure, and acknowledges progress, then the therapist’s own professional life can serve as an antidote to the schema. (The therapist’s professional success can also have the opposite effect, making the patient feel inadequate relative to the therapist. The therapist must be alert to this possibility. The key is that the therapist models a healthy approach to work, not that the actual level of the therapist’s success matters.) The therapist also reparents patients by providing structure, supporting their successes, acknowledging them when they do well, setting realistic expectations, and setting limits.
The most common problem is that patients persist in their maladaptive coping behaviors. They keep surrendering, avoiding, or overcompensating for the schema instead of trying to change. Patients are so convinced they are going to fail that they are reluctant to commit themselves fully to trying to succeed. Mode work can help patients strengthen the Healthy Adult, who is able and willing to fight the schema. In imagery, patients relive past and current moments of failure. The Healthy Adult helps the Failing Child cope in adaptive ways.