These patients feel special. They believe that they are better than other people. Because they feel they are part of some “elite,” they feel entitled to special rights and privileges, and do not feel bound by the principles of reciprocity that guide healthy human interactions. They try to control the behavior of others in order to meet their own needs, without empathy or concern for the others ’ needs. They engage in acts of selfishness and grandiosity. They insist they should be able to say, do, or have what they want, regardless of the cost to others. Typical behaviors include excessive competitiveness, snobbishness, domination of other people, asserting power in a hurtful way, and forcing one’s point of view on others.
We distinguish between two types of patients with Entitlement schemas: those with “pure entitlement,” and those who are typically described as “narcissistic” in the extensive literature on personality disorders. Narcissistic patients behave in an entitled way in order to overcompensate for underlying feelings of defectiveness and emotional deprivation. We refer to narcissism as “fragile entitlement.” The focus of treatment is on the underlying Emotional Deprivation and Defectiveness schemas. Setting limits is important, but it is not as central. (We discuss how to treat fragile entitlement in detail later in Chapter 10.)
In contrast, patients with “pure entitlement” were simply spoiled and indulged as children and continue to act that way as adults. Their entitlement is not an overcompensation for underlying schemas—not a way of coping with a perceived threat. For patients with “pure entitlement,” there are usually no underlying schemas to treat. Setting limits is the central part of the treatment. In this section, we focus on “pure entitlement,” although many of the strategies can also be helpful as an adjunct in working with narcissistic personality disorder.
Another group of patients has what we call “dependent entitlement”—a blending of the Dependence and Entitlement schemas. These patients feel entitled to be dependent on others to take care of them. They believe other people should meet their daily needs for food, clothing, shelter, and transportation, and they become angry when other people fail to do so. In treating these patients, the therapist works on both the Entitlement and the Dependence schemas simultaneously.
The basic goal with the Entitlement schema is to help patients accept the principle of reciprocity in human interactions. We try to teach these patients the philosophy that, when it comes to basic worth, all people are created equal and deserve equal rights (unlike the entitled animals in George Orwell’s (1946) Animal Farm, who changed the commandment to read: “All animals are created equal, but some are created more equal than others.”) All people are equally valuable: One person is not inherently more valuable than another and is not entitled to special treatment. Healthy individuals do not dominate and bully others, but rather respect the other person’s needs and rights; they also try their best to control their impulses so as not to hurt others, and they follow reasonable social norms most of the time.
In order to help patients maintain the motivation to change, the therapist continually highlights all the disadvantages of the Entitlement schema. Often, these patients have not come to therapy voluntarily. They have come because someone is forcing them, or because they are facing some negative consequence of their entitlement—loss of their job, a marriage breaking up, children who have stopped talking to them, or feelings of loneliness and emptiness. They may well be experiencing genuine pain about an impending loss. The therapist finds out what is causing them pain and why they have come to therapy, and uses these as leverage to keep these patients in therapy. The therapist keeps saying, in essence: “If you don’t give up your entitlement, if you aren’t willing to change, people will continue to retaliate against you or leave, and you will continue feeling unhappy.” The therapist keeps reminding patients what the consequences will be if they are not willing to change.
Working on interpersonal relationships and on the therapy relationship are the most important treatment strategies. The therapist encourages patients to feel empathy and concern for others—to recognize the damage they do when they misuse their power over others. Cognitive-behavioral strategies such as anger management and assertiveness training are important as well, so that the patient can learn to replace overly aggressive approaches to others with more assertive approaches. If the patient is in a love relationship with a partner, then it is often helpful to bring the partner into some therapy sessions. The therapist can then work with the couple to stop the patient’s entitled behavior and to help the partner set limits, so that each member of the couple balances his or her own needs with the needs of the other person.
Patients with this schema have spent their lives selectively focusing on their assets and minimizing their flaws. They do not have a realistic view of their own strengths and weaknesses. They do not understand or accept that they have normal human frailties and limitations, as we all do. The therapist uses cognitive strategies to help patients develop a more realistic view of themselves, looking at both their strengths and their weaknesses. In addition, the therapist uses cognitive strategies to challenge their view of themselves as special, with special rights. Entitled patients have to learn to follow the same rules as everyone else. They have to treat people respectfully, as equals. The therapist and patient look at past situations in which the patient behaved in an entitled way and experienced negative consequences.
The therapist uses experiential strategies to help patients express acknowledgment of their parents ’ overly indulgent behavior in their childhood. The therapist enters the imagery as the Healthy Adult who confronts the Entitled Child empathically and teaches the principle of reciprocity. Eventually, patients enter the imagery as their own Healthy Adult modes.
The therapist watches for entitled behavior in the therapy relationship and confronts each instance through empathic confrontation. The therapist reparents by setting limits whenever the patient behaves in a bullying or demeaning way, or expresses anger inappropriately. The therapist uses the therapy relationship to support patients whenever they admit a flaw, view other people as equals, or experience feelings of inferiority. The therapist praises patients when they express feelings of empathy for others, and acknowledges them when they restrain their destructive impulses and hold back unreasonable anger. Finally, the therapist discourages patients ’ overemphasis on status and other superficial qualities in judging themselves and others.
One likely difficulty is helping the patient maintain the motivation to change. A significant proportion of patients with entitlement leave therapy before they are better, because a great deal of secondary gain goes along with this schema. It feels good to get what one wants. Why should the patient change? The therapist has to find the leverage—the ways it is hurting the patient to be entitled or grandiose. Then, the therapist has to remind the patient continually about the negative consequences of the schema.
Patients who have this schema typically lack two qualities: (1) self-control—the ability to appropriately restrain one’s emotions and impulses; and (2) self-discipline—the ability to tolerate boredom and frustration long enough to accomplish tasks. These patients are unable to restrain their emotions and impulses appropriately. In both their personal and work lives, they display a pervasive difficulty in delaying short-term gratification for the sake of meeting long-term goals. They seem not to learn sufficiently from experience—from the negative consequences of their behavior. They either cannot or will not exercise sufficient self-control or self-discipline. (In Postcards from the Edge Carrie Fisher [1989, p. 9] captured this sensibility when she wrote, “The trouble with immediate gratification is that it’s not quick enough.”)
At the extreme end of the spectrum of this schema are patients who seem like badly brought up young children. In milder forms of the schema, patients display an exaggerated emphasis on avoiding discomfort. They prefer to avoid most pain, conflict, confrontation, responsibility, and overexertion—even at the cost of their personal fulfillment or integrity.
Typical behaviors include impulsivity distractibility disorganization, unwillingness to persist at boring or routine tasks, intense expressions of emotion, such as temper tantrums or hysteria, and habitual lateness or unreliability. All of these behaviors have in common the pursuit of short-term gratification at the expense of long-term goals.
The schema does not primarily apply to substance abusers or addicts. Substance abuse is not at the crux of this schema, although it often accompanies it. Addictive behaviors in themselves—such as drug or alcohol abuse, overeating, gambling, compulsive sex—are not what this schema is meant to measure. Addictions can be ways of coping with many other schemas, not just this one: They can be a way of avoiding the pain of almost any schema. Rather, this schema applies to patients who have difficulty controlling or disciplining themselves over a broad range of situations. They fail to impose limits on their emotions and impulses in many areas of their lives and exhibit a broad range of self-control problems in several areas, not just addictive behaviors.
We believe that every child is born with an impulsive mode. A natural part of every human being, it is the failure to bring impulsivity under sufficient control and learn self-discipline that is maladaptive. Children are, by nature, uncontrolled and undisciplined. Through experiences in our families and in society as a whole, we learn how to become more controlled and disciplined. We internalize a Healthy Adult mode that can restrain the Impulsive Child in order to meet long-term goals. Sometimes another problem, such as attention-deficit/hyperactivity disorder, makes it hard for the child to accomplish this.
Often, there are no specific beliefs and feelings that go along with this schema. It is rare for patients with this schema to say, “It’s right to express all my feelings” or “I should act impulsively.” Rather, patients experience the schema as being outside of their control. The schema does not feel ego-syntonic in the way that other schemas do. Most patients we see with this schema want to be more self-controlled and self-disciplined: They keep trying, but they cannot seem to sustain their efforts for very long.
The impulsive mode is also the mode in which a person can be spontaneous and uninhibited. A person in this mode can play, be light, and have fun. There is a positive side to the mode, but when it is excessive—when it is not balanced by other sides of the self—the cost exceeds the benefit, and the mode becomes destructive to the person.
The basic goal is to help patients recognize the value of giving up short-term gratification for the sake of long-term goals. The benefits of venting one’s emotions or doing what is immediately pleasurable are not worth the costs in career advancement, achievement, getting along with other people, and low self-esteem.
Cognitive-behavioral treatment techniques are almost always the most helpful strategies with this schema. The therapist helps patients learn to exercise self-control and self-discipline. The basic idea is that between the impulse and the action, patients must learn to insert thought. They must learn to think through the consequences of giving in to the impulse before acting it out.
In homework assignments, patients go through a series of graded tasks, such as becoming organized, performing boring or routine tasks, being on time, imposing structure, tolerating frustration, and restraining excessive emotions and impulses. Patients start with simple tasks that are only slightly difficult. They force themselves to do these tasks for a limited amount of time, then gradually increase the amount of time. Patients learn techniques that help them control their emotions, such as time-out and self-control techniques (meditation, relaxation, distraction), and flash cards listing reasons they should control themselves, and methods they can use to do it. In therapy sessions, patients can use behavioral rehearsal in imagery or role-playing to practice self-control and self-discipline. They can reward themselves when they successfully exert self-control and self-discipline in their outside lives. Rewards might include acknowledging oneself, treating oneself with a special activity or gift, or free time.
Occasionally, the Insufficient Self-Control/Self Discipline schema is linked with another schema that may be more primary. In this case, the therapist must address the more central schema, as well as the Insufficient Self-Control/Self-Discipline schema. For example, sometimes the schema erupts because patients have suppressed too much emotion for too long. This often happens with the Subjugation schema. Over long periods of time, patients with the Subjugation schema do not express anger when they feel it. Gradually, their anger accumulates, then suddenly bursts forth in an out-of-control way. When patients display a pattern of swinging between prolonged passivity and sudden fits of aggression, they often have underlying Subjugation schemas (see the later section on Subjugation). If patients can learn to express what they need and feel appropriately in the moment, then anger will not build up in the background. The less patients suppress their needs and feelings, the less likely they become to behave impulsively.
Some experiential techniques are helpful. Patients can imagine past and current scenes in which they displayed insufficient self-control or self-discipline. First the therapist, then the patient, enters scenes as the Healthy Adult, who helps the Undisciplined Child exert self-control. When Insufficient Self-Control/Self-Discipline is linked to another schema, the therapist can use experiential techniques to help patients battle the underlying schema. This is especially important in patients with BPD. Because of their Subjugation schemas, these patients feel that they are not allowed to express their needs and feelings. Whenever they do, they feel they deserve to be punished by their internalized Punitive Parent. They repeatedly suppress their needs and feelings. As time passes, their needs and feelings build up, beyond their ability to contain them, and then these patients flip into the Angry Child mode in order to express them. They suddenly become enraged and impulsive. When this happens, the therapist’s general approach is to allow the patient to vent fully, empathize, and then reality-test.
In the therapy relationship, it is important for the therapist to be firm and set limits with these patients. This is especially true when the origin of the schema was not getting enough limits as a child. Some patients who have this schema were “latch-key children.” Because their parents were working and they were left alone, there was no one to discipline them. When lack of parental involvement in childhood is the origin of the schema, the therapist can provide a partial antidote by reparenting the patient in an active way. The therapist sets consequences for such behaviors as being late for sessions and failing to complete homework assignments.
Sometimes the schema appears to be biologically based and therefore very hard to change with therapy alone, for example, when the patient has a learning problem such as attention-deficit/hyperactivity disorder. If the schema is biologically based, then even when patients are highly motivated and expend great effort, they may be unable to develop sufficient self-control and self-discipline. In practice, it is often unclear how much the schema is linked to temperament and how much it is related to insufficient limits in childhood. Medication should be considered for patients who have persistent difficulty fighting the schema despite an apparent commitment to therapy.