These patients allow other people to dominate them. They surrender control to others because they feel coerced by the threat of either punishment or abandonment. There are two forms: The first is subjugation of needs, in which patients suppress their own wishes and instead follow the demands of other people; and the second is subjugation of emotions, in which patients suppress their feelings (mainly anger) because they are afraid other people will retaliate against them. The schema involves the perception that one’s own needs and feelings are not valid and important to other people. The schema almost always leads to an accumulation of anger, which manifests in such maladaptive symptoms as passive-aggressive behavior, uncontrolled outbursts of anger, psychosomatic symptoms, withdrawal of affection, acting out, and substance abuse.
Patients with this schema usually present with a coping style of surrendering to the schema: They are excessively compliant and hypersensitive to feeling trapped. They feel bullied, harassed, and powerless. They experience themselves as being at the mercy of authority figures: The authority figures are stronger and more powerful; therefore, the patients must defer to them. The schema involves a significant level of fear. At the core, patients are afraid that if they express their needs and feelings, something bad is going to happen to them. Someone important is going to get angry with, abandon, punish, reject, or criticize them. These patients suppress their needs and feelings, not because they feel they should suppress them, but because they feel they have to suppress them. Their subjugation is not based on an internalized value or a desire to help others; rather, it is based upon the fear of retaliation. In contrast, the Self-Sacrifice, Emotional Inhibition, and Unrelenting Standards schemas are all similar in that patients have an internalized value that it is not right to express personal needs or feelings: They believe it is in some way bad or wrong to express needs and feelings, so they feel ashamed or guilty when they do. Patients with these other three schemas do not feel controlled by other people. They have an internal locus of control. On the other hand, patients with the Subjugation schema have an external locus of control. They believe that they must submit to authority figures, whether they think it is right or not, or else they will be punished in some way.
Often, this schema leads to avoidant behavior. Patients avoid situations where other people might control them, or where they might become trapped. Some patients avoid committed romantic relationships because they experience these relationships as claustrophobic or entrapping. The schema can also lead to overcompensation such as disobedience and oppositionality. Rebelliousness is the most common form of overcompensation for subjugation.
The basic goal of treatment is to get patients to see that they have a right to have their needs and feelings, and to express them. Generally, the best way to live is to express needs and feelings appropriately at the moment they occur, rather than waiting until later or not expressing them at all. As long as patients express themselves appropriately, it is healthy to express needs and feelings, and healthy people usually will not retaliate against them when they do. People who consistently retaliate against them when they express their needs and feelings are not beneficial people for them to choose for close involvements. We encourage patients to seek out relationships with people who allow them to express normal needs and feelings, and to avoid relationships with people who do not.
All four types of treatment strategies—cognitive, experiential, behavioral, and the therapy relationship—are important in treating this schema.
In terms of cognitive strategies, subjugated patients have unrealistic negative expectations about the consequences of expressing their needs and feelings to appropriate significant others. By examining the evidence and designing behavioral experiments, patients learn that their expectations are exaggerated. Furthermore, it is important for patients to learn that they are acting in a healthy manner when they express their needs and feelings appropriately—even though their parents may have communicated that they were “bad” for doing so as children.
Experiential strategies are extremely important. In imagery, patients express anger and assert their rights with the controlling parent and other authority figures. Often, patients with this schema have trouble expressing anger, especially toward the parent who subjugated them. The therapist should persist with the experiential work until patients are able to vent anger freely in imagery or role-play exercises. Expressing anger is crucial to overcoming the schema. The more patients get in touch with their anger and vent it in imagery or role-play exercises (particularly at the controlling parent), the more they will be able to fight the schema in their everyday lives. The purpose of expressing this anger is not purely for ventilation, but rather to help patients feel empowered to stand up for themselves. Anger supplies the motivation and momentum to fight the passivity that almost always accompanies subjugation.
A vital behavioral strategy is to help patients select relatively non-controlling partners. Usually, subjugated people are drawn to controlling partners. If they can experience attraction to a partner who wants to have an equal relationship, that is ideal. However, more typically, these patients are likely to select someone who is controlling—so they can get the “schema chemistry.” We hope that the partner is not so controlling that patients cannot express their needs and feelings whatsoever. If the partner is dominating enough to create some chemistry, but willing to take the patient’s needs and feelings into account, then this can provide a solution to the schema. There is enough chemistry to sustain the relationship, but also enough schema healing for the patient to live a healthy life. Patients also work on selecting noncontrolling friends. Assertiveness techniques can help patients learn to assert their needs and feelings with their partner and others.
When there is an undeveloped self as a consequence of the schema—when patients have served the needs and preferences of others so assiduously that they do not know their own needs and preferences—then patients can work to individuate. Experiential and cognitive-behavioral techniques can help patients identify their natural inclinations and practice acting on them. For example, patients can do imagery exercises to re-create situations in which they suppressed their needs and preferences. In the images, patients can say aloud what they needed and wanted to do. They can imagine the consequences. Patients can role-play expressing their needs and preferences with others in therapy sessions, and then express them in vivo in homework assignments.
Most subjugated patients initially perceive the therapist as an authority figure who wants to control or dominate them. They perceive the therapist as controlling even when the therapist is not. From a reparenting point of view, it is important for the therapist to be under- rather than overdirective. The therapist aims to be as nondirective as possible, allowing patients to make choices throughout the treatment process: which problems they want to address, what techniques they want to learn, and what homework assignments they want to carry out. The therapist is also careful to point out any deferential behavior on the part of patients with empathic confrontation. Finally, the therapist helps patients recognize and express anger toward the therapist, as it builds up, before it gets to the breaking point.
As patients experiment with expressing their needs and feelings, often they do it imperfectly. At the beginning, they might fail to assert themselves enough to be heard, or they might swing to the opposite extreme and become too aggressive. The therapist can help patients anticipate that it is going to take some time to find the right balance between suppressing and expressing their needs and feelings, and that they should not judge themselves too harshly for this.
When subjugated patients first try to express their needs and feelings, they often say something like: “But I don’t know what I want. I don’t know what I feel.” In cases such as these where Subjugation is linked to an Undeveloped Self schema, the therapist can help patients develop a sense of self by showing them how to monitor their wishes and emotions. Imagery exercises can help patients explore their feelings. Eventually, if they resist subjugating and continue to focus inward, most patients come to recognize what they want and feel.
Because some therapists like the deferential quality exhibited by subjugated patients, they might unwittingly reinforce the subjugation. It is easy to mistake a subjugated patient for a good patient. Both are compliant; however, it is not healthy for subjugated patients to be overly compliant. This perpetuates rather than heals their subjugation schemas.
We have found that, in most cases, this is a relatively easy schema to treat. Clinically, we have a high success rate with subjugation problems.
These patients, like those with the Subjugation schema, display an excessive focus on meeting the needs of others at the expense of their own needs. However, unlike patients with the Subjugation schema, these patients experience their self-sacrifice as voluntary. They do it because they want to prevent other people from experiencing pain, to do what they believe is right, to avoid feeling guilty or selfish, or to maintain a connection with significant others whom they perceive as needy. The Self-Sacrifice schema often results from what we believe to be a highly empathic temperament—an acute sensitivity to the pain of others. Some people feel the psychic pain of others so intensely that they are highly motivated to alleviate or prevent it. They do not want to do things or allow things to happen that will cause other people pain. Self-sacrifice often involves a sense of over-responsibility for others. It thus overlaps with the concept of co-dependence.
It is common for patients with this schema to have psychosomatic symptoms such as headaches, gastrointestinal problems, chronic pain, or fatigue. Physical symptoms may provide these patients with a way to bring attention to themselves, without having to ask for it directly and without conscious awareness. They feel permission to receive care or to decrease their care for others if they are “really sick.” These symptoms may also be a direct result of the stress created by giving so much and receiving so little in return.
Patients with this schema almost always have an accompanying Emotional Deprivation schema. They are meeting the needs of others, but their own needs are not getting met. On the surface, they appear content to self-sacrifice, but underneath, they feel a deep sense of emotional deprivation. Sometimes they feel angry at the objects of their sacrifice. Usually patients with this schema are giving so much that they end up hurting themselves.
Often, these patients believe that they do not expect anything back from others, but when something happens and the other person does not give as much back, they feel resentful. Anger is not inevitable with this schema, but patients who self-sacrifice to a significant degree, and have people around them who are not reciprocating, usually experience at least some resentment.
As we noted in the previous section on the Subjugation schema, it is important to distinguish self-sacrifice from subjugation. When patients have the Subjugation schema, they surrender their own needs out of fear of external consequences. They are afraid that other people are going to retaliate or reject them. With the Self-Sacrifice schema, patients surrender their own needs out of an inner sense or standard. (According to Kohlberg’s [1963] stages of moral development, Self-Sacrifice represents a higher level of moral development than Subjugation.) Subjugated patients experience themselves as being under the control of other people; self-sacrificing patients experience themselves as making voluntary choices.
The origins of these two schemas are different as well. Although the two schemas overlap, they are almost opposite in their origins. The origin of the Subjugation schema is usually a domineering and controlling parent; with the Self-Sacrifice schema, the parent is typically weak, needy, childlike, helpless, ill, or depressed. Thus, the former develops from interaction with a parent who is too strong, and the latter with a parent who is too weak or ill. It is also common for a child, who as an adult develops a Self-Sacrifice schema, to assume the role of the “parentified child” (Earley & Cushway, 2002) from a young age.
Patients with the Self-Sacrifice schema typically exhibit behaviors such as listening to others rather than talking about themselves; taking care of other people, yet having difficulty doing things for themselves; focusing attention on other people, yet feeling uncomfortable when attention is focused on them; and being indirect when they want something, rather than asking directly. (One of our patients told the following story about her self-sacrificing mother: “I was making coffee one morning. My mother came down to the kitchen, and I asked her if she wanted a cup. ‘No, I don’t want to be a bother,’ the mother said. ‘It’s no bother,’ said the patient, ‘let me make you a cup of coffee.’ ‘No, no,’ the mother said, so the patient made only one cup. When the patient was finished, her mother said, ‘So you couldn’t make me a cup of coffee?’”)
There can also be secondary gain with this schema. The schema has positive aspects and is only pathological when brought to an unhealthy extreme. Patients might feel a sense of pride in seeing themselves as caretakers. They might feel that they are good for behaving altruistically, that they are behaving in a morally virtuous way. (In contrast, sometimes the schema has a “never enough” quality, so that no matter how much self-sacrificers do, they still feel guilty that it is not enough.) Another potential source of secondary gain is that the schema might draw other people to them. Many people enjoy the empathy and help of the self-sacrificer. Patients with this schema usually have many friendships, although their own needs often are not being met in these relationships.
In terms of overcompensatory behaviors, after self-sacrificing for a long time, some patients suddenly flip into excessive anger. They become enraged and cut off giving to the other person completely. When self-sacrificers feel unappreciated, they sometimes retaliate by conveying to the other person: “I’m not going to give you anything ever again.” One patient with a Self-Sacrifice schema related the following incident to her therapist in describing what happened after her mother died: She was a young teenager and had begun cooking, cleaning, and doing laundry for her father. One day, while she was ironing, her father walked in and said, “From now on, button my shirts when you hang them on the hanger.” The patient stopped ironing, walked out of the room, and never cleaned, cooked, or did the laundry for her father again. “I washed my own clothes and left his there in a pile on the floor,” she concluded.
One major goal is to teach patients with the Self-Sacrifice schema that all people have an equal right to get their needs met. Even though these patients experience themselves as stronger than others, in reality, most of them have been emotionally deprived. They have sacrificed themselves and have not gotten their own needs met in return. Therefore, they are needy—just as needy as most of the “weaker” people they devote themselves to helping. The primary difference is that patients with a Self-Sacrifice schema do not experience their own needs, at least not consciously. They have usually blocked out the frustration of their own needs in order to continue self-sacrificing.
An important goal of treatment is to help patients with a Self-Sacrifice schema to recognize that they have needs that are not being met, even though they are not aware of them; and that they have as much right to get their needs met as anyone else. Despite any secondary gain that the schema might bring, these patients are paying a high price for their self-sacrifice. They are not getting something they need deeply, which is to be cared for by other human beings.
Another goal of treatment is to decrease the patient’s sense of over-responsibility The therapist shows patients that they often exaggerate the fragility and helplessness of other people. Most other people are not as fragile and helpless as the patient thinks they are. If the patient were to give less, the other person would usually still be fine. In most cases, the other person is not going to fall apart or experience unbearable pain if the patient gives less.
Another goal of treatment is to remedy patients ’ associated emotional deprivation. The therapist encourages patients to attend to their own needs, to let other people meet their needs, to ask for what they want more directly, and to be more vulnerable instead of appearing strong more of the time.
All four change components are important with this schema. In terms of cognitive strategies, the therapist helps patients test their exaggerated perceptions of the fragility and neediness of others. In addition, the therapist helps patients increase their awareness of their own needs. Ideally patients realize that they have needs—for nurturance, understanding, protection, and guidance—that have long gone unmet. They are taking care of others but not allowing others to take care of them.
Furthermore, the therapist helps patients become aware of other schemas that underlie their self-sacrifice. As we have noted, patients with a Self-Sacrifice schema almost always have some degree of underlying emotional deprivation. Defectiveness is also a common linked schema: These patients “give more” because they feel “worth less.” Abandonment can be a linked schema: Patients self-sacrifice in order to prevent the other person from abandoning them. Dependence can be a linked schema: Patients self-sacrifice so that the parent figure will stay connected to them and keep taking care of them. Approval-Seeking can be a linked schema: Patients take care of others to get approval or recognition.
The therapist highlights the imbalance of the “give-get ratio”: the ratio of what patients are giving to what they are getting from significant others in their lives. In a healthy relationship between equals, what each person gives and gets should be approximately equal over time. This balance does not have to occur in each separate aspect of the relationship, but rather in the relationship as a whole. Each person gives and gets according to his or her abilities, but the overall balance is approximately equal. A significant imbalance in the ratio of giving and getting is usually unhealthy for the patient. (The exceptions are relationships of nonequals, such as parents and children. Patients who sacrifice for their children, for example, do not necessarily have a Self-Sacrifice schema. To have the schema, patients have to sacrifice across many relationships as part of a general pattern.)
Experientially the therapist helps patients become aware of their emotional deprivation, both in childhood and in their current lives. Patients express sadness and anger about their unmet emotional needs. In imagery, they confront the parent who deprived them—the self-centered, needy, or depressed parent who did not nurture, listen to, protect, or guide them. They express anger about becoming a parentified child: Even if unintentional on the part of the parent, it was not fair that they were put in this role. Patients acknowledge their lost childhood. In imagery, they express anger toward significant others who deprive them in their current life, and they ask for what they need.
Behaviorally, patients learn to ask to have their needs met more directly, and to come across as vulnerable instead of strong. They learn to select partners who are strong and giving rather than weak and needy. (Patients with this schema are often drawn to weak and needy partners, such as people who are drug addicts, depressed, or dependent, instead of partners who can give to them as equals.) In addition, patients learn to set limits on how much they give to others.
One treatment strategy that would be unhealthy for patients with other schemas can be very helpful for patients with Self-Sacrifice schemas: Patients keep track of how much they are giving and getting with significant others. How much are they doing for, listening to, and taking care of each person, and how much are they getting in return? When the balance is off—as it usually is for patients with the Self-Sacrifice schema—they can aim to make the ratio more equal. They can give less and ask for more.
In a sense, this schema is the opposite of the Entitlement schema. The Entitlement schema involves self-centeredness; the Self-Sacrifice schema involves other-centeredness. These two schemas “fit” together well in relationships: Patients who have one of these schemas often end up with a partner who has the other. Another common combination is one partner with a Self-Sacrifice schema, and the other with Dependent Entitlement. The self-sacrificer does everything for the entitled partner. Therapy can help these couples pull each other toward a healthier middle ground.
When we consider the schemas of psychotherapists, Self-Sacrifice is one of the most common (the other is Emotional Deprivation). For many professionals in the mental health field, a Self-Sacrifice schema was one factor that motivated them to choose their work. If the therapist and patient both have the schema, one potential problem is that the therapist might inadvertently model behavior that is too self-sacrificing. In both the therapy relationship and when discussing other areas of their lives, therapists show that although they are giving, they are not self-denying. The therapist has needs and rights in relationships and appropriately asserts them.
It is important for therapists to be very giving to patients with this schema, because they have been given so little by their parents and others. It is important for therapists to be caring and not to allow the patient to take care of them. Whenever a self-sacrificing patient tries to take care of the therapist, the therapist points out the pattern through empathic confrontation. The therapist encourages the patient to rely on him or her as much as possible. Some of these patients have never relied on another human being. The therapist validates the patient’s dependency needs and encourages the patient to stop acting so adult-like and strong, and instead to be vulnerable and, at times, even child-like with the therapist.
One problem is that there is often a high cultural and religious value placed on self-sacrifice. Furthermore, self-sacrifice is not a dysfunctional schema within normal limits. Rather, it is healthy to be self-sacrificing to a certain degree. It becomes dysfunctional when it is excessive. For a patient’s self-sacrifice to be a maladaptive schema, the self-sacrifice has to be causing problems for the person. It has to be creating symptoms or creating unhappiness in relationships. There has to be some way it is manifesting itself as a difficulty: Anger is building up, the patient is experiencing psychosomatic complaints, feeling emotionally deprived, or otherwise suffering emotionally.
These patients place excessive importance on gaining approval or recognition from other people at the expense of fulfilling their core emotional needs and expressing their natural inclinations. Because they habitually focus on the reactions of others rather than on their own reactions, they fail to develop a stable, inner-directed sense of self.
There are two subtypes. The first type seeks approval, wanting everyone to like them; they want to fit in and be accepted. The second type seeks recognition, wanting applause and admiration. The latter are frequently narcissistic patients: They overemphasize status, appearance, money, or achievement as a means gaining the admiration of others. Both subtypes are outwardly focused on getting approval or recognition in order to feel good about themselves. Their sense of self-esteem is dependent on the reactions of other people, rather than on their own values and natural inclinations. One young female patient with this schema said: “You know how you see women on the street who just look like they’re having a great life? Their life might really be awful, but when you see them walk by, you just think everything’s great. I’ve often thought that if I had to choose, I’d rather look like I’m having a great life than actually have one.”
Alice Miller (1975) writes about the issue of recognition-seeking in Prisoners of Childhood. Many of the cases she presents are individuals at the narcissistic end of this schema. As children, they learned to strive for recognition, because that was what their parents encouraged or pushed them to do. The parents obtained vicarious gratification, but the children grew more and more estranged from their genuine selves—from their core emotional needs and natural inclinations.
The subjects in Miller’s book have both the Emotional Deprivation and the Recognition-Seeking schemas. Recognition-seeking is often, but not always, linked with the Emotional Deprivation schema. However, some parents are both nurturing and recognition-seeking. In many families, the parents are very child-oriented and loving, but also very concerned with outward appearances. Children from these families feel loved, but they do not develop a stable, inner-directed sense of self: Their sense of self is predicated on the responses of other people. They have an undeveloped, or false, self, but it is not a true self. Narcissistic patients are at the extreme end of this schema, but there are many milder forms in which patients are more psychologically healthy yet still devoted to seeking approval or recognition to the detriment of self-expression.
Typical behaviors include being compliant or people-pleasing in order to get approval. Some Approval-Seekers place themselves in a subservient role to get approval. Other individuals may feel uncomfortable around them because they seem so eager to please. Typical behaviors also include placing a great deal of emphasis on appearance, money, status, achievement, and success in order to obtain recognition from others. Recognition-seekers might fish for compliments or appear conceited and brag about their accomplishments. Alternatively, they might be subtler, and surreptiously manipulate the conversation, so that they can cite their sources of pride.
Approval-Seeking/Recognition-Seeking is different from other schemas that might result in approval-seeking behavior. When patients display approval-seeking behavior, it is their motivation that determines whether the behavior is part of this or another schema. Approval-Seeking/Recognition-Seeking is different from the Unrelenting Standards schema (even if the childhood origins may appear similar) in that patients with the Unrelenting Standards schema are striving to meet a set of internalized values, whereas approval-seeking patients are striving to obtain external validation. Approval-Seeking/Recognition-Seeking is different from the Subjugation schema in that the latter is fear-based, whereas the former is not. With the Subjugation schema, patients act in an approval-seeking way because they are afraid of punishment or abandonment, not primarily because they crave approval. The Approval-Seeking/Recognition-Seeking schema is different from the Self-Sacrifice schema in that it is not based on a desire to help others one perceives as fragile or needy. If patients act in an approval-seeking way because they do not want to hurt other people, then they have the Self-Sacrifice schema. The Approval-Seeking/Recognition-Seeking schema is different from the Entitlement/Grandiosity schema in that it is not an attempt to aggrandize oneself in order to feel superior to others. If patients act in an approval-seeking way as a means of gaining power, special treatment, or control, then they have the Entitlement schema.
Most Approval-Seekers probably would endorse conditional beliefs such as “People will accept me, if they approve of me or admire me,” “I’m worthwhile if other people give me approval,” or “If I can get people to admire me, they will pay attention to me.” They live under this contingency: In order to feel good about themselves, they have to gain approval or recognition from others. Thus, these patients are frequently dependent on other people’s approval for their self-esteem.
The Approval-Seeking/Recognition-Seeking schema is often, but not always, a form of overcompensation for another schema, such as Defectiveness, Emotional Deprivation, or Social Isolation. Although many patients use this schema to overcompensate for other issues, many other patients with this schema seek approval or recognition simply because they were raised this way; their parents placed a strong emphasis on approval or recognition. The parents set goals and expectations that were not based on the child’s inherent needs and natural inclinations, but rather on the values of the surrounding culture.
There are both healthy and maladaptive forms of approval-seeking. This schema is common in highly successful people in many fields, such as politics and entertainment. Many of these patients are skillful in intuiting what will gain them approval or recognition and can adapt their behavior in a chameleon-like way, in order to endear themselves to or impress people.
The basic goal is for patients to recognize that they have an authentic self that is different from their approval-seeking, false self. They have spent their lives suppressing their emotions and natural inclinations for the sake of gaining approval or recognition. Because their true self has been suppressed and their approval-seeking self has been directing their lives, their core emotional needs have not been met. Compared to genuine self-expression and being true to oneself, other people’s approval provides only a superficial and transient form of gratification. Here, we state a philosophical assumption of our theory: Humans are happiest and most fulfilled when they are expressing authentic emotions and acting on their natural inclinations. Most patients with this schema do not know what it means to be authentic. They do not know what their natural inclinations are, let alone how to act on them. The goal of treatment is to help patients to focus less on obtaining other people’s approval or recognition, and more on who they are and what they value intrinsically.
All four components of treatment play important roles in treatment: cognitive, experiential, behavioral, and the therapy relationship.
One cognitive strategy is demonstrating to patients the importance of expressing one’s true self rather than continuing to seek the approval of others. It is natural to want approval and recognition, but when this desire becomes extreme, it is dysfunctional. Patients can examine the pros and cons of the schema: They weigh the advantages and disadvantages of discovering who they truly are and acting on that versus continuing to focus on gaining other people’s approval. In this way, patients can make the decision to fight the schema. If they continue to put all their emphasis on money, status, or popularity, then they are not going to enjoy life fully; they will continue to feel empty and dissatisfied. It is not worth it to “sell one’s soul” for approval or recognition. (“I thought I was going up, I was really going down,” thinks the dying, social-climbing Ivan Ilyitch in Tolstoy’s story [1986, p. 495].) Approval and recognition are only temporarily satisfying. They are addictive and not fulfilling in a deep and lasting sense.
Experiential strategies can be helpful, especially mode work. The Approval-Seeker is a mode the patient learned in childhood. The therapist helps the patient identify the Approval-Seeker and the Vulnerable Child modes (using whatever names fit for the patient). The patient relives childhood incidents of seeking approval from a parent, and alternates between the Approval-Seeking mode and the Vulnerable Child, expressing each side aloud. What did the patient truly need at significant moments in childhood? What did the child truly think? Feel? Want to do? Want the parent to do? What was demanded of the child by the parent and other authority figures? The child expresses anger at the Demanding Parent, and grieves for a childhood that was lost to approval-seeking. The Healthy Adult, played first by the therapist, then by the patient, helps the child fight the Approval-Seeker and behave in accord with the Vulnerable Child.
Patients can conduct behavioral experiments to explore their natural inclinations. They can self-monitor their thoughts and feelings, and use behavioral techniques to practice acting on their natural inclinations more frequently in their lives. Learning to tolerate the disapproval of other people is an important behavioral goal. Patients practice accepting situations in which other people do not give them approval or recognition. To the extent that approval-seeking has become like an addiction, patients learn to give up the addiction, tolerate the withdrawal from approval or recognition, and then substitute other, healthier forms of gratification. This process can be painful for patients, especially at first, and the therapist helps by adopting a stance of empathic confrontation. The behavioral component is crucial to the success of the treatment. If patients do not actually shift their focus away from what other people think, toward becoming more true to themselves in everyday situations, especially in relationships with significant others, then the other strategies are not going to work in a lasting way.
In the therapy relationship, it is important for the therapist to watch for instances in which the patient tries to gain approval or recognition. This pattern almost always emerges in therapy with these patients. When it does, the therapist points out the behavior through empathic confrontation and encourages the patient to be open and direct rather than hiding negative reactions.
One problem is that the Approval-Seeking/Recognition-Seeking schema usually provides the patient with a great deal of secondary gain. Approval and recognition can bring potent interpersonal rewards, and this schema is socially sanctioned to a high degree. Getting applause, becoming famous, achieving recognition, being successful, being liked, fitting in—there is a great deal of positive reinforcement in society for all of these. The therapist is thus asking the patient to fight or moderate something that society values heavily. Therapist and patient work together to determine that the cost of excessive approval- or recognition-seeking is not worth the price. Furthermore, the goal is to moderate the tendency, not to eradicate it altogether, because the schema has many valuable aspects when it is balanced with self-actualization.
Patients with this schema are easily mistaken for healthy individuals, and therapists often unknowingly reinforce their schema-driven behaviors. These patients work hard to get therapists to approve of them or admire them, but if what they do is based on a false rather than a true self, then it is an impediment to their progress.