Cognitive therapy schema
A CLIENT’S GUIDE TO SCHEMA-FOCUSED COGNITIVE THERAPY
(Young and Klosko, 2003)
Harry is a 45 year old middle-level manager. He has been married for 16 years, but his marriage has been very troubled. He and his wife are often resentful of each other, they rarely communicate on an intimate level, and they have few moments of real pleasure.
Other aspects of Harry’s life have been equally unsatisfying. He doesn’t enjoy his work, primarily because he doesn’t get along with his co-workers. He is often intimidated by his boss and other people at the office. He has a few friends outside of work, but none that he considers close.
During the past year Harry’s mood became increasingly negative. He was getting more irritable, he had trouble sleeping, and he began to have difficulty concentrating at work. As he became more and more depressed, he began to eat more and gained 15 pounds. When he found himself thinking about taking his own life, he decided it was time to get help. He consulted a psychologist who practices cognitive therapy.
As a result of short-term cognitive therapy techniques, Harry improved rapidly. His mood lifted, his appetite returned to normal, and he no longer thought about suicide. In addition he was able to concentrate well again and was much less irritable. He also began to feel more in control of his life as he learned how to control his emotions for the first time.
But, in some ways, the short-term techniques were not enough. His relationships with his wife and others, while they no longer depressed him as much as they had, still failed to give him much pleasure. He still could not ask to have his needs met, and he had few experiences he considered truly enjoyable. The therapist then began schema-focused cognitive therapy to help Harry change his long-term life patterns.
This guide will present the schema-focused approach, a recent elaboration of cognitive therapy developed by Dr Jeffrey Young that can help people change long-term patterns, including the ways in which they interact with other people. This overview of schema-focused cognitive therapy consists of five parts:
- A brief presentation of short-term cognitive therapy.
- An explanation of what a schema is and examples of schemas.
- An explanation of the processes by which schemas function.
- Several case examples.
- A brief description of the therapeutic process.
SHORT TERM COGNITIVE THERAPY
Cognitive therapy is a system of psychotherapy developed by Aaron Beck and his colleagues to help people overcome emotional problems. This system emphasises changing the ways in which people think in order to improve their moods, such as depression, anxiety, and anger.
Emotional disturbance is influenced by the cognitive distortions that people make in dealing with their life experiences. These distortions take the form of negative interpretations and predictions of everyday events. For instance, a male college student preparing for a test might make himself feel discouraged by thinking: “This material is impossible” (Negative Interpretation) and “I’ll never pass this test” (Negative prediction).
The therapy consists of helping clients to restructure their thinking. An important step in this process is examining the evidence concerning the maladaptive thoughts. In the example above, the therapist would help the student to look at his past experiences and determine if the material was in fact impossible to learn, and if he knew for sure that he couldn’t pass the test. In all probability, the student would decide that these two thoughts lacked validity.
More accurate alternative thoughts would be substituted. For instance, the student might be encouraged to think: “This material is difficult, but not impossible. I’ve learned difficult material before” and “I’ve never failed a test before, so long as I’ve done enough preparation.” These thoughts would probably lead him to feel better and cope better.
Often short-term cognitive therapy is enough to help people overcome emotional problems, especially depression and anxiety. Recent research has shown this to be so. However, sometimes this approach is not enough. Some clients in short-term cognitive therapy find that they don’t get all the benefits they want. This has led us to develop schema-focused cognitive therapy.
SCHEMAS – WHAT THEY ARE
A schema is an extremely stable and enduring pattern that develops during childhood and is elaborated throughout an individual’s life. We view the world through our schemas.
Schemas are important beliefs and feelings about oneself and the environment which the individual accepts without question. They are self-perpetuating, and are very resistant to change. For instance, children who develop a schema that they are incompetent rarely challenge this belief, even as adults. The schema usually does not go away without therapy. Overwhelming success in people’s lives is often still not enough to change the schema. The schema fights for its own survival, and, usually, is quite successful.
Even though schemas persist once they are formed, they are not always in our awareness. Usually they operate in subtle ways, out of our awareness. However, when a schema erupts or is triggered by events, our thoughts and feelings are dominated by these schemas. It is at these moments that people tend to experience extreme negative emotions and have dysfunctional thoughts.
In our work with many patients, we have found 18 specific schemas. Most clients have at least two or three of these schemas, and often more. A brief description of each of these schemas is provided below.
EARLY MALADAPTIVE SCHEMAS
(J Young, Revised Schema Listing; 2002)
Disconnection and Rejection
The expectation that one’s needs for security, safety, stability, nurturance, empathy, sharing of feelings, acceptance, and respect will not be met in a predictable manner. Typical family origin is detached, cold, rejecting, withholding, lonely, explosive, unpredictable, or abusive.
The perceived instability or unreliability of those available for support and connection. Involves the sense that significant others will not be able to continue providing emotional support, connection, strength, or practical protection because they are emotionally unstable and unpredictable (e.g. angry outbursts), unreliable, or erratically present; because they will die imminently; or because they will abandon the patient in favour of someone better.
The expectation that others will hurt, abuse, humiliate, cheat, lie, manipulate, or take advantage. Usually involves the perception that the harm is intentional or the result of unjustified and extreme negligence. May include the sense that one always ends up being cheated relative to others or “getting the short end of the stick.”
- Emotional Deprivation
The expectation that one’s desire for a normal degree of emotional support will not be adequately met by others. The three major forms of deprivation are:
- Deprivation of Nurturance: Absence of attention, affection, warmth, or companionship.
- Deprivation of Empathy: Absence of understanding, listening, self-disclosure, or mutual sharing of feelings from others.
- Deprivation of Protection: Absence of strength, direction, or guidance from others.
The feeling that one is defective, bad, unwanted, inferior, or invalid in important respects or that one would be unlovable to significant others if exposed. May involve hypersensitivity to criticism, rejection, and blame; self-consciousness, comparisons, and insecurity around others; or a sense of shame regarding one’s perceived flaws. These flaws may be private (e.g., selfishness, angry impulses, unacceptable sexual desires) or public (e.g., undesirable physical appearance, social awkwardness).
- Social Isolation/Alienation
The feeling that one is isolated from the rest of the world, different from other people, and/or not part of any group or community.
Impaired Autonomy and Performance
Expectations about oneself and the environment that interfere with one’s perceived ability to separate, survive, function independently, or perform successfully. Typical family origin is enmeshed, undermining of child’s confidence, overprotective, or failing to reinforce child for performing competently outside the family.
Belief that one is unable to handle one’s everyday responsibilities in a competent manner, without considerable help from others (e.g., take care of oneself, solve daily problems, exercise good judgment, tackle new tasks, make good decisions). Often presents as helplessness.
- Vulnerability to Harm or Illness
Exaggerated fear that imminent catastrophe will strike at any time and that one will be unable to prevent it. Fears focus on one or more of the following: (A) Medical catastrophes(e.g., heart attacks, AIDS); (B) Emotionalcatastrophes(e.g., going crazy); (C) External catastrophes (e.g., elevators collapsing, victimization by criminals, airplane crashes, earthquakes).
- Enmeshment/Undeveloped Self
Excessive emotional involvement and closeness with one or more significant others (often parents) at the expense of full individuation or normal social development. Often involves the belief that at least one of the enmeshed individuals cannot survive or be happy without the constant support of the other. May also include feelings of being smothered by or fused with others or insufficient individual identity. Often experienced as a feeling of emptiness and foundering, having no direction, or in extreme cases questioning one’s existence.
The belief that one has failed, will inevitably fail, or is fundamentally inadequate relative to one’s peers in areas of achievement (school, career, sports, etc.). Often involves beliefs that one is stupid, inept, untalented, lower in status, less successful than others, and so forth.
Deficiency in internal limits, responsibility to others, or long-term goal orientation. Leads to difficulty respecting the rights of others, cooperating with others, making commitments, or setting and meeting realistic personal goals. Typical family origin is characterized by permissiveness, overindulgence, lack of direction, or a sense of superiority rather than appropriate confrontation, discipline, and limits in relation to taking responsibility, cooperating in a reciprocal manner, and setting goals. In some cases, the child may not have been pushed to tolerate normal levels of discomfort or may not have been given adequate supervision, direction, or guidance.
The belief that one is superior to other people; entitled to special rights and privileges; or not bound by the rules of reciprocity that guide normal social interaction. Often involves insistence that one should be able to do or have whatever one wants, regardless of what is realistic, what others consider reasonable, or the cost to others; or an exaggerated focus on superiority (e.g., being among the most successful, famous, wealthy) in order to achieve power or control (not primarily for attention or approval). Sometimes includes excessive competitiveness toward or domination of others: asserting one’s power, forcing one’s point of view, or controlling the behavior of others in line with one’s own desires without empathy or concern for others’ needs or feelings.
- Insufficient Self-Control/Self-Discipline
Pervasive difficulty or refusal to exercise sufficient self-control and frustration tolerance to achieve one’s personal goals or to restrain the excessive expression of one’s emotions and impulses. In its milder form, the patient presents with an exaggerated emphasis on discomfort avoidance: avoiding pain, conflict, confrontation, responsibility, or overexertion at the expense of personal fulfillment, commitment, or integrity.
An excessive focus on the desires, feelings, and responses of others, at the expense of one’s own needs in order to gain love and approval, maintain one’s sense of connection, or avoid retaliation. Usually involves suppression and lack of awareness regarding one’s own anger and natural inclinations. Typical family origin is based on conditional acceptance: Children must suppress important aspects of themselves in order to gain love, attention, and approval. In many such families, the parents’ emotional needs and desires—or social acceptance and status—are valued more than the unique needs and feelings of each child.
Excessive surrendering of control to others because one feels coerced—submitting in order to avoid anger, retaliation, or abandonment. The two major forms of subjugation are:
- Subjugation of needs: Suppression of one’s preferences, decisions, and desires.
- Subjugation of emotions: Suppression of emotions, especially anger. Usually involves the perception that one’s own desires, opinions, and feelings are not valid or important to others. Frequently presents as excessive compliance, combined with hypersensitivity to feeling trapped. Generally leads to a buildup of anger, manifested in maladaptive symptoms (e.g., passive–aggressive behavior, uncontrolled outbursts of temper, psychosomatic symptoms, withdrawal of affection, “acting out,” substance abuse).
Excessive focus on voluntarily meeting the needs of others in daily situations at the expense of one’s own gratification. The most common reasons are: to prevent causing pain to others; to avoid guilt from feeling selfish; or to maintain the connection with others perceived as needy. Often results from an acute sensitivity to the pain of others. Sometimes leads to a sense that one’s own needs are not being adequately met and to resentment of those who are taken care of. (Overlaps with concept of codependency.)
Excessive emphasis on gaining approval, recognition, or attention from other people or on fitting in at the expense of developing a secure and true sense of self. One’s sense of esteem is dependent primarily on the reactions of others rather than on one’s own natural inclinations. Sometimes includes an overemphasis on status, appearance, social acceptance, money, or achievement as means of gaining approval, admiration, or attention (not primarily for power or control). Frequently results in major life decisions that are inauthentic or unsatisfying or in hypersensitivity to rejection.
Overvigilance and Inhibition
Excessive emphasis on suppressing one’s spontaneous feelings, impulses, and choices or on meeting rigid, internalized rules and expectations about performance and ethical behavior, often at the expense of happiness, self-expression, relaxation, close relationships, or health. Typical family origin is grim, demanding, and sometimes punitive: performance, duty, perfectionism, following rules, hiding emotions, and avoiding mistakes predominate over pleasure, joy, and relaxation. There is usually an undercurrent of pessimism and worry that things could fall apart if one fails to be vigilant and careful at all times.
A pervasive, lifelong focus on the negative aspects of life (pain, death, loss, disappointment, conflict, guilt, resentment, unsolved problems, potential mistakes, betrayal, things that could go wrong, etc.) while minimizing or neglecting the positive or optimistic aspects. Usually includes an exaggerated expectation—in a wide range of work, financial, or interpersonal situations—that things will eventually go seriously wrong or that aspects of one’s life that seem to be going well will ultimately fall apart. Usually involves an inordinate fear of making mistakes that might lead to financial collapse, loss, humiliation, or being trapped in a bad situation. Because they exaggerate potential negative outcomes, these individuals are frequently characterized by chronic worry, vigilance, complaining, or indecision.
- Emotional Inhibition
The excessive inhibition of spontaneous action, feeling, or communication, usually to avoid disapproval by others, feelings of shame, or losing control of one’s impulses. The most common areas of inhibition involve: (a) inhibition of anger and aggression; (b) inhibition of positiveimpulses(e.g., joy, affection, sexual excitement, play); (c) difficulty expressing vulnerability or communicating freely about one’s feelings, needs, and so forth; or (d) excessive emphasis on rationality while disregarding emotions.
- Unrelenting Standards/Hypercriticalness
The underlying belief that one must strive to meet very high internalized standards of behavior and performance, usually to avoid criticism. Typically results in feelings of pressure or difficulty slowing down and in hyper-criticalness toward oneself and others. Must involve significant impairment in pleasure, relaxation, health, self-esteem, sense of accomplishment, or satisfying relationships.
Unrelenting standards typically present as (a) perfectionism, inordinate attention to detail, or an underestimate of how good one’s own performance is relative to the norm;
(b) rigid rules and “shoulds” in many areas of life, including unrealistically high moral, ethical, cultural, or religious precepts; or (c) preoccupation with time and efficiency, the need to accomplish more.
The belief that people should be harshly punished for making mistakes. Involves the tendency to be angry, intolerant, punitive, and impatient with those people (including oneself) who do not meet one’s expectations or standards. Usually includes difficulty forgiving mistakes in oneself or others because of a reluctance to consider extenuating circumstances, allow for human imperfection, or empathize with feelings.
HOW SCHEMAS WORK
In order to understand how schemas work, there are three schema maintenance processes that must be defined. These processes are schema support, schema avoidance, and schema compensation. It is through these three processes that schemas exert their influence on our behaviour and work to insure their own survival.
Schema maintenance refers to the routine processes by which schemas function and perpetuate themselves. This is accomplished by cognitive distortions and self-defeating behaviour patterns.
Earlier we mentioned that cognitive distortions are a central part of cognitive therapy. These distortions consist of negative interpretations and predictions of life events. Many cognitive distortions are part of the schema maintenance process. The schema will highlight or exaggerate information that confirms the schema and will minimise or deny information that contradicts it.
Schema maintenance works behaviourally as well as cognitively. The schema will generate behaviours which tend to keep the schema intact. For instance, a young man with a Social Undesirability schema would have thoughts and behaviour in line with the schema. At a party he would have thoughts such as: “No-one here likes me” and “I’m not going to succeed at meeting new people”. Behaviourally, he would be more withdrawn and less outgoing.
Schema avoidance refers to the ways in which people avoid activating schemas. As mentioned earlier, when schemas are activated, this causes extreme negative emotion. People develop ways to avoid triggering schemas in order not to feel this pain. There are three types of schema avoidance: cognitive, emotional, and behavioural.
Cognitive avoidance refers to efforts that people make not to think about upsetting events. These efforts may be either voluntary or automatic. People may voluntarily choose not to focus on an aspect of their personality or an event which they find disturbing. There are also unconscious processes which help people shut out information which would be too upsetting to confront. People often forget particularly painful events. For instance, children who have been abused sexually often forget the memory completely.
Emotional or affective avoidance refers to automatic or voluntary attempts to block painful emotion. Often when people have painful emotional experiences, they numb themselves to the feelings in order to minimise the pain. For instance, a man might talk about how his wife has been acting in an abusive manner toward him and say that he feels no anger towards her, only a little annoyance. Some people drink or abuse drugs to numb feelings generated by schemas.
The third type of avoidance is behavioural avoidance. People often act in such a way as to avoid situations that trigger schemas, and thus avoid psychological pain. For instance, a woman with a Failure to Achieve schema might avoid taking a difficult new job which would be very good for her. By avoiding the challenging situation, she avoids any pain, such as intense anxiety, which could be generated by the schema.
The third schema process is schema compensation. The individual behaves in a manner which appears to be the opposite of what the schema suggests in order to avoid triggering the schema. People with a Functional Dependence schema may structure aspects of their life so that they don’t have to depend on anyone, even when a more balanced approach may be better. For instance, a young man may refuse to go out with women because he is afraid of becoming dependent and will present himself as someone who doesn’t need other people. He goes to the other extreme to avoid feeling dependent.
In this section six case examples are presented. In each one, the schema processes are demonstrated. By reading through this section, you will get a better feel for how these processes can operate in real life situations.
Abby is a young woman whose main schema is Subjugation. She tends to see people as very controlling even when they are being appropriately assertive. She has thoughts such as “I can’t stand up for myself or they won’t like me” and is likely to give in to others (Schema Support). At other times she decides that no one will get the better of her and becomes very controlling (Schema Compensation). Sometimes when people make unreasonable demands on her she minimises the importance of her own feelings and has thoughts like “It’s not that important to me what happens”. At other times she avoids acquaintances with whom she has trouble standing up for herself (Schema Avoidance).
Stewart’s main schema is Failure to Achieve. Whenever he is faced with a possible challenge, he tends to think that he is not capable. Often he tries half-heartedly, guaranteeing that he will fail, and strengthening the belief that he is not capable (Schema Support). At times, he makes great efforts to present himself in an unrealistically positive light by spending excessive amounts of money on items such as clothing and automobiles (Schema Compensation). Often he avoids triggering his schema by staying away from challenges altogether and convinces himself that the challenge was not worth taking (Schema Avoidance).
Rebecca’s core schema is Defectiveness/Shame. She believes that there is something basically wrong with her and that if anyone gets too close, the person will reject her. She chooses partners who are extremely critical of her and confirm her view that she is defective (Schema Support). Sometimes she has an excessive defensive reaction and counterattacks when confronted with even mild criticism (Schema Compensation). She also makes sure that none of her partners get too close, so that she can avoid their seeing her defectiveness and rejecting her (Schema Avoidance).
Michael is a middle-aged man whose main schema is Functional Dependence/Incompetence. He sees himself as being incapable of doing daily tasks on his own and generally seeks the support of others. Whenever he can, he chooses to work with people who help him out to an excessive degree. This keeps him from developing skills needed to work alone and confirms his view of himself as someone who needs others to help him out (Schema Support). At times, when he would be best off taking advice from other people, he refuses to do so (Schema Compensation). He reduces his anxiety by procrastinating as much as he can get away with (Schema Avoidance).
Ann’s’ core schema is Social Isolation. She sees herself as being different from other people and not fitting in. When she does things as part of a group she does not get really involved (Schema Support). At times she gets very hostile towards group members and can be very critical of the group as a whole (Schema Compensation). At other times she chooses to avoid group activities altogether (Schema Avoidance).
Sam’s central schema is Emotional Deprivation. He chooses partners who are not very capable of giving to other people and then acts in a manner which makes it even more difficult for them to give to him (Schema Support). At times he will act in a very demanding, belligerent manner and provoke fights with his partners (Schema Compensation). Sam avoids getting too close to women, yet denies that he has any problems in this area (Schema Avoidance).
THERAPEUTIC PROCESS – CHANGING SCHEMAS
In schema-focused cognitive therapy the goal of the treatment is to weaken the early maladaptive schemas as much as possible and build up the person’s healthy side. An alliance is formed between the therapist and the healthy part of the client against the schemas.
The first step in therapy is to do a comprehensive assessment of the client. The main goal of this assessment is to identify the schemas that are most important in the client’s psychological makeup. There are several steps to this process. The therapist generally will first want to know about recent events or circumstances in the clients’ lives that have led them to come for help. The therapist will then discuss the client’s life history and look for patterns which may be related to schemas.
There are several other steps the therapist will take in assessing schemas. There is a “Schema Questionnaire” which the client fills out, listing many of the thoughts related to the different schemas; items on this questionnaire can be rated as to how relevant to the client’s life they are.
There are also various imagery techniques which the therapist can use to assess schemas. One specific technique involves asking clients to close their eyes and create an image of themselves as children with their families. Often the images that appear will lead to the core schemas.
Jonathan is a 28 year old executive whose core schema is Mistrust/Abuse. He came to therapy because he was having bouts of intense anxiety at work, during which he would be overly suspicious and resentful of his co-workers. When asked to create an image of himself with his family, he had two different images. In the first he saw himself being terrorised by his older brother. In the second he saw his alcoholic father coming home and beating his mother, while he cowered in fear.
There are many techniques which the therapist can use to help clients weaken their schemas. These techniques can be broken down into four categories: emotive, interpersonal, cognitive, and behavioural. Each of these categories will be briefly discussed, along with a few examples.
Emotive techniques encourage clients to experience and express the emotional aspects of their problem. One way this is done is by having clients close their eyes and imagine they are having a conversation with the person to whom the emotion is directed. They are then encouraged to express the emotions as completely as possible in the imaginary dialogue. One woman whose core schema was Emotional Deprivation had several such sessions in which she had an opportunity to express her anger at her parents for not being there enough for her emotionally. Each time she expressed these feelings, she was able to distance herself further from the schema. She was able to see that her parents had their own problems which kept them from providing her with adequate nurturance, and that she was not always destined to be deprived.
There are many variations on the above technique. Clients may take on the role of the other person in these dialogues and express what they imagine their feelings to be. Or they may write a letter to the other person, which they have no intention of mailing, so that they can express their feelings without inhibition.
Interpersonal techniques highlight the client’s interactions with other people so that the role of the schemas can be exposed. One way is by focusing on the relationship with the therapist. Frequently, clients with a Subjugation schema go along with everything the therapist wants, even when they do not consider the assignment or activity relevant. They then feel resentment towards the therapist which they display indirectly. This pattern of compliance and indirect expression of resentment can then be explored to the client’s benefit. This may lead to a useful exploration of other instances in which the client complies with others and later resents it, and how the client might better cope at those times.
Another type of interpersonal technique involves including a client’s spouse in therapy. A man with a Self Sacrifice schema might choose a wife who tends to ignore his wishes. The therapist may wish to involve the wife in the treatment in order to help the two of them to explore the patterns in their relationship and change the ways in which they interact.
Cognitive techniques are those in which the schema driven cognitive distortions are challenged. As in short-term cognitive therapy, the dysfunctional thoughts are identified and the evidence for and against them is considered. Then new thoughts and beliefs are substituted. These techniques help the client see alternative ways to view situations.
The first step in dealing with schemas cognitively is to examine the evidence for and against the specific schema which is being examined. This involves looking at the client’s life and experiences and considering all the evidence which appears to support or refute the schema. The evidence is then examined critically to see if it does, in fact, provide support for the schema. Usually the evidence produced will be shown to be in error, and not really supportive of the schema.
For instance, let’s consider a young man with an Emotional Deprivation schema. When asked for evidence that his emotional needs will never be met, he brings up instances in which past girlfriends have not met his needs. However, when these past relationships are looked at carefully, he finds that, as part of the schema maintenance process, he has chosen women who are not capable of giving emotionally. This understanding gives him a sense of optimism; if he starts selecting his partners differently, his needs can probably be met.
Another cognitive technique is to have a structured dialogue between the client and therapist. First, the client takes the side of the schema, and the therapist presents a more constructive view. Then the two switch sides, giving the client a chance to verbalise the alternative point of view.
After having several of these dialogues the client and therapist can then construct a prompt card for the client, which contains a concise statement of the evidence against the schema.
A typical prompt card for a client with a Defectiveness/Shame schema reads: “I know that I feel that there is something wrong with me but the healthy side of knows that I’m OK. There have been several people who have known me very well and stayed with me for a long time. I know that I can pursue friendships with many people in whom I have an interest”.
The client is instructed to keep the prompt card available at all times and to read it whenever the relevant problem starts to occur. By persistent practice at this and other cognitive techniques, the client’s belief in the schema will gradually weaken.
Behavioural techniques are those in which the therapist assists the client in changing long-term behaviour patterns, so that schema maintenance behaviours are reduced and healthy coping responses are strengthened.
One behavioural strategy is to help clients choose partners who are appropriate for them and capable of engaging in healthy relationships. Clients with the Emotional Deprivation schema tend to choose partners who are not emotionally giving. A therapist working with such clients would help them through the process of evaluating and selecting new patterns.
Another behavioural technique consists of teaching clients better communication skills. For instance, a woman with a Subjugation schema believes that she deserves a raise at work but does not know how to ask for it. One technique her therapist uses to teach her how to speak to her supervisor is role playing. First, the therapist takes the role of the client and the client takes the role of the supervisor. This allows the therapist to demonstrate how to make the request appropriately. Then the client gets an opportunity to practice the new behaviours and to get feedback from the therapist before changing the behaviour in real-life situations.
IN SUMMARY, schema focused cognitive therapy can help people understand and change long-term life patterns. The therapy consists of identifying early maladaptive schemas and systematically confronting and challenging them.
Young, J. E., & Klosko, J. (1993). Reinventing Your Life. New York: Dutton ( An Imprint of Penguin USA)