Schema Therapy: A Practitioner's Guide

"Schema therapy represents a brilliant addition to the therapist's armamentarium of techniques. Building on cognitive therapy, the approach provides a means for dealing with many of the problems people face in their daily lives. For example, someone with a social isolation/alienation schema will believe that he or she is isolated from others, but often will act in ways to create or exacerbate this isolation. A complete guide to the use of schema therapy, this book shows how to help clients recognize and overcome such maladaptive patterns. I very highly recommend it."--Robert J. Sternberg, PhD, Department of Psychology, Yale University"This volume demonstrates in a skillful, highly readable fashion how the standard cognitive therapy approaches to Axis 1 disorders can be expanded and modified to treat personality disorders. Working within a comprehensive cognitive model, the authors draw on a variety of strategies to address the specific problems in this population: rigid, lifelong maladaptive characterological patterns; chronic interpersonal difficulties; and transference reactions. The book shows how to attenuate the powerful beliefs underlying these patterns through exploratory and experiential strategies. Highly recommended for all therapists engaged in treating patients with these very difficult personality problems."--Aaron T. Beck, MD, Department of Psychiatry, University of Pennsylvania"The work of Jeffrey E. Young and his colleagues represents both a major contribution to the evolution of cognitive and cognitive-behavioral therapy and an important step toward enhancing the prospects for integrating cognitive therapy with other approaches, particularly psychoanalysis. This book presents schema therapy in clear and generous detail and offers much to the experienced practitioner and the student. A highly valuable and worthwhile contribution."--Paul L. Wachtel, PhD, Doctoral Program in Clinical Psychology, City College, City University of New York"Young et al. have developed an innovative, rich, and intuitively healing approach to therapy based on years of clinical experience and research. Schema therapy incorporates wisdom from a variety of approaches to bring fresh new perspectives to traditional cognitive therapy. In this book, clinicians will find up-to-the-minute, empirically supported approaches to treating such difficult problems as narcissistic and borderline personality disorders. Strategies and procedures are laid out in a clear and compelling manner, including invaluable advice on implementation. All clinicians wishing to incorporate schema-based cognitive approaches into their practices will find this book an invaluable resource and a pleasure to read."--David H. Barlow, PhD, Center for Anxiety and Related Disorders, Department of Psychology, Boston University"In expanding the traditional cognitive model to include an emphasis on the therapeutic relationship and on lifelong patterns of maladaptive behavior, Young et al. have created a place for cognitive-behavioral therapy in treating even the most severe characterological disorders. The combination of solid empirical research; detailed, specific techniques; and clear, concise recommendations for therapy help therapists at every level better conceptualize and treat challenging cases. I have found Schema Therapy to be an invaluable text for graduate courses in clinical interventions and an excellent resource for students wishing to improve their skills in clinical work."--Mary Armsworth, EdD, Department of Educational Psychology, University of Houston"This is an important and valuable book. It develops a model of treatment for challenging populations, typically underserved by traditional CBT. It may well become a 'necessary reading' text for advanced therapy courses in clinical psychology training programs. It is important reading for psychologists working with patients with characterological problems or, who simply wish for techniques to use when patients become 'stuck' and unresponsive to CBT." ― Child and Family Behavior Therapy Published On: 2006-11-05"Recommended for the clinician as well as the researcher." ― Cognitive Behavioral Therapy Book Reviews Published On: 2006-11-05"Useful verbatim examples are given for treatment of several types of patients....A very good book, and I highly recommend it to both novice and veteran therapists." ― Psychiatric Times Published On: 2006-11-05"A rich and highly informative text that outlines the principles of the schema model, schema assessment and evaluation, and all the major components of schema therapy....The richness of the clinical material is enough to give practitioners a basic understanding of how to apply schema therapy....An insightful, innovative, and thorough treatment approach to personality pathology." ― Journal of Psychosomatic Research Published On: 2006-11-05"This is a superb volume, reflecting many years of astute clinical and theoretical work by very able clinicians....It should appeal to psychotherapy integrationists from many traditions." ― Psychotherapy Research Published On: 2006-11-05 Jeffrey E. Young, PhD, is on the faculty in the Department of Psychiatry at Columbia University. He is the Founder and Director of the Cognitive Therapy Centers of New York and Connecticut, and the Schema Therapy Institute in New York City. Janet S. Klosko, PhD, Codirector of the Cognitive Therapy Center of Long Island, in Great Neck, New York, is senior psychologist at the Schema Therapy Institute and at Woodstock Women's Health in Woodstock, New York.Marjorie E. Weishaar, PhD, is Clinical Professor of Psychiatry and Human Behavior at Brown University Medical School, where she teaches cognitive therapy to psychiatry residents and to psychology interns and postdoctoral fellows. She also maintains a private practice in Providence, Rhode Island. Excerpt. © Reprinted by permission. All rights reserved. Schema Therapy A Practitioner's Guide By Jeffrey E. Young Guilford Publications Copyright © 2006 Jeffrey E. YoungAll right reserved. ISBN: 9781593853723 Chapter One SCHEMA THERAPY: CONCEPTUAL MODEL Schema therapy is an innovative, integrative therapy developed by Young and colleagues (Young, 1990, 1999) that significantly expands on traditional cognitive-behavioral treatments and concepts. The therapy blends elements from cognitive-behavioral, attachment, Gestalt, object relations, constructivist, and psychoanalytic schools into a rich, unifying conceptual and treatment model. Schema therapy provides a new system of psychotherapy that is especially well suited to patients with entrenched, chronic psychological disorders who have heretofore been considered difficult to treat. In our clinical experience, patients with full-blown personality disorders, as well as those with significant characterological issues that underlie their Axis I disorders, typically respond extremely well to schema-focused treatment (sometimes in combination with other treatment approaches). THE EVOLUTION FROM COGNITIVE TO SCHEMA THERAPY A look at the field of cognitive-behavioral therapy helps to explain the reason Young felt that the development of schema therapy was so important. Cognitive-behavioral researchers and practitioners have made excellent progress in developing effective psychological treatments for Axis I disorders, including many mood, anxiety, sexual, eating, somatoform, and substance abuse disorders. These treatments have traditionally been short term (roughly 20 sessions) and have focused on reducing symptoms, building skills, and solving problems in the patient's current life. However, although many patients are helped by these treatments, many others are not. Treatment outcome studies usually report high success rates (Barlow, 2001). For example, in depression, the success rate is over 60% immediately after treatment, but the relapse rate is about 30% after 1 year (Young, Weinberger, & Beck, 2001)-leaving a significant number of patients unsuccessfully treated. Often patients with underlying personality disorders and characterological issues fail to respond fully to traditional cognitive-behavioral treatments (Beck, Freeman, & Associates, 1990). One of the challenges facing cognitive-behavioral therapy today is developing effective treatments for these chronic, difficult-to-treat patients. Characterological problems can reduce the effectiveness of traditional cognitive-behavioral therapy in a number of ways. Some patients present for treatment of Axis I symptoms, such as anxiety or depression, and either fail to progress in treatment or relapse once treatment is withdrawn. For example, a female patient presents for cognitive-behavioral treatment of agoraphobia. Through a program consisting of breathing training, challenging catastrophic thoughts, and graduated exposure to phobic situations, she significantly reduces her fear of panic symptoms and overcomes her avoidance of numerous situations. Once treatment ends, however, the patient lapses back into her agoraphobia. A lifetime of dependence, along with feelings of vulnerability and incompetence-what we call her Dependence and Vulnerability schemas-prevent her from venturing out into the world on her own. She lacks the self-confidence to make decisions and has failed to acquire such practical skills as driving, navigating her surroundings, managing money, and selecting proper destinations. She prefers instead to let significant others make the necessary arrangements. Without the guidance of the therapist, the patient cannot orchestrate the public excursions necessary to maintain her treatment gains. Other patients come initially for cognitive-behavioral treatment of Axis I symptoms. After these symptoms have been resolved, their characterological problems become a focus of treatment. For example, a male patient undergoes cognitive-behavioral therapy for his obsessive-compulsive disorder. Through a short-term behavioral program of exposure combined with response prevention, he largely eliminates the obsessive thoughts and compulsive rituals that had consumed most of his waking life. Once his Axis I symptoms have abated, however, and he has time to resume other activities, he must face the almost complete absence of a social life that is a result of his solitary lifestyle. The patient has what we call a "Defectiveness schema," with which he copes by avoiding social situations. He is so acutely sensitive to perceived slights and rejections that, since childhood, he has avoided most personal interaction with others. He must grapple with his lifelong pattern of avoidance if he is ever to develop a rewarding social life. Still other patients who come for cognitive-behavioral treatment lack specific symptoms to serve as targets of therapy. Their problems are vague or diffuse and lack clear precipitants. They feel that something vital is wrong or missing from their lives. These are patients whose presenting problems are their characterological problems: They come seeking treatment for chronic difficulties in their relationships with significant others or in their work. Because they either do not have significant Axis I symptoms or have so many of them, traditional cognitive-behavioral therapy is difficult to apply to them. Assumptions of Traditional Cognitive-Behavioral Therapy Violated by Characterological Patients Traditional cognitive-behavioral therapy makes several assumptions about patients that often prove untrue of those patients with characterological problems. These patients have a number of psychological attributes that distinguish them from straightforward Axis I cases and make them less suitable candidates for cognitive-behavioral treatment. One such assumption is that patients will comply with the treatment protocol. Standard cognitive-behavioral therapy assumes that patients are motivated to reduce symptoms, build skills, and solve their current problems and that, therefore, with some prodding and positive reinforcement, they will comply with the necessary treatment procedures. However, for many characterological patients, their motivations and approaches to therapy are complicated, and they are often unwilling or unable to comply with cognitive-behavioral therapy procedures. They may not complete homework assignments. They may demonstrate great reluctance to learn self-control strategies. They may appear more motivated to obtain consolation from the therapist than to learn strategies for helping themselves. Another such assumption in cognitive-behavioral therapy is that, with brief training, patients can access their cognitions and emotions and report them to the therapist. Early in therapy, patients are expected to observe and record their thoughts and feelings. However, patients with characterological problems are often unable to do so. They often seem out of touch with their cognitions or emotions. Many of these patients engage in cognitive and affective avoidance. They block disturbing thoughts and images. They avoid looking deeply into themselves. They avoid their own disturbing memories and negative feelings. They also avoid many of the behaviors and situations that are essential to their progress. This pattern of avoidance probably develops as an instrumental response, learned because it is reinforced by the reduction of negative affect. Negative emotions such as anxiety or depression are triggered by stimuli associated with childhood memories, prompting avoidance of the stimuli in order to avoid the emotions. Avoidance becomes a habitual and exceedingly difficult to change strategy for coping with negative affect. Cognitive-behavioral therapy also assumes that patients can change their problematic cognitions and behaviors through such practices as empirical analysis, logical discourse, experimentation, gradual steps, and repetition. However, for characterological patients, this is often not the case. In our experience, their distorted thoughts and self-defeating behaviors are extremely resistant to modification solely through cognitive-behavioral techniques. Even after months of therapy, there is often no sustained improvement. Because characterological patients usually lack psychological flexibility, they are much less responsive to cognitive-behavioral techniques and frequently do not make meaningful changes in a short period of time. Rather, they are psychologically rigid. Rigidity is a hallmark of personality disorders (American Psychiatric Association, 1994, p. 633). These patients tend to express hopelessness about changing. Their characterological problems are ego-syntonic: Their self-destructive patterns seem to be so much a part of who they are that they cannot imagine altering them. Their problems are central to their sense of identity, and to give them up can seem like a form of death-a death of a part of the self. When challenged, these patients rigidly, reflexively, and sometimes aggressively cling to what they already believe to be true about themselves and the world. Cognitive-behavioral therapy also assumes that patients can engage in a collaborative relationship with the therapist within a few sessions. Difficulties in the therapeutic relationship are typically not a major focus of cognitive-behavioral treatments. Rather, such difficulties are viewed as obstacles to be overcome in order to attain the patient's compliance with treatment procedures. The therapist-patient relationship is not generally regarded as an "active ingredient" of the treatment. However, patients with characterological disorders often have difficulty forming a therapeutic alliance, thus mirroring their difficulties in relating to others outside of therapy. Many difficult-to-treat patients have had dysfunctional interpersonal relationships that began early in life. Lifelong disturbances in relationships with significant others are another hallmark of personality disorders (Millon, 1981). These patients often find it difficult to form secure therapeutic relationships. Some of these patients, such as those with borderline or dependent personality disorders, frequently become so absorbed in trying to get the therapist to meet their emotional needs that they are unable to focus on their own lives outside of therapy. Others, such as those with narcissistic, paranoid, schizoid, or obsessive-compulsive personality disorders, are frequently so disengaged or hostile that they are unable to collaborate with the therapist. Because interpersonal issues are often the core problem, the therapeutic relationship is one of the best areas for assessing and treating these patients-a focus that is most often neglected in traditional cognitive-behavioral therapy. Finally, in cognitive-behavioral treatment, the patient is presumed to have problems that are readily discernible as targets of treatment. In the case of patients with characterological problems, this presumption is often not met. These patients commonly have presenting problems that are vague, chronic, and pervasive. They are unhappy in major life areas and have been dissatisfied for as long as they can remember. Perhaps they have been unable to establish a long-term romantic relationship, have failed to reach their potential in their work, or experience their lives as empty. They are fundamentally dissatisfied in love, work, or play. These very broad, hard-to-define life themes usually do not make easy-to-address targets for standard cognitive-behavioral treatment. Later we look at how specific schemas can make it difficult for patients to benefit from standard cognitive-behavioral therapy. THE DEVELOPMENT OF SCHEMA THERAPY For the many reasons just described, Young (1990, 1999) developed schema therapy to treat patients with chronic characterological problems who were not being adequately helped by traditional cognitive-behavioral therapy: the "treatment failures." He developed schema therapy as a systematic approach that expands on cognitive-behavioral therapy by integrating techniques drawn from several different schools of therapy. Schema therapy can be brief, intermediate, or longer term, depending on the patient. It expands on traditional cognitive-behavioral therapy by placing much greater emphasis on exploring the childhood and adolescent origins of psychological problems, on emotive techniques, on the therapist-patient relationship, and on maladaptive coping styles. Once acute symptoms have abated, schema therapy is appropriate for the treatment of many Axis I and Axis II disorders that have a significant basis in lifelong characterological themes. Therapy is often undertaken in conjunction with other modalities, such as cognitive-behavioral therapy and psychotropic medication. Schema therapy is designed to treat the chronic characterological aspects of disorders, not acute psychiatric symptoms (such as full-blown major depression or recurring panic attacks). Schema therapy has proven useful in treating chronic depression and anxiety, eating disorders, difficult couples problems, and long-standing difficulties in maintaining satisfying intimate relationships. It has also been helpful with criminal offenders and in preventing relapse among substance abusers. Schema therapy addresses the core psychological themes that are typical of patients with characterological disorders. As we discuss in detail in the next section, we call these core themes Early Maladaptive Schemas. Schema therapy helps patients and therapists to make sense of chronic, pervasive problems and to organize them in a comprehensible manner. The model traces these schemas from early childhood to the present, with particular emphasis on the patient's interpersonal relationships. Using the model, patients gain the ability to view their characterological problems as ego-dystonic and thus become more empowered to give them up. The therapist allies with patients in fighting their schemas, utilizing cognitive, affective, behavioral, and interpersonal strategies. When patients repeat dysfunctional patterns based on their schemas, the therapist empathically confronts them with the reasons for change. Through "limited reparenting," the therapist supplies many patients with a partial antidote to needs that were not adequately met in childhood. EARLY MALADAPTIVE SCHEMAS History of the Schema Construct We now turn to a detailed look at the basic constructs that make up schema theory. We begin with the history and development of the term "schema." The word "schema" is utilized in many fields of study. In general terms, a schema is a structure, framework, or outline. In early Greek philosophy, Stoic logicians, especially Chrysippus (ca. 279-206 B.C.), presented principles of logic in the form of "inference schemata" (Nussbaum, 1994). In Kantian philosophy, a schema is a conception of what is common to all-members of a class. Continues... Excerpted from Schema Therapy by Jeffrey E. Young Copyright © 2006 by Jeffrey E. Young. Excerpted by permission. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site. Read more