Schema Therapy in Practice E-Book

Arnoud Arntz

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 435

Veröffentlichungsjahr: 2017

Beschreibung

Schema Therapy in Practice presents a comprehensive introduction to schema therapy for non-specialist practitioners wishing to incorporate it into their clinical practice. * Focuses on the current schema mode model, within which cases can be more easily conceptualized and emotional interventions more smoothly introduced * Extends the practice of schema therapy beyond borderline personality disorder to other personality disorders and Axis I disorders such as anxiety, depression and OCD * Presented by authors who are world-respected as leaders in the schema therapy field, and have pioneered the development of the schema mode approach

Leseprobe

Table of Contents

Cover

Title

Copyright

About the Authors

Acknowledgments

Introduction

I CASE CONCEPTUALIZATION

1 Basics

1.1 Maladaptive Schemas

1.2 The Focus on Needs

1.3 Schema Coping

1.4 The Schema Mode Model

1.5 FAQ

2 The Mode Concept

2.1 Overview of Schema Modes

2.2 Case Conceptualization with the Mode Model

2.3 Specific Mode Models for Different Personality Disorders

2.4 FAQ

3 Communicating the Mode Concept to the Patient

3.1 Treatment Planning with the Mode Model

3.2 FAQ

II TREATMENT

4 Treatment Overview

4.1 Treatment Goals for Individual Modes

4.2 Treatment Techniques

4.3 The Therapeutic Relationship

4.4 FAQ

5 Overcoming Coping Modes

5.1 The Therapeutic Relationship

5.2 Cognitive Techniques

5.3 Emotional Techniques

5.4 Behavioral Techniques

5.5 FAQ

6 Treating Vulnerable Child Modes

6.1 Reparenting and Extra Reparenting in the Therapeutic Relationship

6.2 Cognitive Techniques

6.3 Emotion-Focused Techniques

6.4 Behavioral techniques

6.5 FAQ

7 Treating Angry and Impulsive Child Modes

7.1 The Therapeutic Relationship

7.2 Cognitive Techniques

7.3 Emotional Techniques

7.4 Behavioral Techniques

7.5 FAQ

8 Treating Dysfunctional Parent Modes

8.1 The Therapeutic Relationship

8.2 Cognitive Techniques

8.3 Emotion-Focused Techniques

8.4 Behavioral techniques

8.5 FAQ

9 Strengthening the Healthy Adult Mode

9.1 The Therapeutic Relationship

9.2 Cognitive Techniques

9.3 Emotional Techniques

9.4 Behavioral Techniques

9.5 Terminating Therapy

9.6 FAQ

References

Index

End User License Agreement

List of Tables

1 Basics

Table 1.1 Early maladaptive schemas (Young et al., 2003) and schema domains

Table 1.2 The relationship between schema domains and basic needs

2 The Mode Concept

Table 2.1 Mode categories—overview

Table 2.2 Schema modes

5 Overcoming Coping Modes

Table 5.1 Pros and cons of Susie’s detached protector mode

Table 5.2 Pros and cons of Nicole’s bully and attack mode

6 Treating Vulnerable Child Modes

Table 6.1 Psychoeducation for vulnerable child modes

Table 6.2 Schema flashcard

Table 6.3 Imagery rescripting process overview

7 Treating Angry and Impulsive Child Modes

Table 7.1 Typical emotions and affects of angry, impulsive, and undisciplined child modes

Table 7.2 Typical biographical background factors of angry or impulsive child modes

List of Illustrations

2 The Mode Concept

Figure 2.1 Phillip’s mode model

Figure 2.2 Maria’s mode model

Figure 2.3 Jane’s mode model

Figure 2.4 Michael’s mode model

Figure 2.5 Elisa’s mode model

Figure 2.6 Nadine’s mode model

Figure 2.7 Peter’s mode model

Figure 2.8 Eric’s mode model

Figure 2.9 Nicole’s mode model

Figure 2.10 Evelyn’s mode model

4 Treatment Overview

Figure 4.1 Treatment overview

Figure 4.2 Cognitive treatment interventions

Figure 4.3 Emotion-focused interventions

Figure 4.4 Behavioral interventions

Figure 4.5 The therapeutic relationship

Guide

Cover

Table of Contents

Begin Reading

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e1

Schema Therapy in Practice

An Introductory Guide to the Schema Mode Approach

ARNOUD ARNTZ, PHD*

Department of Clinical Psychological Science, Maastricht University, The Netherlands & Netherlands Institute for Advanced Study in the Humanities and Social Sciences, Wassenaar, The Netherlands

GITTA JACOB, PHD

Department of Clinical Psychology and Psychotherapy, Freiburg University, Germany

* The order of authors is based on alphabetical order

This edition first published in English in 2013

© 2013

This book is a translated version of: Gitta Jacob and Arnoud Arntz, Schematherapie in der Praxis © 2011 BELTZ Psychologie in der Verlagsgruppe Beltz • Weinheim, Basel

Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientific, Technical and Medical business with Blackwell Publishing.

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Library of Congress Cataloging-in-Publication Data

Arntz, Arnoud.

Schema therapy in practice : an introductory guide to the schema mode approach / Arnoud Arntz, Gitta Jacob.

p. cm.

Includes bibliographical references and index.

ISBN 978-1-119-96285-4 (cloth) – ISBN 978-1-119-96286-1 (pbk.) 1. Schema-focused cognitive therapy. 2. Personality disorders–Treatment. I. Jacob, Gitta. II. Title.

RC489.S34A76 2013

616.89′1425–dc23

2012017512

A catalogue record for this book is available from the British Library.

Cover image © cosmin4000/iStockphoto

Cover design by www.cyandesign.co.uk

About the Authors

Arnoud Arntz is Professor of Clinical Psychology and Experimental Psychopathology at Maastricht University, the Netherlands. He is Scientific Director of the University’s Research Center of Experimental Psycho-pathology. He studies psychological theories and therapies for anxiety and personality disorders, and is the principal investigator for a series of multicenter trials investigating the effectiveness of schema therapy for various personality disorders. He also practices CBT and schema therapy.

Gitta Jacob is a Clinical Psychologist, Cognitive and Schema Therapist in the Department of Clinical Psychology and Psychotherapy, University of Freiburg, Germany. She is a founding board member of the International Society for Schema Therapy, and a past Chair of the Working Group on Borderline Personality Disorders at the Department of Psychiatry and Psychotherapy, University Hospital Freiburg.

Acknowledgments

The authors want to express their thanks to Jeffrey Young, the developer of Schema Therapy, for his teaching and deep insights; as well as to other prominent Schema Therapists who influenced their thinking, including Joan Farrell, Ida Shaw, Hannie van Genderen, and David Bernstein; to their collegues with whom they collaborated in applying and further developing Schema Therapy; and last but not least to their patients who helped them to develop the methods and techniques described in this book. This work was supported by a grant from the Netherlands Institute for Advanced Study in the Humanities and Social Sciences (NIAS) (A.A.) and by the European Social Fund and the Ministry of Science, Research and the Arts Baden-Württemberg (G.A.).

Introduction

Schema therapy is increasingly attracting the attention of therapists and consumers. This is partly based on the good effects reported by various studies, and partly on its appealing basis in the idea that children require fundamental needs to be met in order to develop in a psychologically healthy way. The integration of insights, methods, and techniques derived from a range of schools, including attachment theory, cognitive behavior therapy, and experiential therapies into a comprehensive model formulated in terms of the most prominent current psychological paradigm, the cognitive model, also plays a role. The promise of schema therapy that it can deal with psychological problems largely ignored by mainstream cognitive behavior therapy, such as recurrent problems in intimate relationships and the processing of troublesome memories and patterns from childhood, is attractive. Finally, the finding that schema therapy contributes to real recovery, defined not only by a reduction of symptoms, but by the creation of a life that is satisfying and of high quality, is undoubtedly appealing.

In teaching the model, methods, and techniques, we felt that a book presenting the practical basics of schema therapy for those that want to learn it as a generic method, and not in a specialized form for one disorder, was missing. We therefore decided to write such a book. This book does not compete with other publications on schema therapy, as it doesn’t focus on theory or on a specific disorder. It aims to present the basics of the schema-therapy model based on the relatively new schema mode concept. It is basically an extension of our work with schema modes in almost all personality disorders. As we felt that the mode approach could also have application in some axis-I problems, and in milder personality issues, we decided to present the model, methods, and techniques in a generic way, and to use case examples of various disorders and problems.

The book is divided into two parts. The first deals with case conceptualization and consists of three chapters: Chapter 1, “Basics,” summarizes the original schema approach by describing schemas and schema coping through the use of case examples; Chapter 2, “The Mode Concept,” describes the schema mode concept in general terms, then goes on to provide descriptions of the specific mode models for various personality disorders that have been developed so far; finally, Chapter 3, “Communicating the Mode Concept to the Patient,” explains how an individual mode model can be introduced in therapy.

The second part deals with treatment, in six chapters. Each chapter is devoted to one group of modes and is subdivided into sections on cognitive, emotional, and behavioral interventions and the therapeutic relationship. Chapter 4, “Treatment Overview,” summarizes the central treatment goals and strategies of schema therapy based on the mode concept. Chapter 5, “Overcoming Coping Modes,” describes how to deal with coping modes. It covers avoiding (detached protector, avoiding protector, etc.), surrender, and overcompensating coping modes (self-aggrandizer, bully & attack, etc.). Chapter 6, “Treating Vulnerable-child Modes,” describes how to deal with vulnerable-child modes. It contains a long section on imagery rescripting and discusses the caring part of the therapeutic relationship in depth. Chapter 7, “Treating Angry and Impulsive Child Modes,” describes how to deal with angry, enraged, impulsive, undisciplined, and obstinate child modes. Chapter 8, “Treating Dysfunctional-parent Modes,” describes how to deal with both demanding-and punitive-parent modes. It contains a long section on chair dialogues as a therapeutic technique. Chapter 9, “Strengthening the Healthy-adult Mode,” summarizes how the healthy adult mode is explicitly and implicitly developed in schema therapy. It also addresses how the treatment should develop when completion is near, and how to relate with the patient after formal completion of treatment.

ICASE CONCEPTUALIZATION

1Basics

Schema therapy, which was developed by Jeffrey Young (1990; Young et al., 2003), stems from cognitive behavioral therapy (CBT) and has been attracting increasing attention since it was first proposed. Young created schema therapy predominantly for patients who did not respond well to “classical” CBT treatment. These patients often experience a variety of symptoms and typically display complex interpersonal patterns, which may be either fluctuating or persistent; they usually meet the criteria for one or more personality disorders. Compared to CBT, schema therapy has a more intensive focus on the following three issues:

1 Problematic emotions, which are in the foreground, alongside the cognitive and behavioral aspects of the patient’s problems and symptoms. Schema therapy makes intensive use of experiential or emotion-focused interventions—ones that have previously been developed and used in gestalt therapy or psychodrama. The main experiential intervention techniques consist of chair dialogues or imagery exercises. This focus on emotions is important, since problematic patterns in patients with personality disorders are usually maintained by problematic emotional experiences. For example, patients with borderline personality disorder (BPD) typically experience intense self-hatred; they can hardly distance themselves from this self-hatred on an emotional level, even if they do understand that such hatred is not appropriate. In such cases, the influence of cognitive insight into the connected emotional issues is very low. Such kinds of problem can be treated well by emotional interventions.

2 Childhood issues, which are of much greater importance than in standard CBT, enabling schema therapy to integrate approaches or concepts that have so far been mainly considered psychodynamic or psychoanalytic. Biographical information is mainly used to validate patients by enabling them to understand the childhood origin of their problematic behavioral patterns. One goal is to help patients understand their current patterns as a result of dysfunctional conditions during their childhood and youth. However, in contrast to psychoanalysis, “working through” the biography is not considered to be the most important therapeutic agent.

3 The therapeutic relationship, which plays a very important role in schema therapy. On the one hand, the therapeutic relationship is conceptualized as “limited reparenting,” which means that the therapist takes on the role of a parent and displays warmth and caring behavior towards the patient—within the limits of the therapeutic relationship, of course. It is important to note that the style of this reparenting relationship should be adapted to the patient’s individual problems or schemas. Particularly for patients with personality disorders, the therapeutic relationship is regarded as the place in which the patient is allowed to and dares to open up and show painful feelings, try out new social behaviors, and change interpersonal patterns for the first time. Thus the therapeutic relationship is explicitly regarded as a place for patients to work on their problems.

Schema therapy offers both a complex and a very structured approach to conceptualizing and treating a variety of problem constellations. Thus schema therapy has been developed not for specific disorders, but rather as a general transdiagnostic psychotherapeutic approach. However, during its ongoing development, specific models for treatment of various personality disorders have emerged and been developed within schema therapy, which are introduced later in this book (Section 2.3). In this chapter, we will first give an overview of the original schema concepts, describing each maladaptive schema briefly and illustrating it with a case example. We will then introduce the development of the schema mode concept and the character of schema modes and their assessment. Finally, we will describe schema-therapy interventions based on the schema mode approach. Simply put, most interventions can be used during treatment both with the original schema and with the schema mode approach. Take for example a “chair dialogue” with two different chairs, where the patient’s perfectionist side holds a discussion with the healthier and more relaxed side. This intervention can be regarded both as a dialogue between the modes of the demanding parent and the healthy adult, and as a dialogue between the schema “unrelenting standards” and the healthy side of the patient. Therefore, the interventions described with the schema mode model could also be used in therapy applying the original schema model.

1.1 Maladaptive Schemas

The so-called early maladaptive schemas (EMSs) are broadly defined as pervasive life patterns which influence cognitions, emotions, memories, social perceptions, and interaction and behavior patterns. EMSs are thought to develop during childhood. Depending on the life situation, individual coping mechanisms, and interpersonal patterns of an individual, EMSs may fluctuate throughout the course of life, and often they are maintained by these factors. When an existing schema is activated, intensive negative emotions appear, such as anxiety, sadness, and loneliness. Young et al. (2003) defined 18 schemas, which are ordered into five so-called “schema domains.” The definition of these EMSs is mainly derived from clinical observations and considerations, and is not empirically or scientifically developed, although research supports their existence.

Any person can have either a single schema or a combination of several schemas. Generally all human beings do have more or less strong schemas. A schema is considered pathological only when associated with pathological emotional experiences and symptoms, or impairments in social functioning. Patients with severe personality disorders typically score highly on many of the schemas in the Young schema questionnaire (Schmidt et al., 1995). In contrast, therapy clients with only circumscribed life problems who do not fulfill the diagnostic criteria of a personality disorder and who have a higher level of social functioning usually score highly only on one or two of the schemas. Table 1.1 gives an overview of Young’s schema domains and schemas.

Case example

Susan is a 40-year-old nurse. She takes part in day treatment, with the diagnosis of chronic depression. Susan reports severe problems at work, mainly bullying by her colleagues, which has resulted in her “depressive breakdown.” Susan’s most conspicuous feature is her inconspicuousness. Even 2 weeks after her admission, not every team member knows her name; she does not approach therapists with personal concerns and does not make contact with other patients. In group therapies, she is very quiet. When the group therapist explicitly asks for her contributions, she tends to confirm what everybody else has already said, and generally reacts very submissively and obediently. When faced with a more challenging situation, such as appointments with the social worker to discuss her complicated job situation, she avoids them. However, when confronted with her avoidance, Susan may unexpectedly react in an arrogant manner. After a couple of weeks in treatment, Susan’s antidepressive psychotherapy seems to become stale, as she ostensibly avoids active behavior changes.

In the schema questionnaire, Susan has a high score on the “subjugation” schema. She always orients towards the needs of other people. At the same time, she feels powerless, helpless, and suppressed by others. She does not have any idea how to act more autonomously or how to allow herself to recognize her own needs. Diagnostic imagery exercises are applied, starting from her current feeling of helplessness and lack of power. In the imagery exercises, Susan remembers very stressful childhood situations. Her father was an alcoholic who often became unpredictably aggressive and violent. Her mother, on the other hand, was very submissive and avoidant, and suffered from depressive episodes, and thus was unable to protect Susan from her father. Moreover, as the family managed a small hotel, the children were always required to be quiet and inconspicuous.

In the imagery exercise, “Little Susan” sits helpless and submissive on the kitchen floor and does not dare to talk about her needs with her parents—she is too afraid that this will make her mother feel bad and that her father will become aggressive and dangerous. In the following schema therapy, imagery exercises are combined with imagery rescripting. In imagery rescripting exercises, an adult (first the therapist, later Susan herself) enters the childhood scenario to take care of Little Susan and her needs. Concomitantly, it becomes easier to confront Susan empathically with the negative consequences of her overly shy, obedient, and submissive behavior patterns. Disadvantages of this behavior are discussed: she acts against her own interests, she is not able to care for her own needs, other people become annoyed by her avoidance. Therefore, she must attempt to find the courage to behave more in line with her own interests and needs. With the combination of imagery rescripting and empathic confrontation, Susan becomes increasingly less withdrawn and more engaged and present in the day clinic; she opens up more and starts to articulate her needs. After discussing and analyzing her problematic schema-driven patterns, she reports further problems, which she had hidden at the start of therapy. She starts talking about a sexual relationship with a seasonal worker. She separated from him 2 years ago, as he continuously acted aggressively towards her, but he still gets in contact with her whenever he works in the city. Although she clearly knows that she dislikes this contact, he convinces her time and again to meet and engage in sexual relations, clearly against her needs. After learning about her schemas, Susan herself becomes able to relate this behavior to her overall patterns.

Table 1.1 Early maladaptive schemas (Young et al., 2003) and schema domains

Schema domain

Schemas

Disconnection and rejection

Abandonment/instabilityMistrust/abuseEmotional deprivationDefectiveness/shameSocial isolation/alienation

Impaired autonomy and achievement

Dependency/incompetencyVulnerability to harm and illnessEnmeshment/undeveloped selfFailure

Impaired limits

Entitlement/grandiosityLack of self-control/self-discipline

Other-directedness

SubjugationSelf-sacrificeApproval-seeking

Hypervigilance and inhibition

Negativity/pessimismEmotional inhibitionUnrelenting standardsPunitiveness

1.1.1 Schemas in the “disconnection and rejection” domain

This schema domain is characterized by attachment difficulties. All schemas of this domain are in some way associated with a lack of safety and reliability in interpersonal relationships. The quality of the associated feelings and emotions differs depending on the schema—for example, the schema “abandonment/instability” is connected to a feeling of abandonment by significant others, due to previous abandonment in childhood. Individuals with the schema “social isolation/alienation,” on the other hand, lack a sense of belonging, as they have experienced exclusion from peer groups in the past. Patients with the schema “mistrust/abuse” mainly feel threatened by others, having been harmed by people during their childhood.

(1) Abandonment/instability Patients with this schema suffer from the feeling that important relationships which they have formed will never last and thus they are constantly worried about being abandoned by others. They typically report experiences of abandonment during their childhood; often one parent left the family and ceased to care about them, or important people died early. Patients with this schema often start relationships with people who are unreliable, who thus confirm their schema over and over again. But even in stable relationships, which are not threatened by abandonment, the most minor of events (such as the partner’s return home from work an hour later than expected) may trigger exaggerated and unnecessary feelings of loss or abandonment.

Case example: abandonment/instability

Cathy, a 25-year-old college student, comes to psychotherapy to get treatment for her panic attacks and strong dissociative symptoms. Both symptoms increase when she has to leave her father after staying over at his house during weekends. She studies in another city, but visits her father nearly every weekend and at holidays. While her relationships with members of her family are very close, her relationships with others are typically rather superficial. She rarely feels truly close to other people, and has never been in a committed romantic relationship. She also reports being unable to imagine having a truly intimate relationship. When she ponders the reasons behind this, she starts feeling very upset. She breaks into tears, overwhelmed by the feeling that nobody will ever stay with her for long. This feeling is connected to her own biographical history. Her biological mother became severely ill and died when Cathy was 2 years old. Her father married again 2 years later, and the stepmother became a real mother for her. However, her stepmother died rather young herself, very suddenly from a stroke, when Cathy was 16 years of age.

(2) Mistrust/abuse People with this schema expect to be abused, humiliated, or in other ways badly treated by others. They are constantly suspicious, because they are afraid of being deliberately harmed. When they are treated in a friendly way, they often believe that the other person has a hidden agenda. When they get in touch with the feelings associated with this schema, they usually experience anxiety and threat. In severe cases, patients feel extremely threatened in nearly all social situations. The “mistrust/abuse” schema typically develops because of childhood abuse. This abuse is often sexual; however, physical, emotional, or verbal abuse can also cause severe abuse schemas. In many cases, children were abused by family members, such as a parent or a sibling. However, it is important to keep in mind that cruel acts performed by peers, such as bullying by classmates, can cause extreme abuse schemas as well, often combined with strong failure or shame.

Case example: mistrust/abuse

Helen, a 26-year-old nurse, was sexually and physically abused by her stepfather during her childhood and teens. As an adult she generally mistrusts men and is convinced that it is impossible to find a man who will treat her nicely. She cannot even imagine a man treating a woman nicely. Her intimate relationships are usually short-lived sexual affairs with men whom she meets on the Internet. Sadly, within these affairs she sometimes experiences abuse and violence again.

(3) Emotional deprivation Patients with this schema typically refer to their childhood as a smooth and OK one, but they commonly did not experience much warmth or loving care, and did not feel truly safe, loved, or comforted. This schema is typically not characterized by feelings of much intensity. Instead, the affected patients don’t feel as safe and as loved as they should when others do love them and do want to make them feel safe. Thus, people with this schema often do not suffer strongly from it. Others in the affected persons’ environment, however, often sense this schema quite clearly, because they feel that they cannot get close to them or that they cannot reach them with love and support. People with the emotional deprivation schema seem somehow unable to perceive and acknowledge when others like them. This schema often remains quite unproblematic until the life circumstances of the affected person become in some way overwhelming.

Case example: emotional deprivation

Sally, a 30-year-old office clerk, has a high level of functioning: she is good at her job, she is happily married, and she has nice friends and interpersonal relationships. However, none of her relationships give her a real sense of being close to others and being truly loved by them. Although she does know that her husband and her friends care for her a lot, she simply does not feel it. Sally had been functioning very well for most of her life. Only during the last year, when her responsibilities at work and general workload increased considerably, did she begin to feel increasingly exhausted and lonely, and find herself unable to act in order to change her situation. The therapist suggested she should attempt a better work–life balance and try to integrate more relaxing and positive activities into her life. However, Sally does not regard these issues as very important, as she somehow does not feel herself to be significant or worthy enough. She reports that everything “was OK” in her childhood. However, both parents had busy jobs and therefore were often absent. She says that it was often simply too much for her parents to take care of their children after a long day at work.

(4) Defectiveness/shame This schema is characterized by feelings of defectiveness, inferiority, and being unwanted. People with this schema feel undeserving of any love, respect, or attention, as they feel they are not worthy—no matter how they actually behave. This experience is typically connected to intense feelings of shame. This schema is frequently seen in patients with BPD, often combined with mistrust/abuse. People with this schema typically suffered from intense devaluation and humiliation in their childhood.

Case example: defectiveness/shame

Michael, a 23-year-old male nurse, starts psychological treatment for his BPD. He reports severe problems at work due to pervasive feelings of shame. He regards himself as completely unattractive and uninteresting, despite the fact that others often give him compliments and praise him for being a competent and friendly person. When others say such nice things to him, he is simply unable to believe them. He also cannot imagine why his girlfriend is committed to him and wants to stay with him. Growing up, he reports intense physical and verbal abuse by his parents, mainly his father, who was an alcoholic. The father often called both Michael and his sister names and referred to them as “filthy,” completely independent of the children’s actual behavior.

(5) Social isolation/alienation People with this schema feel alienated from others and have a feeling of not belonging with anyone. Moreover, they typically feel like they are completely different from everybody else. In social groups they do not feel like they belong, even though others might regard them as quite well integrated. They often report that they were literally isolated in their childhood, for example because they didn’t speak the dialect of the region, were not sent to the kindergarten with all the other children, or weren’t part of any youth organizations such as sports clubs. Often there seems to be some discrepancy between the child’s social and family background and their achievements in later life. A typical example is a person growing up in a poor family with a low level of education, but managing to become the first and only educated family member. These people feel that they belong nowhere—neither to their family, nor to other educated people due to their different social background. In such cases, this schema can also be combined with defectiveness/shame, particularly when the own social background is perceived as inferior.

Case example: social isolation

David, a 48-year-old technician, completely lacks feelings of belonging. This applies to all kinds of formal or informal groups alike; he actually reports never feeling any sense of belonging in any group throughout his whole life. In his childhood, his family moved to a very little village when he was 9 years old. Since this village was far away from his birthplace, initially he hardly understood the dialect of the other kids. He never managed to become truly close to other children, and since his parents were very occupied by their new jobs and their own personal problems, they hardly offered him any support. Being different from his classmates, he was not integrated into the sports club or the local music groups. He remembers feeling very lonely and excluded when he didn’t participate in local activities and festivities.

1.1.2 Schemas in the “impaired autonomy and achievement” domain

In this domain, problems with autonomy and achievement potential are at the fore. People with these schemas perceive themselves as dependent, feel insecure, and suffer from a lack of self-determination. They are afraid that autonomous decisions might damage important relationships and they expect to fail in demanding situations. People with the schema “vulnerability to harm and illness” may even be afraid that challenging and changing their fate through autonomous decisions will lead to harm to themselves and others.

These schemas can be acquired by social learning through models, for example from parent figures who constantly warned against danger or illnesses, or who suffered from an obsessive–compulsive disorder (OCD) such as contamination anxiety (schema “vulnerability to harm and illness”). Similarly, the schema “dependency/incompetency” may develop when parents are not confident that their child has age-appropriate skills to cope with normal developmental challenges. However, schemas of this domain can also develop when a child is confronted with demands which are too high, when they have to become autonomous too early and do not receive enough support to achieve it. Thus patients with childhood neglect, who felt extremely overstressed as children, may develop dependent behavior patterns in order to ensure that somebody will provide them the support they lacked earlier in life, and thus do not learn a healthy autonomy.

(6) Dependency/incompetency Patients with this schema often feel helpless and unable to manage their daily life without the help of others. This schema is typically held by patients with a dependent personality disorder. Some people with this schema report experiences of being confronted with excessive demands in their childhood. These are often (implicit) social demands, such as feelings of responsibility for a sick parent. Since they felt chronically overstressed, they could not develop a sense of competence and healthy coping mechanisms. Other patients with this schema, however, report that their parents actually did not ask enough of them. Instead of helping their children to adequately develop their autonomy during adolescence, they refused to let go and continued to help them with everyday tasks, without giving them any responsibilities.

It may take some time in therapy before this schema becomes apparent, as patients often demonstrate very good cooperation in the therapeutic relationship. After some time, the therapist will feel a lack of adequate progress despite the good cooperation. When a patient starts therapy in an extraordinarily friendly manner and reacts enthusiastically to each of the therapist’s suggestions, but a lack of progress is made, the therapist should consider dependent patterns. This might especially be the case when the patient has already been through several therapies with limited success.

Case example: dependency/incompetency

Mary, a 23-year-old student, comes across as very shy and helpless. Her mother still cares for her a lot, particularly by taking over the execution of boring or annoying tasks. She always calls Mary to remind her of deadlines for her studies. Mary has been used to this overly caring behavior all her life. When she was a child and an adolescent, she did not have any chores to attend to, unlike her classmates. The idea of taking over the full responsibility for her life discourages and scares her. She would actually like to look for a job to earn some money, but feels unable to do so. She reports high levels of insecurity when talking with potential bosses and lacks the confidence in her own skills to start working.

(7) Vulnerability to harm and illness This schema is characterized by an exaggerated anxiety about tragic events, catastrophes, and illnesses which due to their nature could strike unexpectedly at any time. This schema is seen particularly frequently in hypochondriac or generalized anxiety disorder patients. Patients with this schema often report their mothers’ or grandmothers’ overcautiousness, frequent worry, warnings against severe illnesses and other of life’s dangers, and requests for extreme carefulness and caution during childhood. This cautious guardian may have instructed the child to obey very strict rules regarding hygiene, such as never eating unwashed fruit or always washing their hands after visits to the supermarket in order to avoid sicknesses. This schema can also be found in patients who actually were the victim of severe and uncontrollable events in their lives, such as natural disasters or severe illnesses.

Case example: vulnerability to harm and illness

Connie, a 31-year-old physician, is unsure whether she should try to have children or not. She loves the idea of having two children, but she becomes horrified when she considers just how many traumatic and catastrophic events could happen to a child. Connie knows she might not get pregnant easily in the first place; if she did, the pregnancy could be difficult; the child could suffer from horrible diseases, it could die or suffer horrendous damage in an accident, and so on. However, Connie does not suffer from any heritable disease, and she has no risk factors for a difficult pregnancy, and thus there is no actual reason for her to be worried to such an extent.

The therapist asks her to recall any childhood events related to her pervasive feelings of insecurity and constant worry. Connie spontaneously starts talking about her maternal grandmother. Granny always got very upset when little Connie did things autonomously. The grandmother complained about her inability to fall asleep when Connie was out, even when Connie was 17. She nearly died from anxiety when Connie went to summer camp at 12. Connie’s mother was always very close with her grandmother, and mostly shared the grandmother’s concerns.

(8) Enmeshment/undeveloped self People suffering from this schema have a weak sense of their own identity. They hardly feel able to make everyday decisions without the need for reassurance from some other—often their mother. Without this special person, they lack the ability to form opinions. This may go as far as an inability to feel like an “individual” altogether. Patients report very close, often also very emotional relationships with the person with whom they are enmeshed. People with enmeshment schema may be very intelligent and well educated, but this does not help or in any way enable them to recognize their own feelings or make their own decisions. Frequently “enmeshed people” do not suffer directly from this schema, because the enmeshed relationship can be experienced as mostly positive. However, secondary problems may arise due to the impairment of autonomy and social functioning, or it could happen that the patient’s spouse or partner becomes frustrated with the enmeshment. Often this schema is also related to obsessive–compulsive symptoms.

Case example: enmeshment/undeveloped self

Tina, a 25-year-old secretary, reports occasional aggressive compulsions towards her boyfriend. Their relationship is very close—they spend every waking minute together, either chatting or watching TV—but neither of them has any hobbies or friends of their own. In spite of this close relationship, sexual interaction is rare, mainly due to a lack of interest on her part. During the first psychotherapy sessions, Tina reports intense feelings of insecurity related to nearly every domain of her life. However, while the therapist sees this insecurity and the lack of hobbies and interests as being part of Tina’s problems, Tina herself regards her life as “perfect,” except for the compulsions. In particular, she is very enthusiastic about her “wonderful parents.” She has a very close relationship with them, too, which she evaluates as 100% positive. She calls her mother several times a day, asking for her advice on virtually any aspect of everyday life, no matter how small, and claims to be happy to discuss any problems with her parents, including her lack of sexual desire.

(9) Failure This schema is characterized by feelings of being a complete failure and of being less talented and intelligent than everybody else. People with this schema believe they will never be successful in any domain of their life. They tend to have frequently experienced very negative feedback in school or in their families, often including global devaluations of their personae. People engaged in a perfectionist, achievement-oriented activity in their childhood and youth (such as playing classical music, competitive sports, etc.) sometimes develop this schema as well. Demanding and stressful situations, including examinations, are very problematic for such people. This schema sometimes functions like a self-fulfilling prophecy: since people with this schema are so afraid of demanding situations, they may avoid them altogether, resulting in poor preparation and—in a vicious circle—in actual bad results when such situations are unavoidable.

Case example: failure

Toby is a 24-year-old university student who comes to therapy because of depressive symptoms and extreme exam anxiety. With regard to his intelligence and interest in his subject, there is nothing disabling him from being successful, however he often stays in bed all day and postpones doing his homework, and his avoidant behavior patterns are prominent. He is convinced that he will never be able to finish his studies, as he regards himself as a complete failure. This feeling of failure has persisted over the last few years, although he was able to achieve good marks at school and during the first year of university. Toby talks a lot about his brother, who is 2 years older. The brother is very talented and has always excelled in any activity he participates in. Toby has always experienced feelings of being less smart than and inferior to his brother. Furthermore, Toby was on a swimming team as a child and teen and participated in local competitions. His coach was very ambitious, and whenever Toby came second, the coach displayed his disappointment at Toby’s failure to win.

1.1.3 Schema in the “impaired limits” domain

People with schemas of this domain have difficulty accepting normal limits. It is hard for them to remain calm and not cross the line, and they often lack the self-discipline to manage their day-to-day lives, studies, or jobs appropriately. People with the schema “entitlement/grandiosity” mainly feel entitled and tend to self-aggrandize. The schema “lack of self-control/self-discipline” is principally associated with impaired discipline and delay of gratification. Just like those of the domain “impaired autonomy and achievement,” these schemas can be learned by direct modeling and social learning. Often patients were spoiled as children, or their parents were themselves spoiled in their childhoods and/or had problems accepting normal limits. However, these schemas can also develop when parents are too strict, when they inflict too much discipline, and when limits are too narrow. In such situations, these schemas develop as a kind of a rebellion against limits and discipline in general.

(10) Entitlement/grandiosity People with this schema regard themselves as very special. They feel that they don’t have to care about usual rules or conventions, and they hate to be limited or restricted. This schema is typically associated with narcissistic personality traits. Patients with this schema strive for power and control, and they interact with others in a very competitive way. They often report that an important figure, such as their father, was a narcissistic role model or a powerful overachiever, thus modeling this schema. It is often the case that controlling and powerful interpersonal behavior was directly reinforced in the patient’s childhood. Perhaps the father reinforced the son when the latter controlled his peers, or the parents told their children to feel special because they belonged to a very special family.

Case example: entitlement/grandiosity

Allan is a 48-year-old team leader who first sought psychological consultation due to being bullied in his workplace. With regard to therapy goals, he says: “I have no idea at all how those morons at work can be taught to behave.” Towards the therapist he acts in a controlling and bossy manner. According to his self-report, he often devalues his coworkers and behaves insolently at work. When the therapist addresses this behavior, he proudly comments that “It’s certainly important to come prepared if you have to deal with me.”

(11) Lack of self-control/self-discipline People suffering from this schema typically have problems with self-control and with the ability to delay gratification. They often give up boring things and don’t have enough patience for tasks requiring discipline and perseverance. Others often perceive such patients as lazy, caring only about their own well-being and not working hard enough to fulfill their obligations. The biographic roots of this schema are often similar to “entitlement/grandiosity.” However, “lack of self-control/self-discipline” can also be found in individuals who suffered some form of abuse in their childhood. In families that neglect or abuse their children, the kids typically lack the guidance necessary to learn sufficient self-discipline.

Case example: lack of self-control/self-discipline

Steven, a 46-year-old, calls himself a “freelance artist.” In reality he relies on social welfare and benefits to make ends meet, but he regularly talks about artistic and musical projects he is currently working on. The only real work he does on his projects is to maintain a very glamorous presence on the Internet. He came to therapy due to depression and a lack of perspective. However, when the therapist tries to identify clear goals with and for him so that he can actually start changing his life for better, he becomes unwilling or unable to make decisions regarding personal goals. Whenever a certain goal becomes more materialized and clearer, he does not want to invest the time and energy to make it a reality.

1.1.4 Schemas in the “other-directedness” domain

People with schemas of this domain typically put the needs, wishes, and desires of others before their own. In consequence, most of their efforts are directed towards meeting the needs of others. However, the ways in which they attempt this differ with the type of schema they possess. Individuals with a strong “subjugation” schema always try to adapt their behavior in a way which best accommodates the ideas and needs of others. In the schema “self-sacrifice,” on the other hand, the focus is more on an extreme feeling of responsibility for solving everyone else’s problems; people with this schema typically feel that it is their job to make everybody feel good. Those with the schema “approval-seeking” have as a sole purpose pleasing others; thus all their actions and efforts reflect that desire, rather than their own wishes. With regard to the biographical background and development during childhood, these schemas are often secondary. The primary schemas are often those from the domain “disconnection and rejection”. I.e., schemas in the domain “other-directedness” may have developed to cope with schemas of disconnection and rejection. Patients may, for example, report that an important parent figure, often the father, was an alcoholic and used to behave aggressively when intoxicated. Thus they felt threatened and developed the schema “mistrust/abuse.” To avoid confrontation with the drunken father, they may have learned to behave submissively in such situations. This “secondary” submissive behavior then resulted in a subjugation schema. Often they also had subjugating models, for example when the mother did not stop the father’s behavior or did not leave the aggressive father all together, but rather subjugated herself to his aggression.

(12) Subjugation People with this schema generally allow others to have an upper hand in interpersonal relationships. They mold and adapt their behavior according to the desires and ideas of others, sometimes even when those desires are not explicitly stated but only deduced or guessed. For individuals with this schema, it can be very difficult to get in tune with their own needs, even with the therapist’s efforts to help them discover these. During their childhood, patients often experienced dangerous family situations, with one parent subjugating to the other one. Perhaps the mother was very submissive when the father was violent or aggressive, or perhaps any expression of needs and desires was severely punished. Susan (see the start of this section) presents a typical example of this schema.

(13) Self-sacrifice Patients with this schema constantly focus on fulfilling the needs of others. This schema differs from “subjugation” however insofar as the main goal is not primarily to adapt and succumb to the ideas of others, but rather to discover the needs of others or situational requirements as quickly as possible and attend to those needs. So it is more active and voluntary. Typically such individuals experience feelings of guilt whenever they focus on their own needs. There are high rates of this schema among people working in fields related to providing care and help. In everyday life it can often be observed that time-consuming and effort-requiring jobs or tasks, which are not associated with much financial gain or respect, are often repeatedly performed by the same people. For example, often a person will be a member of the parent–teacher association (PTA) first in their child’s kindergarten and then later in their primary and secondary schools—even though they may have decided a hundred times not to agree to be elected again. When the PTA holds elections, people with this schema feel so guilty if they do not accept nominations that before they know it they are again reelected. Seen in this light, this schema can frequently be spotted in a number of healthy individuals, often without much clinical repercussion, provided that the person’s support system is healthy enough.

Case example: self-sacrifice

Helen is a 35-year-old nurse who has a very good reputation in the clinic she works at, because she is always willing to do extra tasks, and usually does them extremely well. She is a quality-assurance representative at her clinic, she often provides cover for sick colleagues, and she always does a perfect job. Alongside this involvement at work, she is also very involved in her private life as a member of the PTA and similar groups. Helen first seeks psychotherapeutic treatment for a burn-out syndrome. She seems to be extremely overstressed and overwhelmed by her existing high levels of work and personal engagements. However, when the therapist asks her, “Why on earth would you care about all these things?” she looks truly surprised and says, “Well, it’s not a big deal, is it?”

(14) Approval-seeking People with this schema find it extremely important to make a good impression on others. They spend a lot of time and energy on improving their looks, their social status, their behavior, and so on. The goal, however, is not to become the best (narcissistic self-aggrandizing), but to receive the approval and appreciation of others. Such individuals often find it hard to tune in to their own needs and desires, as the opinions of others and the need for status and approval are always in the foreground.

Case example: approval-seeking

Sarah, a 32-year-old lawyer, seems to be a very satisfied and happy person. She has many friends and interesting hobbies and is married to a very successful man. She comes to therapy because she begins to perceive herself (and her whole life) as “fake.” She reports feelings of being an uninteresting and insufficient person. She describes her active and interesting lifestyle as follows: “I always feel under pressure to be part of all the coolest groups and activities and juggle many balls at once, so that I can at least pretend to be interesting and lovable, although I don’t feel that way myself at all.”

1.1.5 Schemas in the “hypervigilance and inhibition” domain

People with these schemas avoid the experience as well as the expression of spontaneous emotions and needs. People with the schema “emotional inhibition” devalue inner experiences such as emotions, spontaneous fun, and childlike needs as stupid, unnecessary, or immature. The schema “negativity/pessimism” corresponds with a very negative view of the world; people with this schema are always preoccupied with the negative side of things. Those with the schema “unrelenting standards” constantly feel high pressure to achieve; however, they do not feel satisfied even when they achieve a lot, as their standards are extremely high. The “punitiveness” schema incorporates moral codes and attitudes that are very punitive whenever a mistake is made, regardless of whether the mistake was on purpose or accidental.