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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Schema Therapy for Couples represents the first practitioner guide to detail effective Schema Therapy techniques in couple and relationship therapy.
- Shows how the distinctive features of ST make it ideal for addressing the cognitive and emotion-focused problems typical in couple relationships
- Presents and integrates a series of innovative tools and interventions such as Schema Therapy with Needs versus Wants, Mode Cycle Clash Cards, limited re-parenting visualization, and chair work
- Authored by an international team of experts in couples therapy and Schema Therapy
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Seitenzahl: 541
Veröffentlichungsjahr: 2015
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CONTENTS
Cover
Title page
List of Figures and Tables
Figures
Tables
About the Authors
Preface
From all of us
From Chiara Simeone-DiFrancesco, PhD
From Eckhard Roediger, MD
From Bruce A. Stevens, PhD
Acknowledgments
Abbreviations
Introduction
About the Companion Website
1 What Schema Therapy Offers
1.1 What is Hidden, What is Seen
1.2 Listening to the Evidence
1.3 Beyond Just Cognitive Therapy
1.4 Jeff Young and the Development of Schema Therapy
1.5 The Schema Model
1.6 Introducing the Mode Model
1.7 The Challenge of Working with Couples
1.8 Limited Professional Literature
1.9 Brief Outline of the Stages of Schema Therapy for Couples
Summary
2 The Initial Contract and First Interview
2.1 The Initial Interview
2.2 Issues that Present
2.3 Expectations
2.4 “Contracting” for Therapy
2.5 Safety First
2.6 Additional Concerns
2.7 Beginning with a Crisis Intervention
2.8 Ending the First Session
2.9 Starting with One Partner First
2.10 How Many Therapists?
2.11 With the Individual or Couple?
Summary
3 Relationship Assessment
3.1 A Questionnaire
3.2 The Genogram
3.3 Why do a Genogram?
3.4 Autobiography of Relationships
3.5 Schema Identification
3.6 Core and Compensatory Schemas
3.7 Schema Coping Styles
3.8 Schema Chemistry in Therapy
Summary
4 Understanding the Origins of Relational Styles
4.1 Healthy and Unhealthy Co-functioning
4.2 A Dark Legacy
4.3 Unconditional Love?
4.4 Dealing with the Past
4.5 A Note on Attraction
4.6 Brain “Chemistry” linked to Schemas
4.7 An Interlocking Schema Perspective
4.8 Drawing the Threads Together in Case Formulation
4.9 But why Theory?
Summary
5 Foundations for Evidence-Based Practice in Couple Therapy
5.1 Case Study: Bill and Betty
5.2 Repair Attempts
5.3 Accessing the Full Spectrum of Basic Emotions
5.4 A Dead End?
5.5 Additional Thoughts
Summary
6 Schemas and Modes
6.1 From Schemas to Modes
6.2 The Mode Model in Detail
6.3 Additional Modes
6.4 The Infant Mode Concept
6.5 Some Additional Aspects Dealing with Child Modes
6.6 Mode Cycles in Couples
Summary
7 Approaching Schema Therapy for Couples
7.1 Practical Tips for Making Therapy a Safe Place for the Couple
7.2 Balanced Attention Instead of Staying Neutral
7.3 Thinking about Language, Tonal Regulation and the Use of Words
7.4 Using Self-Disclosure and Healthy Family Models, Heroes, Spirituality, and Religion
7.5 Balancing the Level of Activation
7.6 Dealing with Volatile Couples
7.7 Working with Passive Individuals
7.8 Enhancing Communication Skills
7.9 What Schema Therapy brings to the Communication Process
Summary
8 Mode Mapping and Mode Cycle Clash-cards
8.1 Introducing the Dimensional and Dynamic Mode Model
8.2 Mode Maps
8.3 Using Mode Cycle Clash-cards
8.4 Extended Case Example
8.5 Advantages of Mode Maps
8.6 Tim and Carol: Another Extended Example
8.7 Progress Mapped Out
8.8 A Road Map
Summary
9 Interventions in Couple Treatment
9.1 The Role of Empathy
9.2 Imagery Work
9.3 Starting Imagery Rescripting
9.4 Impeachment
9.5 Caring for the Child
9.6 Making Imagery Work Safe for Individuals and Couples
9.7 Case Study: Michael and Amanda
9.8 Mode Dialogs on Multiple Chairs
9.9 Dealing with Anger
9.10 Working with Impulsive and Undisciplined Child modes
9.11 Rewind the Video
9.12 Behavioral Pattern Breaking and Homework Assignments
9.13 The Role of Mindfulness
9.14 A Couple Schema Plan
9.15 Conclusion
Summary
10 Common Problems in Couple Therapy, Including Affairs, Forgiveness, and Violence
10.1 Affairs
10.2 Preparing for Marriage or a Committed Relationship
10.3 Domestic Violence
10.4 Substance Abuse Related Problems
10.5 Returning to Couple Therapy
10.6 The Resistant Partner
10.7 The More Personality Disordered
10.8 Separation and Divorce
Summary
11 Differentiating Needs from Wants, and the Challenge of Integration
11.1 Needs
11.2 The Difference between Needs and Wants
11.3 Practical Application
11.4 Advantages of Distinguishing Needs and Wants
11.5 An Exercise to focus on Unmet Needs
11.6 Bringing it all Together
11.7 Reconnecting the Vulnerable Children
11.8 Tone of Voice
11.9 Preparing for Termination
Summary
12 Building Friendship, Building the Healthy Adult
12.1 Payments into a Relationship
12.2 Communicating as Healthy Adults
12.3 Build the Positives
12.4 Out-of-Session Trust Building
12.5 The Sexual Relationship
12.6 Schemas and Modes in Sexual Therapy
12.7 To Strengthen the Healthy Adult
12.8 Values as Strengthening the Healthy Adult
12.9 Happy Child as Well
Summary
Appendix A Self-care for the Couple Therapist
A.1 The Risk of Working with Severe Personality Disorders
A.2 The Psychopath
A.3 The Borderline Patient
A.4 The Sexual Boundary
A.5 Positive Behaviors for Self-care
Summary
References
Index of Therapy Tools and Interventions
Index
End User License Agreement
List of Tables
Chapter 03
Table 1 Examples of schema coping behaviors
Chapter 06
Table 2 The most important modes
Chapter 08
Table 3 Comparing the two mode models
Chapter 10
Table 4 The six types of affairs
Table 5 Social drinking guidelines
Chapter 11
Table 6 Needs versus wants
Table 7 Essential elements of ST-C
Chapter 12
Table 8 Building friendship or turning into enemies
List of Illustrations
Chapter 01
Figure 1 Basic mode model
Chapter 03
Figure 2 Genogram of Tom and Nancy
Chapter 06
Figure 3 Diagram of generally accepted modesNote: Modes in bold are in SMI 1.1.
Chapter 07
Figure 4 Balancing the therapy relationship.
Figure 5 Movements of a conflict-solving communication
Chapter 08
Figure 6 Descriptive mode map.
Figure 7 Dimensional mode map.
Figure 8 The extended dimensional mode model.
Figure 9 Mode cycle clash-card.
Figure 10 Mode cycle clash-card of Tom and Betty.
Figure 11 Tim’s mode map
Figure 12 Tim and Carol’s mode cycle clash-card.
Chapter 09
Figure 13 The movement of the Healthy Adult.
Figure 14 Two ways to consistency.
Chapter 10
Figure 15 A typical internal drinking mode cycle.
Chapter 11
Figure 16 Needs vs. wants tool for Sylvia and Kurt.
Figure 17 Blank needs vs. wants tool.
Figure 18 Love target-practice.
Figure 19 Sylvia and Kurt’s mode cycle clash-card.
Guide
Cover
Table of Contents
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“Schema Therapy with Couples is a very helpful addition to the clinical couples’ therapy literature, integrating the individual challenges people face in their own growth with managing a relationship with someone else who also faces their own individual challenges. Drs. DiFrancesco, Roediger, and Stevens provide a guide through this very difficult but everyday terrain that every couples therapist must navigate.”
John Gottman, PhD, Author of The Seven Principles for Making Marriage Work
“In 25 years of treating couples and closely following the literature, this is the most significant development I have seen. Schema Therapy with Couples provides a highly developed systems-oriented theoretical model. With its foundation in schema therapy, this approach can deftly deal with the most severely dysfunctional couples by focusing on personality dysfunction, change at a deep cognitive-emotional level, and potent emotive techniques. Schema Therapy with Couples is an extraordinary volume chock-full of figures, instructive clinical examples, and powerful clinical interventions. This innovative work will undoubtedly influence how you treat couples.”
Lawrence P. Riso, PhD, Professor of Clinical Psychology, American School of Professional Psychology at Argosy University, Washington, DC
“Schema therapists working with couples bring to their work the insights of the schema therapy approach usually integrated with concepts and insights from couples therapy approaches such as those of Johnson (emotion-focused therapy), Gottman (Gottman couples therapy), Hendrix (Imago therapy), and cognitive-behavioural approaches. Their interest is in the more difficult cases where one or both parties have longstanding psychological problems, often due to significant trauma, abuse and instability in childhood: a personality disorder, a mood disorder (bipolar or chronic depression), addiction, and so on. For several years, the authors of this book have been active in a schema therapy for couples workgroup and share their own discoveries and insights and those of other workgroup colleagues. They show how the central concepts and approach to case formulation and intervention in schema therapy provide a coherent integrative framework. The authors offer a set of guiding and enabling principles as well as practical examples of how to implement specific schema therapy interventions such as mode clash analysis, the mode clash-card, differentiating needs from wants, and imagery and chair-work. The book is rich in clinical examples that will enable readers to encounter the distinctive contribution of the schema therapy approach to couples therapy.”
David Edwards, Schema Therapy Institute of South Africa and Rhodes University
“This book teaches the basics of couples in conflicts and provides a deeper, need-based understanding of what goes wrong in relationships. Therapists are offered a toolkit to meet, understand, evaluate, handle, and help couples to stay together despite all interpersonal turmoil. Schema therapeutic couple therapy opens a new window of understanding and provides innovative ways to help.”
Gerhard Zarbock, PhD, Clinical psychologist, Director of IVAH, a government approved CBT-training center, Hamburg, Germany, co-author of Mindfulness for Therapists
Schema Therapy with Couples
A Practitioner’s Guide to Healing Relationships
Chiara Simeone-DiFrancesco, PhD
Counseling Psychologist
Eckhard Roediger, MD
Psychiatrist and Psychotherapist
Bruce A. Stevens, PhD
Clinical Psychologist
This edition first published 2015© 2015 John Wiley & Sons, Ltd.
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Library of Congress Cataloging-in-Publication Data
Simeone-DiFrancesco, Chiara. Schema therapy with couples : a practitioner’s guide to healing relationships / Chiara Simeone-DiFrancesco, PhD, counseling psychologist, Eckhard Roediger, MD, psychiatrist and psychotherapist, Bruce A. Stevens, PhD, clinical psychologist. pages cm Includes bibliographical references and index. ISBN 978-1-118-97264-9 (hardback) – ISBN 978-1-118-97267-0 (paper)1. Couples therapy. 2. Couples–Psychology. 3. Schema-focused cognitivetherapy. I. Roediger, Eckhard. II. Stevens, Bruce, 1950- III. Title. RC488.5.S537 2015 616.89′1562–dc23
2015008534
A catalogue record for this book is available from the British Library.
Cover image: Cloudy sky with bright sunshine © TAGSTOCK1/Shutterstock Storm Clouds Saskatchewan ominous wheat fields Saskatchewan © Pictureguy/Shutterstock
List of Figures and Tables
Figures
1
Basic mode model
2
Genogram of Tom and Nancy
3
Diagram of generally accepted modes
4
Balancing the therapy relationship
5
Movements of a conflict-solving communication
6
Descriptive mode map
7
Dimensional mode map
8
The extended dimensional mode model
9
Mode cycle clash-card
10
Mode cycle clash-card of Tom and Betty
11
Tim’s mode map
12
Tim and Carol’s mode cycle clash-card
13
The movement of the Healthy Adult
14
Two ways to consistency
15
A typical internal drinking mode cycle
16
Needs vs. wants tool for Sylvia and Kurt
17
Blank needs vs. wants tool
18
Love target-practice
19
Sylvia and Kurt’s mode cycle clash-card
Tables
1
Examples of schema coping behaviors
2
The most important modes
3
Comparing the two mode models
4
The six types of affairs
5
Social drinking guidelines
6
Needs versus wants
7
Essential elements of ST-C
8
Building friendship or turning into enemies
About the Authors
Dr. Chiara Simeone-DiFrancesco (M.A./M.Ed. 1980/81 Columbia University, NY; Ph.D. 1990 U. of Mississippi), Counseling Psychologist. She founded Wisconsin Family Growth & Reconciliation Center LLC, working with couples for 25 years in private practice. Chiara now directs the Marriage & Family Schema Therapy Institute, a division of Healing International, Inc., a non-profit she co-founded in 1986. Training fellow schema therapists, she founded the ISST Special Interest Group on Couples Schema Therapy, and now chairs its international Subcommittee. Besides training and consulting, Chiara offers 3-day “Couples Intensives” in Wisconsin and Virginia, USA. She speaks and writes in the secular and Christian arena, with a special interest in marriage preparation, healing and support. Her website is www.SchemaTherapyforCouples.com and contact is [email protected]
Dr. Eckhard Roediger (MD, Frankfurt, Germany, 1986) is a neurologist, psychiatrist, and psychotherapist. He trained in psychodynamic and cognitive behavior therapy. Eckhard has been the director of the Psychosomatic Department of a clinic in Berlin, since 2007 working in private practice and as director of the Schema Therapy Training Center in Frankfurt. He is the author of a number of German books on schema therapy (www.schematherapie-roediger.de), currently ISST President.
Dr. Bruce A. Stevens (PhD, Boston University, 1987) was Associate Professor in Clinical Psychology at the University of Canberra, Australia. He is now Wicking Professor of Aging and Practical Theology at Charles Sturt University, Canberra. He also has a part-time private practice at Canberra Clinical and Forensic Psychology, a practice he founded in the early 1990s. Bruce was chair of the Canberra section of the Clinical College of the Australian Psychological Society for four years (2009–2013). He gives many professional workshops on couple therapy throughout Australia. He has written five books, most recently a practitioner book with Dr. Malise Arnstein (Happy Ever After? A Practical Guide to Relationship Counselling for Clinical Psychologists, Australian Academic Press, Brisbane, Queensland, 2011), which is mostly from an emotion-focused therapy for couples perspective.
Preface
From all of us
In this book, we have cited many experts and authors, including colleagues, and have tried to convey their ideas accurately. Sometimes we have illustrated a range of opinion, and we do not necessarily agree with everything we have cited (it would not be good to cite only those we agree with, or only those whose work lacks any hint of controversy). In areas of disagreement, we must not overlook anything that could be useful or valuable. We can only take responsibility for expressing our own opinions in these pages.
The authors participate in the Couples/Marital Interest Group of the International Society of Schema Therapy (ISST) (chaired by Simeone-DiFrancesco). This is a group of experienced schema therapists who meet at least monthly to share ideas about treating difficult couples. Some of those ideas, not yet published in peer-reviewed papers, have informed this book. Where possible, we have tried to acknowledge and give credit for all contributions.
We would like to thank the many clients who have helped us to learn to be better therapists and to use ST more effectively.
Please note: All case examples have been made from a composite of clinical experiences, so any resemblance with any actual client is purely coincidental.
From Chiara Simeone-DiFrancesco, PhD
www.SchemaTherapywithCouples.com
This work is in itself an example of the united effort of three colleagues who have become good friends in the process of writing. While we support and agree with the principles we have put forward, we each apply them differently. We offer our written “jewel” to share, yet we each practice the dialogic attitude of acceptance, even where we may have serious issues of disagreement in working with actual cases. Such is the beauty of this work. We believe its principles are applicable to all cultures, faiths, and situations, but its application can take on individual variations in time, place, and culture. This is the beauty of schema therapy and Healthy Adult mode!
I have found our journey in writing together to be a learning experience on all levels, intellectually, emotionally, and spiritually. Through it, some of my own needs in all those areas have been met, and I am very grateful to my colleagues for this. As you read, I hope that you will be able to sense the spirit of humility and openness to learning that my two colleagues, Bruce and Eckhard, have modeled. It has been one of those blessed growth and transformational experiences in life to be part of this journey together. I hope and pray that you will be as inspired as each of us has been in discovering schema therapy for couples (ST-C).
Many possible research applications can stem from what we have presented here. It is a seedbed for further development. We stand with excitement to see how the minds and especially the hearts of our readers are opened to new possibilities of healing and connecting others. My vision is for ST-C, with its heart-changing possibilities, to have an effect on the worldwide divorce rate. If our collective lives can make an impact on that, then they will have been well spent, especially for the future of children who need their parents to be secure and well-connected in love.
We look forward to you, the therapist-reader, developing your own comfort with, and application of, ST-C. And we look forward to you, the seeking and perhaps hurting couple or individual, to perhaps gaining some hope and some strengthening and turning towards healthy ways. Together, we may dare to hope that we will all grow on the continuum towards the fulfillment of the Healthy Adult—with humility and openness, and much thankfulness for those who model for us the greatest virtues. “And the greatest of these is love which holds and binds everything together.” (1 Corinthians 13:13)
We welcome your feedback through email, mail, or even phone calls, as we believe that ultimately we are better together!
From Eckhard Roediger, MD
Writing in English was a special challenge for me, but writing together with Chiara and Bruce made it surprisingly easy. We all enjoyed the mutual exchange and inspiration. I especially want to thank all members of the ISST Couples/Marital Special Interest Group initiated and conducted by Chiara, for their creative and courageous input. They all contributed very much to this book, and we tried to cite them wherever we remembered their personal contributions. Besides that, looking at my own marriage through ST glasses and applying the model described in this book to ourselves helped my wife and I to deal with life challenges much better. So there were gains in many fields! I hope you, as the reader, feel the same.
From Bruce A. Stevens, PhD
I feel profoundly grateful. I am approaching the age at which many people retire (or at least think about it), but I have found a life of continuing creativity and intellectual stimulation. I am delighted to be with Shayleen. I am surrounded by wonderful colleagues, graduate students and, of course, the courageous couples who challenge any ideas articulated here, saying, “It’s all very well to say that in a book, but will it work with us?” I am very grateful for Chiara and Eckhard, two leading schema therapists whom I have found to be both generous and understanding. I have learned more from them than I can adequately acknowledge.
Acknowledgments
I dedicate this to the most glorious reality of marriage, a unity made in heaven. May all see the hope which is ours to share in Christ Jesus.
—Chiara Simeone-DiFrancesco
I dedicate this to my beloved wife, Andrea, who has shared my life for better or worse for more than 30 years now.
—Eckhard Roediger
To Rowena, Kym, Naomi, and Christopher—four wonderful children. And Shayleen, with thanks for the journey.
—Bruce A. Stevens
Abbreviations
BPD
borderline personality disorder
EFT
emotion-focused therapy
EFT-C
emotion-focused therapy for couples
ISST
International Society of Schema Therapy
SMI
Schema Mode Inventory
ST
schema therapy
ST-C
schema therapy for couples
SUDS
Subjective Units of Distress Scale
YPI
Young Parenting Inventory
YSQ-3
Young Schema Questionnaire, version 3
Introduction
First, a bold statement: There is an urgent need for yet another book on couple therapy.
It is time to bring a new perspective to persistent problems and seemingly irresolvable difficulties in relationships. We believe that schema therapy (ST) is a potentially more effective approach than what is currently available. This therapy can deal with problems largely ignored by mainstream cognitive therapy. This includes dysfunctional patterns in intimate relationships and changing troublesome memories from childhood (Arntz & Jacob, 2013). ST has established itself as an evidence-based therapy for treating the most difficult therapeutic problems, and this book explores ways to apply this “strong” therapy to work with couples in effective interventions.1
ST has easy-to-grasp concepts, such as schemas and modes, which make sense of the couple’s past experiences, educate them, and open the door to allow them to speak freely about ways in which both can feel more connected. These concepts allow the therapist and couple to communicate about what is inside an individual’s inner world—and give clearer explanations of what is experienced, such as bodily sensations, varied feelings, thoughts and beliefs, values, and much more. When an individual learns about the origins of dysfunctional patterns, life and relationships tend to make sense. Better yet, the process, mutually applied, progressively gives the couple effective tools to intercept habitual negative interactions and personality patterns. In the first publication we know in ST-C, Simeone-DiFrancesco (2010) stressed: “ST for Couples and Marriages is a consummate therapy of reality-based hope.” This leads to dramatic changes. Few therapies can offer such potential for change, and at the same time create a culture of mutual acceptance and understanding.
Couple therapy has advanced on many fronts. It has been greatly informed by the research of John Gottman (1999, 2011). The effectiveness of emotion-focused therapy for couples (EFT-C) is now well established through clinical trials (Johnson, 2004). However, couples with traits of personality disorder present the greatest therapeutic challenge because of their typically volatile relationships and disordered thinking. This includes the emotional instability of those with borderline personality disorder, the withdrawal of the schizoid, the self-focus of the narcissist and the “moral insanity” of the psychopath. ST was developed to treat more difficult people who present for therapy with powerful interventions, including active re-parenting in imagery rescripting, chair-work dialogs, and behavioral pattern breaking. ST combines the depth and developmental theory of longer term treatments with the active, change-oriented approach of shorter term therapies (Young et al., 2003). We hope to build on the important contributions of Gottman and EFT-C, but highlight the unique contribution that ST can make to working with difficult relationships.
As authors, we bring two mental health disciplines to this book: psychiatry and clinical/counseling psychology. We have made contributions to the theory and practice of ST with “needs” and “wants” (i.e., re-parenting) (Simeone-DiFrancesco & Simeone, 2016ab); mode explication and stages of treatment (Simeone-DiFrancesco, 2011); understanding the schema–mode model in detail, mode cycles, methods of treatment (i.e., details of the imagery rescripting and chair-work techniques), and using clash-cards (Roediger & Jacob, 2010; Roediger, 2011; Roediger & Laireiter, 2013); and distinguishing infant modes from child, parent and compensatory modes (Stevens, 2012b). We hope that this book will not be read as a simplistic “how to” manual, but as a practical guide for clinical work.
We hope to offer the experienced practitioner a map for the rocky terrain of therapy with the most challenging couples. We have also found, through experience, that using ST for couples can lead to lasting change in relationships.
Note
1
It is interesting that some of the best therapy outcomes, with large effect sizes, also use group therapy. Couple therapy might be thought of as being somewhere on a continuum between individual and group therapy. For a review of the results of randomized controlled trials with ST, see Arntz (2012a), and for the cost-effectiveness and evidence of effectiveness see Arntz (2008), Bamelis (2011) and Bamelis et al. (2012). We postulate that it is precisely these “rough edges” of personality, even the “soft conflict” of detached and unaware couples, that require a similar therapeutic “touch.” Kindel and Riso (2013) were the first to produce evidence-based research on the effectiveness of the treatment of couples with ST. Dr. Robert Brockman will facilitate further research through the ISST Couples/Marital Subcommittee.
About the Companion Website
This book is accompanied by a companion website:
www.wiley.com/go/difrancesco/schematherapywithcouples
The website includes blank versions of forms in the book for your own use.
1What Schema Therapy Offers
1.1 What is Hidden, What is Seen
For couples, the most common clashes are around the “rough edges” of personality. Indeed, there is a great silence in relationship therapy about the influence of personality disorders. Research has established that such traits are very common. Only 23 percent of the general population is relatively free of them; over 70 percent of people “have some degree of personality disturbance” (Yang et al., 2010).
It makes sense that character traits will cause relationship difficulties. We are attracted to a personality but live with a character. If there are long-term character problems, which is another way of describing personality vulnerability, then relationship difficulties are inevitable.
Richard had a history of many short-term relationships, which were perhaps more sexual “flings” to avoid boredom. He would leave when lovers became more “needy”. He had been sexually abused as a child and never experienced warmth or protection by a parent or step-parent. He knew only criticism. Eventually, he married Carol because he wanted a stable relationship to raise children. When he had an affair, it was devastating to his wife. It was hard to even talk issues through because Richard avoided conflict. A lot was happening in this relationship that was far from obvious.
Some couples deny any problems, even to the point of separation and divorce, but there is a long history of hidden clashes underlying the deterioration of their relationship.
Reflect: What has been your most difficult couple to treat? Why? Do you recognize possible traits of personality disorder?
1.2 Listening to the Evidence
There is currently a crisis in relationships, and couples commonly present for therapy. So why not simply use the available evidence-based treatment for relationships? The answer is not straightforward. There is good research. John Gottman (1999) has contributed enormously to what we know through his “Love Lab.” He has provided years of longitudinal data on couple processes. This includes easy-to-understand principles thoroughly grounded in extensive research. This can inform our practice. While Gottman and his colleagues have not yet produced randomized controlled trials, his work would meet the criteria of the American Psychological Association’s policy statement on evidence-based practice in psychology: “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (see APA, 2006).
Sexton and Gordon (2009) distinguished three levels of evidence:
evidence-informed interventions based on pre-existing evidence
promising interventions, but preliminary results not replicated
evidence-based treatments with systematic high-quality evidence demonstrating efficacy with clinical problems that the interventions are designed to address.
There is some Level 3 support for behavioral marital therapy (Jacobson & Margolin, 1979), cognitive behavioral marital therapy (Baucom & Epstein, 1990), integrative couple therapy (Jacobson & Christensen, 1996), and emotion-focused therapy for couples (EFT-C; Greenberg & Goldman, 2008).
In our experience, EFT-C works with many, and perhaps most, couples. But there is no specifically evidence-based therapy for couples with personality disorder (or for couples with strong traits, even if not diagnosed). What exists is evidence of the effectiveness of individual treatment for individuals with personality disorder, initially borderline personality disorder (BPD). It makes clinical sense that difficult couples may need an enhanced approach with ST or dialectical behavior therapy (Linehan, 1993). Both employ stronger interventions aimed at changing ingrained aspects of character. A 2010 review concluded that dialectical behavior therapy has Level 3 and ST has Level 2 evidence for effectiveness with adults diagnosed with BPD (APS, 2010, p. 112). A study of ST treatment of BPD inpatients using groups has reported large effect sizes (Farrell & Shaw, 2012), and a study has recently indicated the effectiveness of ST with other personality disorders (Bamelis et al., 2014).
We believe that ST has significant advantages over dialectical behavior therapy,2 so applying ST to working with couples (schema therapy for couples, ST-C) is the focus of this book. We hope that it may prove to have some of the strengths already demonstrated by ST case conceptualization and interventions in individual and group therapy.
1.3 Beyond Just Cognitive Therapy
One of the strengths of ST is its origins in cognitive therapy, which has the advantage of conceptual clarity and ease of understanding. Now, in the twenty-first century, it incorporates a good deal more than talk. This includes both non-verbal cognitions (imagery) and embodiment techniques (Rosner et al., 2004). It is essentially integrative.
Aaron Beck (1963) initiated the “cognitive revolution” and developed what is now extensively researched cognitive behavioral therapy for the treatment of depression. This approach was then applied to the whole range of psychological disorders. But cognitive behavioral therapy did not prove as effective with the personality disordered, which led to “third wave” therapies, including dialectical behavior therapy and ST.
While Beck referred to schemas, it was more in the sense of clusters of negative beliefs about the self. A similar understanding of schemata is found in the work of Theodore Millon, in which patterns of dysfunction are foundational to personality disorder (Millon, 1990, p. 10). Jesse Wright and colleagues followed in this approach and noted that people typically have a mix of different kinds of schemas: “even patients with the most severe symptoms or profound despair have adaptive schemas that can help them cope … efforts to uncover and strengthen positively oriented beliefs can be quite productive” (Wright et al., 2006, p. 174).
1.4 Jeff Young and the Development of Schema Therapy
ST was developed from cognitive therapy as a means of treating difficult people. Jeffery Young et al. (2003) linked maladaptive schemas to neglect and toxic childhood experiences. They reflect the unfulfilled yet important needs of the child and represent adaptations to negative experiences, such as family quarrels, rejection, hostility, or aggression from parents, educators or peers, as well as inadequate parental care and support (van Genderen et al., 2012). This approach has more of an emotional focus and a willingness to explore the childhood/adolescent origins of psychological problems.
Young identified a comprehensive set of early maladaptive schemas, which were defined as “self-defeating emotional and cognitive patterns that begin early in our development and repeat throughout life” (Young et al., 2003, p. 7). Schemas are identified by clinical observation (Arntz & Jacob, 2013). The expression of such patterns has different levels of severity and pervasiveness. The idea of schema activation is fundamental to an understanding of Young’s contribution. A more severe schema is distinguished by how readily it is activated, the intensity of affect and how long distress lasts (Young et al., 2003, p. 9).
ST provides a blueprint for the child and later adult’s world. While schemas might have had some survival value for the child (Kellogg, 2004), by adulthood they are “inaccurate, dysfunctional, and limiting, although strongly held and frequently not in the person’s conscious awareness” (Farrell & Shaw, 2012, p. 9).
Young et al.’s (2003) understanding of schemas drew on a variety of sources. Indeed, they outlined parallels and differences with major approaches, including Beck’s “reformulated” model, psychoanalytic theory, Bowlby’s attachment theory (especially internal working models), and emotion-focused therapy (EFT). ST has integrated techniques adapted from transactional analysis and gestalt therapy (Edwards & Arntz, 2012). Jeff Young (2012) also described ST as an individual therapy with systemic implications. There is a breadth, applicability and ease of understanding that encourages a broader application.
Young (1999, p. 20) also identified needs of childhood in five “domains,” which can be seen as five tasks for therapy:
connection and acceptance
autonomy and performance
realistic limits
inner-directed ness and self-expression
spontaneity and pleasure.
1.5 The Schema Model
Young identified the following 18 schemas: Abandonment (instability), Mistrust-Abuse, Emotional Deprivation, Defectiveness-Shame, Social Isolation (alienation), Dependence Incompetence, Vulnerability to Harm or Illness, Enmeshment (undeveloped self), Failure (to achieve), Entitlement Grandiosity, Insufficient Self-control (or self-discipline), Subjugation, Self-Sacrifice, Approval Seeking (recognition seeking), Negativity Pessimism, Emotional Inhibition, Unrelenting Standards (hyper-criticalness), and Punitiveness. Maladaptive schemas hinder people from recognizing, experiencing, and fulfilling their own needs (Arntz & Jacob, 2013).
Reflect: You can think about schemas as patterns of vulnerability, or as domains in which emotional learning took place in childhood.
Young also looked at patterns of response to schema vulnerability, including surrender, avoidance, and compensation leading to specific coping behavior. The 18 maladaptive schemas are very comprehensive, especially when coupled with three response patterns. However, there are potential treatment difficulties:
Complexity.
The whole list of the schemas with response patterns is potentially 54 different schema–coping presentations. While most people may only have a few schemas with characteristic response patterns, more disturbed people, such as those with BPD, typically will be troubled by many schemas. This leads to considerable complexity.
Instability
. The relative instability of low-functioning clients adds another layer to the difficulty. In a session, there may be frequent “flipping” between various schema activations and coping behaviors, which the therapist needs to track. These difficulties led to the development of
modes
to describe schema activation in the “here and now” of treatment.
Couple interaction
. Volatile couples present in ways even more unstable than the same people in individual therapy. Thus the intensity of reactions, more frequent flipping in sessions and difficulty tracking changes make up a real therapeutic challenge. Since modes (defined in
Section 1.6
) are “what you see,” the changing states can be seen and interventions used to target what is happening in the here and now of the session.
However, it is very useful for a therapist to keep thinking in terms of schemas. This provides a very useful clinical context. It is the “depth picture” behind the more obvious presentation of modes.
1.6 Introducing the Mode Model
When Young started working with severely disturbed lower functioning borderline clients he soon found that his schema model was too complicated, so he searched for a different conceptualization. He described the triggering of a schema—its activation, which he called a “mode” (initially called “modus” or “schema states”). So modes are the way schemas appear. A mode can also be the expression of multiple schemas and incorporate different coping styles (van Genderen et al., 2012). The number of possible reactions to schema activation is unlimited.
We do not actually see a schema, but only the activation in the here-and-now of experience (Kellogg & Young, 2006; Roediger, 2012b, p. 3). Recognizing modes helps a therapist to see the “action.” Thus, a mode is a transient expression of schema vulnerability. This includes the emotional, cognitive, and behavioral dimensions of personality (which are further integrated in ST; Farrell & Shaw, 2012). While you have a schema; you are in a mode.
The major groups of modes are as follows (see Figure 1; for details of the mode model, see Section 6.2):
child modes
, which are regarded as an activation of body systems, such as attachment and self-assertiveness leading to basic emotions
internalized parent modes
, which preserve the messages, beliefs and appraisals the child heard since infancy
maladaptive coping modes
, which present as visible behaviors resulting from the interaction of child and parent modes, including social emotions
healthy modes
, which are the integrative and adaptive modes “Healthy Adult” and “Happy Child.”
Figure 1 Basic mode model
ST sees adult interpersonal problems as the result of negative schemas fixed in childhood. The schemas remain more or less unchanged. Once triggered, they revive the same feelings, appraisals, and tendencies to react as in a distressed child. You might liken it to a person who steps into a time machine and then returns to childhood to a similar reaction. The adult becomes the child again. Hence, this state is called a child mode.
The activation of a child mode indicates that a core need has not been meet (The exception is the Happy Child mode). Usually, the person keeps seeking some fulfillment. In this way, child modes have a signal character.
Young proposed that a schema therapist respond with “limited re-parenting.” This intervention may differ from what is proposed by therapies that discourage any dependence upon the therapist. But when the child’s needs are more consistently met, first by our re-parenting and then by the client’s own Healthy Adult mode, and possibly later by the Healthy Adult mode of their partner, the client will grow stronger. This is the result we seek through both individual and couples ST.
Reflect: Do you think this might parallel attachment theory? The assumption, from an attachment perspective, is that securely attached children become more autonomous.
Vera had a traumatic childhood in which she was neglected by an alcoholic single mother. An uncle repeatedly sexually abused her. She had a disturbed attachment with her mother, and her schema therapist identified a number of schemas, including Abandonment, Mistrust-Abuse, Emotional Deprivation, Dependence, Defectiveness- Shame and Subjugation. The therapist found her highly unstable in sessions. Vera kept changing between activated modes (what is called “flipping”), and it seemed at times that her distressed states were fed into by a number of schemas. So the therapist used a mode conceptualization to focus on the states that were being fed by the schemas. This made it simpler for her to keep track of how to relate to Vera and help, and also to help Vera understand herself. In early sessions, Vera was mostly in Vulnerable or Angry Child modes, and regardless of which schema or schemas were putting her in those modes, that was what needed to be attended to there and then. The therapist also tried to keep Vera more in the Vulnerable Child mode so she could get at her unmet needs—reversing the emotional legacy of childhood. This also helped her to attach to the therapist as a parenting source. Later, this led to Vera being able to allow her partner to meet her needs in a healthy way.
Therapy Tip: Once a schema is activated, the person may be in a child mode. In this state, a client should be addressed gently, as we would speak with children. Child-related needs should be met through reassurance, affirmation, empathic limit-setting, blocking a parental mode, and so on.
In summary, a schema is a trait—a tendency to react. A mode is a mental state. As long as schemas are not activated, they remain in the background. Once activated, schemas appear as constantly changing states called modes. We cannot work directly with schemas, only with activated schemas, or modes. This helps case conceptualization because it integrates what is seen with potential interventions to enable an effective treatment plan (van Genderen, 2012). We introduce some helpful resources, such as the mode map in Section 8.2.
Therapy Tip: Try to introduce the mode model early in therapy, usually within the first two or three sessions (Arntz & Jacob, 2013).
1.7 The Challenge of Working with Couples
How does this help us to understand couple relationships? Schemas and modes help to provide a comprehensive framework for understanding relationship dynamics. If a person wants to understand their own relationship, or when we are working in individual therapy, then perhaps the complexity of focusing on individual schemas is less challenging than for a couple. Indeed, some schema problems are relatively straightforward (for example, working with Enmeshment, which might be focused on a single relationship). If this is the case, it might be easiest to work with a single schema related to a specific difficulty.
Natalie brought Sigmund to couple therapy. She had discovered an affair that he had kept hidden for over 12 months. She wanted to understand the vulnerability in their relationship: “Why did this happen?” Sig was contrite and wanted to recommit to his marriage. Through ST-C, Natalie faced her schema vulnerability of Emotional Inhibition and Unrelenting Standards. Sig saw his actions in terms of an Entitlement schema. Both had influential childhood experiences, which were addressed through re-parenting imagery. Behavioral pattern breaking was very important in rebuilding trust.
However, understanding modes enriches the entire experiential process for both individuals and couples in therapy. It reduces the complexity of the schema interactional cycles for couples. Working with modes is usually the most practical way to do ST-C, because it allows a here-and-now approach to the current interaction by demonstrating the clash between modes, sequencing the mode cycle and the common elements of unmet “needs” without being flooded by unnecessary detail early in therapy. Working with modes provides direction and immediate gains in couple sessions.
1.8 Limited Professional Literature
Not much has been published in relation to schema work with couples. A somewhat dated review of the cognitive literature was provided by Wisman and Uewbelacker (2007) in their chapter “Maladaptive schemas and core beliefs in treatment and research with couples.” The focus on schemas was cognitive, at best providing a review of cognitive behavioral therapy and attachment with some cognitive measures, but there was almost nothing that could be considered creative or cutting edge in terms of treatment. The authors concluded that “no published studies to date have evaluated the efficacy of cognitive therapy specifically devoted to modifying maladaptive schemas or core beliefs” (Wisman & Uewbelacker, 2007, p. 216).
Travis Atkinson (2012) contributed a chapter in the more recently published Wiley-Blackwell Handbook of Schema Therapy (van Vreeswijk et al., 2012a). He argued that ST provides “an expansive compass to help the couple’s therapist assess and differentiate core maladaptive themes underlying relationship distress” (Atkinson, 2012, p. 323).
Reflect: What have you always wanted in a therapy for couples?
ST offers the following:
Language.
ST uses an easily understood language of patterns in the self and in relationships. Key concepts such as schemas, coping styles, and modes are easy to understand. Indeed, the ideas are close to a commonsense psychology. The concepts educate and make sense of past experiences for people—and open the door to allow them to speak freely about what they presently feel is relevant.
A focus on the difficult.
Hard-to-treat personality disorders are the normal focus and are not treated as exceptional cases.
Effective interventions.
There are powerful techniques, such as imagery work related to limited re-parenting, chair-work to address core beliefs in an experiential way, and behavioral pattern breaking. There are important ideas about transforming schemas and strengthening the Healthy Adult mode, and guidance in how to more effectively communicate with a partner who is stuck in a child mode. In this way, ST can realistically address the most problematic aspects of interpersonal behavior and allow us to understand it in terms of prior interpersonal experiences.
Influence of the past.
In ST, the therapist has techniques to counter the past when it intrudes on current relationships. This approach can enhance family-of-origin work, taking the burden off the present relationship so the couple can make a new start in therapy without the legacy of unresolved issues from childhood. You can find an effective balance of couple and individual sessions so that progress can be maintained.
Progress with individuals.
It is even possible to do considerable work “solo” to improve the relationship without the participation of a partner. By including dialog and even limited schema/mode conceptualization about the absent partner in individual therapy, the scope is broadened beyond presenting problems. The therapist can work with the individual on all of their schema vulnerabilities, even those triggered by the relationship, and blind spots in therapy are reduced. Couples and marital work can even have significant accomplishments with this one-person scenario. Even one session with the unengaged partner can have benefit and provide a wealth of data for the therapist working with the other in the schema model.
The relationship or marriage is a combination of two people. When one partner changes their behavior, the relationship changes. ST is not wasted work, even if the couple separate, because it can provide a more solid foundation for future relationships.
Needs.
The therapist will fulfill core needs in counseling and provide a model for functional self-disclosure and the communication of needs. This modeling of a Healthy Adult can be learned by the couple.
Integrative process.
The experiential techniques applied in ST integrate cognitive, emotional, and behavioral changes in one therapeutic process. Functional behavior is enhanced by healing early maladaptive schemas.
ST offers more than technical eclecticism. There is a deep “assimilative integration” (Messer, 2001) of different perspectives and insights from various schools into a system of therapy with a coherent, conceptually economic model that translates into a workable practice for the therapist (Edwards & Arntz, 2012, p. 20). This approach encourages a schema-based case conceptualization tied closely to treatment planning.
Reflect: Why are you reading this book? Have you used ST with individuals and now want to try it with couples? Are you new to ST and hope to find an effective therapy for working with traits of personality disorder?
1.9 Brief Outline of the Stages of Schema Therapy for Couples
The following is a suggested outline of treatment (unfamiliar terms and techniques are explained later in the book):
Empathic engagement.
Make an emotional connection with the couple. The challenge in the first session is to see issues “through the eyes of both.” Allow the couple to demonstrate their dysfunctional way of relating.
Initial contract for alliance and therapy
. This can include the two commitments of working on the relationship and not deliberately behaving badly towards the partner (Hargrave, 2000).
Assessment.
Possibly use a genogram. Use ST questionnaires and other resources. Focus on understanding the childhood origin of adult relationship problems. What issues belong where? Be guided by Young’s five tasks. Try to conceptualize the information in a “mode map” for both partners as a reference point for your further work.
Formulation.
Clarify an ST-C understanding of problems in terms of Young’s schema chemistry, clashes, and locking. What are the dynamics of attraction? Put gridlocked problems and patterns into schema and mode conceptualizations. Use mode cycle clash-cards to identify how dysfunctional modes play out. Develop a comprehensive but focused treatment plan.
Treatment interventions.
Base interventions primarily on mode maps, eventually including the most prominent schemas, to deal with the legacy from the family of origin. De-escalate mode clashes. Use ST interventions, including imagery, limited re-parenting, chair-work, strategies to strengthen Healthy Adult mode, and behavior pattern breaking. Find a balance of individual and couple sessions. Move from dysfunctional modes to healthier coping modes. This includes coaching the couple to identify and de-escalate schema activations and mode clashes (using mode cycle clash-cards, mode dialogs, empathic confrontation, and empathic compassion). If possible, encourage couple interactions that enable a re-parenting of each other and dealing with bad memories. The couple learns to apply dialog tools and special techniques to enhance re-parenting.
Building friendship.
Conduct connection exercises to build friendship (Gottman & Silver, 1999) and provide building blocks for more secure attachment (similar to emotion-focused therapy for couples) to increase positive behaviors. Encourage the couple to take responsibility for their own relationship. Strengthen Healthy Adult and Happy Child modes. Use new clashes for the couple to practice skills and to coach them in the use of those skills. Use the concept of bringing in the “A team” to resolve conflict.
Termination and relapse prevention.
Work towards a successful end of therapy with periodic “relapse prevention” sessions. Help the couple to articulate a relationship story, incorporate the experience of therapy, learn how to anticipate future mode clashes, and create a plan for dealing with crises. Arrange periodic check-ups and readjustments. Perhaps the couple can make an agreement about being willing to return to therapy for a minimum of one session if problems reoccur.
Reflect: As you look over this outline of ST-C, what aspects do you think would be easy for you to put into practice? What would be very challenging? Think about making small steps to build up your skills and to gain confidence before attempting more advanced skills.
Summary
In this chapter we have introduced some of the defining characteristics of ST, including how it developed first with schemas and then with modes. The focus has always been on treating difficult people, and there is growing evidence of therapeutic effectiveness with individuals, especially in group treatment programs. ST-C is designed to use similar interventions in treating couples. This chapter has also outlined the stages of treatment with couples.
Note
2
Dialectical behavioral therapy, while effective, is essentially a “here and now” cognitive therapy. It also makes the assumption that a “wise mind” or “healthy adult” is always available, while ST deals with that not being the case. ST also goes to the developmental origins of adult problems, to effectively “repair” experiences of neglect and trauma through imagery work embedded in a re-parenting relationship.
2The Initial Contract and First Interview
In Genesis, the first book of the Bible, God created. We have a similar task in working with couples: to bring order out of chaos. Usually, the couple arrives in a crisis and very little is predictable except for the mutual blame of the other for problems in the relationship. There is an almost universal belief: “I would be happy if only my partner would change.”
2.1 The Initial Interview
The first interview begins with initial contact. Generally, the more suffering (or anxious) person will ring and arrange the first session. An exception is when one of the two has already decided to leave the relationship and wants to leave the abandoned partner with a caretaker (the therapist). Such agendas are not always obvious. In another scenario, one person wants to save the relationship but the other refuses to come.
The first session will give a number of meaningful clues. How do they greet you? First name? Formally, with Mr., Ms., or Dr.? Or perhaps, “We’re so desperate that we need to see a shrink.” This will indicate something of the relationship expected and possibly provide your first indication of schemas or modes that might be present. Where do the couple choose to sit? Those in marital distress will tend to sit as far apart as the room allows! You may find that the one who arranged the interview will sit closer to you—implying that they believe they have found an ally.
Generally, one of the two is more reluctant to come. He or she may already be strongly retreating from the relationship. If there is to be any effective couple treatment, it is a matter of the highest priority for the therapist to engage that distancing person (Johnson, 2004). Make sure that you give that individual considerable attention, affirming their perspective, and try to be very empathic to what they have experienced. Only in this way can you achieve a working alliance with a couple. Also, listen and try to understand the partner as well, but you usually have more latitude with him or her. Only people who feel heard and understood will want to return for another session.
Sometimes it is helpful to bring your initial impression to the couple, in a self-disclosing way:
It seems to me that you, Nancy, are more convinced that this therapy might be helpful. I’m afraid that you, Tom, are “half out of the door.” So my first task is to find a way for this process to be useful to you as well. So initially I’ll address myself more to you than to Nancy. I hope you, Nancy, can tolerate this for the sake of the relationship. Please give me a sign when you feel you’re dropping out too much, OK?
Openly addressing the unwanted result (Tom leaving therapy) may seem confronting, but it increases the possibility of realistic engagement in therapy and demonstrates transparency as fundamental to ST-C.
2.2 Issues that Present
Usually the couple will have a few “target complaints.” It is valuable to draw these out in a balanced way, trying to give more-or-less equal attention to both in the relationship, and then turn complaints into realistic goals.
First, try to achieve an initial understanding of the two perspectives. This can be challenging when the couple have come because of “bad behavior”: perhaps an incident or pattern of violence, infidelity, financial irresponsibility, substance abuse, or criminal activity.
Martius and Mary came for counseling after he was charged with accessing child pornography on a work computer. Mary was shocked, understandably, but wanted to preserve their marriage if at all possible.
You may feel judgmental, but to work well with a couple you need to empathically immerse yourself in how they see the world and each other. This is foundational to couple therapy. You will have achieved this when you can begin to understand why the bad behavior felt justified or even necessary. Indeed, with personality-disordered couples you can, more or less, be assured that there have been impulsive actions that may have damaged the relationship.
Therapy Tip: Try to gain some understanding of the needs behind maladaptive coping behavior (“needs” and “wants” are examined in detail in Chapter 11).
Occasionally, a couple will be equally motivated to work on difficulties. This is a good prognostic sign. Sometimes, a couple will both want to end their relationship, in which case it can be a worthwhile therapeutic goal to achieve this with a minimum of hurt to them, their children, and their wider families.
If possible, schedule 60–90 minutes for the first appointment with the couple. Some time is usually needed to make a preliminary assessment (described in Chapter 3). Towards the end of the first interview some therapists give a few minutes, others longer, for each person to talk with them alone so they can ask, “Is there anything that you can only say to me without your partner being here?” You may then be told about violence or alcohol abuse or some “dark secret.” It is, of course, important to appear non-judgmental. Ask a specific question about whether there is a current affair. Usually this is answered truthfully, but not always. It is a powerful secret, which has an influence on the progress of therapy. Another useful question is, “Is there anything I should know in order to help you?”
