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New Treatment Developments
At the Center we want to
incorporate any ideas or techniques that might enhance the effectiveness
of treatment. There are two therapy approaches, Schema-Focused Therapy
and Emotion-Focused Therapy, that offer interesting and useful concepts
which can increase the scope and effectiveness of cognitive therapy.
These models are described below with a particular emphasis on how they
can be integrated with cognitive therapy and how they might improve
treatment with certain kinds of problems.
Schema-Focused Therapy
Schema-Focused Therapy (SFT)
was developed by Jeffrey E. Young, Ph.D. While working with Dr. Aaron
Beck at the Center For Cognitive Therapy, Dr. Young noticed there was a
group of clients that did not respond as quickly or strongly to
traditional cognitive therapy as one would hope. These clients, who
tend to have long-standing problems and entrenched, dysfunctional
beliefs, what Dr. Young calls schemas, seem to respond better to a
different set of treatment strategies.
What are
Schemas?
Schemas can be thought of as
central and enduring themes in a person’s life. Schemas reflect deep,
difficult to change views of ourselves, others, and the world. Schemas
also refer to a broad organizing structure that significantly influences
our moment-to-moment experiences. Schemas develop early in life. The
building blocks of schemas often are the important experiences of
childhood, particularly how our caretakers responded to us. Schemas
typically consist of thematically connected feeling states, thinking
patterns, expectations, predispositions to believe and emotionally
significant memories.
Schemas have a purpose: to
rapidly inform us of what is important to our well-being and how we
might meet our deepest needs. Maladaptive schemas, as you might guess,
don’t assist is getting our needs met and typically result in painful
patterns in thinking and feeling. For example, John, a 24 year old
graduate, is told by a friend that a fellow female graduate student
likes John and wishes he would ask her out. Upon hearing this, John
experiences the following:
1. An anxious, jittery feeling that has the
quality of vulnerability rather than excitement
2. Specific thoughts, such as “this can’t be
true”, “she won’t like me if she gets to know me”, “I’d be a fool to ask
her out”
3. Specific memories of other unrequited
longings, instances where he perceived he was rejected, memories of his
parents criticizing him for being socially awkward and “too
quiet
4. An inclination to withdraw and forget what his
friend told him
We would say that John has a
Defectiveness or Unlovability Schema that was triggered by his friend’s
comment.
List of
Maladaptive Schemas
Perhaps the key contribution
of Schema-Focused Therapy is the identification of the major maladaptive
schemas that can afflict us. Dr Jeffrey Young has identified the
following schemas:
Emotional Deprivation –
The belief and expectation that your primary needs will never
be met. The sense that no one will nurture, care for, guide,
protect or empathize with you.
Abandonment – The belief
and expectation that others will leave, that others are unreliable,
that relationships are fragile, that loss is inevitable, and that
you will ultimately wind up alone.
Mistrust/Abuse – The
belief that others are abusive, manipulative, selfish, or looking to
hurt or use you. Others are not to be trusted.
Defectiveness – The
belief that you are flawed, damaged, or unlovable, and you will
thereby be rejected.
Social Isolation – The
pervasive sense of aloneness, coupled with a feeling of alienation.
Vulnerability – The
sense that the world is a dangerous place, that disaster can happen
at any time, and that you will be overwhelmed by the challenges that
lie ahead.
Dependence/Incompetence
– The belief that you are unable to effectively make your own
decisions, that your judgment is questionable, and that you need to
rely on others to help get you through day-to-day responsibilities.
Enmeshment/Undeveloped
Self – The sense that you do not have an identify or “individuated
self” that is separate from one or more significant others.
Failure – The
expectation that you will fail, or belief that you cannot perform
well enough.
Subjugation – The belief
that you must submit to the control of others, or else punishment
or rejection will be forthcoming.
Approval-Seeking/Recognition-Seeking – The sense that approval,
attention an recognition are far more important than genuine
self-expression and being true to oneself.
Emotional Inhibition –
The belief that you must control your self-expression or others will
reject or criticize you.
Negativity/Pessimism –
The pervasive belief that the negative aspects of life outweigh the
positive, along with negative expectations for the future.
Unrelenting Standards –
The belief that you need to be the best, always striving for
perfection or to avoid mistakes.
Punitiveness – The
belief that people should be harshly punished for their mistakes or
shortcomings.
Entitlement/Grandiosity –
The sense that you are special or more important than others, and
that you do not have to follow the rules like other people even
though it may have a negative effect on others. Also can manifest
in an exaggerated focus on superiority for the purpose
of having power or control.
Insufficient Self-Control/Self-Discipline – The sense that you cannot
accomplish your goals, especially if the process contains boring,
repetitive, or frustrating aspects. Also, that you cannot resist acting
upon impulses that lead to detrimental results.
What Can Schema-Focused
Therapy Add to Cognitive Therapy?
1. The assessment process in SFT is more
comprehensive. The therapist wants to develop a good understanding
of the origin of the maladaptive schema (early interactions with
significant others) and how the schema has expressed itself
throughout the patient’s life (the pattern of painful feelings,
self-defeating choices and unmet needs).
2. There is a greater
emphasis on understanding the origins of the maladaptive schemas.
This enables the client to see his life, especially his struggles
and self-defeating behavior, and how they are influenced him to
avoid certain situations or tasks that fulfill his basic desires.
This kind of understanding can promote not only self-compassion, but
also increase motivation to change by appreciating the “price one
has paid”.
3.
Schema-Focused-Therapy spells out powerful change techniques to
“heal”maladaptive schemas. These techniques include working with
painful memories and images that are an intregral part of the
schema. Evoking such memories can be emotional for the client.
However, it appears to be crucial to restructuring the memory and
help “heal” the schema.
For What Types
of Clients or Problems Would Schema-Focused-Therapy be Indicated?
For clients who do not
respond well to traditional cognitive therapy or who seem to suffer
frequent relapses of their problems. Clients who feel they have been
entrenched in self-defeating patterns and whose thinking is rigid and
harsh (e.g. “this is the way I am – I just am defective – no matter what
I do, I’ll always be unloveable”). Clients who seem to fall into the
same relationship traps throughout their life. Here there is almost
always a maladaptive schema that needs to be identified and changed.
How to Learn
More About Schema-Focused Therapy
There is a schema therapy
website (www.schematherapy.com) that has a user-friendly slide show
explaining the therapy model. Reinventing Your Life by Jeff Young and
Janet Klosko is an excellent self-help book which identifies eleven of
the most common schemas (called lifetraps in this book) and accompanying
self-help strategies to understand and counteract the schema. Schema
Therapy, A Practitioner’s Guide by Young, Klasko,and Weishaar is the
first major ttext written for clinicians. This text describes the
background and development of SFT and spells out the innovative
assessment and change strategies of the mode. However, since the SFT
model is straightforward and the writing is lucid, non-clinicians can
easily absorb the material in the book.
Emotional-Focused Therapy
Emotion-Focused Therapy (EFT)
was developed primarily by Leslie
Greenberg, Ph.D. and colleagues at York
University in Toronto, Ontario. Like cognitive therapy, EFT if a
structured and focused treatment that has received empirical support
with various disorders including depression, victims of childhood abuse,
and marital dysfunction. However, EFT differs from cognitive therapy
with its emphasis on:
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the focus on the
constructive aspects of emotions, even painful and difficult ones.
EFT emphasizes that all emotions contain valuable information that
need to be brought into the open and understood
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making essential
distinctions between emotional states.
How can EFT
ADD to the Effectiveness of Cognitive Therapy?
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By helping the therapist
look for the constructive aspects of emotions. For example,
emerging anger in a client who is often submissive in relationships
probably needs to be evoked, explored, supported, and validated.
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To help make clinically
significant distinctions with difficult emotional states. This
involves helping clients explore the full meaning of their emotional
reactions. Possible benefits include assisting clients to sort
through different layers of feeling; promoting emotional resilience
by facing painful or dreaded feelings; determining whether feelings
are adaptive and thus might guide behavior or maladaptive and
therefore should be changed.
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EFT has elucidated the
importance of fully experiencing all of the components thoughts,
feelings, memories, unmet needs) and nuances of maladaptive
emotions/schemas. When clients fully access the pain in their
maladaptive schemas, they recognize the unmet need in pain (e.g. the
need for security in the fear of abandonment; the need for
self-worth in the shame of feeling defective; the need for
compassion in the contempt of self-punitiveness). Becoming
aware of such needs often provides direction and motivation to
transform the unhealthy feeling. Research studies validate the link
between such deep experiencing and positive change
For What
Types of Clients Would EFT be Particularly Indicated?
EFT seems especially helpful
to clients who are “over-controlled”, that is clients who tend to
disavow or dampen their feelings. Like schema-focused therapy, EFT
offers innovative change strategies to clients with long-standing
seemingly intractable difficulties.
How Can I
Learn More About EFT?
There are two websites that
provide a good deal of material on the EFT model. Les Greenberg’s
website (emotionfocusedtherapy.org)
provides answers to questions about the model, as well as links to other
useful cites. The Process-Experiential Therapy Website
(process-experiential.org) contains a brief tutorial on a recent
book, Learning Emotion-Focused Therapy published by the American
Psychological Association (2004). This book, written for clinicians, is
a comprehensive and clear description of the theory and clinical
approach of EFT.
Dr. Les Greenberg has written
a number of books on EFT. His most recent effort, Emotion-Focused
Therapy: Coaching Clients to Work Through Their Feelings, is a
thoughtful and down-to-earth description of the critical steps in
accessing and understanding important emotions and then deciding
intelligently whether to regulate, express, or change particular
emotions.
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SM