Schemas in clinical practice: What they are and how we can change them

Full text

ƵůůĞƟŶŽĨ
WƐLJĐŚŽůŽŐŝƐƚƐŝŶ/ŶĚĞƉĞŶĚĞŶƚWƌĂĐƟĐĞ
ŝǀŝƐŝŽŶŽĨƚŚĞŵĞƌŝĐĂŶWƐLJĐŚŽůŽŐŝĐĂůƐƐŽĐŝĂƟŽŶ
/ŶĚĞƉĞŶĚĞŶƚ
WƌĂĐƟƟŽŶĞƌ
tŝŶƚĞƌϮϬϭϰͻsŽůƵŵĞϯϰEƵŵďĞƌϭ
ĚŝǀŝƐŝŽŶϰϮ͘ŽƌŐ
Pages 10-13
Schemas in clinical practice: What
they are and how we can change
them
by David Edwards
Extracted
from

ϭϬ tŝŶƚĞƌϮϬϭϰ /ŶĚĞƉĞŶĚĞŶƚWƌĂĐƟƟŽŶĞƌ
Schemas in clinical practice: What they are and how we can
change them
— David Edwards
Many current approaches to
psychotherapy emphasize
the importance of chang-
ing schemas. In this article I look at
what schemas are and what we know
about changing them. Addressing the
schema level has always been part
of Beck’s cognitive therapy. This
approach identifies three levels of cog-
nition. Automatic thoughts, the strings
of words that go through our minds as
we go about daily activities, are closest
to awareness. Underlying assumptions
may not be explicit at first, but care-
ful questioning and guided discovery
often result in clients articulating the
“if … then …” beliefs (“if I ask for
what I want, I will be ridiculed” … “If
I try to do this, I will fail”) and implicit
rules (“Don’t get angry with your
father,” … “Don’t let people see you’re upset”) found at
this level. At the schema level, “core beliefs” are uncon-
ditional: “I am worthless” … “no one could love me,
I’m unlovable” … “I am too helpless to get by without
having someone strong around to show me what to do.”
The “downward arrow” technique uses a series of “What
if…?” questions to help clients move from the level of
automatic thoughts down to the level of underlying
assumptions and on to the level of core beliefs. For
example, “I’m late, I am going to get into trouble” ) “if I
get into trouble, I will be scolded and ridiculed” ) “that
means I am worthless and defective.” Since schema
level beliefs are often at the root of dysfunctional under-
lying assumptions, which in turn underlie problematic
automatic thoughts, they may need to be addressed in
order prevent relapse.
But why is the term “schema” used to refer to this deep-
est level? The concept has been central to psychology
from the beginning. A century ago, Alfred Adler used
the term “schema of apperception,” for the underlying
cognitive structures that organize personal meanings
(Ansbacher & Ansbacher, 1958). This concept evolved
from Kant (1724-1804) and Herbart (1776-1841). Kant
used the term “schemas” and recognized the abstrac-
tive processes involved, which is why he called them
“transcendental.” Herbart, one of the first philosophers
to contribute to psychology, used the
term “apperceptive mass” for this orga-
nized, underlying meaning structure.
These writers, in turn, influenced
Vaihinger (1852-1933), who, in The
philosophy of ‘as if ’, published in 1911
(though written three decades earlier),
argued that we experience the world
not as it is but in terms of a represen-
tational model of it built up through
experience. This model is abstrac-
tive, in that it distils generalizations
and principles rather than presenting
a fixed snapshot. It was Vaihinger’s
exposition that Adler drew on (Ellen-
berger, 1970). Schemas are not only
abstractive, they are reconstructive.
In perception, past experience shapes
what we see and how we see it: a
person with a history of abuse and
maltreatment looks out at the world mistrustfully and
may see a neutral face as threatening or interpret a
neutral statement as hostile. This is called projection:
the individual’s internal working model is projected
onto his/her everyday world. Identifying such “cogni-
tive distortions” and testing and restructuring them is,
of course, a basic intervention in cognitive therapy.
Today the term “internal working model” is associated
with Bowlby’s exposition of attachment theory. How-
ever, the concept of schema had been used in this sense
in 1920 by the neurologist Henry Head who studied how
individuals use an underlying mental model of their
body located in space. This explains how individuals
can (among other things) touch one part of their body
with another with their eyes closed. “By means of per-
petual alterations in position,” observed Oldfield and
Zangwill (1942, p.272), “we are always building up a
postural model of ourselves which constantly changes.
Every new posture or movement is recorded on this
plastic schema.”
This example shows how schemas are not only the
basis of perception and our conceptual system, but
also the basis of behaviors. Behavioral repertoires are
also abstractive and reconstructive so that they can
be applied to new situations, different from the ones
&ŽĐƵƐŽŶůŝŶŝĐĂůWƌĂĐƟĐĞ

/ŶĚĞƉĞŶĚĞŶƚWƌĂĐƟƟŽŶĞƌ tŝŶƚĞƌϮϬϭϰ ϭϭ
in which they were learned. Touching my nose with
my finger is a specific performance of a generic behav-
ior that is controlled and calibrated in the moment in
terms of the schematic model of my body. Similarly, the
wary and hostile behavior of the mistrustful person is
tailored and adapted to the specifics of each new social
situation.
By the late 19th century, two other features of the
organization of schemas were well understood. First,
representations of self, others and the world develop
from birth (if not before). As Adler observed, “We must
always reckon with the misinterpretations made in
early childhood, for these dominate the subsequent
course of our existence” (Ansbacher & Ansbacher, 1958,
p.183). Today, the pervasive impact of early schemas
in later life has been documented in the impressive
body of research on attachment theory. The second
aspect is that cognitive organization is not a single
coherent system. There are interacting subsystems and
some schematic organizations encode information in a
manner that is at variance with information encoded
in others. In the second half of the 19th Century, many
clinical descriptions of dissociative phenomena were
collected and studied and Janet’s theory of désagréga-
tion, and, in English, the concept of dissociation were
used to explain the existence of this kind of disorga-
nization or incompatibility. The concept of splitting
- the development of two incompatible meaning sys-
tems relating to a single event, was used by Freud to
account for a range of more subtle clinical phenomena
(Ellenberger, 1970). The same insight would later
appear in Kelly’s (1955) cognitive theory as the frag-
mentation corollary: “a person may successively employ
a variety of construction subsystems which are inferen-
tially incompatible with each other.”
Some of this incompatibility results from there being
parallel systems of cognitive organization that encode
information in different ways. Leventhal’s (1979)
perceptual motor theory of emotion separated out a
conceptual system from a system of emotional sche-
mas. This was taken up in Teasdale’s (1993) Interacting
Cognitive Subystems (ICS) model. This has a “proposi-
tional” system, where encoding is through language and
the rules of logic and reason can be brought to bear. In
the “implicational” system, the world is represented in
a holistic way that can be accessed through imagery
and metaphor. Language plays little or no role and if
words are to impact on this system, their impact will
be through metaphorical or poetic expression not logi-
cal statements. The ICS model, based on fundamental
cognitive and brain research includes a very important
feature: emotional systems in the brain are not directly
connected to the propositional system. So work with
language, logic, reason and insight has limited impact
on the systems that drive emotional states. By con-
trast, the implicational system is directly connected to
emotional systems with the result that changes in the
implicational system can have a direct impact on emo-
tions. The often observed disjunction between “head”
and “heart,” “reason” and “passion,” or “thought” and
“feeling” reflects this structural reality.
The term “cognitive” is often mistakenly used to refer
exclusively to language based meanings (i.e., those in
the propositional system). This is unfortunate since any
system that makes meaning of experience and behav-
ior is cognitive; this is why a great deal of fundamental
cognitive research has been performed on animals,
birds and even invertebrates. The meanings in the
implicational system are no less cognitive than those
in the propositional system. Emotions themselves
are replete with meaning. They may have organized
systems of expression in the limbic system, but these
are mobilized in response to the meaning of events:
danger, disappointment, loss, blame, social exclusion
etc.
This means that the so called schema level where, for
cognitive therapists, the core beliefs are encoded is
far more than a set of propositions. In fact, it is not
primarily encoded as propositions at all. Twenty five
years ago Safran and Greenberg (1984) used Leventhal’s
theory to argue that in psychotherapy change in these
schemas required activating them and working with
them affectively. This evolved into Greenberg’s (2004)
emotion-focused therapy (EFT) in which emotional
focusing techniques play a central role. Around this
time, Blatt was discussing “cognitive-affective schemas,”
integrating concepts from object relations with attach-
ment theory, and pointing out how this was leading to
a convergence of the theories on which psychodynamic
and cognitive-behavioral therapies were based (Blatt
& Levy, 2003). In this period, too, Young (1990) used
the term “early maladaptive schemas” to refer to these
fundamental patterns that are often the source of psy-
chopathology. Of course, early schemas based in the
attachment system can be adaptive and unproblematic.
It is when they are maladaptive that they become the
focus of clinical attention. Like Greenberg, Young real-
ized that, in order to change maladaptive schemas,
it was essential to activate them and work to change
them. His schema therapy was developed as a system-
atic approach to effecting this by promoting corrective
experiences (Young, Klosko & Weishaar, 2003).
We might expect that early maladaptive schemas would
automatically change in response to new experiences.
The schemas of individuals raised in abusive homes
should be updated and correct themselves automati-
cally if the individuals get into a more stable social
environment or into relationships with more secure
and balanced people. While there is evidence that this
can happen, it often does not. This is partly due to
the self-fulfilling nature of schema driven behavior.

ϭϮ tŝŶƚĞƌϮϬϭϰ /ŶĚĞƉĞŶĚĞŶƚWƌĂĐƟƟŽŶĞƌ
The wariness and suspicion of mistrustful individu-
als may alienate others and elicit the very hostility
they are expecting. But It is also due to what Sullivan
(1953) aptly termed “security operations,” self-protective
coping mechanisms that block the underlying schemas
which, when activated bring with them intense emo-
tional distress. Recognition that coping takes the form
of various kinds of avoidance and compensation is also
found in Adler’s early work. Therapists will not make
headway changing schemas in clients who are emotion-
ally cut off (avoidant coping) or focusing on putting
across to the therapist how important they are (a self-
aggrandizing compensation). An important focus in
schema therapy is to identify coping mechanisms and
to weaken them to allow access to the underlying child-
hood schemas.
Therapies directed at modifying early schema patterns
offer a number of approaches to bringing about schema
change. One is through the relationship with the thera-
pist. Individuals who have never felt safe, valued or
cared for because of experiences with primary caretak-
ers that were neglectful, inconsistent or abusive, will
have relational schemas that embody attachment pat-
terns that are insecure or disorganized. By providing
an interpersonal experience that is consistent, authori-
tative, trustworthy and caring, therapists can actively
impact these schemas by providing a corrective experi-
ence. In schema therapy, this is explicitly referred to
as “limited reparenting.” As schemas are activated, the
painful memories associated with them are recovered
and the therapist relates to the child in the memory just
as s/he would to his/her own child or to a distressed
child brought for therapy. However, this can only
happen if the schemas are activated. So relational work
requires that therapists engage emotionally with cli-
ents, and break through avoidances and compensations
that prevent that engagement.
Another way to change schemas is through imag-
ery. Clients are asked to relive painful childhood
experiences and these are rescripted by bringing new
characters into the story. For a client who recalls as
a child being scolded by a teacher, the rescript might
involve the therapist or the client as an adult coming
in and talking to the child, asking about his/her feel-
ings, offering comfort and actively correcting negative
beliefs such as “you are bad … you are useless …your
feelings and concerns are not important.” The grow-
ing literature on imagery rescripting is documenting
how effective it can be as part of the treatment of a
large number of disorders including depression, social
anxiety, OCD, eating disorders and many personality
disorders (Arntz, 2011, 2012).
A related approach is through chair work. Different
voices or parts of the self are allocated empty chairs.
Clients sit on a chair and articulate the voice of each
part. One chair may be for the child who believes
she is unlovable and defective, another for a criti-
cal parent voice that is speaking disdainfully to the
child, another for a coping mode such as emotional
detachment, using alcohol or drugs, or escaping into
watching TV or pornography. Chair work can clarify
the nature of the conflicts that prevent access to the
schema level of childhood emotions and memories. It
can also be used to provide the child with a corrective
experience as in imagery rescripting described above.
Depending on what is being worked with, chairwork
may focus on rational evaluation, articulation and
clarification, reviewing the role and value of coping
strategies, or on engagement with the level of affec-
tive schemas and the problematic childhood memories
they carry (Arntz, Bernstein & Jacob, 2013; Kellogg &
Young, 2006).
Our models of assessment remind us that we need to
understand both the predisposing and the maintain-
ing factors that underlie the client’s difficulties. The
schema level, based on predisposing factors, embod-
ies habits that are well entrenched and that mostly
will not be changed by a single corrective experience.
For change to endure, therapy also needs to promote
new habits and experiences in current situations and
relationships that reconfigure the maintaining fac-
tors. So, bottom-up interventions at the level of early
maladaptive schemas, need to be complemented by
top-down approaches designed to build new schemas
in the here and now. In schema therapy this is called
“building the healthy adult” and involves the kinds
of cognitive restructuring and skill building meth-
ods that are usually associated with CBT. Thus, for
a client who believes “I am unlovable, no one could
possibly care about me” imagery rescripting of memo-
ries of childhood neglect can be complemented by
examining the evidence from the client’s life, log-
ging data from ever yday situations and looking at the
evidence these provide, and performing behavioral
experiments in which the belief is actively put to the
test. In “strengths-based cognitive-behavioral therapy,”
Padesky and Mooney (2012) focus on helping clients
identify existing strengths and expand them into new
areas of their lives and so build resilience by develop-
ing new schemas. This approach “helps people with
personality disorders construct and strengthen new
systems of interpersonal strategies, core beliefs, and
underlying assumptions” (Christine Padesky, personal
communication, 11th June 2013).
Another present centered approach is to use emotion
focused techniques to promote corrective experiences
in current significant relationships. In EFT for couples
(Johnson, 2009) and Attachment Based Family Therapy
(ABFT) for depressed adolescents (Diamond, Siqueland
& Diamond, 2003), the therapist works to help family
members bypass avoidant and compensatory coping

/ŶĚĞƉĞŶĚĞŶƚWƌĂĐƟƟŽŶĞƌ tŝŶƚĞƌϮϬϭϰ ϭϯ
and engage with each other at an emotional level in a
manner that is empathic and respectful and that acti-
vates the genuine care and concern characteristic of
secure attachment. There is growing evidence for the
effectiveness of both these treatments.
As evidence accumulates for the value of both top-
down and bottom-up approaches, there is often
debate between those who champion one approach
over t he other. In practice, therapists need to be
responsive to the unique context and presentation
of each client and what s/he brings week by week
(Edwards, 2013). This means attending to what a
client is ready for, or motivated to do, to what is help -
ful and what is not, and using this awareness to tailor
treatment to the individual on an ongoing basis.
Where top-down approaches are, by themselves,
ineffective, bottom up approaches that address early
maladaptive schemas may provide the leverage that
is needed to promote meaningful change. W here
emotion focused techniques are destabilizing or fail
to bring about change that generalizes to everyday
situations, more emphasis on top down approaches
may be appropriate. As clinicians, we face the daily
challenge of responsively crafting interventions to
the wide rang ing needs of those clients we work with.
In this process we can draw on and flexibly integrate
top-down and bottom-up methods to bring about posi-
tive changes in early maladaptive schemas.
References
Ansbacher, H. L., & Ansbacher, R. R. (Eds.). (1958). The indi-
vidual psychology of Alfred Adler: A systematic presentation
in selections from his writings. London: George Allen &
Unwin.
Arntz, A. (2011). Imagery rescripting for personality disor-
ders. Cognitive and Behavioral Practice, 18, 466- 481.
Arntz, A. (2012). Imagery rescripting as a therapeutic
technique: Review of clinical trials, basic studies, and
research agenda for personality disorders. Journal of
Experimental Psychopathology, 3, 189-208.
Arntz, A., Bernstein, D. P., & Jacob, G. (2013). Schema ther-
apy in practice: An introductory guide to the schema mode
approach. Chichester, UK: Wiley.
Blatt, S. J., & Levy, K. N. (2003). Attachment theor y, psycho-
analysis, personalit y development, and psychopathology.
Psychoanalytic Inquiry, 23, 102-150. doi:http://dx.doi.
org/10.1080/07351692309349028
Diamond, G., Siqueland, L., & Diamond, G. M. (2003). Attach-
ment-based family therapy for depressed adolescents:
Programmatic treatment development. Clinical Child and
Family Psychology Review, 16(2), 107-127.
Edwards, D. J. A. (2013). Responsive integrative treatment
of PTSD and trauma related disorders: An expanded
evidence-based model. Journal of Psychology in Africa, 23,
7-20.
Ellenberger, H. F. (1970). The discovery of the unconscious: The
history and evolution of dynamic psychiatry. New York:
Basic Books.
Greenberg, L. S. (2004). Emotion–focused therapy. Clinical
Psychology and Psychotherapy, 11, 3-16.
Greenberg, L. S., & Safran, J. D. (1984). Integrating affect and
cognition: A perspective on the process of therapeutic
change. Cognitive Therapy and Research, 8(6), 559-578.
Johnson, S. M. (2009). Attachment theory and emotionally
focused therapy for individuals and couples: Perfect part-
ners. In J. H. Obegi, & E. Berant (Eds.), Attachment theory
and research in clinical work with adults (pp. 410-433). New
York: Guilford.
Kellogg.S.H., & Young, J. E. (2006). Schema therapy for bor-
derline personality disorder. Journal of Clinical Psychology,
62(4), 445-458.
Kelly, G. A. (1955). The psychology of personal constructs.
Volume 1: A theory of personality. New York: W. W.
Norton.
Leventhal, H. (1979). A perceptual motor processing model
of emotion. In P. Pliner, K. R. Blankstein & I. M. Spigel
(Eds.), Advances in the study of communication and affect,
volume 5. Perception of emotions in self and others. New
York: Academic.
Oldfield, R. C., & Zang will, O. L. (1942). Head’s concept of the
schema and its application in contemporary British Psy-
chology. British Journal of Psychology, 32, 267-286.
Padesky, C. A., & Mooney, K. A. (2012). Strengths-based cog-
nitive–behavioral herapy: A four-step model to build
resilience. Clinical Psychology and Psychotherapy, 19, 283-
290.
Sullivan, H. S. (1953). The interpersonal theory of psychiatry.
New York: W. W. Norton.
Teasdale, J. D. (1993). Emotion and two kinds of mean-
ing: Cognitive therapy and cog nitive science. Behavior
Research and Therapy, 31, 339-354.
Young, J. E. (1990). Cognitive therapy for personality disorders:
A schema-focused approach. Sarasota FL: Professional
Resource Press.
Young, J. E., Klosko, J., & Weishaar, M. E. (2003). Schema
therapy: A practitioner’s guide. New York: Guilford.
David Edwards from Rhodes University in South Africa is
ƚƌĂŝŶĞĚŝŶĞĐŬ͛ƐĐŽŐŶŝƟǀĞƚŚĞƌĂƉLJĂŶĚŝƐĂĐĞƌƟĮĞĚƐĐŚĞŵĂ
ƚŚĞƌĂƉŝƐƚƚŚƌŽƵŐŚƚŚĞ/ŶƚĞƌŶĂƟŽŶĂů^ŽĐŝĞƚLJŽĨ^ĐŚĞŵĂdŚĞƌĂƉLJ͘
,ĞŚĂƐƉƵďůŝƐŚĞĚŽǀĞƌϳϬĂĐĂĚĞŵŝĐĂƌƟĐůĞƐĂŶĚŬĐŚĂƉƚĞƌƐ
on a range of clinical topics including conscious and uncon-
scious processes in psychotherapy, the use of imagery methods
in psychotherapy, the history of imagery methods, case stud-
ies of the treatment of social anxiety and simple and complex
PTSD, guidelines on the treatment of trauma related disorders,
and case study as a research methodology. Email: Ě͘ĞĚǁĂƌĚƐΛ
ru.ac.za Website: www.schematherapysouthafrica.co.za