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Includes the latest revisions of

the Young Schema Questionnaire,
a Client’s Guide to this approach,
and Schema Listings

~ PRACTITIONER’S RESOURCE SERIES

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Theology

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(909) 447-2589
eee
554
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COGNITIVE THERAPY
FOR PERSONALITY DISORDERS:
A SCHEMA-FOCUSED APPROACH
Third Edition

Jeffrey E. Young, PhD

Director
Cognitive Therapy Centers of New York
and Connecticut

Department of Psychiatry
Columbia University
College of Physicians & Surgeons

Ep
Professional Resource Press
Sarasota, Florida
 otHOF Th.
SCiiishecloy" ON
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(An imprint of the Professional Resource Exchange, Inc.)
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. All rights reserved

No part of this book may be reproduced, stored in a retrieval sys-

tem, or transmitted, in any form or by any means, either electronic,
mechanical, photocopying, microfilming, recording, or otherwise,
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The copy editor for this book was David Anson, the managing edi-
tor was Debbie Fink, the typesetter was Denise Franck, and the cover
designer was Laurie Girsch.

Library of Congress Cataloging-in-Publication Data

Young, Jeffrey E., date.

Cognitive therapy for personality disorders : a schema-focused
approach / Jeffrey E. Young. -- 3rd ed.
p. cm. -- (Practitioner’s resource series)
Includes bibliographical references.
ISBN 1-56887-047-7 (alk. paper)
1. Personality disorders--Treatment. 2.Schema-focused cognitive
therapy. I. Title. II. Series.
[DNLM: 1. Personality Disorders--therapy. 2. Cognitive Therapy-
-methods. WM 190 Y73c 1999]
RC554.Y68 1999
616,85'8--de21
DNLM/DLC
for Library of Congress 98-50869
(ae
 ACKNOWLEDGMENTS

The author would like to express appreciation to the following

people: Wayne Swift, Janet Klosko, Dan and Tara Goleman,
William Zangwill, Arthur Weinberger, and Center colleagues for
their invaluable feedback and support in the development of this
approach; Tim Beck, for his important role in guiding the author’s
professional growth; and to his family for their ongoing confidence
in him -- his father, mother, Stephen, and Debbie.

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 SERIES PREFACE

As a publisher of books, cassettes, and continuing education

programs, the Professional Resource Press and Professional Resource
Exchange, Inc. strive to provide mental health professionals with
highly applied resources that can be used to enhance clinical skills
and expand practical knowledge.
All the titles in the Practitioner’s Resource Series are designed
to provide important new information on topics of vital concern to
psychologists, clinical social workers, marriage and family thera-
pists, psychiatrists, and other mental health professionals.
Although the focus and content of each book in this series will
be quite different, there will be notable similarities:

ite Each title in the series will address a timely topic of critical
clinical importance.
a The target audience for each title will be practicing mental
health professionals. Our authors were chosen for their
ability to provide concrete “how-to-do-it” guidance to col-
leagues who are trying to increase their competence in deal-
ing with complex clinical problems.
The information provided in these books will represent “state-
of-the-art” information and techniques derived from both
clinical experience and empirical research. Each of these
guide books will include references and resources for those
who wish to pursue more advanced study of the discussed
topics.
The authors will provide numerous case studies, specific rec-
ommendations for practice, and the types of “nitty-gritty”
details that clinicians need before they can incorporate new
concepts and procedures into their practices.
 Cognitive Therapy for Personality Disorders (3rd ed.)

We feel that one of the unique assets of the Professional Re-

source Press is that all of its editorial decisions are made by mental
health professionals. The publisher, all editorial consultants, and
all reviewers are practicing psychologists, marriage and family thera-
pists, clinical social workers, and psychiatrists.
If there are other topics you would like to see addressed in this
series, please let me know.

Lawrence G. Ritt, Publisher

Vi
 ABSTRACT

Personality disorders are among the most resistant clinical prob-

lems presented to therapists -- and they are evident in the majority
of private practice patients. This book discusses schema-focused
therapy, an integrative approach developed by the author to treat
characterological patients including borderline, narcissistic, avoid-
ant, dependent, obsessive-compulsive, passive-aggressive, and his-
trionic personality disorders. Schema-focused treatment techniques
have also been utilized in preventing relapse withdepression, anxi-
ety disorders, and substance abuse, and in the treatment of physical
and psychological abuse, eating disorders, and chronic pain. Dr.
Young’s model is a pioneering integration of cognitive behavior
therapy with gestalt, object relations, and psychoanalytic approaches.
It expands on conventional cognitive behavior therapy by placing
more emphasis on the therapeutic relationship, affective experience,
and the discussion of early life experiences. In addition to present-
ing the rational, theory, and practical techniques of schema-focused
therapy, this third edition includes an extended case example and
revised editions of the Young Schema Questionnaire (Long Form,
Second Edition), Client’s Guide, and schema listings.

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 TABLE OF CONTENTS

ACKNOWLEDGMENTS ili

SERIES PREFACE
vii
ABSTRACT
Part I - SCHEMA-FOCUSED THERAPY:
RATIONALE AND THEORY

RATIONALE
Introduction
Assumptions in Short-Term Cognitive Therapy
Personality Disorders and Cognitive Therapy
Rigidity
Avoidance
Interpersonal Difficulties
SCHEMA THEORY
Early Maladaptive Schemas
as
Schema Domains and the Origins of Schem
Biology and Tempe ramen t
Disconnection and Rejection
Impaired Autonomy and Performance
Impaired Limits
Other-Directedness
Overvigilance and Inhibition
Schema Processes
Schema Maintenance
Schema Avoidance DANW
KH
4
OCOODA
DNF
eer
eS
NNN
Schema Compensation
THERAPY:
Part Il - SCHEMA-FOCUSED
AND
CASE CONCEPTUALIZATION
PATIEN T ASS ESS MEN T
21
OVERVIEW
28
The Evaluation Zo
Questionnaires
Cognitive Therapy for Personality Disorders (3rd ed.)

OVERVIEW (Continued)

Educating Patients About Schemas

Triggering Schemas
Imagery
Current Events
Past Memories
Therapeutic Relationship
Books and Movies
Group Therapy
Dreams
Homework
Confronting Schema Avoidance
Identifying Schema-Driven Behavior
Conceptualizing the Patient in Schema Terms

Part III - SCHEMA-FOCUSED THERAPY:

STRATEGIES FOR CHANGE

OVERVIEW 43

COGNITIVE TECHNIQUES 44

Review Evidence in Support of the Schemas 44

Critically Examine the Supporting Evidence
Review Evidence Contradicting the Schema 47
Illustrate How the Patient Discounts
Contradictory Evidence 48
Develop Flashcards that Contradict the Schemas 50
Challenge the Schema Whenever it is Activated
During the Therapy Session or Outside the Session 51

EXPERIENTIAL TECHNIQUES ae

INTERPERSONAL TECHNIQUES 52

BEHAVIORAL TECHNIQUES 54

CONCLUSION Po

Appendix A: YOUNG SCHEMA QUESTIONNAIRE

(Long Form, Second Edition) 39
Appendix B: CLIENT’S GUIDE TO
SCHEMA-FOCUSED THERAPY 71

REFERENCES 81
 COGNITIVE THERAPY
_ FOR PERSONALITY DISORDERS:
A SCHEMA-FOCUSED APPROACH

Third Edition
 Part I

SCHEMA-FOCUSED THERAPY:
RATIONALE AND THEORY

RATIONALE*

INTRODUCTION

One of the challenges for cognitive therapy today is to develop

effective treatment strategies for working with patients with per-
sonality disorders and other difficult, chronic patients.
The first section will outline seven characteristics that patients
must have in order to succeed in short-term cognitive therapy.
“Short-term cognitive therapy” refers to the 16- to 20-session cog-
nitive therapy approach originally developed by Beck and his col-
leagues (1979) for depression. The section will go on todemonstrate
how patients with personality disorders and other difficult patients
violate some of these basic assumptions.
The next section will discuss how short-term cognitive therapy
can be adapted and expanded to describe more fully what we ob-
serve in patients with personality disorders. A clinical theory of
schemas will be outlined briefly. The final sections will describe
the adaptation of short-term cognitive therapy techniques to over-
come the obstacles presented by patients with personality disorders.
This new approach is called “Schema-Focused Therapy.”

ee
De
*Names and identifying characteristics of persons in all case examples have been disguised
thoroughly to protect privacy.
Cognitive Therapy for Personality Disorders (3rd ed.)

ASSUMPTIONS IN SHORT-TERM
COGNITIVE THERAPY

Short-term cognitive therapy makes seven assumptions about

patients:

ic Patients have access to feelings with brief training. In short-

term cognitive therapy we assume that with arelatively short
amount of training we can teach patients to report when they
are feeling anxious, sad, angry, guilty, or another emotion.
However, in a variety of patients with longer-term disorders,
this ability to report their feelings does not seem to be present.
Many patients are blocked and out of touch with what they
feel; for these patients we have to modify the short-term cog-
nitive therapy approach.
The second assumption in short-term cognitive therapy is that
the patient has access to thoughts and images with brief train-
ing. Many patients with personality disorders cannot report
to us what their automatic thoughts are, or they claim not to
have images. For these patients as well, we have to develop
new strategies that are not currently available in short-term
cognitive therapy.
. Short-term cognitive therapy presumes that the patient has
identifiable problems on which to focus. Some difficult pa-
tients have vague or hard-to-define problems. They may have
a general malaise for which they are not able to identify
specific triggers. We have to modify short-term cognitive
therapy to work with patients for whom there are no specific
target problems.
. Short-term cognitive therapy assumes that the patient has
motivation to do homework assignments and to learn self-
control strategies. However, in working with many longer-
term patients, we find that they are unwilling orunable to do
homework assignments and show tremendous resistance to
learning self-control strategies. These patients seem far more
motivated to lean on the therapist and to obtain support than
to learn strategies for helping themselves.
. Short-term cognitive therapy assumes that the patient can
engage in a collaborative relationship with the therapist
within a few sessions. However, with many patients, engag-
ing them in a collaborative relationship is nearly impossible.
The therapist/patient relationship is so problematic that some
 Part I; Rationale and Theory

patients either become consumed in trying to get the thera-

pist to meet their needs or are so disengaged and hostile that
they are unable to collaborate.
. The sixth assumption is that difficulties in the therapeutic
relationship are not a major problem focus. However, in
many patients with personality disorders, if we assume that
the problems in the therapeutic relationship are merely ob-
stacles to overcome so that we can then get on with short-
term cognitive therapy, we often miss the real core of the
problem. In many patients with personality disorders, the
core of their problem is interpersonal, and one of the best
arenas for observing these problems is in the therapeutic re-
lationship. With these patients, dealing with the therapeutic
relationship as a primary focus of therapy becomes far more
important; unfortunately, short-term cognitive therapy has
little to say about how to work in depth with the therapeutic
relationship.
. Aseventh assumption in short-term cognitive therapy is that
all cognitions and behavior patterns can be changed through
empirical analysis, logical discourse, experimentation,
gradual steps, and practice. With many chronic patients,
their cognitions and self-defeating behavior patterns are ex-
tremely resistant to modification solely through short-term
cognitive behavioral techniques. Such patients may repeat-
edly report that they understand intellectually what the thera-
pist is demonstrating, but that emotionally their feelings,
behaviors, and beliefs remain unchanged. Even after months
of chipping away at such beliefs and behavior patterns, there
is often no change or improvement. Such patients are often
hopeless about modifying their core beliefs or behavior pat-
terns, insisting that these cognitions and behaviors are too
much a part of themselves to change at this point in their
lives.

The five patients described below illustrate how these assump-

tions can be violated. Sally was a 20-year-old student who spent
the first 10 sessions sitting in the corner, facing away from the thera-
She would give only terse “yes” or “no” answers to questions.
When the therapist asked what she wanted to work on or what she
felt, she said she did not know. Sally presented a variety of prob-
lems for short-term cognitive therapy. First, her sitting in the cor-
ner made it very difficult to collaborate. Second, her inability to

3
Cognitive Therapy for Personality Disorders (3rd ed.)

state a problem or to describe her feelings made it difficult to find a

problem focus or to elicit emotions and their associated automatic
thoughts.
Sam was a 45-year-old attorney who claimed he did not feel or
think about anything. He claimed to be numb all the time, with
several anxiety symptoms, but reported no thoughts before or dur-
ing his periods of anxiety and numbness. He appeared very con-
trolled and highly intelligent. With this patient we also found a
major difficulty in undertaking short-term cognitive therapy. The
patient reported no automatic thoughts connected with his anxiety
symptoms, and furthermore there seemed to be no specific trigger
events that set off his symptoms.
Karl was a 40-year-old writer who avoided most social contact
because he was afraid he would sound foolish to other people. He
would not do homework assignments designed to increase social
contact, no matter how minimal the contact was. Karl presented a
problem because he was unable or unwilling to do homework as-
signments, yet the crux of the problem was his avoidance of social
contact. Even though he was able to report his thoughts and feel-
ings, because he was unwilling to take even minimal steps to ini-
tiate social contact, short-term cognitive therapy seemed to be
perpetually at an impasse with him.
Kathleen was a 21-year-old college student who lived at home
and felt chronically depressed. She would not do cognitive home-
work assignments because she wanted the therapist to make her better
by being available as often as possible, day and night. Every time
the therapist suggested homework assignments, Kathleen refused
to do them. She interpreted these assignments as an unwillingness
on the part of the therapist to be there for her when she needed him.
Mark was a 43-year-old man who entered therapy frustrated be-
cause he could not find a suitable woman to marry. Upon closer
examination, Mark’s pattern in relationships was to bail out soon
after women expressed strong affection and love toward him. He
would remain indefinitely with women who were either ambivalent
or rejecting toward him. When he got close to women who loved
him, he would devalue them by asking why anyone worthwhile
would want to get close to him. His feelings of unlovability proved
completely resistant to the therapist’s attempts at collaborative em-
piricism of any sort. The rigidity of his cognitions and behaviors
made short-term cognitive therapy frustrating and unrewarding.
Mark was unable to defend these beliefs, except by saying he “just
 Part I: Rationale and Theory

feels defective.” Yet his cognitions, emotions, and behaviors re-

mained dysfunctional.
Each of these five patients illustrates one or more of the ways in
which short-term cognitive therapy does not fit with certain patients.
The next section will attempt to explain why such patients are often
diagnosed with personality disorders and why chronic, difficult pa-
tients frequently fail to respond to short-term cognitive therapy.

PERSONALITY DISORDERS
AND COGNITIVE THERAPY

Rigidity. Short-term cognitive therapy assumes a certain flexi-

bility on the part of patients, an assumption that does not hold true
in most personality disorders. Typically, the cognitive therapist
employs a variety of strategies to help patients see the inaccuracy or
maladaptiveness of their thinking. The therapist assumes that, with
enough practice and rehearsal, cognitions and behavior patterns are
flexible enough to be modified through collaborative empiricism.
However, according to DSM-IV (American Psychiatric Asso-
ciation, 1994), and consistent with our own clinical experience, one
of the hallmarks of personality disorders is the presence of perva-
sive, inflexible patterns that are enduring (DSM-IV, p. 629). Millon
(1981) reinforces this point by specifying adaptive inflexibility and
vicious circles as two of the major criteria for personality patholo-
gy: “the alternative strategies the individual employs for relating to
others, for achieving goals, and for coping with stress are not only
few in number but appear to be practiced rigidly” (p. 9).
He elaborates on this process through which patients with per-
sonality disorders set up vicious cycles of self-defeating sequences:

Maneuvers such as protective constriction, cognitive dis-

tortion, and behavior generalization are processes by
which individuals restrict their opportunities for new learn-
ing, misconstrue essentially benign events, and provoke re-
actions from others that reactivate earlier problems. (Millon,
1981, p. 9)

He goes on to contrast personality disorders with “symptom dis-

orders” such as depression:

Personality patterns are deeply embedded and pervasive, and

are likely to persist, essentially unmodified, overlong peri-
Cognitive Therapy for Personality Disorders (3rd ed.)

ods of time. ... Symptom disorders possess well-delineated

clinical features that are less difficult to modify than the
ingrained personal traits from which they arise. (Millon,
1981, p. 10)

Finally, Millon points out that personality traits “feel right” to

the individual who possesses them (“ego syntonic”).

Avoidance. Short-term cognitive therapy assumes that patients

have relatively free access to their thoughts and feelings. In many
personality disorders, however, thoughts and feelings are often
avoided, or blocked out, because they are painful. This “cognitive
avoidance” or “affective avoidance” can be explained as the result
of aversive conditioning: anxiety and depression have become con-
ditioned to memories and associations, leading to avoidance. This
becomes a chronic strategy that can then defeat short-term cogni-
tive treatment.
The traditional psychoanalytic view is that defenses such as re-
pression (i.e., avoidance) are most effective in personality disor-
ders:

The defenses of patients with personality disorders have been

part of the warp and woof of their life histories and of their
personal identities. However maladaptive their defenses
may be, they represent homeostatic solutions to inner prob-
lems. . . . Breaching their defenses evokes enormous
anxiety and depression. (Kaplan & Sadock, 1985, p. 965)

Millon (1981) states that “Repression thwarts the individual from

‘unlearning’ disturbed feelings or learning new, potentially more
constructive ways of coping with them” (p. 101).
Although cognitive therapists reject much of psychoanalytic
theory, it is undeniable that many difficult, chronic patients seem
actively to avoid looking at their deepest cognitions and emotions.
Regardless of how this phenomenon is explained, therapists still
must develop therapeutic strategies to deal with this avoidance, or
else they will be continually stymied by personality disorders.

Interpersonal Difficulties. The third hallmark of patients with

personality disorders is their dysfunctional interpersonal relation-
ships. In fact, most of the DSM-IV personality disorder definitions
 Part I; Rationale and Theory

highlight these interpersonal difficulties, including histrionic, schiz-

oid, dependent, paranoid, avoidant, and borderline disorders.

_ _ To summarize, three characteristics of personality disorders --

rigidity, avoidance, and long-term interpersonal difficulties -- lead
to considerable difficulty in applying short-term cognitive therapy,
as illustrated by the case examples earlier. The next section de-
scribes an expanded clinical theory that takes these three factors
Into account.

SCHEMA THEORY

To permit the more complete conceptualization and treatment

of patients with personality disorders, the following five theoreti-
cal constructs are proposed as an expansion of the short-term cogni-
tive model proposed by Beck and his colleagues (1979):

Early Maladaptive Schemas

Schema Domains
Schema Maintenance
Schema Avoidance
ee
ae
Ne Schema Compensation

This expansion of terms (to be elaborated upon later) is not in-

tended as a comprehensive theory of psychopathology or person-
ality but rather as a “convenient clinical heuristic” (Segal, 1988).
We offer a straightforward working theory, comprehensible to pa-
tients, that enables patients and therapists to communicate about
deeper-level phenomena that have not yet been incorporated into
most short-term cognitive behavior therapies. The constructs pro-
posed here have not yet been tested empirically, and so must be
viewed as speculative. Furthermore, although we often speak to
patients about schemas as if they exist structurally and have a life
and force of their own, we do this only for ease of communication,
aware that this is an unsophisticated explanation of a hypothetical
construct.
In some of his earliest work, Beck (1967) emphasized the im-
portance of schemas in depression:

A schema is a [cognitive] structure for screening, cod-

ing, and evaluating the stimuli that impinge on the
Cognitive Therapy for Personality Disorders (3rd ed.)

organism. . . . On the basis of the matrix of schemas, the

individual is able to orient himself in relation to time and
space and to categorize and interpret experiences in a mean-
ingful way. (p. 283)

Beck goes on to make a number of additional points about

schemas. He hypothesizes that schemas may account for the repeti-
tive themes in free associations, images, and dreams. He notes that
they may be inactive at one point in time, and then “energized or de-
energized rapidly as a result of changes in the type of input from
the environment” (1967, p. 284).
Another important observation Beck makes is that schemas bias
our interpretations of events in a consistent manner. These biases
in “psychopathology” are “reflected in the typical misconceptions,
distorted attitudes, invalid premises, and unrealistic goals and ex-
pectations” (1967, p. 284).
Segal (1988) provides the following definition of schemas, drawn
from a consensus of many researchers: “organized elements of past
reactions and experience that form a relatively cohesive and persis-
tent body of knowledge capable of guiding subsequent perception
and appraisals” (p. 147). Our own concept of “schema”is consis-
tent with this definition and with Beck’s but is more limited and
specific, as outlined later.
Segal goes on to contrast several different models of schemas.
These models offer differing explanations regarding (a) the rela-
tionship between moods and personal constructs, and (b) the
interconnectedness of personal constructs within the self-system.
We will not attempt to provide a competing theory of schemas,
nor will we ally with any of the specific existing approaches. In-
stead, the main purpose of the schema theory presented below is to
provide direction for the clinical interventions outlined later. Only
enough theory is included to guide the therapist in developing prac-
tical case conceptualizations that can be explained to patients in
simple terms, and that will lead to effective intervention strategies.

EARLY MALADAPTIVE SCHEMAS

Short-term cognitive therapy focuses primarily on three levels

of cognitive phenomena: automatic thoughts, cognitive distortions,
and underlying assumptions. We are proposing a primary emphasis
on the deepest level of cognition, the Early Maladaptive Schema
(EMS).
 Part I: Rationale and Theory

Early Maladaptive Schemas refer to extremely stable and en-

during themes that develop during childhood, are elaborated
throughout an individual’s lifetime, and are dysfunctional to a
significant degree. These schemas serve as templates for the
processing of later experience. Structurally, this concept of
schema is similar to Lakatos’ “metaphysical hard-core”:

[A] deep, relatively indisputable metaphysical hard-

core . . . identified essentially in the tacit self-knowledge
that has been progressively elaborated during the course
of development and that . . . is for individuals a kind of
implicit general view of themselves. (Cited in Guidano &
Liotti, 1983, p. 66)

Early Maladaptive Schemas have several defining characteris-

tics:

1. Most Early Maladaptive Schemas are unconditional beliefs

and feelings about oneself in relation to the environment.
Schemas are a priori truths that are implicit and taken for
granted. Guidano and Liotti state that “The deepstructure’s
irrefutability is therefore a real... necessity. For us as indi-
viduals, our own tacit self-knowledge is a constitutive part
of ourselves; with no real alternatives” (1983, p. 67).
We can contrast EMS’s with underlying assumptions.
Underlying assumptions hold out the possibility of success
for an individual. “If I can be perfect, if I can please other
people all the time, if I am loved, then I am worthwhile.”
Schemas, in contrast, are usually unconditional, and there-
fore more rigid. “No matter what I do I’m incompetent, un-
lovable, ugly; I’Il be abandoned; I'll be punished.” When
the schema is activated, individuals believe that they can, at
best, delay or hide the inevitable bad outcome such as rejec-
tion or punishment.
2. Early Maladaptive Schemas are self-perpetuating, and there-
fore much more resistant to change. Because schemas are
developed early in life, they often form the core of an
individual’s self-concept and conception of the environment.
These schemas are comfortable and familiar, and when they
are challenged, the individual will distort information to
maintain the validity of these schemas. The threat of sche-
Cognitive Therapy for Personality Disorders (3rd ed.)

matic change is too disruptive to the core cognitive organi-

zation. Therefore the individual automatically engages in a
variety of cognitive maneuvers (described later) to maintain
the schema intact.
Millon (1981) makes the same point in his discussion of
personality disorders:

Once individuals acquire a system of expectancies,

they respond with increasing alertness to similar
elements in their life situation. .. . The importance
of expectancies, sensitivities, and language habits
lies in the fact that they lead to the distortion of
objective realities. (p. 102)

Guidano and Liotti (1983) similarly emphasize the cir-

cular nature of schemas:

The selection of data from outside reality that

are coherent with self-image obviously confirms --
in an automatic and circular way -- the perceived
personal identity... .
Let us consider a young woman who has devel-
oped a self-image as “intrinsically unlovable.” . . .
Since every time she is abandoned she processes
the data derived from the experience on the basis of
her self-image (so that it is reconfirmed and made
more stable each time), little by little her own
“unlovableness” becomes something certain and
“proved.” (pp. 88-89)

3. Early Maladaptive Schemas, by definition, must be dysfunc-

tional in some significant and recurring manner. We hy-
pothesize that they can lead directly or indirectly to psycho-
logical distress like depression or panic; to loneliness or
to destructive relationships; to inadequate work perfor-
mance; to addictions like alcohol, drugs, or overeating; or to
psychosomatic disorders like ulcers or insomnia.
. Early Maladaptive Schemas are usually activated by events
in the environment relevant to the particular schema. For
example, when an adult with a Failure schema is assigned a
difficult task in which performance will be scrutinized, the

10
 Part I; Rationale and Theory

schema erupts. Thoughts begin to arise such as “I can’t

handle this. I'll fail. I’ll make a fool of myself.” These
thoughts are usually accompanied by a high level of affec-
tive arousal, in this case anxiety. Depending on the circum-
stances and the particular schema, the individual might
experience other emotions, such as sadness, shame, guilt, or
anger.
. EMS’s are usually much more closely tied to high levels of
affect when activated than are underlying assumptions. For
example, when some patients discover that they hold the as-
sumption that “really bad things only happen to bad people,”
it is rare for them to break down in tears or begin shaking
with anxiety. However, when patients identify an Early Mal-
adaptive Schema, such as Defectiveness/Shame, there is of-
ten a high level of affective arousal.
. Finally, Early Maladaptive Schemas seem to be the result
of the child’s innate temperament, interacting with dys-
functional experiences with parents, siblings, and peers
during the first few years of life. Rather than resulting
from isolated traumatic events, most schemas are prob-
ably caused by ongoing patterns of everyday noxious ex-
periences with family members and peers, which
cumulatively strengthen the schema. For example, a child
who is repeatedly criticized when school performance does
not meet parental standards is prone to develop the Fail-
ure schema.

Millon (1981) emphasizes the persisting influences of

early negative experience:

Significant experiences of early life may never

recur again, but their effects remain and leave their
mark ... they are registered as memories, a perma-
nent trace and an embedded internal stimulus. . . .
Once registered, the effects of the past are indel-
ible, incessant and inescapable. .. .
The residuals of the past do more than passively
contribute their share to the present . . . they guide,
shape or distort the character of current events. Not
only are they ever present, then, but they operate
insidiously to transform new stimulus experiences
in line with past. (p. 101)

11
Cognitive Therapy for Personality Disorders (3rd ed.)

Eighteen Early Maladaptive Schemas have been identified thus

far. These 18 encompass the themes we have observed in almost all
of the longer-term patients in our clinical practices. Most chronic
psychotherapy patients have more than one of these core schemas.
Furthermore, each schema can have many variations on the same
theme. Table 1 (pp. 12-16) lists the 18 EMS’s, along with defini-
tions of each schema. The schemas are grouped into five broad
schema domains (described in the next section), corresponding to
the five developmental needs of the child that we hypothesize may
not be met.

TABLE 1: EARLY MALADAPTIVE SCHEMAS WITH

ASSOCIATED SCHEMA DOMAINS
(Revised November, 1998)*

DISCONNECTION AND REJECTION

(Expectation that one’s needs for security, safety, stability, nurturance, empa-
thy, sharing offeelings, acceptance, and respect will not be met in a predictable
manner. Typical family origin is detached, cold, rejecting, withholding, lonely,
explosive, unpredictable, or abusive.)

1. Abandonment/Instability. The perceived instability or unreliability of

those available for support and connection.
Involves the sense that significant others will not be able to continue
providing emotional support, connection, strength, or practical protec-
tion because they are emotionally unstable and unpredictable (e.g., angry
outbursts), unreliable, or erratically present; because they will die immi-
nently; or because they will abandon the patient in favor of someone
better.

2. Mistrust/Abuse. The expectation that others will hurt, abuse, humiliate,

cheat, lie, manipulate, or take advantage. Usually involves the percep-
tion that the harm is intentional or the result of unjustified and extreme
negligence. May include the sense that one always ends up being cheated
relative to others or “gets the short end of the stick.”

3. Emotional Deprivation. Expectation that one’s desire for a normal de-

gree of emotional support will not be adequately met by others. The
three major forms of deprivation are:

*Developed by Jeffrey E. Young, PhD. Copyright © 1998. Unauthorized reproduction with-

out written consent of the author is prohibited. For more information, write: Cognitive Therapy
Center of New York, 120 E. 56th Street, Suite 530, New York, NY 10022 or telephone (212)
588-1998.

12
 Part I: Rationale and Theory

(a) Deprivation of Nurturance - Absence of attention, affection, warmth,

or companionship.
(b) Deprivation of Empathy - Absence of understanding, listening,
self-
disclosure, or mutual sharing of feelings from others.
(c) Deprivation of Protection - Absence of strength, direction, or guid-
ance from others.

4, Defectiveness/Shame. The feeling that one is defective, bad, unwanted,

inferior, or invalid in important respects; or that one would be unlovable
to significant others if exposed. May involve hypersensitivity to criti-
cism, rejection, and blame; self-consciousness, comparisons, and
insecurity around others; or a sense of shame regarding one’s perceived
flaws. These flaws may be private (e.g., selfishness, angry impulses,
unacceptable sexual desires) or public (e.g., undesirable physical appear-
ance, social awkwardness).

5. Social Isolation/Alienation. The feeling that one is isolated from the rest
of the world, different from other people, and/or not part of any group or
community.

IMPAIRED AUTONOMY AND PERFORMANCE

(Expectations about oneself and the environment that interfere with one’s per-
ceived ability to separate, survive, function independently, or perform success-
fully. Typical family origin is enmeshed, undermining of child’s confidence,
overprotective, or failing to reinforce child for performing competently outside
the family.)

6. Dependence/Incompetence. Belief that one is unable to handle one’s

everyday responsibilities in a competent manner, without considerable
help from others (e.g., take care of oneself, solve daily problems, exer-
cise good judgment, tackle new tasks, make good decisions). Often pre-
sents as helplessness.

7. Vulnerability to Harm or Illness. Exaggerated fear thatimminent catas-

trophe will strike at any time and that one will be unable to prevent it.
Fears focus on one or more of the following: (a) Medical Catastrophes -
for example, heart attacks, AIDS; (b) Emotional Catastrophes - for ex-
ample, going crazy; (c) External Catastrophes - for example, elevators
collapsing, victimized by criminals, airplane crashes, earthquakes.

8. Enmeshment/Undeveloped Self. Excessive emotional involvement and

closeness with one or more significant others (often parents), at the
expense of full individuation or normal social development. Often
involves the belief that at least one of the enmeshed individuals can-
not survive or be happy without the constant support of the other.
May also include feelings of being smothered by, or fused with, oth-
ers or insufficient individual identity. Often experienced as a feeling
of emptiness and floundering, having no direction, or, in extreme cases
questioning one’s existence.

ie:
Cognitive Therapy for Personality Disorders (3rd ed.)

9. Failure. The belief that one has failed, will inevitably fail, or is funda-
mentally inadequate relative to one’s peers, in areas of achievement
(school, career, sports, etc.). Often involves beliefs that one is stupid,
inept, untalented, ignorant, lower in status, less successful than others,
and so on.

IMPAIRED LIMITS

(Deficiency in internal limits, responsibility to others, or long-term goal-

orientation. Leads to difficulty respecting the rights of others, cooperating
with others, making commitments, or setting and meeting realistic personal
goals. Typical family origin is characterized by permissiveness, overindul-
gence, lack of direction, or a sense of superiority -- rather than appropriate
confrontation, discipline, and limits in relation to taking responsibility,
cooperating in a reciprocal manner, and setting goals. In some cases, child
may not have been pushed to tolerate normal levels of discomfort or may
not have been given adequate supervision, direction, or guidance.)

10. Entitlement/Grandiosity. The belief that one is superior to other people;

entitled to special rights and privileges; or not bound by the rules of reci-
procity that guide normal social interaction. Often involves insistence
that one should be able to do or have whatever one wants, regardless of
what is realistic, what others consider reasonable, or the cost to others;
or an exaggerated focus on superiority (e.g., being among the most suc-
cessful, famous, wealthy) -- in order to achieve power or control (not
primarily for attention or approval). Sometimes includes excessive com-
petitiveness toward, or domination of, others: asserting one’s power,
forcing one’s point of view, or controlling the behavior of others in line
with one’s own desires -- without empathy or concern for others’ needs
or feelings.

11. Insufficient Self-Control/Self-Discipline. Pervasive difficulty or refusal

to exercise sufficient self-control and frustration tolerance to achieve one’s
personal goals, or to restrain the excessive expression of one’s emotions
and impulses. In its milder form, patient presents with an exaggerated
emphasis on discomfort-avoidance: avoiding pain, conflict, confronta-
tion, responsibility, or overexertion -- at the expense of personal fulfill-
ment, commitment, or integrity.

OTHER-DIRECTEDNESS

(An excessive focus on the desires, feelings, and responses of others, at the
expense of one’s own needs -- in order to gain love and approval, maintain
one’s sense of connection, or avoid retaliation. Usually involves suppression
and lack of awareness regarding one’s own anger and natural inclinations.
Typical family origin is based on conditional acceptance: children must sup-
press important aspects of themselves in order to gain love, attention, and ap-
proval. In many such families, the parents’ emotional needs and desires -- or
social acceptance and status -- are valued more than the unique needs and
feelings of each child.)

14
 Part I: Rationale and Theory

12. Subjugation. Excessive surrendering of control to others because one

feels coerced -- usually to avoid anger, retaliation, or abandonment. The
two major forms of subjugation are:

(a) Subjugation of Needs - Suppression of one’s preferences, decisions,

and desires.
(b) Subjugation of Emotions - Suppression of emotional expression, es-
pecially anger.

Usually involves the perception that one’s own desires, opinions, and
feelings are not valid or important to others. Frequently presents as ex-
cessive compliance, combined with hypersensitivity to feeling trapped.
Generally leads to a build up of anger, manifested in maladaptive symp-
toms (e.g., passive-aggressive behavior, uncontrolled outbursts of tem-
per, psychosomatic symptoms, withdrawal of affection, “acting out,”
substance abuse).

£3. Self-Sacrifice. Excessive focus on voluntarily meeting the needs of oth-

ers in daily situations, at the expense of one’s own gratification. The
most common reasons are to prevent causing pain to others, to avoid
guilt from feeling selfish, or to maintain the connection with others per-
ceived as needy. Often results from an acute sensitivity to the pain of
others. Sometimes leads to a sense that one’s own needs are not being
adequately met and to resentment of those who are taken care of. (Over-
laps with concept of co-dependency.)

14. Approval-Seeking/Recognition-Seeking. Excessive emphasis on gaining

approval, recognition, or attention from other people, or fitting in, at the
expense of developing a secure and true sense of self. One’s sense of
esteem is dependent primarily on the reactions of others rather than on
one’s own natural inclinations. Sometimes includes an overemphasis on
status, appearance, social acceptance, money, or achievement -- as a means
of gaining approval, admiration, orattention (not primarily for power or
control). Frequently results in major life decisions that are inauthentic or
unsatisfying; or in hypersensitivity to rejection.

OVERVIGILANCE AND INHIBITION

(Excessive emphasis on suppressing one’s spontaneous feelings, impulses,

and choices or on meeting rigid, internalized rules and expectations about
performance and ethical behavior -- often at the expense of happiness, self-
expression, relaxation, close relationships, or health. Typical family origin
is grim, demanding, and sometimes punitive: performance, duty, perfec-
tionism, following rules, hiding emotions, and avoiding mistakes predomi-
nate over pleasure, joy, and relaxation. There is usually an undercurrent
of pessimism and worry -- that things could fall apart if one fails to be
vigilant and careful at all times.)

ee Negativity/Pessimism. A pervasive, lifelong focus on the negative as-

pects of life (pain, death, loss, disappointment, conflict, guilt, resent-

15
Cognitive Therapy for Personality Disorders (3rd ed.)

ment, unsolved problems, potential mistakes, betrayal, things that could

go wrong, etc.) while minimizing or neglecting the positive or optimistic
aspects. Usually includes an exaggerated expectation -- in a wide range
of work, financial, or interpersonal situations -- that things will eventu-
ally go seriously wrong, or that aspects of one’s life that seem to be going
well will ultimately fall apart. Usually involves an inordinate fear of
making mistakes that might lead to financial collapse, loss, humiliation,
or being trapped in a bad situation. Because potential negative outcomes
are exaggerated, these patients are frequently characterized by chronic
worry, vigilance, complaining, or indecision.

16. Emotional Inhibition. The excessive inhibition of spontaneous ac-

tion, feeling, or communication -- usually to avoid disapproval by
others, feelings of shame, or losing control of one’s impulses. The
most common areas of inhibition involve: (a) inhibition of anger
and aggression; (b) inhibition of positive impulses (e.g., joy, affec-
tion, sexual excitement, play); (c) difficulty expressing vulnerability
or communicating freely about one’s feelings, needs, and so on; or
(d) excessive emphasis on rationality while disregarding emotions.

17, Unrelenting Standards/Hypercriticalness. The underlying belief that

one must strive to meet very high internalized standards of behavior
and performance, usually to avoid criticism. Typically results in feel-
ings of pressure or difficulty slowing down, and in hypercriticalness
toward oneself and others. Must involve significant impairment in
pleasure, relaxation, health, self-esteem, sense of accomplishment, or
satisfying relationships.
Unrelenting standards typically present as (a) perfectionism, inor-
dinate attention to detail, or an underestimate of how good one’s own
performance is relative to the norm; (b) rigid rules and “shoulds” in
many areas oflife, including unrealistically high moral, ethical, cul-
tural, or religious precepts; or (c) preoccupation with time and effi-
ciency so that more can be accomplished.

18. Punitiveness. The belief that people should be harshly punished for mak-
ing mistakes. Involves the tendency to be angry, intolerant, punitive, and
impatient with those people (including oneself) who do not meet one’s
expectations or standards. Usually includes difficulty forgiving mistakes
in oneself or others because of a reluctance to consider extenuating cir-
cumstances, allow for human imperfection, or empathize with feelings.

SCHEMA DOMAINS AND THE ORIGINS OF SCHEMAS

In considering the origins of these schemas, we have observed

five primary developmental tasks that we believe the child must
negotiate in order to develop in a healthy manner. When any of
these tasks are not met, we hypothesize that the patient will have
difficulty functioning in one or more of the five schema domains:

16
 Part I: Rationale and Theory

(a) Disconnection and Rejection, (b) Impaired Autonomy and Per-

formance, (c) Impaired Limits, (d) Other-Directedness, and (e)
Overvigilance and Inhibition. When schemas develop in childhood,
they block the child in one or more of these domains.

Biology and Temperament. Before we discuss the individual

domains, it should be noted that biology and temperament un-
doubtedly play some role in the development of some of these
schemas. For example, a child who is especially anxious by na-
ture may have more difficulty moving from dependence to au-
tonomy. Similarly, a child who is shy by disposition may be more
prone to developing the Social Isolation schema. The child’s abil-
ity to negotiate each of the developmental tasks outlined below may
in part be determined by a child’s innate temperament, in combina-
tion with the parenting styles and social influences to which he or
she is exposed. For the remainder of this section, however, we will
assume that the child does not present any exceptional biological
traits that would significantly interfere with the mastery of each
task. The emphasis, therefore, will be on the roles of parents, sib-
lings, and peers in the development of EMS’s.

Disconnection and Rejection. Connection is the sense that

one is connected to other people in a stable, enduring, and trusting
manner. One form of connection involves intimacy: close emo-
tional ties to others. A second form of connection involves social
integration: a sense of belonging and fitting into a group of friends,
family, and community. Social integration is promoted when indi-
viduals believe they are socially desirable and skilled, and when
they feel similar to other people.
Acceptance involves the sense that one is lovable, acceptable,
and desirable to others and that one is worthy of the attention, love,
and respect of others. Children who do not get acceptance experi-
ence rejection.
In order to develop a sense of connection, children need reliable
love and nurturance, and dependable motheringand fathering. This
leads children to feel cared for. Children also need empathy from
the parents for the children’s feelings. This leads to a sense of being
understood. Children need a secure family environment without
excessive fighting. They need equal love and attention in relation-
ship to their brothers and sisters. Parents should encourage chil-
dren to socialize with other children. Finally, to develop the sense
of connection, children need to have successful experiences social-

17
Cognitive Therapy for Personality Disorders (3rd ed.)

izing with peers individually and in groups, throughout perlaiioe

and adolescence.
In order to develop a sense of acceptance instead of majectiOn
children need the love and respect of parents and siblings, and the
social acceptance of peers.
When children do not have this kind of secure environment,
with love, empathy, attention, respect, acceptance, and positive so-
cial experiences, they are prone to the schemas related to Discon-
nection and Rejection: Abandonment/Instability, Mistrust/Abuse,
Emotional Deprivation, Defectiveness/Shame, and Social Isolation/
Alienation.
Children are prone to developing these schemas when they do
not receive enough love, affection, respect, acceptance, or atten-
tion from their parents. Sometimes this happens when parents die
or leave the home permanently, or when children are frequently left
alone during very early years. Rejection develops when children
are repeatedly criticized by parents or made to feel unwanted or
when they are ostracized by peers. These schemas can also develop
when children lack qualities that are considered highly desirable
for social attractiveness to the opposite sex or when they do not
have interests that are traditionally gender-appropriate. Finally, dis-
connection can arise when children are abused, cheated, or lied to
by either parents or peers.

Impaired Autonomy and Performance. Autonomy is the sense

that one can function independently in the world, without continual
support from others. Autonomous individuals establish a sense of
individual identity and learn to separate from parents and survive in
the world outside the family. They have a sense of integrity and
control within themselves, physically, mentally, and psychologi-
cally. Finally, autonomous people believe that their environment is
relatively safe, and they are not hypervigilant to threat. Performance
refers to the ability to perform successfully at school and work.
In order to develop a sense of themselves as autonomous and
competent individuals, children need encouragement to function in-
dependently and perform at school, without excessive help from the
parents. They need assurance that they are healthy, robust, compe-
tent individuals and that the world is relatively safe. Finally, chil-
dren should be assigned responsibilities to undertake on their own
and made to feel that their decisions and judgments are valid.
When parents fail to provide an environment that encourages
autonomy, one of the four schemas related to autonomy and perfor-

18
 Part I; Rationale and Theory

mance can develop. These include Dependence/Incompetence,

Vulnerability to Harm and Illness, Enmeshment/Undeveloped Self,
and Failure.
These often arise when parents overprotect their children; for
example, by continually warning them of exaggerated dangers and
risks. Autonomy problems can arise when children observe parents
worrying continually and unnecessarily, or when children are not
given enough independent responsibility. Many parents intercede
" when children are having even minimal difficulty. The opposite
extreme can also lead toproblems with dependency: when children
are rarely helped to do anything and receive little guidance or di-
rection. It appears that either extreme -- either doing everything
for children or providing too little direction for them -- can lead to
difficulties with autonomy.

Impaired Limits. The term Realistic Limits refers to the ca-

pacity to discipline oneself, to control one’s impulses, and to take
the needs of others into account, all to an appropriate degree.
It is important for children to develop a sense of limits. This is
best accomplished by providing an environment that is not too per-
missive. Children benefit from realistic limits on their behavior
so they can learn self-control and concern for others. The scehmas
of Entitlement/Grandiosity and Insufficient Self-Control/Self-
Discipline develop when children are overindulged by parents;
praised inordinately for accomplishments; allowed to do whatever
they want, without regard for the needs of others; not taught that
relationships involve sharing and reciprocity; and not taught how to
deal with defeat or frustration. These children may be told that they
are special and few limits are set.

Other-Directedness. It is important for healthy development

that children learn to express their own unique needs and emotions
without undue fear of reprisal or guilt. In order to develop a healthy
sense of inner-directedness, children need parents who encourage
them to express their own autonomous needs appropriately and to
act on these needs without undue restriction, punishment, or with-
drawal of support.
In families that support unhealthy other-directedness, children
learn to place excessive emphasis on the desires, feelings, and re-
sponses of others, at the expense of their own legitimate needs. They
do this to gain the love and approval of their parents, to maintain
connection, or to avoid retaliation. Children with these issues usu-

19
Cognitive Therapy for Personality Disorders (3rd ed.)

ally suppress awareness and expression of their own anger and “natu-
ral inclinations,” including their interests and talents. They may
become too adept at conforming to the expectations of others.
Parents who offer conditional acceptance foster problems in this
domain: children learn to suppress important aspects of themselves.
Often, parents value their own emotional needs and desires more
than the unique needs and feelings of their children. This pattern
leads to the development of the schemas in this domain: Subjuga-
tion, Self-Sacrifice, and Approval/Recognition-Seeking.

Overvigilance and Inhibition. Children need encouragement

to express feelings, impulses, and choices with spontaneity. It is
unhealthy for them to be constantly vigilant to the possibility of
making mistakes or failing to meet rigid rules and expectations.
When children are taught overvigilance and inhibition, it is often at
the expense of their happiness, self-expression, relaxation, pleasure,
intimacy, or health.
Parents who create problems in this domain are often grim, strict,
or punitive. They overemphasize performance, duty, perfection-
ism, following rules, and avoiding mistakes. Life can become joy-
less, characterized by worry and pessimism. Some of the problems
within this domain develop when children are asked to do more
than they can reasonably complete and are taught that whatever they
accomplish is not enough. These parents place a higher priority on
achievement than on happiness. Children often feel that the only
way they can earn the love of such parents is by achieving at an
extremely high level. Parents who engage in behaviors like these
can engender any of the four schemas in this domain: Negativity/
Pessimism, Emotional Inhibition, Unrelenting Standards/Hyper-
criticalness, and Punitiveness.

To summarize, children have five primary tasks: connection

and acceptance, autonomy and performance, realistic limits, inner-
directedness and self-expression, and spontaneity and pleasure.
When the parents and the social environment are optimal, children
develop in a healthy manner in all five areas. However, when the
parental or social environment is not optimal, children are vulner-
able to developing Early Maladaptive Schemas in one or more of
these schema domains. These schemas then persist over a lifetime
and become organizing principles for patients’ cognitive, emotional,
interpersonal, and behavioral functioning.

20
 Part I: Rationale and Theory

SCHEMA PROCESSES

We have identified three major schema processes: schema main-

tenance, schema avoidance, and schema compensation. These proc-
esses explain how schemas function within the individual. They
explain how schemas are maintained and how they are avoided, and
how patients sometimes adapt to schemas by overcompensation.
These processes can occur within the cognitive realm, the affective
* domain, and in long-term behavioral functioning.

Schema Maintenance. We emphasized earlier that, for many

patients, Early Maladaptive Schemas form the cornerstone of their
self-concepts. EMS’s are central to the organization of personality.
Schema maintenance refers to processes by which these Early
Maladaptive Schemas are reinforced. These processes include both
cognitive distortions and self-defeating behavior patterns. Schema
maintenance processes account for the rigidity which is so charac-
teristic of personality disorders.
At the cognitive level, schema maintenance is usually accom-
plished by highlighting or exaggerating information that confirms
the schema and by negating, minimizing, or denying information
that contradicts the schema. Many of these schema maintenance
processes have already been described by Beck as cognitive dis-
tortions (Beck, 1967). Some of the most common distortions are
magnification, minimization, selective abstraction, and overgener-
alization. When therapists begin to doubt or challenge these schemas,
they often encounter enormous resistance. The patient often ac-
tively attempts to prove to the therapist that the schema is true.
Information is distorted to maintain schemas intact.
At the behavioral level, schema maintenance is achieved through
self-defeating behavior patterns. These schema-driven behavior
patterns may have been adaptive and functional in patients’ early
family environments. In later life, outside the original family set-
ting, these behaviors often are self-defeating and ultimately serve
to reinforce patients’ schemas.
For example, a woman with the Subjugation schema may re-
peatedly select men who are domineering. By doing so, she adopts
a subordinate role which feels comfortable and familiar, while rein-
forcing her view of herself as subjugated. Maladaptive partner se-
lection is one of the most common mechanisms through which
schemas are maintained.

21
Cognitive Therapy for Personality Disorders (3rd ed.)

Schema maintenance often leads patients to feel hopeless about

changing their schemas, even after they learn to recognize and moni-
tor them. Early Maladaptive Schemas seem so inextricably tied to
their view of themselves that many patients cannot conceive of
changing them, no matter how motivated patients are.
To summarize, cognitive filters and self-defeating behaviors
are the primary mechanisms of schema maintenance, and together
serve to perpetuate schemas, making them increasingly inflexible.

Schema Avoidance. The importance of avoidance as a charac-

teristic of personality disorders has already been emphasized. To
reiterate, when EMS’s are triggered, the individual usually experi-
ences a high level of affect, such as intense anger, anxiety, sadness,
or guilt. This emotional intensity is usually unpleasant; therefore
the individual often develops both volitional and automatic proc-
esses for avoiding either the triggering of the schema or the experi-
encing of affect connected to the schema. These processes can be
explained as aversive conditioning.
We have observed several types of schema avoidance. Some of
these processes involve cognitive avoidance. Cognitive avoidance
refers to automatic or volitional attempts to block thoughts or im-
ages that might trigger the schema. For example, when some pa-
tients are asked to recall an event that triggers a schema, they reply:
“T don’t want to think about that” or “I forgot”; and, if asked to
visualize the situation, they might close their eyes and say, “All I
see is a blank screen.”
Some of these cognitive avoidance processes overlap with the
psychoanalytic concept of defense mechanisms. Examples of these
include repression, suppression, and denial. Another strategy for
cognitive avoidance can be depersonalization, a process by which
patients remove themselves psychologically from the situation that
triggers an EMS. Compulsive behavior can often serve the same
function of distracting patients from focusing their thoughts on po-
tentially upsetting life events that trigger schemas.
A second type of schema avoidance process is affective avoid-
ance. Affective avoidance refers to automatic or volitional attempts
to block feelings that are triggered by schemas. For example, some
borderline patients have reported to us that they cut their wrists to
numb themselves to the unbearable pain triggered byearly schemas.
More frequently, though, we observe patients who seem to have
learned automatic processes for dulling their emotional experience.
Such patients rarely feel extreme anger, sadness, or anxiety, even

pH:
 Part I; Rationale and Theory

in situations that would certainly trigger these emotions for most

other people. This affective avoidance can take place even when
there is no cognitive avoidance. In other words, in the face of a dis-
ruptive life event, some patients are fully capable of reporting their
cognitions, yet deny experiencing the emotions that would normally
accompany these thoughts. The result of this affective avoidance
process seems to be that avoidant patients experience more chronic,
diffuse emotions and psychosomatic symptoms, in comparison with
nonavoidant patients who experience more intense, acute emotions
that pass quickly, followed by periods of normal mood.
The final type of schema avoidance is behavioral avoidance.
Behavioral avoidance refers to the tendency of many patients to
avoid real-life situations or circumstances that might trigger pain-
ful schemas. At its most extreme, behavioral avoidance can be dem-
onstrated through social isolation, agoraphobia, or failure to attempt
any type of productive career or family responsibilities.
As an example of a less extreme form of behavioral avoidance,
consider a male patient with the Failure schema. He assumes
a priori that he will fail at any work task. Based on this premise, he
avoids committing himself to a demanding career and does not seek
promotions or advancement on the job. This underachievement is
an example of a schema-driven process. By not pursuing challenges,
he avoids the pain of what he anticipates will be inevitable failure;
however, by maintaining the status quo at work, he also reinforces
his view of himself as incompetent. Thus, schema-avoidant be-
haviors protect individuals from committing themselves fully to
situations that might trigger early schemas, yet this process of
noncommitment is itself self-defeating and never challenges the
validity of the schema itself.
In summary, all three major types of schema avoidance -- cog-
nitive, affective, and behavioral -- allow patientsto escape the pain
associated with their EMS’s. However, the price of this avoidance
is (a) the schema may never be brought into the open and ques-
tioned, and (b) life experiences are precluded that might disprove
the validity of these schemas.

Schema Compensation. Schema compensation refers to proc-

esses that overcompensate for Early Maladaptive Schemas. We have
observed that many patients adopt cognitive or behavioral styles
that seem to be the opposite of what we would predict from a knowl-
edge of their early schemas. (Analysts discuss the notion of reac-
tion formation, which is a related concept.) For example, some

23
Cognitive Therapy for Personality Disorders (3rd ed.)

patients who have experienced significant Emotional Deprivation

as children behave in a narcissistic manner as adults. Their appar-
ent sense of entitlement obscures the underlying deprivation.
Schema compensation is often functional to a certain extent.
For example, instead of behaving in a manner that reinforces a
sense of deprivation, some patients put all their effort into get-
ting these needs met. Unfortunately, these attempts often over-
shoot the mark and ultimately backfire. The narcissistic patient
may end up alienating friends, spouses, and colleagues, return-
ing once again to a state of deprivation.
The counterdependent patient may reject all help from others
and end up excessively self-reliant -- unable to ask for help even
when necessary and appropriate. Or the patient with a Dependence/
Incompetence schema may vehemently deny the validity of any
criticism -- and thus never receive the benefit of constructive feed-
back that might lead to greater competence or success.
Schema compensation processes may be viewed as partially suc-
cessful attempts by patients to challenge their schemas. Unfortu-
nately, schema compensation almost always involves a failure to
recognize the underlying vulnerability and therefore leaves the pa-
tient unprepared for the powerful emotional pain if schema com-
pensation fails and the schema erupts. Furthermore, schema-driven
behaviors that overcompensate may infringe unfairly on the rights
of others and ultimately lead to deleterious real-life consequences.

Table 2 (p. 25) highlights the distinctions between the three

major types of schema-driven behaviors: schema maintenance,
compensation, and avoidance behaviors. For each schema, the ta-
ble provides an example of each process as well as an example of
adaptive behavior that is not schema-driven, and is thus typical of
individuals who do not have the schema in question.

24
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 Part II

SCHEMA-FOCUSED THERAPY:
CASE CONCEPTUALIZATION
AND PATIENT ASSESSMENT

OVERVIEW

Schema-focused therapy is divided into two phases: (a) assess-

ment and case conceptualization and (b) schema change. This chapter
will focus on the first phase, which requires eight basic steps. These
steps, briefly, are:

ie Identify presenting symptoms and problems in the initial

evaluation session.
Obtain a brief, focused life history.
2. Administer the Multimodal Life History Inventory
(A. Lazarus & C. Lazarus, 1991) and the Young.Schema
Questionnaire (Long Form, Second Edition) (YSQ; see Ap-
pendix A, pp. 59-69).
. Educate the patient about schemas and discuss the YSQ.
. Trigger schemas in the session and outside the session through
imagery, discussing upsetting events in the past and present,
examining the therapeutic relationship, recommending rel-
evant books and movies, reviewing dreams, and assigning
homework.
. Confront schema avoidance, if necessary.
. Identify schema-driven behaviors: schema maintenance,
avoidance, and compensation. Administer the Young-Rygh
Avoidance Inventory (YRAI; Young & Rygh, 1994) and the
Young Compensation Inventory (YCI; Young, 1995) if ap-
propriate.

Zid.
Cognitive Therapy for Personality Disorders (3rd ed.)

7. Integrate the preceding information into a coherent con-

ceptualization of the patient. Administer the Young Parenting
Inventory (YPI; Young, 1994). Link presenting problems,
childhood experiences (origins), adolescent and adult be-
havioral patterns, emotions, and the therapeutic relationship
with the EMS’s. Complete the Schema Conceptualization
Form (Young, 1992). Get feedback from the patient about
the case conceptualization.
8. Distinguish between primary, secondary, and linked schemas.
Target one or two core schemas for the change process.

THE EVALUATION

The first stage in identifying schemas is the evaluation session.

During the evaluation session, the therapist tries to identify the pre-
senting symptoms and problems. The therapist begins to formcon-
nections among specific emotions, symptoms, life problems, and
schemas. During the course of inquiry about life events and symp-
toms, hypotheses are developed about possible themes. Issues of
Disconnection and Rejection, Impaired Autonomy and Performance,
Impaired Limits, Other-Directedness, and Overvigilance and Inhi-
bition are explored to see which domains present significant prob-
lems for the patient.
In order to illustrate the process of identifying and changing
schemas, we will present a patient named Carla, a 22-year-old
woman in her first year of law school when she initially came for
treatment.*
When Carla came for her first session, the symptoms she pre-
sented were panic, agitation, depression, lethargy, tiredness, diffi-
culty sleeping, depersonalization, and a sense of being lost. In terms
of specific life events, she attributed these feelings to (a) “Pushing
myself at school but not knowing why,” (b) questioning her own
identity (“Who am I?”), (c) not having any close friends or relation-
ships, and (d) difficulties with her family. Her Beck Depression
Inventory (Beck & Steer, 1987) score was 17, with particularly high
scores on items having to do with guilt, being disgusted with her-
self, and blaming herself all the time for her faults.

*Minor changes have been made in the case conceptualization of Carla for this new edition to
reflect recent changes in the names of schemas.

28
 Part II: Case Conceptualization and Patient Assessment

QUESTIONNAIRES

The second stage in the identification process is the administra-

tion of the Multimodal Life History Inventory and the Young Schema
Questionnaire. These are usually assigned as homework during
the weeks between sessions two and four.
On Carla’s Multimodal Life History Inventory, she indicated
that the major behavior problems she wanted to change were “I
want to have more balance in my life,” and “I cannot concentrate on
anything any more.” She listed her major fears: fear of failure, fear
of being alone, fear of losing people who were important to her,
and fear of not being able to share her life with others. She also
reported continual feelings of being cold but not knowing what the
cold feelings were from, and of depersonalizing periodically.
In the section regarding images, Carla reported having unpleas-
ant childhood images: helpless images and lonely images. She
pictured herself as being hurt, not being able to cope, losing con-
trol, hurting others, failing, and being trapped. In the section
regarding her view of herself, Carla indicated that she saw her-
self as useless, unlovable, unattractive, undesirable, and not being
able to do anything right.
In the section having to do with values and underlying assump-
tions, Carla indicated very strong belief in the statement “It is my
responsibility to make other people happy.” She also endorsed state-
ments that she should be good at everything she does, that it is very
important to please other people, and that she should strive for per-
fection. In the sentence completion section, she completed the stem,
“Eyer since I was a child...” by writing, “. . ve loved my family
more than myself.” Carla added an addendum to the questionnaire
in which she wrote the following:

Over the past 4 months I have been troubled by every-

thing and anything. I have been tense, irritable, and de-
pressed most of the time. I do not seem to be able to relax
or get any relief from any activity. I worry constantly. I’m
having a hard time dealing with pressures of school and
family. I cannot concentrate. I do not know what I want for
myself in terms of career or anything. I don’t feel like I
have much of a life, just an existence, and I’m not very
happy.

29
Cognitive Therapy for Personality Disorders (3rd ed.)

I do not sleep well at all. I have had lots of nightmares

over the past few months -- the most frightening thing about
them is that they have been actual life experiences. I’m
afraid of being a failure, of not being able to do anything
well or that makes me feel good. I don’t really know who I
am: My life seems inseparable from my parents. I’ve tried
so hard to live up to my parents’ expectations and yet I never
seem to be able to do that. I used to be good-natured and
cheerful; I now feel like I’m upset all the time; I’m a vol-
cano waiting to erupt.

EDUCATING PATIENTS ABOUT SCHEMAS

The third step in the identification process is to educate patients

about the nature of schemas. The therapist explains that a schema is
an extremely strong theme regarding themselves and others that
they learned at a very young age and that is self-defeating. The
beliefs and feelings are so strong that patients simply assume them
to be true. The therapist points out that a schema is different from
most other types of thinking in the respect that it has tremendous
emotional strength behind it. It has the strength of a lifetime of
memories and of constant repetition to back it up.
Schemas are often central to patients’ entire self-image and view
of the world. Naturally, the schema is going to fight very hard for
survival. It may feel very comfortable and even reassuring to pa-
tients to hold onto the schema, regardless of its negative conse-
quences for their lives. We sometimes compare a schema to a
comfortable old shoe that is not of much use anymore but feels too
comfortable to throw out.
We explain to patients that we anticipate that they are going to
distort information to maintain the schema, so they should not be-
come discouraged because the schema is so slow to change. We are
trying to prepare them for what the process of schema change is
going to be like. We use the metaphor of a war and emphasize
that we are going to have to do battle with the schema. We then
usually suggest that patients read Reinventing Your Life (Young &
Klosko, 1994), a self-help book based on the schema-focused ap-
proach, as well as the “Client’s Guide to Schema-Focused Therapy”
(see Appendix B, pp. 71-80).
After explaining about the nature of schemas, the therapist re-
views the Young Schema Questionnaire (Long Form, Second Edi-
tion) in detail with the patient. The therapist pays particular attention

30
 Part II: Case Conceptualization and Patient Assessment

to items on which the patient scored high (5 or 6) by asking for

examples to amplify and clarify the patient’s responses. When pos-
sible, the therapist attempts to link YSQ responses with presenting
problems or with Multimodal Life History Inventory responses in
order to demonstrate the relevance of schemas to the patient’s life.
Below are the schemas on which Carla scored high on the Young
Schema Questionnaire.

Li Enmeshment/Undeveloped Self. Carla mentioned that she

could not separate her own life from her parents’ life. She
also mentioned not having a sense of identity, of not know-
ing what she wanted.
. Subjugation and Self-Sacrifice. Carla stated in her question-
naire and during the session that she put the needs of others
ahead of her own and that she would like to be able to think
about herself more. She also noted the symptom of anger.
These are all typical of patients with Subjugation and Self-
Sacrifice schemas, in which the issue is one of suppressing
her own needs and her own feelings in order to please other
people.
. Failure. Carla mentioned that she was afraid of being a fail-
ure, that she made too many mistakes, and that she could not
do anything right.
. Abandonment/Instability, Defectiveness/Shame, and Emo-
tional Deprivation. These all seemed to be major themes
for Carla. She mentioned a fear of being alone, a fear of
losing people important to her, lonely images, being unlov-
able and undesirable, and a sense of being lost. Carla also
indicated that she saw herself as unattractive and ugly.
. Unrelenting Standards/Hypercriticalness. Carla seemed to
have considerable difficulty in setting reasonable expecta-
tions for herself, particularly in the realm of unrealistic
achievement and responsibility. Carla mentioned that she
was pushing herself but did not know why, that she should
be good at everything she does, that she should strive for
perfection, and that she wanted to have more balance be-
tween work and other areas. She identified working too hard
as a problem behavior.
_ Punitiveness. Finally, it appeared that Carla might be hav-
ing difficulty with Punitiveness. She mentioned in her
Multimodal Life History Inventory that she was trying to
make people understand her but “They’re angry at me. They

31
Cognitive Therapy for Personality Disorders (3rd ed.)

think I did something but I didn’t.” This is the typical think-

ing of patients with the Punitiveness schema: thatsomehow
they have done something wrong or are bad, and they feel
they deserve to be punished.

TRIGGERING SCHEMAS

Up to this point, the identification process has been primarily

cognitive, that is, rational and intellectual. The next step is for the
therapist to trigger schemas in an affective manner during the ses-
sion and outside the session. By utilizing experiential techniques to
trigger schemas, the therapist can test each of the schemas hypoth-
esized during the first four steps to see whether it applies to the
case. One can usually determine that a schema has been triggered
when a high level of affect is aroused. The higher the level of af-
fect, the more primary the schema is likely to be. Secondary schemas
are generally less emotionally charged and may not be triggered at
all during this phase. There are a variety of strategies for triggering
schemas:

Imagery. One extremely helpful technique is to ask patients to

close their eyes and to report whatever imagescome to mind spon-
taneously. A variation of this technique is to ask the patient to get
an image of a specific type of situation that the therapist believes,
from previous data obtained from the patient, will trigger the schema.
This, for example, could be a scene with a spouse or a parent.
Returning to our case example, Carla reported two images dur-
ing her second therapy session. One image was of her parents and
brother when she was a child. She reported that her parents looked
very unhappy and were fighting about her brother. Her brother was
not working enough in school and was not taking care of his room.
While reporting this image, Carla reported that her head was spin-
ning, the noise was very loud, and her head was aching.
In a second image, she was alone in her room. She reported
feeling cold and “closed up. There is nothing inside and nothing
outside. I feel different, I’m out of control.”
These images reinforced hypotheses formed earlier about Carla
regarding specific schemas. The themes of Punitiveness, Subjuga-
tion, and Unrelenting Standards/Hypercriticalness were evident in
the first image. The theme of being abandoned was apparent in the
second image.

32
 Part II: Case Conceptualization and Patient Assessment

Current Events. A second technique for triggering schemas is

to discuss upsetting events currently taking place in the patient’s
life. By asking the patient to discuss events that are distressing or
that trigger strong feelings and by inquiring about the meaning of
those events, the therapist can get further information about schemas.
In the third session Carla reported getting extremely angry and
anxious about her law school work. The anger, she said, was be-
cause “I’ve got to wear this image because that’s all the professors
' care about.” Upon further questioning she mentioned that her
whole life had involved wearing an image -- being what other people
wanted her to be, not what she felt like herself. When asked what
she would be like if she was just herself, she responded that she did
not know and could not find out so long as she was trying so hard to
be what other people wanted her to be. This discussion of current
problems, specifically the image she felt she had to “wear”at school,
offered confirmation of the Subjugation and Approval/Recognition-
Seeking schemas.

Past Memories. The third technique for eliciting schemas is to

invite the patient to discuss memories and distressing experiences
from the past. Recalling early childhood experiences, often through
imagery, generates a high level of affect. These experiences, we
presume, served to initiate the schema. We also ask patients to
complete the Young Parenting Inventory (YPI; Young, 1994), a form
that involves rating their mothers and fathers on behaviors we hy-
pothesize are the most common origins for each of the schemas.
Discussing high-scoring items from the YPI with patients can serve
as another inroad into exploring the childhood origins of schemas.
In the fourth session, the therapist asked Carla if she would dis-
cuss her parents and how she dealt with pressure when she was
younger. She reported that her parents had always made decisions
for her. As she began to talk about her daily routine as a youngster,
she became increasingly agitated. She recalled that she was spend-
ing 9 hours doing homework every day by the age of 12. She was
so afraid of failing in seventh grade that she had no life of her own.
of
She also mentioned that during her teenage years she was afraid
growing up in front of her mother because it had been so painful to
watch her adolescent brother fighting with her mother. She said, “I
wanted to protect my mother.” This discussion of the past offered
well
confirmation of the Subjugation and Self-Sacrifice schemas, as
as the Punitiveness and Unrelenting Standards/Hypercriticalness
schemas.

33
Cognitive Therapy for Personality Disorders (3rd ed.)

Therapeutic Relationship. Another strategy for activating

schemas is to discuss the therapeutic relationship -- what analysts
refer to as the transference. In schema-focused therapy, the thera-
pist pays close attention to the therapeutic relationship, looking for
events that seem to trigger schemas during the session. When these
events arise, the therapist spends time discussing those aspects of
the therapeutic relationship that are difficult for the patient.
During the second, third, and fourth months of therapy with
Carla, considerable time was devoted to discussion of the therapeu-
tic relationship. As early as the sixth session, Carla reported fear-
ing that she would become dependent on the therapist and eventually
would not be able to separate herself. She also reported that
she wanted someone to be there for her but was afraid that he
would leave her. Carla was asked to write more about these
thoughts for homework. These are excerpts:

So much of the time I am afraid of you -- what you

think, what you ask me. I pray all the time that somebody
could really understand me and what I feel -- especially since
I don’t -- and that he’d never leave me alone. ButI’m al-
ways alone. ...
It hurts so much to want somebody to care because
it just never materializes. I feel like a thing that most of
the time is a pain in the ass and once in a while a conven-
ience ... I don’t want to be alone.

These discussions about the therapeutic relationship further con-

firmed Carla’s Abandonment/Instability, Emotional Deprivation,
and Defectiveness/Shame schemas.

Books and Movies. Schemas can also be triggered by assign-

ing books and films that are relevant to the hypothesized schemas.
Books and movies have proven to be very powerful ways of activat-
ing schemas, which can then be discussed at the next session.
During the course of Carla’s therapy, the therapist proposed
several books or movies, including Drama of the Gifted Child by
Alice Miller (1981); Desert Bloom (Corr, 1986), a film; and Sepa-
ration by John Bowlby (1973). Drama of the Gifted Child was
selected because it deals with the theme of a child subjugating her
own needs to please a parent; Separation because it deals specifi-
cally with the theme of abandonment; and Desert Bloom because it
deals with a young girl similar to Carla. Carla described Desert

34
 Part II: Case Conceptualization and Patient Assessment

Bloom: “The kid was trying so hard to please and the mother didn’t
understand the child. She was closed out of the family, just trying
to keep the peace.” Carla reported that she was fuming with anger
and hostility after watching the movie. She reported similarly pow-
erful emotions to Drama of the Gifted Child and Separation.

Group Therapy. Group therapy is an excellent forum for trig-

_ gering schemas that are interpersonal in nature. The therapist ar-
ranged for Carla to enter a group that was specifically focused on
intimacy and interpersonal relationships. The other members of the
group were dealing with similar issues of failure, abandonment, and
subjugation. Each week, Carla and the therapist would briefly re-
view what had happened in the group that week, with particular
emphasis on key moments or themes that triggered strong emotions
for Carla.
During the first group session, Carla was completely immobi-
lized and panicked and could say nothing. She reported that she
was afraid her feelings would go out of control, that she would be
attacked by the group, and that she felt ashamed of herself. She
said, “No one can put up with me.”
In a later group session she became extremely distressed when
another group member spoke about being forced by parents to do
things he did not want to do as a child. Carla commented to the
therapist that “the only way to have contact is to live their way.”
This session set off an entire week in which her schema about her
family controlling her and forcing her to do things their way was
triggered. She felt continual anger and fear. These group experi-
ences offered further support for the importance of the Subjugation
and Defectiveness/Shame schemas.

Dreams. Dreams are another helpful technique for eliciting

schemas. In an early session, Carla reported having repeated night-
mares. Each night she would dream that her mother was leaving
her in a strange house, that her mother was very mad at her, and that
she had not cleaned up properly. Dreams like this validated schemas
of Abandonment/Instability, Punitiveness, and Unrelenting Stand-
ards/Hypercriticalness.

Homework. The final strategy for triggering schemas is to ask

to
patients to do homework assignments in which they are asked
write about a specific schema-relat ed topic or to keep a Schema
Diary (Young, 1993).

35
Cognitive Therapy for Personality Disorders (3rd ed.)

During the third month of therapy the therapist asked Carla to

keep a Schema Diary in which she would write down her thoughts
and feelings whenever she became particularly upset. One week
she reported feeling panicky and nervous, afraid that she was losing
her grip on everything. She wrote the following:

I only want to be a good person. I want to be able to

love and be loved back, and I don’t want it to be taken away
or have to give it up. I’m always making mistakes, hurting
those who care for me the most.
I’m just not as good as other people. Everyone is so
disappointed and angry with me and I am too. I know other
people hate me too, wish I were out of the way. I want
somebody to hold me, but nobody is ever there. And even
if someone were there, I wouldn’t want to bother him.

In this diary excerpt, Carla poignantly conveys schemas related

to Defectiveness/Shame, Abandonment/Instability, Self-Sacrifice,
Emotional Deprivation, and Punitiveness.

CONFRONTING SCHEMA AVOIDANCE

Most patients with personality disorders evidence some degree

of schema avoidance. This schema avoidance is usually the patient’s
way of avoiding the high emotional intensity and unpleasantness
that is experienced when a schema erupts. It is important to be able
to recognize when the patient is having a symptom that is part of a
schema and when the patient is experiencing a symptom that is pri-
marily an avoidance of a schema.
Two characteristics seem to differentiate schema avoidance from
the schema itself. When a patient experiences symptoms or emo-
tions but cannot identify the content connected with them, this is
usually typical of schema avoidance. In Carla’s case, she would
frequently feel anxious, sad, or angry but not be able to report what
she was anxious, sad, or angry about.
Another identifying characteristic of schema avoidance is the
presence of somatic symptoms like dizziness, faintness, fever, de-
personalization, and numbness, rather than “primary” emotions
such as anger, fear, sadness, or guilt. Vague somatic symptoms are
very often indications of schema avoidance.
In Carla’s case, the therapist frequently observed that as soon as
they began to discuss issues of abandonment, she would begin to

36
 Part II: Case Conceptualization and Patient Assessment

report feeling very cold or dizzy. Sometimes she would depers

on-
alize and not be able to go on with the sessions.
This was a particular problem during the third month of therapy.
Carla would often become immobilized and be unable to speak for
20 minutes at a time because the material being dealt with was too
painful for her to focus on. During these long stretches of silence,
Carla would report that she did not know what she was thinking
about but had depersonalized or felt cold or dizzy and wanted to
' escape from the session.
These symptoms are all indications of schema avoidance. By
examining the themes being discussed when the schema avoidance
begins, it is often possible to deduce the areas in which core schemas
are likely to be found.
When the therapist recognizes that schema avoidance is taking
place, it is essential to push the patient to confront the thoughts,
images, and emotions that are connected with the schema and not to
run away from them. (This may not always be possible with more
fragile, lower functioning patients.) This can be accomplished by
discussing with the patient the pros and cons of looking at these
upsetting issues.
With Carla, each time she would start to feel cold, depersonal-
ized, or dizzy, the therapist would ask her what she was thinking
about just before depersonalizing. When she said she could not
remember, he would remind her what they were talking about and
insist that she begin to talk about that issue again. He would also
push her to focus on an image that he knew from previous experi-
ence might trigger the schema again. When Carla expressed the
desire to escape, the therapist suggested to her that escaping would
just prolong the process and would not allow them to examine the
issues that were so important to her.
After repeated pushing and confrontation by the therapist, the
patient is often able to refocus on the schema and begin once again
to discuss the content connected with the schema. The therapist
must help the patient see that the short-term pain of experiencing
the schema will be outweighed by the long-term benefits of ac-
knowledging the schema and working to change it.
Six months after the therapy had begun with Carla, most of the
material connected with her schemas, including early memories and
issues connected with the therapeutic relationship, had been dis-
cussed and experienced. Many of the somatic symptoms stopped
completely. Specifically, the dizziness, faintness, coldness, fever,
depersonalization, and numbness disappeared. Her primary emo-
tions -- namely fear, anger, sadness, and guilt -- remained. Now she
was able to identify the events in the past and present that triggered

37
‘ Cognitive Therapy for Personality Disorders (3rd ed.)

those feelings, and she could see how her interpretations of events
in the past and present were related to these emotions.

IDENTIFYING SCHEMA-DRIVEN BEHAVIOR

The sixth step in identifying schemas is to recognize the schema-

driven behaviors. As mentioned earlier in this guide, one of the
reasons that early schemas are so often maladaptive is that patients
develop self-defeating behavior patterns that reinforce the schemas.
These schema-driven behaviors are the processes by which patients
learn to cope with and adapt to their environment, based on the
self-perceptions generated by the schemas. Each schema-driven
behavior can be classified as schema maintenance, schema avoid-
ance, or schema compensation, depending on its function.
These behaviors simultaneously maintain the schema intact, al-
low the patient to avoid triggering the schema, and permit the pa-
tient to function in the world with as little distress as possible.
Schema-driven behaviors, therefore, maintain an uneasy equilib-
rium for the patient. In this regard, they parallel the concept of
neurosis: They are partially reinforced responses.
On the positive side, the patient avoids the painful affect con-
nected to the schema and is usually able to function adequately in
the world. On the negative side, the schema itself is never really
changed, so the patient is always vulnerable to trigger events that
threaten to disrupt the uneasy balance between coping and not cop-
ing. Furthermore, these behaviors often involve the avoidance of
major life concerns, such as close relationships or a challenging
career.
Identifying schema-driven behaviors requires a careful analysis
of the patient’s actual behaviors in specific problem areas. Once
these schema-driven behaviors have been confirmed, the therapist
presents them to the patient and obtains feedback.
Carla dealt with romantic relationships by either avoiding them
altogether or by terminating them very quickly as soon as intimacy
began. She developed this behavior as a way of coping with schemas
about Defectivenes/Shame and Abandonment/Instability. Carla was
so convinced that she was undesirable, and that partners she got
close to would leave once they got to know her, that she saw no
reason to pursue relationships and face certain abandonment.
Table 3 (p. 39) illustrates each of Carla’s problem areas, the
relevant schemas, and the schema-driven behaviors. It is important
to note that more than one schema can be associated with each life

38
 Part I: Case Conceptualization and Patient Assessment
eee
TABLE 3: CASE EXAMPLE ILLUSTRATING RELATIONSHIP
BETWEEN PROBLEM AREAS, SCHEMAS, AND
SCHEMA-DRIVEN BEHAVIORS

PROBLEM AREAS SCHEMAS SCHEMA-DRIVEN BEHAVIORS

a
n Ener c eae aroha
Romantic Abandonment/ Avoids men most of the time.
Relationships Instability Terminates relationships as
Defectiveness/Shame soon as she begins to feel
close. (Schema avoidance)
School Subjugation Studies constantly. No time
Performance Unrelenting for pleasure. Does whatever
Standards/Hyper- professors expect. (Schema
criticalness maintenance)

Family All of Her Schemas Constantly tries to meet par-

Relationships ents’ expectations. Sup-
presses own emotions and
needs. (Schema maintenance)

Therapy Abandonment/ Constantly tries to please

Relationship Instability therapist. Thanks therapist
Emotional Deprivation _inordinately. Apologizes for
Defectiveness/Shame not being a good patient.
Subjugation (of Keeps head down during ses-
Emotions) sions. Tries to suppress anger
and crying during sessions.
Worries inordinately about
therapist abandoning her, es-
pecially when he goes on vaca-
tion. (Schema maintenance)

area. Furthermore, a schemamay be activated in one life area for a

particular patient yet not be activated in other problem domains.

_ CONCEPTUALIZING THE
PATIENT IN SCHEMA TERMS

Steps seven and eight both involve conceptualizing the patient

in schema terms. First, the therapist must link the material obtained
through the procedures described earlier and then demonstrate the
connection between schemas, emotions, current trigger events, the
therapeutic relationship, and origins from the past.

39
Cognitive Therapy for Personality Disorders (3rd ed.)

Once the therapist is able to identify these schemas and to see

how they manifest themselves in the past and present, the therapist
summarizes these conclusions for the patient and asks for feedback.
These schemas are then fine-tuned until the patient and therapist
agree that the formulation is accurate. Table 4 (p. 41) describes
the schemas as the therapist summarized them for Carla, after ob-
taining feedback from her.
The final step is for the therapist to distinguish among primary,
secondary, and linked schemas. To do this, the therapist must un-
derstand how all the relevant schemas interrelate.
The therapist’s first objective is to identify the one or two core,
or primary, schemas; these generally serve as the initial targets for
the change procedures outlined in the next section. These core
schemas can be isolated by paying close attention to events trigger-
ing high levels of affect, to the most serious and enduring life prob-
lems, and to the early origins of the patient’s emotional distress.
Primary schemas are identified through three criteria: The first
is that a primary schema usually triggers the highest level of emo-
tion. The second is that a primary schema is almost always closely
linked to the most distressing, pervasive, and enduring life prob-
lems experienced by the patient. Third, the core schemas are usu-
ally closely tied to the patient’s most serious developmental problems
with parents, siblings, or peers during the early years of life.
After identifying the primary schemas, the therapist looks for
other schemas that are /inked with each primary schema. A linked
schema is one that can be best explained by reference to a primary
schema. For example, with Carla, the Subjugation schema was linked
to the Abandonment schema: If she failed to comply with the
desires of others, she felt certain they would withdraw or leave her.
After delineating primary and linked schemas, the therapist iden-
tifies the secondary schemas. These schemas are relatively inde-
pendent of the primary schemas and seem to be of lower priority
and salience. These secondary schemas are targeted for change later
in the treatment process.
Table 5 (p. 42) illustrates the differentiation of primary, sec-
ondary, and linked schemas in the case of Carla.

40
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Part II: Case Conceptualization and Patient Assessment
Cognitive Therapy for Personality Disorders (3rd ed.)

TABLE 5: CASE ILLUSTRATION OF PRIMARY, SECONDARY,

AND LINKED SCHEMAS
SCHEMA
SCHEMAS RANKING EXPLANATION

. Abandonment/ Primary Parents left her alone so often

Instability as an infant that she never
developed a stable sense of
attachment.

Subjugation Primary Patient was made to feel guilty

Self-Sacrifice Linked to and bad when she asserted her
Abandonment own needs. Parents withdrew
and left her alone when she did
not comply.

Defectiveness/ Primary Patient was made to feel

Shame Linked to ashamed of her appearance by
Abandonment mother’s continual criticism.
This later led to a feeling of
being unattractive and undesir-
able to men and to fear that they
would leave her.

Emotional Primary Absence of nurturance and

Deprivation empathy contributed to feelings
of deprivation.

Unrelenting Secondary Had to meet parents’ high stand-

Standards ards for achievement. Patient
Punitiveness was made to feel like a failure if
she was less than perfect. Pa-
tient and brother were punished
for being bad if they made even
minor mistakes.

42
 Part III

SCHEMA-FOCUSED THERAPY:
STRATEGIES FOR CHANGE

OVERVIEW

In this final section, four major types of intervention will be

outlined: cognitive, experiential, interpersonal, and behavioral.
Cognitive techniques are generally utilized first to systematize the
process of schema change. Patients are taught cognitive techniques
that enable them to fight schemas each time they arise outside
the session. They learn how to battle their emotional beliefs per-
sistently with rational arguments. Patients also learn how
schemas distort information and thus reinforce the strength of
beliefs that otherwise would seem illogical.
Experiential techniques are usually emphasized next to “loosen
up” the schemas and make them more flexible for change. After
cognitive and experiential work, the therapy focuses on behavioral
change. This is usually the longest phase because it involves chang-
ing long-term, self-defeating behavioral patterns that have become
deeply entrenched. It is often easier to alter emotions and beliefs
than to change these behaviors, such as patterns of partner selection
or intimacy.
Interpersonal techniques are emphasized throughout treatment
with patients who display their schemas in the therapeutic relation-
ship (“transference”). This is particularly important for patients
with core schemas in the Disconnection and Rejection domain, in-
cluding Emotional Deprivation, Abandonment/Instability, and
Mistrust/A buse.
Regardless of which phase of treatment the patient is undergo-
ing, we have found it essential that schemas be challenged when

43
Cognitive Therapy for Personality Disorders (3rd ed.)

they are triggered, that is, when affective arousal relevant to the
schema has been activated inthe patient. Even during the cognitive
phase, discussing schemas in the abstract or intellectually is rarely
as powerful as questioning them in the presence of affect.
For example, ifa particular patient has an Abandonment schema,
the therapist will probably make more headway with the issue dur-
ing a session just before going away for a vacation than at some
other time. Just before the therapist’s vacation, the patient is most
likely to be angry, anxious, or depressed in session. The schema
will probably be activated and therefore more accessible.
The remainder of the book will be devoted to elaborating on the
four types of interventions, drawing again on the case of Carla for
illustration.

COGNITIVE TECHNIQUES

Many of the techniques drawn from short-term cognitive therapy

can be adapted to schema work. We will devote considerable time
to these strategies in order to emphasize the value of cognitive tech-
niques in changing deeper structures.

REVIEW EVIDENCE IN
SUPPORT OF THE SCHEMAS

Before trying to change a schema, it is very important to elicit

all of the information that the patient uses to support it. Patients
have a lifetime of evidence which they can draw on to support the
validity of their schemas. To elicit this evidence, the therapist first
does a life review. The therapist reviews the origins of the schema
in childhood by evoking any memories the patient recalls that might
be relevant to the schema. The therapist then traces the schema as it
developed and was reinforced through adolescence and adulthood.
The therapist can also ask the patient to play “devil’s advocate,”
defending the schema. The therapist introduces this technique by
saying, “I want you to defend the schema while I try to show you
why I think the schema is not true. Make the best case you possibly
can in support of the schema, and be sure to give me as many ex-
amples as possible to validate it.”
Returning to our case illustration the therapist asked Carla to
defend her Abandonment/Instability and Defectiveness/Shame
schemas. She gave him three basic arguments in support of her

44
 Part IIT: Strategies for Change

unlovability: First, her parents and brother were constantly angry

at her and critical of her when she was a child; therefore, she
must
not be very lovable. Second, she had been rejected by three boy-
friends. Finally, she was left alone a lot. Inthe next stage of schema
change, the therapist begins to cast doubt on this evidence.

CRITICALLY EXAMINE
THE SUPPORTING EVIDENCE

The goal in this stage is to go through each piece of evidence

that the patient offers in support of the schema and to try to discover
some other way of viewing that same information so that it does not
really prove the schema. The therapist can discredit the evidence in
a variety of ways. One method is to use collaborative empiricism or
guided discovery to help patients see for themselves that the schema
is invalid. At other times the therapist will have to use a more con-
frontational style, depending on how strong the schema maintenance
processes seem to be.
In working with early schemas, the therapist adopts a style we
call “empathic confrontation” or “empathic reality-testing.” The
therapist is continually working to find a balance between empa-
thizing with the patient for the pain brought on by the schema and
confronting the patient with evidence that discredits the schema. If
the therapist is too confrontational, the patient will ignore the
counterarguments advanced by the therapist on the grounds that
the therapist does not really understand how the patient feels.
One method for invalidating evidence is to discount early fami-
ly experiences as reflecting the maladaptive standards and expec-
tations of their parents. We emphasize that these parental stand-
ards do not generalize to teachers, bosses, friends, and so on, out-
side of the home. Other family evidence can be discounted by point-
ing out the psychological maladjustment of each parent, of the marital
couple, or of the family system. The therapist emphasizes that chil-
dren are often assigned roles in a family that are not in the children’s
best interest yet may serve a psychological need for one or both of
the parents. These roles do not reflect any inherent flaws in the
children, but rather they are the result of distorted family dynamics.
The therapist often examines each family member individually, with
the patients’ help, until the therapist can shift patients to a more
realistic perspective on their early family life. By the end of this
process, the therapist hopes that patients will experience sadness or
anger about what happened to them in their childhood yet not view

45
Cognitive Therapy for Personality Disorders (3rd ed.)

these early experiences as proof of some inherent unlovability, flaw,

incompetence, or badness.
In Carla’s case, she and the therapist concluded, after examin-
ing each of the family members, that her whole family was living a
lie. Following are some of the specific conclusions they reached
about each of her family members.
Carla’s mother was denying her own need for other people. She
could not express positive feelings, even with her husband. She
valued her career over her children. She was cold to everyone, not
just to the patient. She was a perfectionist who considered the chil-
dren to be a nuisance interfering with her career. Carla concluded
that her mother really did not single her out for coldness and criti-
cism because she treated her husband and her son the same way.
Her father, she concluded, was not getting his needs met from
her mother, and he turned inappropriately to the patient to get his
needs met. He then got angry when the patient would not give him
enough support and affection. His demands were interfering with
her need to individuate. Like the mother, her father was a perfec-
tionist. He had a terrible temper, which he frequently took out on
both children. Carla concluded that she was wrong in believing that
her father was making realistic demands on her and that she was too
inadequate to meet them. Rather she came to understand that her
father was trying to get his own needs met inappropriately through
her.
Finally, the therapist arranged for a joint therapy session with
the patient and her brother. The brother confirmed that he had re-
sented Carla because, even as a teenager, he was asked by his par-
ents to take care of Carla all the time because the parents were never
at home. Carla recognized that it was not her fault that she was a
nuisance to her older brother. The problem was that the parents
were making unreasonable demands on the brother, which placed
Carla in the middle. Carla then became the scapegoat for the
brother’s frustration at not being able to spend time with his own
friends.
A second strategy for discrediting evidence is to demonstrate to
patients that, because of their schema-driven behaviors, they have
never really given the schema a fair test. Remember that schema-
driven behaviors are designed to keep the schemas intact while help-
ing patients avoid situations that might trigger the schema.

46
 Part III: Strategies for Change

Carla’s second argument to prove she was unlovable was her

view that three boyfriends had rejected her. To discount this evi-
dence, she and the therapist had to review each of the three relation-
ships with great care. They were soon able to identify her pattern of
schema maintenance and avoidance behaviors: In each instance,
she had chosen an unavailable boyfriend who was bound to leave.
In one case it was a man who was visiting her city only for the
winter; she met another man while she was traveling overseas shortly
before she had to return to America; and in the third case, the man
was a foreign student who would soon be going back to Denmark.
Furthermore, with each of these men, it was Carla who distanced
herself whenever the man tried to get close. Thus, even though the
men may ultimately have been the ones who left, it was Carla who
initiated the distance. Carla and the therapist agreed that the schema
had never really been tested because she had used so many maneu-
vers to avoid becoming fully engaged in and committed to relation-
ships that might trigger the schema.
Through this process, the therapist carefully examines patients’
supporting evidence, pointing out ways in which patients have mis-
construed past situations so that the schema is repeatedly confirmed.
By the end of this stage of schema change, patients have begun to
get some distance from their schemas. They are beginning to won-
der if the schema may be a disastrous myth they have been perpetu-
ating. Nevertheless, the schema still feels more powerful than the
disconfirming evidence that they are only beginning to accumulate.

REVIEW EVIDENCE
CONTRADICTING THE SCHEMA

By this point, the therapist and patient have discredited the nega-
tive information which the patient uses to prove the schema. Now
the therapist has to build up all of the positive information about the
patient that will directly contradict the schema. In Carla’s case, this
included evidence that she is an effective person, ways in which she
does take responsibility, areas of competence and success, and ex-
amples of mutually satisfying friendships in which she is valued for
being herself. Keep in mind, however, that eliciting this positive
information may prove much more difficult than eliciting the nega-
tive information. The selective forgetting of positive information is
part of the schema maintenance processes that are operating con-
tinuously in the patient.

47
Cognitive Therapy for Personality Disorders (3rd ed.)

ILLUSTRATE HOW THE PATIENT

DISCOUNTS CONTRADICTORY EVIDENCE

It is a basic premise of schema theory that the patient will ac-

tively discount evidence contradictory to the schema. This discount-
ing is part of the schema maintenance process. In this phase of
schema change, the therapist must demonstrate to the patient how
this mechanism of discounting operates.
One excellent technique for doing this is the Point-Counterpoint
(P-CP) technique. Point-Counterpoint can be practiced either
aloud in the session or as part of a homework assignment. (The
“devil’s advocate” technique mentioned earlier is a variation of
Point-Counterpoint.) The therapist introduces P-CP by asking the
patient to play the schema. The therapist takes the role of the healthy
side. They have a debate back and forth in which the therapist makes
a point in the patient’s support; then the patient discounts it accord-
ing to the schema; then the therapist responds to the discounting;
and so forth. They then trade roles; the therapist plays the patient’s
schema and the patient plays the healthy part. When P-CP is used
as a homework assignment, the patient plays both parts: the schema
and the adaptive point of view.
In using this technique, it usually becomes obvious quickly that
the patient has no difficulty whatsoever playing the role of the
schema. This is understandable because the schema represents the
patient’s core beliefs throughout a lifetime. The patient can see
how skillfully any positive evidence contrary to the schema can be
discounted. However, when asked to play the healthy, adaptive
view, the patient generally gets stuck almost immediately. Often
the patient is unable to repeat what the therapist said just 2 minutes
earlier to contradict the schema.
This discrepancy between the patient’s ease at playing the schema
and the enormous difficulty in responding rationally to the schema
is often a very powerful lesson. The patient can now see how hard
the schema will fight to maintain itself even when the evidence to
the contrary is overpowering. By continuing to repeat this exercise
session after session, and through homework assignments, the pa-
tient becomes better and better at fighting the schema. The patient
observes how the schema negates positive information and then
learns to reclaim the positive evidence through reason and logic.
An important variation of this technique is to have the patient
get angry at the schema. With this variation, the therapist provokes
the patient by playing the schema in its most extreme, unyielding

48
 Part III: Strategies for Change

form. The patient tries to do battle with the schema by getting an-
gry and refusing to give in to it. The addition of emotion to the
P-CP technique often makes this adaptation even more effective.
Getting angry at the schema seems to create even more distance
between the healthy part of the patient and the maladaptive schema.
Below is an example of a P-CP homework assignment that Carla
completed. The therapist had suggested that she base the assign-
ne on the positive feedback she was getting while working with
children.

+: I’m very loving and giving when I feel safe.

- : But I’m only that way because I need people.
+: It may be true that I need people, but that’s certainly not
the only reason that I’m loving. I sincerely empathize
with people and don’t want to hurt them.
- : But somehow I only end up hurting them anyway.
+: I don’t hurt them, but they hurt themselves. And not
everyone involved with me ends up getting hurt, just
my family. They’re screwed up. I was their scapegoat
when things went wrong.

Carla takes the positive evidence and discounts it, but then she
tries to reclaim the positive evidence by countering her negating of
the positive. This process goes back and forth until she can end the
exercise on a positive statement.
Below is another example of P-CP related to Carla’s schemas
of Abandonment/Instability, Emotional Deprivation, and Defective-
ness/Shame: ;

- : I feel detached from people. I feel lonely.

+: But I don’t feel lonely when I’m at my work. Already
over the past 3 months I’ve met new people who are
receptive to me. I know the staff really likes me and
cares about me and is happy to have me around.
- : I feel lonely outside of work, though.
+: It takes time to build friendships. It'll take time before
I really feel secure again with a new group of people.
I’ve already done a lot to change my life with Jeff's
help, and I just have to be patient and keep working at
it. I can’t give up.

49
Cognitive Therapy for Personality Disorders (3rd ed.)

Again we see her struggling with the schema. Each time, there
is a negative schema trying to prove that she is bad and unlovable,
but, as the therapy progresses, there is also another side gradually
growing stronger, a weak voice initially that is trying to see herself
in a positive light.

DEVELOP FLASHCARDS THAT

CONTRADICT THE SCHEMAS

One of the most effective techniques for changing early schemas

is the constant repetition of rational responses, especially whenever
the schema is being activated. One of the simplest methods for
providing this rehearsal and practice is to develop one or more
Schema Flashcards (Young, D. Wattenmaker, & R. Wattenmaker,
1995) for each of the patient’s major schemas or recurring trigger
events. The flashcard is simply an index card, usually developed
jointly by the patient and the therapist. It should incorporate the
most powerful evidence and counterarguments against the schema
itself. The evidence on the flashcards should include several spe-
cific instances when the schema was untrue. Patients should be
encouraged to carry the flashcards with them wherever they go and
to pull them out whenever a relevant schema has been triggered.
In the flashcard that follows, Carla addresses her schema that
she is a bad, selfish person who is not deserving of love:

In a safe environment, I am loving and caring. I try to be

giving and generous with all people, but most of all with
children. Overall, I try to make people happy: I’m sensi-
tive to people’s needs and wishes, and I do everything I can
to respect and satisfy them.

A second flashcard responds to Carla’s schema that she is un-

lovable because her mother was so cold toward her:

My mother cannot love me or anyone because she denies

her needs for others. She’s afraid of being dependent on
someone else, of being controlled, and of ultimately getting
hurt -- like she was hurt as a child. . . . She and the people
who love her suffer.

These flashcards almost always prove invaluable in making the

slow transition from intellectual understanding to emotional accep-
tance of more adaptive thinking patterns.

50
 Part IIT: Strategies for Change

CHALLENGE THE SCHEMA WHENEVER IT IS

ACTIVATED DURING THE THERAPY SESSION
OR OUTSIDE THE SESSION

_ A crucial aspect of schema-focused therapy is constant prac-

tice, as mentioned earlier in the discussion of flashcards. Every
time we see the schema arising during the session, we point it out
and help the patient to counteract it. Every time it comes up outside
the session, we instruct the patient to write down what happened
and either develop a new rational response or locate a flashcard
from his or her “deck” of cards that might be relevant to the schema.

EXPERIENTIAL TECHNIQUES

There are a number of helpful techniques available to the thera-

pist to change schemas at an emotional level for the patient. Most
of these techniques are drawn from gestalt therapy and many in-
volve triggering schemas in the session so that greater change can
take place.
One of these techniques is to create imaginary dialogues with
the patient’s parents. The therapist usually asks patients to close
their eyes and try to get an image of their mother or father. After
obtaining a brief description of the event they are picturing, the thera-
pist will suggest that they carry on a dialogue with the parent, in
which they tell the parent exactly what they want and feel. Some-
times patients can alternately play themselves, then their parents.
At other times, the therapist will play one of the roles while the
patient plays the other. The therapist asks patients to keep their
eyes closed so that the realism gained through imagery is not lost.
By playing themselves as they would have liked to respond to their
parents, patients usually begin to change their beliefs about them-
selves. They can see more clearly the role of their parents in per-
petuating the schemas, and, by talking back to their parents and
defending themselves, patients usually observe that their schemas
start to weaken.
A second useful technique is emotional catharsis. Gestalt thera-
pists often stress the importance of unfinished emotional busi-
ness. Chronic patients often have unexpressed anger and rage based
on early life experiences. Frequently, they also have other painful
issues (such as early deprivation or loss) that they have not yetac-
knowledged and “grieved” for. When the therapist raises these is-

51
Cognitive Therapy for Personality Disorders (3rd ed.)

sues through imagery, role playing, or current life experiences, and

encourages the patient to express (“ventilate”) the associated feel-
ings, the schemas associated with these feelings often change.
In Carla’s case, for example, there were two areas in which she
needed emotional catharsis. The first involved her anger toward
her parents for their mistreatment and neglect of her when she was
a child. The therapist had her write a letter to her parents listing all
of the ways in which she felt she had been mistreated, withspecific
examples of each type of neglect, but he asked her to wait until he
checked with her parents before mailing it. The therapist prepared
the parents in advance by touching on some of the issues that might
come up and by asking them whether they could handle an ex-
tremely critical letter from their daughter. Both parents felt they
could handle it, so he asked Carla to mail her letter.
It seemed important to complete this process of encouraging
Carla to ventilate some of her justifiable anger so that she could
then start letting go of it. The therapist then arranged an extremely
successful family session in which her mother apologized and ac-
knowledged that she had been negligent in all the specific ways
Carla had described in her letter. Carla evidenced an enormous
mood improvement after this experience. After ventilating her an-
ger, Carla began to see that she was not really the terrible person in
the family she had been led to believe she was.

INTERPERSONAL TECHNIQUES

One of the most potent methods for changing schemas is through

the therapeutic relationship itself. The therapist is constantly alert
for indications that patients’ schemas are being activated in rela-
tionship to the therapist. When this happens, the therapist helps
patients test the reality of their beliefs through direct interaction
between the therapist and patient. This often involves self-
disclosure on the part of the therapist to correct patient distortions.
During one session Carla told the therapist that she thought that
he viewed her as physically repulsive. Thetherapist used this as an
opportunity to challenge her Defectiveness/Shame schema. He uti-
lized the Point-Counterpoint technique (described earlier). Most of
the session was devoted to a dialogue in which she told him her
negative physical image of herself, and he corrected this view as he
saw her physically. In other words, she played her negative schema
while the therapist provided the alternate point of view. They later

+2
 Part III: Strategies for Change

changed roles, and she had to argue against her schema, that he
found her repulsive. By the end of the session, Carla could see that
she was operating on the basis of an early schema that was leading
her to predict, inaccurately, what the therapist thought about her.
Another interpersonal strategy is for the therapist to provide a
therapeutic relationship that counteracts Early Maladaptive
Schemas. In some respects, we are advocating a “limited re-
parenting” role for the therapist. With some patients like Carla, we
urge therapists to try to find out what needs of the child did not get
met and to try to meet them to a reasonable degree -- within the
therapy relationship -- without violating the boundaries of the
therapist-patient relationship.
For example, if the patient has suffered a great deal of emo-
tional deprivation, the therapist can try, within limits, to be nurtur-
ing and caring. A knowledge of each patient’s schemas can guide
the therapist in deciding what aspects of the reparenting process
might be especially important. One patient might need a lot of au-
tonomy, another discipline, another reassurances of competence;
and still another patient may need the therapist to set lower expec-
tations for performance. The limited reparenting process can pro-
vide one of the most powerful mechanisms for invalidating the
patient’s schemas.
For Carla, it was extremely important for her to see that the
therapist was there for her in a consistent way when she needed
him, that he was not punitive or critical of her, that he cared for her
(within the confines of a therapeutic relationship), and that he liked
her. Carla said to the therapist during the sixth month of treatment,
“I know that you’re there for me. This is the first time anyone has
been, and I’m afraid of losing you.” She also wrote the following
flashcard (a technique discussed in more detail earlier), in response
to her schema that she would be abandoned and left alone forever:

Jeff won’t leave me. Jeff will help me find someone I love
who will keep loving me. I am lovable. I have to learn
how to choose men who can get close and make commit-
ments. I will not be alone forever. I can take steps to be loved.

Another interpersonal strategy is to arrange group therapy ex-

periences for patients in order to provide an environment that will
counteract schemas and help break self-defeating interpersonal
patterns.

53
Cognitive Therapy for Personality Disorders (3rd ed.)

As mentioned earlier, the therapist arranged for Carla to partici-

pate in group therapy. The group served to highlight some of the
positive experiences Carla would be able to have with other people.
One group member told her how helpful and perceptive she was.
Carla’s individual therapist relayed to her the opinion of the group
therapist that he used her as the thermometer for the group; she
could feel whatever the group was feeling. This positive feedback
represented evidence she could draw on that was contrary to her
schemas.

BEHAVIORAL TECHNIQUES

The final step in changing schemas is to change schema-driven

behaviors. This involves pushing the patient to change long-term
behavior patterns that have reinforced the schemas for most ofthe
patient’s lifetime.
For example, early on in Carla’s treatment, the therapist identi-
fied a schema avoidance behavior that effectively kept men at a
distance. Carla wrote the following flashcard to clarify the dys-
functional aspect of this pattern with men:

I feel unlovable because I was left alone a lot as a child and

was yelled at all the time. Because I felt unlovable, I avoided
close contact with men, or I chose men who I knew could
not make a commitment. By doing this, I have been able to
continually confirm my negative schema that I am unlov-
able.

The therapist worked with Carla to select men who were more
truly available emotionally for her and to develop better intimacy
skills in the earlier stages so that she would not distance herself
inappropriately.
There were many other areas as well in which the therapist helped
Carla change her maladaptive schema-driven behaviors: He urged
her to express anger toward her parents, which she had never done
before. The therapist urged her to choose a new career based on her
interests, which involved working with children. This was extremely
important because it was the first time in her life that she had ever
been allowed to do anything that she loved and that she had chosen
because she wanted it, not to please someone else.

54
 Part III: Strategies for Change

Carla began expressing her emotions in session much more

freely. As she did this, her emotional symptoms like numbness,
coldness, and dizziness disappeared. Soon in a session she could
cry, get angry, be nervous, and not feel that she had to hide it from
the therapist. She could look at him without hiding her face. She
stopped apologizing to him and stopped thanking him for normal
therapy sessions.
Finally, she learned to balance work with pleasure. Carla was
no longer working 20 hours a day, and she had more realistic expec-
tations of herself in school. She was no longer pushing herself to be
the very best in her class.
Another strategy for bringing about behavioral change is tomake
environmental changes when necessary. It is very important to make
changes in the patient’s environment when the therapist believes
that these changes can either make therapy more productive or can
give the patient enough “breathing room” to focus on the therapy.
We will sometimes work with spouses conjointly. We might en-
courage patients to move away from their homes temporarily, re-
duce work responsibilities temporarily, try out new hobbies or
athletic activities, or initiate new relationships and friendships.
In the case of Carla, the therapist recommended a number of
environmental changes. First, he urged her to stop her schooling
temporarily because she seemed too unstable to deal with both the
therapy and her severe work pressures. He also supported her de-
sire to work with children. The therapist also did a lot of work to
strengthen her relationship with her brother while simultaneously
having her cut off all contact with her parents except for the family
sessions during the early phases of treatment. Therefore, it was
necessary to make a number of specific environmental changes in
order to enable Carla to make maximum use of the schema-focused
cognitive therapy.
Carla had expressed an interest in working with children earlier
in the treatment but had dismissed it on the grounds that her parents
would not approve and that it would not be financially practical.
The therapist reasoned that, if she could make this life change, she
might get evidence contradicting several schemas: She would not
be subjugating her needs to her parents, she would be able to suc-
ceed at something she valued, she might form connections with chil-
dren and other counselors, and she might even gain insight into how
parental upbringing can affect the self-confidence of children.

DD
Cognitive Therapy for Personality Disorders (3rd ed.)

The therapist suggested that she find a setting where she could
work with children who were being abused or mistreated. The camp
proved to be an extremely powerful experience. First, Carla could
see how successful she was at working with these children, that she
was very loving toward them, and that they reciprocated. Second,
she started to observe many parallels in her own childhood as she
observed interactions between these children and their parents. Carla
could clearly see that these were not bad children; they simply had
neglectful parents. These associations stimulated enormous rage
toward her parents. This rage increased her belief that perhaps her
schema was not true, that her parents had been unfair to her and, in
fact, had mistreated her.

56
 CONCLUSION

Schema-focused therapy differs from short-term cognitive

therapy in a number of respects:

l. There is less guided discovery and more confrontation.

ps There is much greater use of the therapeutic relationship as a
vehicle of change.
> There is much more resistance to change. Therefore, the
therapy is lengthier.
. The level of affect is much higher during schema-focused
sessions.
. The therapist is much more concerned with identifying and
overcoming cognitive, affective, and behavioral avoidance.
. Schema-focused therapy devotes considerably more time to
the childhood origins of schemas and to experiential tech-
niques surrounding these early issues.

At the same time, the schema-focused approach retains most of

the important elements that differentiate Beck’s approach from more
traditional psychoanalytic or client-centered therapies.

The therapist is much more active.

The change techniques are much more systematic.
There is a strong emphasis on self-help homework assign-
WNre
ments.
The therapeutic relationship is collaborative rather than neu-
tral.
The schema-focused approach is much more rapid and direct
than conventional psychotherapy.
The therapist uses an empirical approach insofar as the analy-
sis of evidence is a critical aspect of schema change.

37
Cognitive Therapy for Personality Disorders (3rd ed.)

Schema-focused therapy, therefore, can be viewed as a signifi-

cant extension of cognitive therapy, integrating techniques from other
approaches to meet the special therapeutic requirements of difficult
patients with longer-term personality disorders and those with
chronic anxiety or depression.

58
 Appendix A

YOUNG SCHEMA QUESTIONNAIRE

(Long Form, Second Edition)*

Name Date

INSTRUCTIONS

Listed below are statements that a person might use to describe himself or
herself. Please read each statement and decide how well it describes you. When
you are not sure, base your answer on what you emotionally feel, not on what
you think to be true.
If you desire, reword the statement so that the statement would be even more
true of you. Then choose the highest rating from 1 to 6 that describes you (in-
cluding your revisions), and write the number in the space before the statement.

RATING SCALE

= Completely untrue of me
= Mostly untrue of me
= Slightly more true than untrue
Il Moderately true of me
= Mostly true of me
HS =
NnhWN Describes me perfectly

EXAMPLE

I care about
A. I worry that people * will not like me.

ie People have not been there to meet my emotional needs.

Ds I haven’t gotten love and attention.

*Developed by Jeffrey E. Young, PhD, and Gary Brown, MEd. Copyright © 1990
by the authors. Unauthorized reproduction without written consent of the authors
is prohibited. For more information, write: Cognitive Therapy Center of New York, 120 E.
56th Street, Suite 530, New York, NY 10022 or telephone (212) 588-1998.

59
Cognitive Therapy for Personality Disorders (3rd ed.)

33 For the most part, I haven’t had someone to depend on for advice
and emotional support.
Most of the time, I haven’t had someone to nurture me, share
himself/herself with me, or care deeply about everything that hap-
pens to me.
For much of my life, I haven’t had someone who wanted to get
close to me and spend a lot of time with me.
In general, people have not been there to give me warmth, hold-
ing, and affection.
For much of my life, I haven’t felt that I am special to someone.
For the most part, I have not had someone who really listens to
me, understands me, or is tuned into my true needs and feelings.
I have rarely had a strong person to give me sound advice or
direction when I’m not sure what to do.

10. I worry that the people I love will die soon, even though there is
little medical reason to support my concern.
11. I find myself clinging to people I’m close to because I’m afraid
they’ll leave me.
£23 I worry that people I feel close to will leave me or abandon me.
13. I feel that I lack a stable base of emotional support.
14. I don’t feel that important relationships will last; I expect them
to end.
to I feel addicted to partners who can’t be there for me in a com-
mitted way.
16. In the end, I will be alone.
LI When I feel someone | care for pulling away from me, I get des-
perate.
18. Sometimes I am so worried about people leaving me that I drive
them away.
1D: I become upset when someone leaves me alone, even for a short
period of time.
20. I can’t count on people who support me to be there on a regular
basis.
PUN I can’t let myself get really close to other people because I can’t
be sure they’ll always be there.
ant It seems that the important people in my life are always coming
and going.

60
 Appendix A

a3 I worry a lot that the people I love will find someone else they
prefer and leave me.
24. The people close to me have been very unpredictable; one mo-
ment they’re available and nice to me; the next, they’re angry,
upset, self-absorbed, fighting, and so on.
25. I need other people so much that Iworry about losing them.
26. I feel so defenseless if I don’t have people to protect me that I
worry a lot about losing them.
at. I can’t be myself or express what I really feel, or people will
leave me.

28. I feel that people will take advantage of me.

20. I often feel that I have to protect myself from other people.
30. I feel that I cannot let my guard down in the presence of other
people, or else they will intentionally hurt me.
31. If someone acts nicely towards me, I assume that he/she must be
after something. :
es It is only a matter of time before someone betrays me.
ao: Most people only think about themselves.
34. I have a great deal of difficulty trusting people.
IDs I am quite suspicious of other people’s motives.
36. Other people are rarely honest; they are usually not what they
appear.
37, I’m usually on the lookout for people’s ulterior motives.
38. If I think someone is out to hurt me, I try to hurt him or her first.
39. People usually have to prove themselves to me before I can trust
them.
40. I set up “tests” for other people to see if they are telling me the
truth and are well-intentioned.
41. I subscribe to the belief: “Control or be controlled.”

42. I get angry when I think about the ways I have been mistreated
by other people throughout my life.
43. Throughout my life, those close to me have taken advantage of
me or used me for their own purposes.
44, I have been physically, emotionally, or sexually abused by im-
portant people in my life.

61
Cognitive Therapy for Personality Disorders (3rd ed.)

45. I don’t fit in.

46. I’m fundamentally different from other people.
47. I don’t belong; I’m a loner.
48. I feel alienated from other people.
49. I feel isolated and alone.
50. I always feel on the outside of groups.
51. No one really understands me.
52. My family was always different from the families around us.
33. I sometimes feel as if I’m an alien.
54. If I disappeared tomorrow, no one would notice.

2B): No man/woman I desire could love me once he/she saw my de-

fects.
56. No one I desire would want to stay close to me if he/she knew
the real me.
ey I am inherently flawed and defective.
58. No matter how hard I try, I feel that I won’t be able to get a
significant man/woman to respect me or feel that I am worth-
while.
Oo: I’m unworthy of the love, attention, and respect of others.
60. I feel that I’m not lovable.
61. I am too unacceptable in very basic ways to reveal myself to
other people.
62. If others found out about my basic defects, I could not face them.
63. When people like me, I feel I am fooling them.
64. I often find myself drawn to people who are very critical or re-
ject me.
65. I have inner secrets that I don’t want people close to me to find
out.
66. It is my fault that my parent(s) could not love me enough.
677 I don’t let people know the real me.
68. One of my greatest fears is that my defects will be exposed.
69. I cannot understand how anyone could love me.
*ds
70. I’m not sexually attractive.

62
 Appendix A

a1, I’m too fat.

ae. I’m ugly.
73, I can’t carry on a decent conversation.
74. I’m dull and boring in social situations.
75. People I value wouldn’t associate with me because of my social
status (e.g., income, educational level, career).
76. I never know what to say socially.
ree People don’t want to include me in their groups.
78. I am very self-conscious around other people.

iF Almost nothing I do at work (or school) is as good as what other

people can do.
80. I’m incompetent when it comes to achievement.
81. Most other people are more capable than I am in areas of work
and achievement.
82. I’m a failure.
83. I’m not as talented as most people are at their work.
84. I’m not as intelligent as most people when it comes to work (or
school).
85. I am humiliated by my failures and inadequacies in the work
sphere.
86. I often feel embarrassed around other people because I don’t
measure up to them in terms of my accomplishments.
87. I often compare my accomplishments with others and feel that
they are much more successful.

88. I do not feel capable of getting by on my own in everyday life.

89. I need other people to help me get by.
90. I do not feel I can cope well by myself.
ol. I believe that other people can take care of me better than I can
take care of myself.
2. I have trouble tackling new tasks outside of work unless I have
someone to guide me.
93. I think of myself as a dependent person, when it comes to every-
day functioning.
94. I screw up everything I try, even outside of work (or school).

63
Cognitive Therapy for Personality Disorders (3rd ed.)

95. I’m inept in most areas of life.

96. If I trust my own judgment in everyday situations, I’1l make the
wrong decision.
oF. I lack common sense.
98. My judgment cannot be relied upon in everyday situations.
99. I don’t feel confident about my ability to solve everyday prob-
lems that come up.
100. I feel Ineed someone I can rely on to give me advice about prac-
tical issues.
101. I feel more like a child than an adult when it comes to handling
everyday responsibilities.
102. I find the responsibilities of everyday life overwhelming.
*di
103. I can’t seem to escape the feeling that something bad is about to
happen.
104. I feel that a disaster (natural, criminal, financial, or medical) could
strike at any moment.
105. I worry about becoming a street person or vagrant.
106. I worry about being attacked.
107. I feel that I must be very careful about money or else I might end
up with nothing.
108. I take great precautions to avoid getting sick or hurt.
109. I worry that I'll lose all my money and become destitute.
110. I worry that I’m developing a serious illness, even though noth-
ing serious has been diagnosed by a physician.
111. I am a fearful person.
L2: I worry a lot about the bad things happening in the world: crime,
pollution, and so on.
113. I often feel that I might go crazy.
114. I often feel that I’m going to have an anxiety attack.
Lis. I often worry that I might have a heart attack, even though there
is little medical reason to be concerned.
116. I feel that the world is a dangerous place.
*vh
117. I have not been able to separate myself from my parent(s), the
way other people my age seem to.

64
 Appendix A
118. My parent(s) and I tend to be overinvolved in each other’s lives
and problems.
119. It is very difficult for my parent(s) and me to keep intimate de-
tails from each other, without feeling betrayed or guilty.
120. My parent(s) and I have to speak to each other almost every day
or else one of us feels guilty, hurt, disappointed, or alone.
121. I often feel that I do not have a separate identity from my parents
or partner.
122. I often feel as if my parents are living through me -- I don’t have
a life of my own.
123. It is very difficult for me to maintain any distance from the people
I am intimate with; I have trouble keeping any separate sense of
myself.
124. I am so involved with my partner or parents that I do not really
know who I am or what I want.
E25. I have trouble separating my point of view or opinion from that
of my parents or partner.
126. I often feel that I have no privacy when it comes to my parents or
partner.
127, I feel that my parents are, or would be, very hurt about my living
“on my own, away from them.

128. I let other people have their way because I fear the consequences.
12o. I think if I do what I want, I’m only asking for trouble.
130. I feel that I have no choice but to give in to other people’s wishes,
or else they will retaliate or reject me in some way.
es In relationships, I let the other person have the upper hand.
132. I’ve always let others make choices for me, so I really don’t know
what I want for myself.
S32 I feel the major decisions in my life were not really my own.
134. I worry a lot about pleasing other people so they won’t reject me.
135. I have a lot of trouble demanding that my rights be respected and
that my feelings be taken into account.
136. I get back at people in little ways instead of showing my anger.
137. I will go to much greater lengths than most people to avoid con-
frontations.
*sb
138. I put others’ needs before my own or else I feel guilty.

65
Cognitive Therapy for Personality Disorders (3rd ed.)

139. I feel guilty when I let other people down or disappoint them.
140. I give more to other people than I get back in return.
141. I’m the one who usually ends up taking care of the people I’m
close to.
142. There is almost nothing I couldn’t put up with if I loved some-
one.
143. I am a good person because | think of others more than of my-
self.
144. At work, I’m usually the one to volunteer to do extra tasks or to
put in extra time.
145. No matter how busy I am, I can always find time for others.
146. I can get by on very little because my needs are minimal.
147. I’m only happy when those around me are happy.
148. I’m so busy doing for the people that I care about that I have
little time for myself.
149. I’ve always been the one who listens to everyone else’s prob-
lems.
150. I’m more comfortable giving a present than receiving one.
ley, Other people see me as doing too much for others and not enough
for myself.
152: No matter how much I give, it is never enough.
53% If I do what I want, I feel very uncomfortable.
154. It’s very difficult for me to ask others to take care of my needs.

155; I worry about losing control of my actions.

156. I worry that I might seriously harm someone physically or emo-
tionally if my anger gets out of control.
Love I feel that I must control my emotions and impulses or some-
thing bad is likely to happen.
158. A lot of anger and resentment build up inside of me that I don’t
express.
poo. I am too self-conscious to show positive feelings to others (e.g.,
affection, showing I care).
160. I find it embarrassing to express my feelings to others.
161. I find it hard to be warm and spontaneous.
162. I control myself so much that people think I am unemotional.

66
 Appendix A

163. People see me as uptight emotionally.

164. “eae be the best at most of what I do; I can’t accept second
est.
165. I strive to keep almost everything in perfect order.
166. I must look my best most of the time.
167. I try to do my best; I can’t settle for “good enough.”
168. I have so much to accomplish that there is almost no time to
really relax.
169. Almost nothing I do is quite good enough; I can always do bet-
ter.
170. I must meet all my responsibilities.
T71. I feel there is constant pressure for me to achieve and get things
done.
rid. My relationships suffer because I push myself so hard.
ifs. My health is suffering because I put myself under so much pres-
sure to do well.
174. I often sacrifice pleasure and happiness to meet my own stand-
ards.
WD. When I make a mistake, I deserve strong criticism.
176. I can’t let myself off the hook easily or make excuses for my
mistakes.
ere I’m a very competitive person.
178. I put a good deal of emphasis on money or status.
£79: I always have to be “Number One,” in terms of my performance.

180. I have a lot of trouble accepting “no” for an answer when I want
something from other people.
181. I often get angry or irritable if 1 can’t get what I want.
182. I’m special and shouldn’t have to accept many of the restrictions
placed on other people.
183. I hate to be constrained or kept from doing what I want.
184. I feel that I shouldn’t have to follow the normal rules and con-
ventions other people do.
185. I feel that what I have to offer is of greater value than the contri-
butions of others.

67
Cognitive Therapy for Personality Disorders (3rd ed.)

186. I usually put my needs ahead of the needs of others.

187. I often find that I am so involved in my own priorities that I don’t
have time to give to friends or family.
188. People often tell me I am very controlling about the ways things
are done.
189. I get very irritated when people won’t do what I ask of them.
190. I can’t tolerate other people telling me what to do.
*et
LON: I have great difficulty getting myself to stop drinking, smoking,
overeating, or other problem behaviors.
192 I can’t seem to discipline myself to complete routine or boring
tasks.
193: Often I allow myself to carry through on impulses and express
emotions that get me into trouble or hurt other people.
194. If I can’t reach a goal, I become easily frustrated and give up.
LOS: I have a very difficult time sacrificing immediate gratification to
achieve a long-range goal.
196. It often happens that, once I start to feel angry, I just can’t con-
trol it.
197. I tend to overdo things, even though I know they are bad for me.
198. I get bored very easily.
LO. When tasks become difficult, I usually cannot persevere and com-
plete them.
200. I can’t concentrate on anything for too long.
201. I can’t force myself to do things I don’t enjoy, even when I know
it’s for my own good.
202. I lose my temper at the slightest offense.
203. I have rarely been able to stick to my resolutions.
204. I can almost never hold back from showing people how I really
feel, no matter what the cost may be.
205. I often do things impulsively that I later regret.
*is

68
 Appendix A

Interpreting the
YOUNG SCHEMA QUESTIONNAIRE
(Long Form, Second Edition)*

We do not yet have statistical norms for the Young Schema Questionnaire
although this research is in progress. In the meantime, we have developed the
following informal procedures for clinical use.
Items on the questionnaire are clustered according to specific schemas. These
clusters of items are separated by an asterisk and a two letter code that is an
abbreviation for the schema. For example, Items 1-9 are followed by the abbre-
viation “*ed,” indicating that these specific items assess the Emotional Depriva-
tion schema. The abbreviations for the 16 schemas are

ed Emotional Deprivation
ab Abandonment
ma Mistrust/Abuse
si Social Isolation/Alienation
ds Defectiveness/Shame
su Social Undesirability
fa Failure
di Dependence/Incompetence
vh Vulnerability to Harm and Illness
em Enmeshment
sb Subjugation
Ss Self-Sacrifice
el Emotional Inhibition
us Unrelenting Standards
et Entitlement
is Insufficient Self-Control/Self-Discipline

ee
and the names of some schemas
*Since the publication of this inventory, the number of schemas
y, a new version of the YSQ will reflect these changes.
have changed. Eventuall

69
 — see “9 ne
=
: i
7
ge %natalia dlna
e e oe .
e. oe iieteseg eee ee
ae a am oe ee mg peerg tee
ve a =
ae ag
ea itnbei co, ee

et ih

‘ 7 a or“oy vrsii
NOS Went Wi et ay

Sedatenianmeninelinr a mmnce nenGite’

im
ra baal, poh cee
.
(pene went svell’
 Appendix B

CLIENT’S GUIDE
TO SCHEMA-FOCUSED THERAPY*

HARRY is a 45-year-old middle-level manager. He has been married for 16

years, but his marriage has been very troubled. He and his wife are often resent-
ful of each other, they rarely communicate on an intimate level, and they have
few moments of real pleasure.
Other aspects of Harry’s life have been equally unsatisfying. He doesn’t
enjoy his work, primarily because he doesn’t get along with his co-workers. He
is often intimidated by his boss and other people at the office. He has a few
friends outside of work, but none that he considers close.
During the past year Harry’s mood became increasingly negative. He was
getting more irritable, he had trouble sleeping, and he began to have difficulty
concentrating at work. As he became more and more depressed, he began to eat
more and gained 15 pounds. When he found himself thinking about taking his
own life, he decided it was time to get help. He consulted a psychologist who
practices cognitive therapy.
As a result of short-term cognitive therapy techniques, Harry improved rap-
idly. His mood lifted, his appetite returned to normal, and he no longer thought
about suicide. In addition he was able to concentrate well again and was much
less irritable. He also began to feel more in control of his life as he learned how
to control his emotions for the first time.
But, in some ways, the short-term techniques were not enough. His relation-
ships with his wife and others, while they no longer depressed him as much as
they had, still failed to give him much pleasure. He still could not ask to have his
needs met, and he had few experiences he considered truly enjoyable. The thera-
pist then began schema-focused therapy to help Harry change his long-term life
patterns.
This guide will present the schema-focused approach, an elaboration of cog-
nitive therapy developed by Dr. Jeffrey Young that can help people change long-
term patterns, including the ways in which they interact with other people. This
overview of schema-focused therapy consists of five parts:

*Developed by David C. Bricker, PhD, and Jeffrey E. Young, PhD. Copyright © 1999 by
Cognitive Therapy Center of New York. Unauthorized reproduction without written consent
of the authors is prohibited. For more information, write: Cognitive Therapy Center of New
York, 120 E. 56th Street, Suite 530, New York, NY 10022 or telephone (212) 588-1998.

71
Cognitive Therapy for Personality Disorders (3rd ed.)

A brief presentation of short-term cognitive therapy.

An explanation of what a schema is and examples of schemas.
An explanation of the processes by which schemas function.
Several case examples.
A brief description of the therapeutic process.
ABWN

SHORT-TERM COGNITIVE THERAPY

Cognitive therapy is a system of psychotherapy developed by Aaron Beck

and his colleagues to help people overcome emotional problems. This system
emphasizes changing the ways in which people think in order to improve their
moods, such as depression, anxiety, and anger.
Emotional disturbance is influenced by the cognitive distortions that people
make in dealing with their life experiences. These distortions take the form of
negative interpretations and predictions of everyday events. For instance, a male
college student preparing for a test might make himself feel discouraged by think-
ing “This material is impossible” (Negative Interpretation) and “/’// never pass
this test” (Negative Prediction).
The therapy consists of helping clients to restructure their thinking. An im-
portant step in this process is examining the evidence concerning the maladaptive
thoughts. In the preceding example, the therapist would help the student to look
at his past experiences and determine if the material was in fact impossible to
learn and if he knew for sure that he couldn’t pass the test. In all probability, the
student would decide that these two thoughts lacked validity.
More accurate alternative thoughts would be substituted. For instance, the
student might be encouraged to think “This material is difficult but not impos-
sible. I’ve learned difficult material before” and “I’ve never failed a test before,
so long as I’ve done enough preparation.” These thoughts would probably lead
him to feel better and cope better.
Often short-term cognitive therapy is enough to help people overcome emo-
tional problems, especially depression and anxiety. Recent research has shown
this to be so. However, sometimes this approach is not enough. Some clients in
short-term cognitive therapy find that they don’t get all the benefits they want.
This has led us to develop schema-focused therapy.

SCHEMAS - WHAT THEY ARE

A schema is an extremely stable and enduring pattern that develops during

childhood and is elaborated throughout an individual’s life. We view the world
through our schemas.
Schemas are important beliefs and feelings about oneself and the environ-
ment which the individual accepts without question. They are self-perpetuating,
and are very resistant to change. For instance, children who develop a schema
that they are incompetent rarely challenge this belief, even as adults. The schema
usually does not go away without therapy. Overwhelming success in people’s
 Appendix B

lives is often still not enough to change the schema. The schema fights for its
own survival and, usually, is quite successful.
Even though schemas persist once they are formed, they are not always in
our awareness. Usually they operate in subtle ways, out of our awareness. How-
ever, when a schema erupts or is triggered by events, our thoughts and feelings
are dominated by these schemas. It is at these moments that people tend to expe-
rience extreme negative emotions and have dysfunctional thoughts.
In our work with many patients, we have found 18 specific schemas. Most
clients have at least two or three of these schemas, and often more. A brief
description of some of these schemas is provided below.

Emotional Deprivation

This schema refers to the belief that one’s primary emotional needs will
never be met by others. These needs include nurturance, empathy, affection,
protection, guidance, and caring from others. Often parents were emotionally
depriving to the child.

Abandonment/Instability

This schema refers to the expectation that one will soon lose anyone with
whom an emotional attachment is formed. The person believes that, one way or
another, close relationships will end imminently. As children, these clients may
have experienced the divorce or death of parents. This schema can also arise
when parents have been inconsistent in attending to the child’s needs; for in-
stance, there may have been frequent occasions when the child was left alone or
unattended to for extended periods.

Mistrust/Abuse

This schema refers to the expectation that others will intentionally take ad-
vantage in some way. People with this schema expect others to hurt, cheat, or put
them down. They often think in terms of attacking first or getting revenge after-
wards. In childhood, these clients were often abused or treated unfairly by par-
ents, siblings, or peers.

Social Isolation/Alienation

This schema refers to the belief that one is isolated from the world, different
from other people, and/or not part of any community. This beliefis usually caused
by early experiences in which children see that either they or their families are
different from other people.

Defectiveness/Shame

This schema refers to the belief that one is internally flawed, and that, if
others get close, they will realize this and withdraw from the relationship. This
feeling of being flawed and inadequate often leads to a strong sense of shame.
Generally parents were very critical of their children and made their children feel
as if they were not worthy of being loved.

73
Cognitive Therapy for Personality Disorders (3rd ed.)

Failure

This schema refers to the belief that one is incapable of performing as well
as one’s peers in areas such as career, school, or sports. These clients may feel
stupid, inept, untalented, or ignorant. People with this schema often do not try to
achieve because they believe that they will fail. This schema may develop if
children are put down and treated as if they are a failure in school or other spheres
of accomplishment. Usually the parents did not give enough support, discipline,
and encouragement for the child to persist and succeed in areas of achievement,
such as schoolwork or sports.

Dependence/Incompetence

This schema refers to the belief that one is not capable of handling day-to-
day responsibilities competently and independently. People with this schema
often rely on others excessively for help in areas such as decision making and
initiating new tasks. Generally, parents did not encourage these children to act
independently and develop confidence in their ability to take care of themselves.

Vulnerability to Harm and Illness

This schema refers to the belief that one is always on the verge of experienc-
ing a major catastrophe (financial, natural, medical, criminal, etc.). It may lead
to taking excessive precautions to protect oneself. Usually there was an extremely
fearful parent who passed on the idea that the world is a dangerous place.

Subjugation

This schema refers to the belief that one must submit to the control of others
in order to avoid negative consequences. Often these clients fear that, unless they
submit, others will get angry or reject them. Clients who subjugate ignore their
own desires and feelings. In childhood there was generally a very controlling
parent.

Self-Sacrifice

This schema refers to the excessive sacrifice of one’s own needs in order to
help others. When these clients pay attention to their own needs, they often feel
guilty. To avoid this guilt, they put others’ needs ahead of their own. Often
clients who self-sacrifice gain a feeling of increased self-esteem or a sense of
meaning from helping others. In childhood the person may have been made to
feel overly responsible for the well-being of one or both parents.

Emotional Inhibition

This schema refers to the belief that one must inhibit emotions and impulses,
especially anger, because any expression of feelings would harm others or lead
to loss of self-esteem, embarrassment, retaliation, or abandonment. Such clients
may lack spontaneity or be viewed as uptight. This schema is often brought on
by parents who discourage the expression of feelings.

74
 Appendix B

Unrelenting Standards/Hypercriticalness

This schema refers to two related beliefs. Clients believe that whatever they
do is not good enough, that they must always strive harder; and/or there is exces-
sive emphasis on values such as status, wealth, and power at the expense of other
values such as social interaction, health, or happiness. Usually these clients’
parents were never satisfied and gave their children love that was conditional on
outstanding achievement.

Entitlement/Grandiosity

This schema refers to the belief that people should be able to do, say, or
have whatever they want immediately regardless of whether it hurts others or
seems reasonable to them. They are not interested in what other people need,
nor are they aware of the long-term costs of alienating others. Parents who
overindulge their children and who do not set limits about what is socially
appropriate may foster the development ofthis schema. Alternatively, some
children develop this schema to compensate for feelings of emotional depri-
vation, defectiveness, or social undesirability.

Insufficient Self-Control/Self-Discipline

This schema refers to the inability to tolerate any frustration in reaching

goals, as well as an inability to restrain expression of impulses or feelings. When
lack of self-control is extreme, criminal or addictive behavior rule their life. Par-
ents who did not model self-control, or who did not adequately discipline their
children, may predispose them to have this schema as adults.

HOW SCHEMAS WORK

In order to understand how schemas work, there are three schema processes
that must be defined. These processes are schema maintenance, schema avoid-
ance, and schema compensation. It is through these three processes that schemas
exert their influence on our behavior and work to ensure their own survival.

Schema Maintenance

Schema maintenance refers to the routine processes by which schemas func-

tion and perpetuate themselves. This is accomplished by cognitive distortions
and self-defeating behavior patterns.
Earlier we mentioned that cognitive distortions are a central part of cogni-
tive therapy. These distortions consist of negative interpretations and predictions
of life events. Many cognitive distortions are part of the schema maintenance
process. The schema will highlight or exaggerate information that confirms the
schema and will minimize or deny information that contradicts it.
Schema maintenance works behaviorally as well as cognitively. The schema
will generate behaviors which tend to keep the schema intact. For instance, a
young man with a Defectiveness/Shame schema would have thoughts and be-

WD
Cognitive Therapy for Personality Disorders (3rd ed.)

haviors in line with the schema. Ata party he would have such thoughts as “No
one here likes me” and “Ifpeople here really get to know me, they'll reject me.”
Behaviorally, he would be more withdrawn and less outgoing.

Schema Avoidance

Schema avoidance refers to the ways in which people avoid activating

schemas. As mentioned earlier, whert schemas erupt, people usually experi-
ence extreme negative emotions. They develop ways to avoid triggering
schemas in order not to feel this pain. There are three types of schema avoid-
ance: cognitive, emotional, and behavioral.
Cognitive avoidance refers to efforts that people make not to think about
upsetting events. These efforts may be either voluntary or automatic. People
may voluntarily choose not to focus on an aspect of their personality or an event
which they find disturbing. There are also unconscious processes which help
people to shut out information which would be too upsetting to confront. People
often forget particularly painful events. For instance, children who have been
abused sexually often have no memory of the traumatic experience.
Emotional or affective avoidance refers to automatic or voluntary attempts
to block painful emotion. Often when people have painful emotional experi-
ences, they numb themselves to the feelings in order to minimize the pain. For
instance, a man might talk about how his wife has been acting in an abusive
manner toward him and say that he feels no anger towards her, only a little an-
noyance. Some people drink or abuse other drugs to numb feelings generated by
schemas.
The third type of avoidance is behavioral avoidance. People often act in
such a way as to avoid situations that trigger schemas, and thus avoid psychologi-
cal pain. For instance, a woman with a Failure schema might avoid taking a
difficult new job which would be very good for her. By avoiding the challenging
situation, she avoids any pain, such as intense anxiety, which could be generated
by the schema.

Schema Compensation

The third schema process is schema compensation. In order to avoid trigger-

ing the schema, the individual behaves in a manner which appears to be the oppo-
site of what the schema suggests. People with a Dependence/Incompetence
schema may structure aspects of their life so that they don’t have to depend on
anyone, even when a more balanced approach may be better. For instance, a
young man may refuse to go out with women because he is afraid of becoming
dependent and will present himself as someone who doesn’t need other people.
He goes to the other extreme to avoid feeling dependent.

CASE EXAMPLES

In this section six case examples are presented. In each one, the schema
processes are demonstrated. By reading through this section, you will get a better
feel for how these processes can operate in real life situations.

76
 Appendix B

Abby is a young woman whose main schema is Subjugation. She tends to

see people as very controlling even when they are being appropriately assertive.
She has such thoughts as “I can't stand up for myself or they won't like me” and is
likely to give in to others (Schema Maintenance). At-other times she decides
that no one will get the better of her and becomes very controlling (Schema
Compensation). Sometimes when people make unreasonable demands on her,
she minimizes the importance of her own feelings and has thoughts like “/t’s not
that important to me what happens.” At other times she avoids acquaintances
with whom she has trouble standing up for herself (Schema Avoidance).
Stewart's main schema is Failure. Whenever he is faced with a possible
challenge, he tends to think that he is not capable. Often he tries half-heartedly,
guaranteeing that he will fail and strengthening the belief that he is not capable
(Schema Maintenance). At times, he makes great efforts to present himself in
an unrealistically positive light by spending excessive amounts of money on items
such as clothing and automobiles (Schema Compensation). Often he avoids
triggering his schema by staying away from challenges altogether and con-
vincing himself that the challenge was not worth taking (Schema Avoid-
ance).
Rebecca's core schema is Defectiveness/Shame. She believes that there
is something basically wrong with her and that if anyone gets too close, the
person will reject her. She chooses partners who are extremely critical of her
and who confirm her view that she is defective (Schema Maintenance).
Sometimes she has an excessive defensive reaction and counterattacks when
confronted with even mild criticism (Schema Compensation). She also
makes sure that none of her partners gets too close so that she can avoid their
seeing her defectiveness and rejecting her (Schema Avoidance).
Michael is a middle-aged man whose main schema is Dependence/
Incompetence. He sees himself as being incapable of doing daily tasks on his
own and generally seeks the support of others. Whenever he can, he chooses to
work with people who help him out to an excessive degree. This keeps him from
developing skills needed to work alone and confirms his view of himself as some-
one who needs others to help him(Schema Maintenance). At times when he
would be best off taking advice from other people, he refuses to do so (Schema
Compensation). He reduces his anxiety by procrastinating as much as he can get
away with (Schema Avoidance).
Ann’s core schema is Social Isolation/Alienation. She sees herself as
being different from other people and not fitting in. When she does things as
part of a group, she does not really get involved (Schema Maintenance).
At times she gets very hostile toward group members and can be very critical
of the group as a whole(Schema Compensation). At other times she chooses
to avoid group activities altogether (Schema Avoidance).
Sam’s central schema is Emotional Deprivation. He chooses partners
who are not very capable of giving to other people, and then he acts in a manner
which makes it even more difficult for them to give to him (Schema Mainte-
and pro-
nance). At times he will act in a very demanding, belligerent manner
partners (Schema Compensa tion). Sam avoids getting too
voke fights with his
in this area (Schema Avoid-
close to women yet denies that he has any problems
ance).

dal
Cognitive Therapy for Personality Disorders (3rd ed.)

THERAPEUTIC PROCESS - CHANGING SCHEMAS

In schema-focused therapy the goal of the treatment is to weaken the early

maladaptive schemas as much as possible and build up the person’s healthy side.
An alliance against the schemas is formed between the therapist and the healthy
part of the client.
The first step in therapy is to do a comprehensive assessment of the client.
The main goal of this assessment is to identify the schemas that are most impor-
tant in the client’s psychological makeup. There are several steps to this process:
The therapist generally will first want to know about recent events or circum-
stances in the client’s life that has led him or her to come for help. The therapist
will then discuss the client’s life history and look for patterns which may be
related to schemas.
There are several other steps the therapist will take in assessing schemas.
There is the “Young Schema Questionnaire” which the client fills out, listing
many of the thoughts related to the different schemas; items on this questionnaire
can be rated as to how relevant to the client’s life they are.
There are also various imagery techniques which the therapist can use to
assess schemas. One specific technique involves asking clients to close their
eyes and create an image of themselves as children with their families. Often the
images that appear will lead to the core schemas.
Jonathan is a 28-year-old executive whose core schema is Mistrust/
Abuse. He came to therapy because he was having bouts of intense anxiety
at work, during which he would be overly suspicious and resentful of his co-
workers. When asked to create an image of himself with his family, he had
two different images. In the first he saw himself being terrorized by his older
brother. In the second he saw his alcoholic father coming home and beating
his mother while he cowered in fear.
There are many techniques which the therapist can use to help clients weaken
their schemas. These techniques can be broken down into four categories: emo-
tive, interpersonal, cognitive, and behavioral. Each of these categories will be
briefly discussed, along with a few examples.

Emotive Techniques

Emotive techniques encourage clients to experience and express the emo-

tional aspects of their problem. One way this is done is by having clients close
their eyes and imagine they are having a conversation with the person to whom
the emotion is directed. They are then encouraged to express the emotions as
completely as possible in the imaginary dialogue. One woman whose core schema
was Emotional Deprivation had several such sessions in which she had an op-
portunity to express her anger at her parents for not being there enough for her
emotionally. Each time she expressed these feelings, she was able to distance
herself further from the schema. She was able to see that her parents had their
own problems which kept them from providing her with adequate nurturance
and that she was not always destined to be deprived.
There are many variations on the preceding technique. Clients may take on
the role of the other person in these dialogues and express what they imagine

78
 Appendix B

their feelings to be. Or they may write a letter to the other person,
which they
eh no intention of mailing, so that they can express their feelings without
inhi-
ition.

Interpersonal Techniques

Interpersonal techniques highlight the client’s interactions with other people

so that the role of the schemas can be exposed. One way is by focusing on the
relationship with the therapist. Frequently, clients with a Subjugation schema
go along with everything the therapist wants, even when they do not consider
the assignment or activity relevant. They then feel resentment towards the thera-
pist, which they display indirectly. This pattern of compliance and indirect ex-
pression of resentment can then be explored to the client’s benefit. This may lead
to a useful exploration of other instances in which the client complies with others
and later resents it, and how the client might better cope at those times.
Another type of interpersonal technique involves including a client’s spouse
in therapy. A man with a Self-Sacrifice schema might choose a wife who
tends to ignore his wishes. The therapist may wish to involve the wife in the
treatment in order to help the two of them to explore the patterns in their relation-
ship and change the ways in which the couple interacts.

Cognitive Techniques

Cognitive techniques are those in which the schema-driven cognitive distor-

tions are challenged. As in short-term cognitive therapy, the dysfunctional thoughts
are identified and the evidence for and against them is considered. Then new
thoughts and beliefs are substituted. These techniques help the client see alterna-
tive ways to view situations.
The first step in dealing cognitively with schemas is to examine the evidence
for and against the specific schema which is being examined. This involves look-
ing at the client’s life and experiences and considering all the evidence which
appears to support or refute the schema. The evidence is then examined critically
to see if it does, in fact, provide support for the schema. Usually the evidence
produced will be shown to be in error and not really supportive of the schema.
For instance, let’s consider a young man with an Emotional Deprivation
schema. When asked for evidence that his emotional needs will never be met, he
brings up instances in which past girlfriends have not met his needs. However,
when these past relationships are looked at carefully, he finds that, as part of the
schema maintenance process, he has chosen women who are not capable of giv-
ing emotionally.
This understanding gives him a sense of optimism; if he starts selecting his
partners differently, his needs can probably be met.
Another cognitive technique is to have a structured dialogue between the
client and therapist. First, the client takes the side of the schema, and the thera-
pist presents a more constructive view. Then the two switch sides, giving the
client a chance to verbalize the alternative point of view.
After having several of these dialogues the client and therapist can then con-
struct a flashcard for the client, which contains a concise statement of the evi-
dence against the schema.

12
Cognitive Therapy for Personality Disorders (3rd ed.)

A typical flashcard for a client with a Defectiveness/Shame schema reads

“I know that Ifeel that there is something wrong with me, but the healthy side
of me knows that I'm OK. There have been several people who have known
me very well and stayed with me for a long time. I know that I can pursue
friendships with many people in whom I have an interest.”
The client is instructed to keep the flashcard available at all times and to read
it whenever the relevant problem starts to occur. By persistent practice at this
and other cognitive techniques, the client’s belief in the schema will gradually
weaken.

Behavioral Techniques

Behavioral techniques are those in which the therapist assists the client in
changing long-term behavior patterns so that schema maintenance behaviors are
reduced and healthy coping responses are strengthened.
One behavioral strategy is to help clients choose partners who are appropri-
ate for them and capable of engaging in healthy relationships. Clients with the
Emotional Deprivation schema tend to choose partners who are not emotionally
giving. A therapist working with such clients would help them through the proc-
ess of evaluating and selecting new patterns.
Another behavioral technique consists of teaching clients better commu-
nication skills. For instance, a woman with a Subjugation schema believes
that she deserves a raise at work but does not know how to ask for it. One
technique her therapist uses to teach her how to speak to her supervisor is role
playing. First, the therapist takes the role ofthe client and the client takes the
role of the supervisor. This allows the therapist to demonstrate how to make
the request appropriately. Then the client gets an opportunity to practice the
new behaviors and to get feedback from the therapist before changing the
behavior in real-life situations.

IN SUMMARY, schema-focused therapy can help people understand and

change long-term life patterns. The therapy consists of identifying Early Mal-
adaptive Schemas and systematically confronting and challenging them.

80
 REFERENCES

CITED REFERENCES

American Psychiatric Association. (1994). Diagnostic and Statis-

tical Manual of Mental Disorders (4th ed.). Washington, DC:
Author.
Beck, A. T. (1967). Depression: Causes and Treatment. Philadel-
phia: University of Pennsylvania Press.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cogni-
tive Therapy of Depression. New York: Guilford.
Beck, A. T., & Steer, R. A. (1987). Revised Beck Depression In-
ventory. San Antonio, TX: Psychological Corporation.
Bowlby, J. (1973). Separation: Anxiety and Anger (Vol. II of
Attachment and Loss). New York: Basic Books.
Corr, E. (Director). (1986). Desert Bloom [Film]. (Available from
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Culver City, CA 90232-3195. Website: www.cthv.com.)
Guidano, V. F., & Liotti, G. (1983). Cognitive Processes and Emo-
tional Disorders. New York: Guilford.
Kaplan, H. I., & Sadock, B. J. (1985). Comprehensive Textbook
of Psychiatry (4th ed.). Baltimore: Williams & Wilkins.
Lazarus, A., & Lazarus, C. (1991). Multimodal Life History Inven-
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Miller, A. (1981). The Drama of the Gifted Child. New York:
Basic Books. (Originally published as Prisoners of Childhood)
Millon, T. (1981). Disorders of Personality. New York: Wiley.
Segal, Z. (1988). Appraisal of the self-schema: Construct in cog-
nitive models of depression. Psychological Bulletin, 103,
147-162.
Young, J. E. (1992). Schema Conceptualization Form. (Available
from the Cognitive Therapy Center of New York, 120 East 56th
Street, Suite 530, New York, NY 10022.)

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Cognitive Therapy for Personality Disorders (3rd ed.)

Young, J. E. (1993). Schema Diary. (Available from the Cogni-

tive Therapy Center of New York, 120 East 56th Street, Suite
530, New York, NY 10022.)
Young, J. E. (1994). Young Parenting Inventory. (Available from
the Cognitive Therapy Center of New York, 120 East 56th Street,
Suite 530, New York, NY 10022.)
Young, J. E. (1995). Young Compensation Inventory. (Available
from the Cognitive Therapy Center of New York, 120 East 56th
Street, Suite 530, New York, NY 10022.)
Young, J. E., & Klosko, J. (1994). Reinventing Your Life. New
York: Plume.
Young, J. E., & Rygh, J. (1994). Young-Rygh Avoidance Inven-
tory. (Available from the Cognitive Therapy Center of New
York, 120 East 56th Street, Suite 530, New York, NY 10022.)
Young, J. E., Wattenmaker, D., & Wattenmaker, R. (1995). Schema
Flashcards. (Available from the Cognitive Therapy Center of
New York, 120 East 56th Street, Suite 530, New York, NY
10022.)

ADDITIONAL REFERENCES

Bricker, D. C., Young, J. E., & Flanagan, C. M. (1993). Schema-

focused cognitive therapy: A comprehensive framework for
characterological problems. In K. T. Kuehlwein & H. Rosen
(Eds.), Cognitive Therapies in Action (pp. 88-125). San Fran-
cisco: Jossey-Bass.
McGinn, L. K., & Young, J. E. (1996). Schema-focused therapy.
In P. M. Salkovskis (Ed.), Frontiers of Cognitive Therapy (pp.
182-207). New York: Guilford.
McGinn, L. K., Young, J. E., & Sanderson, W. C. (1995). When
and how to do longer-term therapies without feeling guilty.
Cognitive and Behavioral Practice, 2(1), 187-212.
Schmidt, N. B., Joiner, T. E., Young, J. E., & Telch, M. J. (1995).
The Schema Questionnaire: Investigation of psychometric prop-
erties and the hierarchical structure of a measure of maladaptive
schemas. Cognitive Therapy and Research, 19(3), 295-321.
Stein, D. J., & Young, J. E. (1993). Cognitive Science and Clinical
Disorders. San Diego: Academic Press.
Young, J. E. (Speaker). (1998). Challenging Cases: Innovations in
Brief Cognitive-Behavioral Therapy (Audiotape set from New

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 References

England Educational Institute, Cape Cod Summer Symposia).

Yarmouth, MA: Coastal Audio/Visuals. (To order, call 508-
394-3617.)
Young, J. E., Beck, A. T., & Weinberger, A. (1993). Depression.
In D. H. Barlow (Ed.), Clinical Handbook of Psychological Dis-
orders (2nd ed., pp. 240-277). New York: Guilford.
Young, J. E., & First, M. (1996). Schema Mode Listing. (Avail-
able from the Cognitive Therapy Center of New York, 120 East
56th Street, Suite 530, New York, NY 10022.)
Young, J. E., & Flanagan, C. (1998). Schema-focused therapy for
narcissistic patients. In E. Ronningstam (Ed.), Disorders of
Narcissism: Diagnostic, Clinical, and Empirical Implications
(pp. 239-268). Washington, DC: American Psychiatric Press.
Young, J. E., & Gluhoski, V. L. (1996). Schema-focused diagnosis
for personality disorders. In F. W. Kaslow (Ed.), Handbook of
Relational Diagnosis and Dysfunctional Family Patterns (pp.
300-321). New York: Wiley.
Young, J. E., & Gluhoski, V. L. (1997). A schema-focused per-
spective on satisfaction in close relationships. In R. J. Sternberg
& M. Hojjat (Eds.), Satisfaction in Close Relationships (pp.
356-381). New York: Guilford.

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 JEFFREY E. YOUNG, PhD, is Founder
and Director of the Cognitive Therapy
Centers of New York and Connecticut.
He is also on the faculty in the Depart-
ment of Psychiatry at Columbia Univer-
sity. Dr. Young received his bachelor’s
degree from Yale University and his
doctorate from the University of Pennsylvania. He then
completed a post-doctoral fellowship at the Center for
Cognitive Therapy with Aaron Beck, founder of the cog-
nitive therapy approach, and went on to serve there as
Director of Research and Training. Using well-known
procedures and materials he has developed over the past 18
years, the author has trained thousands of cognitive therapists
at workshops throughout the world. Dr. Young is co-author
of a major psychotherapy outcome study evaluating the
effectiveness of cognitive therapy, has served as consultant on
several research grants, and was on the editorial board of
Cognitive Therapy and Research. He has published widely
on cognitive therapy, and has co-authored Cognitive Science
and Clinical Disorders (with Dan Stein) and Reinventing
Your Life (with Janet Klosko), a self-help book based on his
schema-focused approach.

ISBN 175@867=047—7

J, 90000>

Professional Resource Press

PO Box 15560
Sarasota, FL 34277-1560

9 "781568'870472