You’ll Need Them If CBT Doesn’t Work
One of the nice things about being a reflective eclectic is I have loads of methods I can use to help people who see me for psychotherapy. Sometimes it’s simple. If you come in and say you’re anxious, I can teach you a method of breathing that may make you feel better. If you’re depressed, we can talk about finding something easy and meaningful to accomplish. If you’re early in recovery from an addiction, we’ll devise a relapse prevention plan you can follow. These are all methods of Cognitive Behavioral Therapy (CBT), the most direct and rudimentary approach towards helping someone who’s suffering.
But what if you’ve tried all that and are still suffering? It’s not like you didn’t know how to breathe, get busy, or do something besides getting high before I told you. What if you can breathe fine when reminded, but can’t remember to breathe on your own when you’re anxious? What if you’ve been to a dozen therapists and nothing has gotten better? Luckily, I have a plan B, and C, and D, and E, etc. Here I’ll tell you about a type of psychotherapy that’s designed to be plan B, schema therapy.
But first, let’s examine the reasons CBT, the usual Plan A, often fails.
CBT requires you to meet with a therapist and share the most personal things about yourself before you know whether you can trust her. Many people need longer to feel comfortable than others. If you’ve been hurt in the past by someone you should have been able to trust, then you might not be so keen on it now. In that case, you won’t take her suggestions. You may need a therapy that strengthens your relationship with the therapist before you can ever get down to the issues that brought you to therapy.
Also, with CBT, you need to know what your problem is. You must be able to identify the issue correctly, so the therapist can give you the right homework. Maybe you’re vaguely, but intensely dissatisfied with your relationships, your work, or your self, but you can’t put your finger on what’s wrong. Or maybe you’re depressed one day, anxious the next, and someone thinks you drink too much, but you aren’t sure. You may have never developed the ability to look within and find the words to describe your feelings. It might be you relapse shortly after treatment is complete or your symptoms change as soon as you address them, like a diabolical game of whack-a-mole. You may have some hidden issues that need to be addressed. Sometimes there’s a deep dark secret that must be brought to light, a grief that you never worked through, or an aspiration that has never been pursued. You won’t get anywhere towards solving your problems the CBT way if you don’t know what they are.
You must be flexible enough to change. It can be impossible if you don’t think you can change, if your anxiety, depression, or addiction have become so much a part of you that changing feels like you’re abandoning yourself. Think about how hard recovery from addiction is, for instance. You must stop doing the very thing that helps you cope, right when you have so much to cope with. CBT has no patience for that. It wants you to get on with it and cut the ties you have with dysfunction.
Nor will CBT work if you need comfort more than challenge. CBT is a challenge. It takes a lot of dedication and consistency to change habits. If you’re so depleted and beaten down from a lifetime of adversity and trauma, it may not be possible to take on anything additional. You may need consolation from a therapist for your suffering before you can do anything to help yourself.
Finally, not everything can be addressed by therapy, any kind of therapy. You might need a lawyer, or a cop, or a doctor more than a shrink. Perhaps moving to a safe environment, getting out of a toxic relationship, or getting a better job, government benefits, or a more equitable society will do you more good than anything I can help you with.
So, what is this plan B and what the heck is a schema? A schema is a pattern imposed on reality that guides your perception and suggests a response. For instance, if something walks like a duck and quacks like a duck, the schema we have of waterfowl says it must be a duck. If you’re out duck hunting, you’ll shoot it. If you’re walking with your grandson, you’ll bring bread to feed it. A schema is an abstract representation of distinctive characteristics, a blueprint of prominent elements, together with a prescribed action. You formed your schemas early in life and superimposed them on later experiences. You do this to be consistent, so you can maintain a stable view of yourself and the world around you.
It can be hard to identify the schemas that guide your thoughts, feelings, and behavior. A fish may not realize it lives in the water because that’s all it knows. A therapist can help, there are tests you can take, and there’s a self-help book you can read. The number of possible schemas is probably infinite, but Jeffrey Young, Janet Klosko, and Marjorie Weishaar, identified eighteen particularly maladaptive schemas in their book, Schema Therapy: A Practitioner’s Guide. These are the schemas therapists most often encounter: Mistrust, Emotional Deprivation, Defectiveness, Alienation, Incompetence, Vulnerability, Enmeshment, Failure, False Entitlement, Insufficient Self-Control, Subjugation, Self-Sacrifice, Approval-Seeking, Pessimism, Emotional Inhibition, Unrelenting Standards, and Punitiveness.
Once you’ve identified your most pesky schema from that list, it’s natural to wonder where you got it from. Personally, I can say I have a bit of an alienation schema. I got it from growing up with no other kids around. When I started school, I didn’t know what to make of them, and they didn’t know what to make of me. Mystified by their ways, I kept my distance and found solitary things to do, like reading lots of books. This, of course made me all the more peculiar to everyone else and reinforced my sense of alienation.
Compared to the awful things that happen in some people’s childhoods, this doesn’t sound all that traumatic, but when you’re a little kid, it doesn’t take much. Childhood experiences become foundational for the person you later become. No, let me rephrase that. They become foundational for your schemas. This is a point I’d like to stress. Contrary to appearances, schemas do not define you. You are not your schemas. I am not permanently alienated. I just sometimes think I am.
If you can trace your schemas back to their sources, you’ll see how these beliefs have recurred throughout your life. But it’s also important to know what your schemas make you do, your response when a schema is activated. My alienation schema is sometimes triggered when I’m alone in a public place, like when I’m at a party and no one is talking to me for a few moments. I see everyone else grouped together and having a good time, but I’m in the middle of the room and no one seems to know I’m there. Either that, or they take one look at me and walk away. Something as ordinary as this can engender some very painful, often unnecessary feelings. Sometimes I can’t just sit with those feelings. I’m compelled to do something about them.
Responses to schemas fall into three categories: surrender, avoidance, and overcompensation (corresponding to freeze, flight, and fight). Surrendering would mean I would just stand there, unable to do anything, or move out of the way and line the walls with all the other wallflowers. My mind would be busy, though. I’d be thinking of all the ways I’m different from everyone. Just the narrative the schema demands. If I were to choose avoidance, I’d leave the party or pull out my phone and spend all my time staring at a little screen. I might also get another drink and numb the feelings that are being triggered.
If I overcompensate for my alienation schema, I might decide to circulate at the party, find a group that’s talking, and join in. Or I’ll locate another solitary individual and bend their ear. This involves some degree of imposition and risk-taking, the very things you wouldn’t think my alienation schema wants me to do. It looks like I’m defying the schema, but they’re tricky. If I feel compelled to become the party animal, then I’ll do it wrong. I’ll be forcing it. I’ll overlook those subtle social cues that would tell me I’m coming on too strong and the other people will not greet me enthusiastically. Overcompensation often ends up strengthening the schema, rather than destroying it.
You know when you’re dealing with a schema when it feels like something is taking you over. If you go home to see your parents and find yourself behaving like a child, you have a schema to blame. If you’re feeling anxious and crave a drink, then a schema is behind it. If you’ve wanted to get pregnant and can’t get happy for your friend who’s having a baby, then a schema is in the way. Some clients take readily to the idea that they can dialogue with parts of themselves that take over. If they’re open to the idea of an inner child, an addicted side, or a green faced monster, there’s a lot we can do with it. It allows us to utilize my plans C, D, E, F, and G: Voice Dialogue, Gestalt Therapy, Internal Family Systems, Psychodrama, or Jungian, and have a good talk with them.
If we were to go back to the reasons CBT often doesn’t work, we can see that many of those reasons correspond to various schemas. Abandonment, Mistrust, Emotional Deprivation, and Shame schemas would get in the way of establishing trust with a therapist. Clients with Dependence, Vulnerability, Enmeshment, and Failure schemas may not know who they are and what they want. Schemas of Subjugation, Self-Sacrifice, or Approval-Seeking result in someone too intent on pleasing the therapist to look within themselves and know their own feelings. Clients with schemas of False Entitlement or Insufficient Self-Control may be too unmotivated or undisciplined to do the work of change. If you have more than one maladaptive schema, we’ll start on the ones that interfere with therapy first. We’ll remove the barriers to change before attempting change.
A lot of good things happen when you have psychological awareness, when you’re able to observe yourself in a curious, non-judgmental way. You’ll want to know what schemas you use and how they distort reality. Once you identify and decide to work on a schema, go about your day, and try to catch it in action. I did this with my alienation schema and found it popping up all over the place. I can always count on it to visit me whenever I’m alone in public. When you catch it, observe what it prompts you to do. I’ve done lots of stuff with my alienation; everything from studying psychology so I can understand people, to writing, so I can communicate with them. It also causes me to rebel, pretend to be a loner, and to have a book, a podcast, or a laptop with me whenever I’m eating out alone. I’ve been known to avoid some social occasions or leave early, which alleviates it for the moment but, in the long run makes my sense of alienation worse. Try not to beat yourself up when you catch a schema making you do crazy stuff. Your schema is not being bad and you’re not being bad. The schema was trying to help you make sense of the world and give you suggestions about what to do. It’s just out of date.
After watching your schema operate, you may conclude that it needs updating. I took a look at my alienation schema and found a lot wrong with it. Most people I meet are friendly, they include me, and listen to what I have to say. I have no reason to be alienated in the bosom of family, in a safe and vibrant community, a citizen of one of the most consequential nations on earth, belonging to a race that enjoys widespread privilege. It’s ridiculous to conclude on the basis of this misbegotten schema that I’m unlikable and friendless.
When you take a look at facts that undermine your schemas, be sure you can accommodate all the information, rather than explain it away. Schemas operate a lot like conspiracy theories, they don’t permit contradiction. At one point, I was so convinced of my alienation that I was blind to all information to the contrary. The schema had me convinced and there was no arguing with it. Destructive as some can be, schemas provide you with feelings of security and predictability, much like belief in a conspiracy theory gives you an identity. People resist giving up schemas because they’ve mistaken their identity for their schemas.
If you’re open to facts that contradict your schema, you will end up with a debate in your head. On one side will be your schema, telling you things you already thought, and on the other side will be this new information, bearing facts that undermine the schema. We’ll call these two sides the schema side and the healthy side. Now, here’s where you devise your own plan B. Plan A was to use the old schema to guide your behavior. That didn’t work so well, so make a plan to abstain from whatever perpetuates it. Use the healthy side to suggest some new behaviors. Test what the healthy side says and see if it’s true.
When I did that with my alienation schema, my healthy side pointed out all the ways I belong. The next time I went to a party, I assumed I belonged there. Then, I could go up to people and talk to them if they appeared receptive. I didn’t force it. If they weren’t receptive then I behaved as if I was content by myself and watched people. I figured if they didn’t want to talk, it had more to do with them than me. I abstained from looking at my phone, disappearing from the party, or drinking to quiet the voice of my schema.
When I acted as if the healthy side was right, I found out it was; but it’s not always going to happen that way. Sometimes the influence of the schema is so strong that you don’t give it a good test, you give in to the demands of the schema and behave as you always have. Other times, the healthy side, as you constructed it, proves to be wrong. In my case, I don’t belong everywhere. There will be groups of people who systematically exclude people like me, no matter who I am. Maybe I never paid the price for admission, I didn’t get that degree, formally joined, cleaned myself up, or learned to behave in an acceptable manner. If that’s true, then there are steps I can take to belong if I really want to. Then there are the groups that will never accept people like me. They don’t like the color of my skin, the slant of my eyes, or the way I pronounce my vowels. There’s nothing I can do about it then, but I may not want to join their group, anyway.
If you put the healthy side to the test and find that it’s true, then you are well on the road to recovery. It’ll take some deliberate practice, though. You can’t count on doing it the healthy way once and expect it to stick. In my case, I had to go to a few parties, sit alone in a restaurant many times, and go the places I used to avoid before the healthy way became automatic. However, it won’t be long till you can tell your therapist goodbye and get on with your life.
If you try it the healthy way and find that the schema and your usual responses to it persist, then we need to take what we learned about your schemas and apply them to Plan C. My Plan C is one of the more experiential forms of therapy: Voice Dialogue, Gestalt Therapy, Internal Family Systems, Psychodrama, or Jungian. We’ve given rationality a crack at updating your schema, now you need to see if your emotions can talk to it. Here’s where a willingness to engage with schemas by personifying them is helpful. You basically go back in your memory to whatever trauma caused your schema in the first place, use imagery to pretend it’s happening again, and have a corrective emotional experience.
If it sounds terrifying to go back in memory to trauma and re-experience it, you are wise to be cautious. The memory of trauma will activate the schema involved and set into motion your usual responses. Some can be very self-destructive. We want to first be able to predict what you might do, so we can guard against it. For instance, if the memory of your father beating you up triggers your vulnerability schema, you could easily become violent to defend yourself. You need get past that, so we can contact that inner child who still lives inside, like a set of Russian nesting dolls. You need to take care of him with the healthy, adult side that you developed. Sometimes play and make-believe will help us do what work cannot.
I did this with my alienation schema. I remembered a prototypical incident when no other kid would sit with me on the school bus. I imagined sitting, as I am now, with myself, as a child, on the bus. I talked to that child and asked him if he would like me to take over because I’m an adult. He was happy to let me choose healthy behaviors that he didn’t know how to do.
This is a very different way for me to think, for I used to be ashamed of that little boy. I used to treat that boy in the way that boy imagined everyone was treating him. I would never sit with him. Now, I’m not ashamed of him anymore. I keep him around, along with the schema, for the same reason people keep any memorabilia from their childhood. I’ve got collection of old drawings and a story I wrote during that time, too; all of which are just as embarrassingly inept and childish. It’s important to keep them around to remind myself I haven’t always been as I am now, to demonstrate the reality of change.
Now that I’ve told you about schema therapy, you should know about its limitations. I’ve told you where it fits in, after CBT has failed, and before you try the woo-woo methods like talking to yourself. The other thing I like to say is that the eighteen schemas identified are not enough. People rarely fit neatly into those boxes. Sometimes the creature that walks like a duck and quacks like a duck is a duck-billed platypus and you don’t know where it belongs. The fact is, schema therapy itself is a schema, one that does not correspond perfectly with the actual world and needs to be tailored to fit each person I work with.
However, if this article has done anything at all, I hope it inspires you to identify your own expectations, observe them in action as you go about your day, and consider what they make you do. Do they explain the world the way they’re supposed to, or do they keep you stuck, doing what you’ve always done, and getting what you’ve always got?
Keith R Wilson 