Skills in Cognitive Behaviour Counselling & Psychotherapy CHAPTER 7: Skills for working with enduring negative patte

1. Skills in Cognitive Behaviour Counselling & PsychotherapyCHAPTER 7: Skills for working with enduring negative patterns FRANK WILLS (2008) London: SAGE

2. Schemas, core beliefs and assumptions: different ways of working • Schemas, core beliefs, assumptions and negative automatic thoughts represent different levels of cognition. • Different methods are required for working with these different levels of cognition (Padesky & Greenberger, 1995). • There is overlap and continuity between the different levels and different ways of working, but also differences in the nature (e.g., older–newer, surface–depth) of the cognitions being tackled.

3. Schema and core beliefs • In CBT, ‘schema’ has come to be a term to describe ‘early maladaptive schema’ (Young, 1994). • Schemas are now seen as complex networks of feeling, thinking, behaviour and physiology. They may be very old, even pre-verbal, vague and give direction of perception. • Schemas may have different dimensions (e.g., ‘mistrust schema’ might have different dimensions for men, women, young, old people, etc. • As the different dimensions of schemas become operationalised and verbalised, they may be represented as ‘core beliefs’ – e.g., ‘I can’t trust other men to respect my feelings.’ • Schemas and core beliefs can be identified by questionnaires (e.g., Young, 1994; Young & Klosko, 1993).

4. Schema and core belief change • Negative schemas tend to be vague feelings about the self and the world. They have strong maintenance systems and may be quite impervious to change. It is probably best to think in terms of ‘chiselling them down’ at the same time as trying to build alternative more positive schemas. • Core beliefs tend to be stated in categorical and ‘black and white’ terms: e.g., ‘I am crap’ – no ifs, no buts! Their weak point, offering a therapeutic target, is that they are nearly always too constrained to accommodate all the data that may be relevant to them. Change efforts therefore focus on opening them out to wider sources of data.

5. Unhelpful assumptions: nature and change • Core beliefs are hard to live with – even we here in this audience can’t be crap all the time! • Assumptions may therefore develop as compensatory strategies for core beliefs – e.g., ‘If I could get someone to love me, maybe I wouldn’t feel so crap.’ • They may also change form into ‘rules of living’ – ‘As long as lots of people love me, I’m okay.’ • These rules may work for a while carry a tendency for the holder to get ‘hoist with his own petard’ – trying to make people love one may get on their nerves! • Unhelpful assumptions easily develop into overly rigid rules, and effort for change again therefore centres on fostering adaptability to more varied situations.

6. Ways of modifying assumptions • The downward-arrow technique consists of identifying and pushing assumptions to the limit of their credibility by asking questions like ‘What would be so bad about people not loving you?’ This may reveal the limitation of the rule to people and begin to loosen belief in it. • FLASHCARDS give a format for identifying where assumptions come from, their positive and negative (price) aspects, and offer an alternative for the client to contemplate in hours of rumination on the negative version.

7. Assumptions flashcard • I sometimes assume that … I can only feel okay about myself if lots of people seem to love and approve of me. • It is understandable that I think this because … when I was younger, my parents seemed to consistently favour my brothers and sisters over me. • This works against me because … I often try too hard to make people love and approve of me and ‘sell myself cheap’ and get on peoples’ nerves too. • The assumption is wrong because … ‘You can please some people some of the time… but you can’t please all of the people all of the time’! • The best way forward for me now is … To concentrate on my life goals and realise that some people will like what I do and some won’t.

8. Developing more flexible rules of living (the example of BRUCE) OLD RULE: • I must not show my weak points to anyone at any time. NEW RULE: • It might be possible to show my weak points to some people some times. • I can explore different ways of showing weak points – some might be better than others. • Taking the initiative sometimes could give me more sense of control. • Taking the initiative sometimes might also lessen the sense of dread about being ‘found out’. (NB: Notice the new rule is more ‘variegated’ than the old).

9. Schema and core belief change methods • Because schemas are so omnipresent, they frequently show themselves in the therapeutic relationship and so may also be worked with and through in that context. • Schema work tends to be longer term so that the therapy relationship becomes a key focus of change. • There is also the need, however, to get on with the work of therapy via specific schema-change techniques.

10. Examples of how schemas can show and be worked through in the therapy relationship (1) • MISTRUST SCHEMA: The client wonders how he is supposed to know how far he can trust you to tolerate him and sets up ‘transference tests’ to test your tolerance of him (coming late, forgetting to pay, etc.). • ENTITLEMENT SCHEMA: This is often underlain by low self-esteem. If the therapist accepts the ‘good part’ then the client will suspect her judgement; if she points out the ‘bad part’ she may be accused of being ‘just like my mum’.

11. Examples of how schemas can show and be worked through in the therapy relationship (2) • AVOIDANT SCHEMA: This may show itself by avoidance of issues, non- or pseudo-cooperation with agenda setting and the work of therapy. • DEPENDENT SCHEMA: This may show itself by over-compliance, exaggerated accounts of how much the client has changed and how helpful the therapy has been, followed by signs of distress and/or alarm by the suggestion that therapy could now end.

12. Examples of how schemas can show and be worked through in the therapy relationship (3) • As discussed in Chapter 3, the first step that the therapist needs to master is that of ‘unhooking’ herself from the schema-driven interpersonal tangle. These transferences tests are inherently provoking and can’t be dealt with from the ‘hooked-in’ position. Supervision is often very helpful here. • The next step is to look at how the client’s schema may be interacting with one’s own – it is not unknown, for example, that therapists can feel gratified by dependent clients. • The therapist can then develop empathy for the client’s position – a good formulation should tell us why the client has this pattern. We can now consider whether anyone with such a history might develop such pattern. • The next step is to formulate a non-threatening way to raise the issue with the client so that a therapeutic plan can be developed – perhaps including some of the methods and techniques shown in the following slides.

13. The use of continua • The basic problem with negative client schemas is that they only let certain types of ‘schema-confirming data’ in. • They need therefore to be ‘stretched out’ and loosened up to let in consideration of wider factors that are likely to be more benign in relation to the client’s self-image. • Continua are visual representations of such efforts in which the client is asked to draw a line with an aspect of the schema (e.g., ‘0% worthiness’) at one end and its opposite (100% worthiness) at the other end. Other people or aspects of the client’s behaviour can be placed along this line. • The net effect seems to be to demonstrate the fact that all of us human beings are basically quite flawed, and realising this helps us to join the common band of humanity – ‘We are all in this together.’

14. Historical tests of a schema • As with continua, rules and beliefs can be tested to see how well they seem justified at different stages of the client’s history. • Because the client is currently often mired in a bad place where their experiences seem to confirm their negative beliefs, they may be ignoring information about different times when this was not the case – the historical test can often reveal this and may even reveal positive aspects of the current situation that are being ignored.

15. Positive diaries, psychodrama and schema debates • Positive diaries focus on collecting and writing down positive aspects of the client’s past and current life that are being forgotten. Negative bias in memory and attention is counteracted by the purposeful act of writing and then re-reading. • Psychodrama is a form of role-play in which negative previous experiences can be re-run with different types of outcome and interventions penned in. • Schema debate is a form of role-play in which the client can gain practice from reflecting on how the negative voice of the schema is most effectively opposed.