Clinician's Guide to Mind Over Mood (19 page)

In addition to treating Axis I problems such as depression and anxiety,
Mind Over Mood
can be used to treat Axis II disorders directly. When maladaptive schemas are weakened and alternative, more adaptive schemas are developed personality disorders can be successfully treated. Treatment is successful when a client meeting full diagnostic criteria for a personality disorder no longer meets the diagnostic criteria by the end of treatment. Case studies attest to the potential efficacy of cognitive therapy for personality disorders based on schema change and development of alternative behavioral coping patterns (Beck et al., 1990). Some suggestions follow for using the treatment manual to assist this therapy approach.

For a detailed description of clinical methods used to change core schemas, see Padesky (1994a). This section highlights the use of the treatment manual to facilitate schema change. Summaries of methods used to identify and change core schemas are provided along with clinical illustrations.

Chapter 9 of
Mind Over Mood
includes the primary cognitive tools necessary to identify and change negative schemas. Worksheets 9.1, 9.2, 9.3, and 9.4 ask questions to help clients identify negative core schemas about the self, others, and the world. It is important to help clients identify all three types of schemas because these cognitive domains interact. As a cluster, these three types of schemas help explain emotional, behavioral, and motivational responses better than any single schema. For example, two people may have the self-schema “I am weak.” If the first person has the other-schema “Others will hurt you if they get the chance,” he or she will try to hide this weakness for self-protection and may adopt an avoidant style. If the second person has the other-schema “Someone is always weaker than I and deserves to be taken,” she or he will be on the alert for weaker people and try to take advantage of them, adopting an antisocial pattern of coping.

Once maladaptive schemas have been identified and stated in the client’s own words, alternative schemas can be identified. Pages 143–152 in Chapter 9 of
Mind Over Mood
can be used to help a client identify more adaptive schemas and state them in the client’s own words. The process of identifying current schemas and desired new schemas can take several weeks, during which changes often occur in the words or concepts used to label the schemas. It is especially important to identify an alternative, more adaptive schema that has a desirable meaning for the client because this new schema forms the foundation of schema change processes. The following dialogue between Gary and his therapist illustrates the search for an alternative schema.

T:   Last week we talked about your negative core belief “I’m no good” and came up with the alternative belief, “I’m good enough.” I asked you to think this week about the phrase, “I’m good enough,” to see if it captures how you’d like to see yourself. Did you do that?

G:   Yes. It would be nice to see myself that way. But I don’t think it’s quite right.

T:   What’s not right?

G:   When I think, “I’m no good,” it’s not just me I’m thinking about. It’s how other people see me.

T:   So is it more like “Others see I’m no good”?

G:   No. That’s not it, either. I think it’s “I’ll be punished for my faults.”

T:   I see. That is a different meaning. What would be the alternative to that? How would you like it to be?

G:   Safe. (
Pauses.
) I’m safe even if others see my faults. (
Shoulders relax, eyes moisten.
)

T:   How does it feel to say that?

G:   Good. Scary. Relief, if I could ever believe that.

T:   Let’s write this down, “I’m safe even if others see my faults,” and you can think about this idea this week and see if it seems to capture how you’d like things to be in your life.

In this interchange, the therapist listens carefully and asks questions that help Gary articulate a nuance to his negative schema that was out of his awareness before he tried to construct an alternative core belief. Note that Gary had moderately strong affect when the new alternative belief was stated. Schemas are closely tied to affect and clients usually show some emotion when an old or new schema is named for the first time. Gary’s disbelief that the new schema could be true is also a characteristic response to an alternative, more adaptive schema.

Gary identified a schema somewhat different in form from the schema statements provided in Chapter 9 of the manual, “I am ______________,” “Others are ______________,” “The world is ______________.” His negative schema combines aspects of both self (“I have faults”) and others (“Others will punish me”). It is important to help clients state the negative and alternative schemas in the form most meaningful to them and not force them to conform to the manual’s template. Schemas take many shapes including images. For example, one woman had a pictorial schema of a small critical gnome sitting on her shoulder and worked to develop an alternative, more adaptive image. Once old and new schema are identified, clients can use the exercises in Chapter 9 of
Mind Over Mood
to actively work on schema change by weakening their conviction that the old schema is true and strengthening their confidence in the alternative belief they have constructed.

A change in core beliefs requires simultaneous efforts to weaken old schemas and strengthen new ones. The manual includes worksheets to guide the client to use three primary schema change processes: continuum practice, core belief records, and historical tests of schemas. The following therapy excerpts show how Gary used each of these methods to weaken his schema “I’ll be punished for my faults” and build confidence in the alternative schema “I’m safe even if others see my faults.”

Continuum Methods

T:   How does that new alternative belief, “I’m safe even if others see my faults,” fit for you this week?

G:   That seems like what I’d like. But the more I think about it, the more I’m sure it’s impossible.

T:   What makes it seem impossible to you?

G:   I’ve never been safe. At work, at home, people clobber me if I screw up.

T:   Let’s make a safety scale. (
Draws a line and labels endpoints 0% and 100%.
) Here’s 0% safety and here’s 100% safety. At the top we’ll write, “How safe I am when others see my faults.” Where do you generally think of yourself on this scale?

G:   At 0%.

T:   Put an “X” at 0%, Gary, and note that that is where you see yourself.

(
Gary puts an “X” at 0% and writes “Me.”
)

T:   Now, let’s make a list of times others have seen your faults.

G:   Last week at work when I couldn’t figure out the sales tax when my calculator broke. Let’s see, I promised my son I’d fix his toy but I was too tired and didn’t do it. That’s all I can think of right now.

T:   Any times you can think of when I’ve seen your faults?

G:   When I first came here, I’d agree to do some work in the book and then I wouldn’t do it.

T:   So it sounds like when you say, “my faults,” you mean mistakes you make or times you don’t follow through on what you promise, or things you don’t know how to do.

G:   Yeah, that’s right.

T:   What do you mean by “safe”?

G:   Safe from being hurt.

T:   Physically hurt? Or emotionally hurt?

G:   Both. When I was a kid my dad would beat me up pretty bad when I screwed up. But I feel just as bad if someone makes fun of me or calls me dumb.

T:   Has that happened to you, too?

G:   Yeah. In school, and sometimes at work my boss will get mad and call me a “dumb_______.”

T:   So let’s write on this scale what safety means for you. At 0% let’s write what no safety would mean. For example, you might get beat up until you’re almost dead.

G:   Yes. Beat up real bad or attacked and stood up in front of the group to be made fun of. (
Writes these ideas below 0% on the scale.
)

T:   What would 100% safety look like?

G:   I’m not sure.

T:   Well, if 0% is being beaten within an inch of your life, I guess 100% safety would be feeling protected from physical harm.

G:   Like having a bodyguard.

T:   Yes. What would be the safest you could imagine?

G:   Protected by a safety shield so no one could touch me.

T:   OK. Write that under 100% safe. (
Pauses while Gary writes.
) Now, what about 100% safe from public shame or criticism? What would that look like?

G:   If people were patient and encouraging me, instead of making fun of me.

T:   Write that under 100% safe. (
Pause while Gary writes
) On this scale we are making, what would 50% safe look like? Something halfway between these endpoints.

G:   Physically, I guess being shoved but not hurt. And I guess someone being critical or upset with me one-on-one, not in front of a group.

T:   Write those down under the midpoint of the continuum, which we’ll label 50%. Now, let’s mark on this scale these three experiences you gave me where others saw your faults. First, you couldn’t figure the sales tax at work when your calculator broke. Where would you put your safety then?

G:   Hmmm. I guess about 25%. My boss made fun of me but only one other person was there and he didn’t beat me up or anything.

T:   Put an “X” there and label it so you know what the “X” means. (
Pauses.
) And how about when you didn’t fix your son’s toy?

G:   I guess about 80%. He was disappointed but he wasn’t mad at me.

T:   Put an “X” there and label it. (
Pause
) How about in here when you didn’t do what you said you would in the book?

G:   Well, you didn’t beat me up. (
Laughs.
)

T:   Did you expect me to?

G:   I sort of did.

T:   And what did happen?

G:   You asked me questions and were nice about it. And you helped me be not so afraid of screwing up.

T:   So where would that go on this scale?

G:   I think 90% safe.

T:   Write that down. (
Pauses.
) Now we’ve got four “X’s” on this scale, one for where you see yourself (0%) when others see your faults and three for recent events (25%, 80%, 90%). What do you notice when you look at this scale and these marks?

G:   Where I see myself is different from what has happened lately.

T:   Good point. What if we put some of your childhood events here, like that time your dad beat you up for making a mistake?

G:   That would be 0%.

T:   So, do you think as a kid you lived in 0% safety more often?

G:   Not all the time. But I never knew when my dad would blow up.

T:   So, seeing yourself as 0% safe might have been a good thing to do as a kid. I mean, it might have been better to assume you were never safe and be careful since you never knew when your dad would blow up.

G:   Yeah. I think that’s true.

T:   How about today? Do you think it’s still better to assume you’re never safe?

G:   (
Pauses
) No, I guess not. It looks from this line here that I may be safer than I think.

T:   And what would be the advantage for you in thinking of yourself as being safer? Why not still think of yourself as only 0% safe?

G:   Well . . . I could be more relaxed if I felt safer. And maybe I’d face up to people more.

T:   And how do you think that would help you?

G:   If I acted stronger, my boss might back off. He doesn’t give Pete as hard a time as he gives me.

T:   That’s an interesting idea. It might be good to find out if your boss would back off if you acted stronger. We could practice in here how you might do that. First, though, maybe it would be helpful to keep track on this scale how safe you are this week when others see your faults. It might help to find out more about when you are safe and when you are not. What do you think?

G:   That makes sense.

In this session, Gary’s therapist uses a scale and guided discovery to begin to weaken Gary’s conviction that he is 0% safe and also to introduce the concept of safety in the face of having faults. The first step of cbib-1 schemas is usually clarification of schema concepts. The therapist in the case example asks Gary to specify what he means by “faults” and “safety,” then introduces a scale that provides a visual summary of Gary’s experiences to assess whether they support or contradict his schema.

A scale or continuum is most therapeutic when it is constructed and its data evaluated for the new schema rather than the old. A small shift that strengthens the new schema is usually more hopeful for the client than a small shift that weakens the old schema. Consider the difference Gary would probably feel if he moved to “It’s 90% true that I’ll be punished for my mistakes” versus “I’m 10% safe when others see my faults.”

Once a scale is constructed for the new schema, the therapist helps Gary qualitatively define the endpoints and midpoint. It is important to help the client label the endpoints in extreme terms so that the entirety of human experience is accounted for on the scale. On their own, clients sometimes define the endpoints in more moderate terms, which weakens the value of the scale to measure change. For example, if Gary had defined 0% safe as “Someone is displeased with me,” then there would be little room for variability across the scale and his father’s beatings would end up equivalent to his boss’s reprimands and his son’s disappointment.

Once the endpoints are defined, the therapist asks Gary to place recent experiences on the scale. She then asks Gary to compare his schema-driven perception that he is 0% safe when faults are revealed to his actual experience. Note that the therapist does not focus single-mindedly on disproving the schema. She links Gary’s schema to early developmental experiences and empathically notes the adaptive value of his schema growing up with a physically abusive father. Once the origins and occasional adaptiveness of the old schema are validated, the therapist asks Gary to consider if this schema is always adaptive in his current circumstances.