Schema Assessment

Schemas can be assessed by using a number of methods. In addition to the deduction of schemas through the ongoing review of the automatic thoughts that are elicited in different situations, schemas can be evaluated through more formalized methods. One commonly employed method is the downward arrow technique, which was discussed earlier in this chapter. This technique can be used early or late in therapy both to help develop a case formulation and to evaluate a formulation that has already emerged. It can be used to examine the direct meaning attached to a particular thought or to fully explore the broader implications of a thought down to the deepest level. It can also be applied to events that the patient has experienced and to hypothetical events to see how the patient predicts he or she might respond.

In addition to clinical deduction and the downward arrow technique, other techniques can be used. As the therapist and patient start to name a schema and to consider its operation, they can engage in education and reading. Therapists could describe different schemas, for example, to see what the patients think might best fit themselves. If patients concur, therapists can assign readings about different beliefs and assumptions. This may help patients to determine which assumptions or schemas are operating in their lives. I sometimes have patients read Reinventing Your Life (Young & Klosko, 1994) because it describes common schemas and provides case illustrations. The popular book Feeling Good (Burns, 1980) provides good descriptions of a number of depression-related schemas or beliefs and how they can be effectively changed over the course of therapy. Therapists may know of a novel or book that describes a schema relevant to the patient and could be assigned as homework. For example, The Elegance of the Hedgehog (Barbery, 2008/2006) is a novel that includes an excellent description of a woman who lives as a spectator in relative seclusion and isolation, who through her interactions discovers that she can find deeper meaning in life through interpersonal connection and the potential for hurt and suffering that relationships involve.

Another method of assessing core schemas is through the use of questionnaires. Several questionnaires to assess beliefs or schemas related to cognitive therapy are available: the Dysfunctional Attitudes Scale (Olinger, Kuiper, & Shaw, 1987; Sahin & Sahin, 1992; A. Weissman & Beck, 1978), the Sociotropy–Autonomy Scale (A. T. Beck, Epstein, Harrison, & Emery, 1983; Bieling & Alden, 2001; Bieling, Beck, & Brown, 2000), and the Schema Questionnaire (Lee et al., 1999; Schmidt, Joiner, Young, & Telch, 1995; Welburn, Coristine, Dagg, Pontefract, & Jordan, 2002). Each of the scales has its particular domains, although the first two are more general and are designed to provide only information related to interpersonal dependencies or sociotropy and the need for independence or autonomy. The Schema Questionnaire provides scores on 16 personality dimensions, which are conceptually related to Young’s schema theory. Each of the questionnaires has been evaluated in a series of studies, and the general psychometric properties of these questionnaires are sound.

Cognitive therapists need to consider when to assess schemas formally by using questionnaires. If the assessment is done too early in therapy, the patient’s emotional distress may affect his or her scores. If the questionnaires are used too late, it may be difficult to get a true reading of the patient’s functional belief or schemas because the patient may be out of distress or actively trying to resist thinking about his or her previous problems (Leahy, 2001). One recommendation is to use the questionnaires at the midpoint of therapy, when the therapist is beginning to formalize or is becoming clearer about the core beliefs that operate for a given patient. The patient’s distress is still present and accessible enough to affect the schema questionnaire, and results of the assessment can be integrated into the case conceptualization. In my experience, questionnaires are particularly helpful if the core beliefs or schemas of the patient are confusing, complex, or conflicting among themselves. In such cases, the use of a questionnaire can significantly advance the case conceptualization. Furthermore, a discussion of the results of the questionnaire with the patient will improve the patient’s understanding of the case conceptualization and will provide further information about the accuracy of the questionnaire results.

As stated previously, a general principle of cognitive therapy is that the patient and therapist work together. The process of collaborative empiricism also applies to the development of the case conceptualization. Indeed, it is good practice for the therapist to describe the general concepts of beliefs and schemas to the patient and how they operate in general. From this discussion, a more specific presentation of the critical beliefs and schemas that are critical to the patient’s case conceptualization can ensue. If indicated, the therapist and patient can design behavioral homework to clarify the ways in which the patient’s beliefs affect how he or she interprets situations and the emotional reactions that result from these interpretations. The cognitive therapist and patient should develop a shared case conceptualization before any efforts are made to intervene at the level of beliefs or schemas.