Figure 4.7
Pros-and-cons worksheet for schema change.
Examination of the advantages of the current negative schema or the disadvantages of a new and likely more adaptive schema may at first seem counterintuitive. However, these issues must be considered as part of the process of schema change because the patient will almost certainly do this work by himself or herself. For example, common disadvantages of schema change can include disequilibrium or confusion in social relationships, anxiety about enacting new schemas, and social disruption. Often what therapists experience as resistance to change is actually the natural and healthy way that people protect themselves from anxiety and threat (Leahy, 2001), and such reactions should be anticipated when a schema change is attempted. On the other side of the chart, a common advantage of maintaining the existing negative schema is that it is more “comfortable” for the patient; even though it may cause certain forms of distress, it involves known processes, and the patient will experience relatively little confusion in his or her social roles if the old schema is maintained. Sometimes the exploration of the short- and long-term advantages and disadvantages of the old and new schema will lead to a reevaluation of the new schema and the amount of turmoil it may cause. In such cases, an alternative new schema may be developed during therapy, and the process of examining the pros and cons of change can be repeated.
As with automatic thoughts, evidence-based strategies can be used to promote schema change. The data log is commonly used if the therapist believes that the patient already has life experiences that are consistent with the new schema being developed but is not paying attention to the experience. The data log has two blocks of space (see Figure 4.8) for recording experiences that might be consistent with the new schema or inconsistent with the old schema. The patient is also asked to pay attention to experiences that might be more consistent with or supportive of the old schema and to try reinterpreting the experiences either to minimize their effect or to see them as consistent with the new schema. The data log can also be used in conjunction with homework assignments, in which the patient purposely tries to act in a manner consistent with the new schema. This can be helpful to the patient in seeing the types of reactions generated in the social environment and whether the experiences are consistent with the new schema. If this homework strategy is used, the therapist must review the evidence to ensure that the patient interprets his or her experience as consistent with the new schema.
Figure 4.8
Data log method.
Public declaration is another technique for the promotion of schema change. Once the patient is ready, he or she speaks with important other people in his or her life and makes a commitment to change. The commitment can be relatively simple, such as “I have always lived my life as if I am second best, but I’m going to try to treat myself better from now on.” It can be more elaborate and include a long discussion about the desired changes that the patient wants to create or detailed descriptions of the proposed new self. These declarations ideally are made in person, but patients also can write detailed descriptions of the changes they want to make and present them to important people in their lives as preludes to discussion. This technique is helpful in the identification of social supports for intended change as well as of people who may present resistance to intended change.
Another technique that can be used to promote schema change is the personal eulogy. In this technique, patients write the type of eulogy that they would want to have read at their funeral. This technique, perhaps somewhat morbid, encourages patients to look forward and imagine the type of person that they would like to be remembered as. This exercise can be kept private or can be shared with other people.
Behavioral enactment is perhaps the single most potent technique for schema change. Also referred to as the “as if” technique, this strategy involves the patient actually acting in a manner consistent with the new schema as a way to explore the schema and its effects. In a sense, this strategy is like trying on a new overcoat to see how it feels and to observe the reactions of other people. If the developmental work that involved imagining the new schema has been thorough and the patient is fully committed to trying out the new schema, this technique will provide powerful information about its advantages and disadvantages. If this technique is used, the therapist must fully evaluate how the experiment felt to the patient in the subsequent session. Equally important is evaluation of the reactions of others to the patient, although the patient will need to be encouraged to keep clear the distinction between his or her experience of the technique and the reactions of others.
When the as if technique is used, the patient should be prepared for the range of interpersonal reactions that might occur. For example, people in the patient’s life may provide considerable negative feedback for the intended changes, and as a result the patient may experience distress and doubt about the course of action that he or she has chosen. Preparation for negative outcomes is paramount in enabling the patient to learn from the experience and not simply view it as a failure. At the other extreme, the patient may discover a new and different way to live and idealize or overreact to the experience. As with other aspects of cognitive therapy, therapists and patients should explore both the advantages and disadvantages of any changes that are observed.
Another technique that can promote schema change, especially as related to past experiences, is confrontation and exploration. The technique can vary dramatically in terms of content and scope. For example, it can involve something as basic as thinking about the past and the developmental experiences associated with negative schemas. A historical review can help the patient to determine key experiences and people who were involved in the development of dysfunctional schemas. Perusing photograph albums and visiting areas of personal historic significance are more dramatic ways of evoking emotional memories.
A riskier form of confrontation and exploration involves the patient talking with other people who were present during key developmental phases in his or her life to explore from the others’ perspectives what occurred and how the patient responded to the events. In its most dramatic form, this strategy can include direct confrontation of people in the patient’s life, in particular, the people who were associated with negative developmental experiences. For example, a patient could confront his mother about the negative parenting practices that led to beliefs or schemas that subsequently caused problems in his life. A female adolescent might confront her father about a pattern of verbal or physical abuse that he meted out to her as a child. Obviously, the use of confrontation or exploration needs to be carefully considered, and both the advantages and the disadvantages of the technique should be fully explored before the technique is attempted.