7 Things I learned writing the Cambridge Guide to Schema Therapy
I asked Susan Simpson to write a book with me while I was training in schema therapy about 7 years ago - both because I was keen to work on publications generally and because I wanted the chance to work with an expert and ask them the questions I couldn’t find in the existing books. Although it took a little longer than expected, it ended up being an amazing opportunity to work with a whole team of experts…from Rob, whom I met through the ACT community and who got the book deal, Chris who had supervised the end of my schema therapy training, and Remco, whose videos I watched so much that I effected a Dutch accent when I delivered limited reparenting. I was extremely lucky that they included me in the writing. My role was to represent beginners and make sure their common questions were addressed well enough that someone not already familiar with schema therapy would understand core terms and procedures.
So, here are my seven key learnings…
1. How To Envision A Full Course Of Schema Therapy
Something I struggled with as a beginning schema therapist was trying to picture how such a potentially long course of therapy would “play out” over time. One of my favourite chapters in the book is called “the Road Ahead”, in which my co-authors lay out the stages of schema therapy and explain how the activities and role of the therapist changes across the course of treatment. I was particularly interested in learning to discriminate when it was time to move on in therapy versus when we should hold at a specific stage to ensure it was mastered. So, for example, stage 1 is Pretreatment, in which you conduct your assessment, provide basic psychoeducation about schemas, modes and schema therapy and work up a shared case conceptualisation. I think it’s helpful during this stage to assume that the client isn’t committed yet, to expect they will still have their “armour” on, and although the therapist is trying to forge an alliance with the client, they will reserve their really determined efforts to bypass coping modes and get the client to inhabit their more vulnerable side until the beginning phase of treatment. So, the marker to move from Pretreatment into the Beginning Phase of treatment is that the client and therapist agree on a schema therapy-based conceptualisation that links their reasons for presenting to modes and schemas and the client can give informed consent to the activities that will make up a course of schema therapy. See the book chapter for an explanation of the other stages and markers to move on.
2. How To Broaden Assessments For Schema Therapy
In my experience, people are often not taught basic psychological intake assessments very well and there are surprisingly few good textbooks or chapters I could recommend on the subject. So, something I think the Cambridge Guide… does really well is provide more detail about what to cover in a schema therapy assessment to set up a good case conceptualization and lots of concrete examples of questions to assess whether basic psychological needs were met during the client’s developmental history. The quality of this chapter is thanks to Susan graciously responding to my persistent nagging/borderline-bullying to give more specific examples, even after she had already turned in thousands of words and was extremely time poor. I won’t reproduce the examples here (we are expected to sell this thing) but I noticed a couple of types of questions and ensuring you incorporate all of these types of questions is likely to uphold a good standard of questioning: 1) general open-ended questions about what caregivers and other key people in the client’s life were like and asking about how the client was similar or different to them; 2) Asking direct questions about whether specific needs were met (e.g., “Did you do things together as a family? Did you spend time playing together?”); 3) Asking direct questions about whether specific needs were thwarted (e.g., “Did either of your parents lash out physically or verbally when feeling upset, angry, or intoxicated?”); 4) Asking hypothetical questions to infer whether basic needs were met (e.g., “Did you ever feel you would be more lovable if you’d been different in some way?”). The point is not to memorise these specific questions as though they were the path to the holy grail. However, supervisors should remember that beginners already have a lot on their mind, they haven’t seen this play out successfully yet, and they likely need some multiple (concrete) exemplar training before they can take the principles and generate enough broad instantiations of questions on their own. I think Susan’s done beginners a huge service in this book.
3. What Schema Therapists Mean By Attunement And How They Do It
My co-authors used the word “attunement” a lot. Like, all the time. And I though I kind of knew what they meant but something I got from the book was a clearer, deeper appreciation for what they mean by attunement and how they do it. It is fairly simple and basic…perhaps so basic that it’s really easy to take it for granted and not give it the attention it’s due.
For a starter, as an activity, it consumes a third of therapy time in the beginning phase of therapy. The basic session structure is to spend up to 15 minutes attuning to a client’s recent distressing experience. It involves: 1) careful listening through repeated curious questioning; 2) making tentative summaries; and 3) checking the summary ‘resonates’ with the client. Business as usual? Perhaps, depending on how you practice. However, this amount of time wouldn’t be typical of how long I would spend on an incident in a typical course of cognitive therapy with an emotionally literate adult. However, in schema therapy we assume little, if any, emotional literacy, and the time spent exploring the felt sense of the emotion in the body, the ideas – only vaguely or fleetingly forming in the mind sometimes, and the specific turning point in the physical and social environment during the events leading up to the moment the client felt a palpable change in emotion is the medium through which emotional literacy grows. The word “resonates” was also used a lot by my co-authors. I now think it means for the client to have something more than an approximate agreement with the therapist’s summaries or reflections. I think it’s something more like a “Yes! Exactly!” response. An “aha” experience. Clients who need schema therapy might not be so expressive. It might be indicated by more like a hopeful look or relief at being understood. Nevertheless, I think the skill to work on is tuning in to the discrimination between having understood something “in the ball park”, “kind of”, or “almost, but not quite” and “nailing it”; putting into words an experience that the client wasn’t able to describe adequately themselves so that they can finally recognise it and be confident that another person can hear them and know what they mean.
I will probably be working on slowing down for the rest of my life. I think the book helped me more properly appreciate how valuable the prize for slowing down is.
4. A Deeper Understanding of Limited Reparenting
Limited reparenting is clearly one of the aspects of schema therapy which most characterises it and distinguishes it from other styles of working. And again, although I felt I a decent understanding of it, as a beginner, it was clearly unfamiliar territory and the aspect of schema therapy that I could always use more illustrations of. Without going into details here, these are some of the ways in which the Cambridge Guide contributed to me having a deeper understanding of limited reparenting.
It provided a table of concrete examples of limited reparenting messages tailored to the client’s dominant early maladaptive schemas
It elaborates on the importance of giving guidance and direct advice to clients
It highlighted the need to balancing attention evenly between providing nurturance to the client’s vulnerable side and limiting the therapy-interfering behaviours of the client’s dysfunctional coping modes
Elaborating how schema therapists embody genuineness
Providing more detail on how to respond to the Angry Child mode in a nuanced way
Incorporating and maintaining a focus on anger in work with Cluster C Personality Disorder clients
5.How To Structure Behavioural Pattern Breaking
The Cambridge Guide made clearer to me how to structure focusing on client behaviour throughout therapy. It’s not going to make a LinkedIn meme, but having a plan for managing the potentially enormous list of problematic behaviours is critical to a successful therapy outcome…and I’m pretty sure I never did this when practising as a clinician! So, at the conceptualisation stage, develop with the client a list of problem behaviours and prioritise the ones that will keep the client from getting their needs met in relationships. In the beginning stage of therapy, there is less emphasis on behaviour change outside of sessions; however, therapy-interfering behaviours such as attendance problems, demanding behaviours and avoidance that interferes with emotional experiencing require addressing before anything else can be achieved. In the later stages of therapy, the problem list made at the beginning of treatment should be worked through in order of impact on wellbeing and functioning. Common cognitive behavioural strategies can be used, including: enhancing motivation prior to making a behaviour change attempt through recognising the origin of the motive for the problematic behaviour as now outdated and exploring its current pros and cons; grading the task through breaking into steps and keeping written records of the plan and outcomes of attempts.
6. What To Do When Clients Say They Don’t Have A Vulnerable Side
One of the most common obstacles to progress I faced in my schema therapy work was clients who had trouble recognising the presence of their emotions. The Cambridge Guide describes two therapy activities for this situation that I hadn’t heard of before, Contaminating the Chair, and Role-Playing the client’s Vulnerable Child mode. Contaminating the chair involves the therapist sitting in the ‘Vulnerable Child’ chair and expressing empathic statements about what it would have been like for the client as a child. The therapist then leaves this chair, asks the client to sit in the chair and recall what the therapist just said as a “running start” for the client to continue talking from the Vulnerable Child perspective. Role-playing the vulnerable child mode means the therapist doing so in a dialogue where the client plays the Coping mode. Once the impact of maladaptive coping on the vulnerable side is made clear, the therapist invites the client to reflect on the interaction, then take the Vulnerable Child chair to begin an emotional processing exercise (e.g., attunement to emotions in a recent triggering situation, imagery rescripting).
7. Adapting schema therapy for video-conferencing format
My co-authors successfully delivered schema therapy during COVID-19 and Remco in particular shared some great practical ideas for adapting experiential exercises for delivery via video-conferencing. For example, chairwork can be done in one of three ways: 1) having the client move just enough to adopt either the left or rightmost position on the screen; 2) having the client make available different chairs in their room (for internal or external dialogues); or 3) the therapist having multiple chairs available in their room (especially useful for dialogues confronting Critic modes). The chapter also describes clever ways for the therapist to use a laptop or webcam to alter the perspective for the client.
So, there you have it, 7 things I learnt from writing about schema therapy!