A Client with a Past: Schema-based Case Formulation

Therapists who are dismayed at the lack of any detailed exploration of the client’s past, and especially their early development, in cognitive-behavioural approaches such as REBT and Choice Theory, will hopefully be relieved to know that Integrative CBT sees such an exploration as essential, though it may or may not need to be a central focus of therapy, depending on the client’s issues and goals.

Even when the focus is mainly at other levels, therapeutic choices are best guided by a broad Case Formulation (more on this in future blogs). Working at Level 4 involves adding a developmental perspective to the vicious cycles discussed in the previous blog, expanding the formulation to include hypotheses about the client’s underlying dysfunctional cognitions (see e.g. Persons, Padesky). Our earlier learning experiences leave us with deeply held ways of viewing the world, ourselves, and others, ‘templates’ through which we process current experience, and which therefore tend to be self-perpetuating and rigid in nature (blocking experiential re-learning at an even deeper level than that discussed in the previous blog). These templates can be called Schemas; their contents (e.g. “I’m unlovable”, “Men can’t be trusted” etc) can be called Core Beliefs.

Persons suggests that this kind of formulation can explain how current problems are precipitated, and how they actually make sense in the light of underlying schemas and current triggers. It can also suggest origins of the underlying beliefs in the client’s early life. A typical diagram for a Schema-based case formulation is shown below.

Negative Automatic Thoughts are seen as arising, in relevant trigger situations, from underlying Schemas/Core Beliefs. For instance, a depressed client’s negative automatic thoughts could arise out of underlying beliefs such as ‘I’m no good’ and ‘If I try anything, I make a mess of it’, triggered by some current situation which is seen as a failure (e.g. applying for a job and not being called for an interview). These beliefs could be rooted in the client’s early experiences of being treated as no good, or being told that he was no good.

A useful addition to the general concept of Schemas is Jeffrey Young’s proposed set of 18 Early Maladaptive Schemas. They are grouped within 5 domains, each referring to a core childhood developmental need, as follows:

Disconnection/Rejection: Emotional Deprivation, Abandonment, Mistrust/Abuse, Social Isolation/Alienation and Defectiveness/Shame.

Impaired Autonomy/performance: Failure to Achieve, Functional Dependence/Incompetence, Vulnerability to Harm/Illness and Enmeshment/Undeveloped Self.

Other Directedness: Subjugation, Self-Sacrifice and Approval-Seeking.

Overvigilance/Inhibition: Emotional Inhibition, Unrelenting Standards, Punitiveness and Pessimism.

Impaired Limits: Entitlement and Insufficient Self-Control/Self-Discipline.

These Schemas can be explored with clients through the use of handouts which describe each schema in more detail, as well as by using the Young Schema Questionnaire (more information at schematherapy.com). Many clients find it reassuring to realise that their underlying patterns of thinking are not unique, but human and well-known.

Young’s Schema Therapy is one approach to working with the deeper level of Cognitive/Emotional restructuring which is needed here. He proposes that we continue to use the traditional CBT interventions of Socratic Dialogue and Behavioural Experimentation, as described in the previous blog, though he emphasises that the process of change is likely to be slower when working at the Schema level. He also incorporates techniques such as guided imagery, and adds some other interesting therapeutic strategies, especially Limited Re-parenting.

This level of work allows a lot of room for overlap and integration with theoretical constructs from other schools, such as Models of Attachment, Transactional Analysis Scripts, Object Relations, Conditions of Worth, etc. Integrative CBT uses primarily CBT language, partly for theoretical consistency (not just with CBT, but also with the Cognitive Sciences of Psychology, Neurology etc), but also because this language has become quite accessible to clients through its use in self-help books, where terms such as “Core Beliefs” are now commonly used, along with equivalent terms such as “Bottom Line”. This accessibility is important, because the case formulation process should be shared with the client. Many clients find the notion of particular beliefs acting as a link between their past experiences and their present difficulties to be an illuminating one, and it may even help them to have more compassion for themselves in their struggle with difficult issues such as depression or addiction.

Tune in to next week’s blog, when compassion will once again get a mention…