Skills in Cognitive Behaviour Counselling

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Skills in Cognitive Behaviour Counselling
PsychotherapyCHAPTER 7 Skills for working with
enduring negative patterns

• FRANK WILLS (2008)
• London SAGE

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Schemas, core beliefs and assumptions different
ways of working

• Schemas, core beliefs, assumptions and negative
  automatic thoughts represent different levels of
  cognition.
• Different methods are required for working with
  these different levels of cognition (Padesky
  Greenberger, 1995).
• There is overlap and continuity between the
  different levels and different ways of working,
  but also differences in the nature (e.g.,
  oldernewer, surfacedepth) of the cognitions
  being tackled.

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Schema and core beliefs

• In CBT, schema has come to be a term to
  describe early maladaptive schema (Young,
  1994).
• Schemas are now seen as complex networks of
  feeling, thinking, behaviour and physiology. They
  may be very old, even pre-verbal, vague and give
  direction of perception.
• Schemas may have different dimensions (e.g.,
  mistrust schema might have different dimensions
  for men, women, young, old people, etc.
• As the different dimensions of schemas become
  operationalised and verbalised, they may be
  represented as core beliefs e.g., I cant
  trust other men to respect my feelings.
• Schemas and core beliefs can be identified by
  questionnaires (e.g., Young, 1994 Young
  Klosko, 1993).

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Schema and core belief change

• Negative schemas tend to be vague feelings about
  the self and the world. They have strong
  maintenance systems and may be quite impervious
  to change. It is probably best to think in terms
  of chiselling them down at the same time as
  trying to build alternative more positive
  schemas.
• Core beliefs tend to be stated in categorical and
  black and white terms e.g., I am crap no
  ifs, no buts! Their weak point, offering a
  therapeutic target, is that they are nearly
  always too constrained to accommodate all the
  data that may be relevant to them. Change efforts
  therefore focus on opening them out to wider
  sources of data.

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Unhelpful assumptions nature and change

• Core beliefs are hard to live with even we here
  in this audience cant be crap all the time!
• Assumptions may therefore develop as compensatory
  strategies for core beliefs e.g., If I could
  get someone to love me, maybe I wouldnt feel so
  crap.
• They may also change form into rules of living
  As long as lots of people love me, Im okay.
• These rules may work for a while carry a tendency
  for the holder to get hoist with his own petard
  trying to make people love one may get on their
  nerves!
• Unhelpful assumptions easily develop into overly
  rigid rules, and effort for change again
  therefore centres on fostering adaptability to
  more varied situations.

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Ways of modifying assumptions

• The downward-arrow technique consists of
  identifying and pushing assumptions to the limit
  of their credibility by asking questions like
  What would be so bad about people not loving
  you? This may reveal the limitation of the rule
  to people and begin to loosen belief in it.
• FLASHCARDS give a format for identifying where
  assumptions come from, their positive and
  negative (price) aspects, and offer an
  alternative for the client to contemplate in
  hours of rumination on the negative version.

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Assumptions flashcard

• I sometimes assume that I can only feel okay
  about myself if lots of people seem to love and
  approve of me.
• It is understandable that I think this because
  when I was younger, my parents seemed to
  consistently favour my brothers and sisters over
  me.
• This works against me because I often try too
  hard to make people love and approve of me and
  sell myself cheap and get on peoples nerves
  too.
• The assumption is wrong because You can please
  some people some of the time but you cant
  please all of the people all of the time!
• The best way forward for me now is To
  concentrate on my life goals and realise that
  some people will like what I do and some wont.

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Developing more flexible rules of living (the
example of BRUCE)

• OLD RULE
• I must not show my weak points to anyone at any
  time.
• NEW RULE
• It might be possible to show my weak points to
  some people some times.
• I can explore different ways of showing weak
  points some might be better than others.
• Taking the initiative sometimes could give me
  more sense of control.
• Taking the initiative sometimes might also lessen
  the sense of dread about being found out.
• (NB Notice the new rule is more variegated
  than the old).

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Schema and core belief change methods

• Because schemas are so omnipresent, they
  frequently show themselves in the therapeutic
  relationship and so may also be worked with and
  through in that context.
• Schema work tends to be longer term so that the
  therapy relationship becomes a key focus of
  change.
• There is also the need, however, to get on with
  the work of therapy via specific schema-change
  techniques.

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Examples of how schemas can show and be worked
through in the therapy relationship (1)

• MISTRUST SCHEMA The client wonders how he is
  supposed to know how far he can trust you to
  tolerate him and sets up transference tests to
  test your tolerance of him (coming late,
  forgetting to pay, etc.).
• ENTITLEMENT SCHEMA This is often underlain by
  low self-esteem. If the therapist accepts the
  good part then the client will suspect her
  judgement if she points out the bad part she
  may be accused of being just like my mum.

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Examples of how schemas can show and be worked
through in the therapy relationship (2)

• AVOIDANT SCHEMA This may show itself by
  avoidance of issues, non- or pseudo-cooperation
  with agenda setting and the work of therapy.
• DEPENDENT SCHEMA This may show itself by
  over-compliance, exaggerated accounts of how much
  the client has changed and how helpful the
  therapy has been, followed by signs of distress
  and/or alarm by the suggestion that therapy could
  now end.

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Examples of how schemas can show and be worked
through in the therapy relationship (3)

• As discussed in Chapter 3, the first step that
  the therapist needs to master is that of
  unhooking herself from the schema-driven
  interpersonal tangle. These transferences tests
  are inherently provoking and cant be dealt with
  from the hooked-in position. Supervision is
  often very helpful here.
• The next step is to look at how the clients
  schema may be interacting with ones own it is
  not unknown, for example, that therapists can
  feel gratified by dependent clients.
• The therapist can then develop empathy for the
  clients position a good formulation should
  tell us why the client has this pattern. We can
  now consider whether anyone with such a history
  might develop such pattern.
• The next step is to formulate a non-threatening
  way to raise the issue with the client so that a
  therapeutic plan can be developed perhaps
  including some of the methods and techniques
  shown in the following slides.

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The use of continua

• The basic problem with negative client schemas is
  that they only let certain types of
  schema-confirming data in.
• They need therefore to be stretched out and
  loosened up to let in consideration of wider
  factors that are likely to be more benign in
  relation to the clients self-image.
• Continua are visual representations of such
  efforts in which the client is asked to draw a
  line with an aspect of the schema (e.g., 0
  worthiness) at one end and its opposite (100
  worthiness) at the other end. Other people or
  aspects of the clients behaviour can be placed
  along this line.
• The net effect seems to be to demonstrate the
  fact that all of us human beings are basically
  quite flawed, and realising this helps us to join
  the common band of humanity We are all in this
  together.

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Historical tests of a schema

• As with continua, rules and beliefs can be tested
  to see how well they seem justified at different
  stages of the clients history.
• Because the client is currently often mired in a
  bad place where their experiences seem to confirm
  their negative beliefs, they may be ignoring
  information about different times when this was
  not the case the historical test can often
  reveal this and may even reveal positive aspects
  of the current situation that are being ignored.

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Positive diaries, psychodrama and schema debates

• Positive diaries focus on collecting and writing
  down positive aspects of the clients past and
  current life that are being forgotten. Negative
  bias in memory and attention is counteracted by
  the purposeful act of writing and then
  re-reading.
• Psychodrama is a form of role-play in which
  negative previous experiences can be re-run with
  different types of outcome and interventions
  penned in.
• Schema debate is a form of role-play in which the
  client can gain practice from reflecting on how
  the negative voice of the schema is most
  effectively opposed.