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Cognitive Strategies
Educating the Patient
• After completing the assessment process, therapist educate the patient about the schema model.
• Patients become educated through;
discussion
assigned reading
self observation
Cognitive Strategies
• Through the assessment process therapist and patient identified:
Patient’s dysfunctional life patterns
EMSs
Childhood origins of the schemas
Linked schemas to presenting problem
Cognitive Strategies• Cognitive strategies help patients articulate healthy voice
to dispute schema and strengthen Healthy Adult mode.
• Cognitive strategies helps patients step outside of schema and evaluate its accuracy.
• Patients see that there is a truth outside of schema and they fight with the schema with empirical and objective evidence.
Cognitive Strategies• Testing the validity of the schema
• Reframing the evidence supporting the schema
• Evaluating the advantages and disadvantages of the patient’s coping style
• Conducting dialogues between the schema side and the healthy side.
• Constructing schema flash cards
• Filling our Schema Diary forms
Cognitive StrategiesTesting the validity of the schemas
This process is similar to testing the validity of automatic thoughts in cognitive therapy except that therapist uses the patient’s whole life as empirical data.
The therapist and the patient make a list of evidence supporting the schema and then refuting the schema.
Cognitive StrategiesTesting the validity of the schemas
Shari, 28, F, M
Her father divorced her mother and left the family when she was 4. Throughout her childhood, her mother humiliated her by appearing drunk in public places. She avoided bringing friend to home. She developed “Defectiveness” schema.
Cognitive StrategiesTesting the validity of the schemas
List of evidence +
• I am not like everyone else. I am different and always have been.
• My family was different from other families.
• My family was shameful.
• I am inappropriate with other people. I don’t know the rules.
• No one ever loved me or cared for me.
List of evidence -
• My husband and children loves me.
• My husband’s family loves me.
• I am sensitive to other people’s feelings.
• My patients like and respect me. I really get good feedback.
• I loved my mom even she cared drinking more than me.
• I try to be good and do the right thing.
Cognitive StrategiesTesting the validity of the schemas
Another step is examine the evidence of how the patient discount the evidence against the schema.
• I tell myself that I am fooling my husband and children, and thats why they love me. They don’t know the real me.
• When people give me good feedback, I don’t believe them. I think that there is some other reason they’re saying it.
• I tell myself that I am only sensitive to people’s feelings out of weakness. I am afraid to assert myself.
Cognitive StrategiesReframing the Evidence Supporting the Schema
The goal is discredit the evidence supporting the schema.
1. Evidence from the patient’s early childhood
“My father did not love me because I am unloveable.”
Father’s incapability of loving, his attitude toward all other children.
Cognitive StrategiesReframing the Evidence Supporting the Schema
2. Evidence from the patient’s life since childhood
“All the men in my life treated me badly.”
She had three boy friend, one abused her, the other left her and the other frequently slept with other women.
Therapist reframes it as schema perpetuation.
Cognitive StrategiesEvaluating the advantages and disadvantages of the patient’s coping responses
Therapist and patient identified the coping style of the patient in the assessment phase.
The goal is to recognise the self defeating nature of the coping styles and replace them with healthy ones.
Cognitive StrategiesEvaluating the advantages and disadvantages of the patient’s coping responses
Kim has “Abandonment” schema. She copes with her schema by avoidant coping style. She stays away from men by refusing the date offer, spend her free time alone or with girlfriends.
Avoidance provides her sense of control. (advantage)
I feel alone. I lose a lot good relationships. (disadvantage)
Patient faces with reality.
Cognitive StrategiesConducting dialogues between the “schema side” and the “healthy side”
Adapting the Gestalt empty chair technique, the therapist instructs patient to switch chairs as they play two sides:
One chair schema side, the other one healthy side
“Lets have a debate between schema side and healthy side. I’II pay the healthy side, you will play schema side. Try as hard as you can to prove that the schema is true, and I ‘ll try as hard as to prove the schema is false.”
Cognitive StrategiesConducting dialogues between the “schema side” and the “healthy side”
Eventually the patient takes over the role of healthy side and patient play both sides.
Daniel, 35, M. His father was alcoholic, his mother was abusive. He had sought therapy for social anxiety and anger management problem. His goal was to marry a woman, but he mistrust women, expect them to reject him. He avoids social situations. (Mistrust)
Cognitive StrategiesConducting dialogues between the “schema side” and the “healthy side”
SS: She looks a really nice person, but I don’t think she’d go for me. I’m probably not even up for that person intellectually and emotionally. She will probably go for some other guy.
HS: Dont be so quick to judge. You have a lot of good parts that will be appealing that woman. You have a definite value system. You know boundaries, you can allow her to be her own person.
Cognitive StrategiesSchema Flash Card
After completing schema restructuring, therapist and patient begin to write flash cards.
Flash cards summarise the responses of healthy side to spesific schema triggers.
Patients carry flash cards, read them when relevant schemas are triggered.
Ideally, flash cards contain the most powerful evidence and arguments against schema and provides rehearsal.
Cognitive StrategiesAcknowledgment of the current feeling:
Right now, I feel ______ because ________.
Identification of schema:
I know that this is probably my _________ schema, which I learn through _________. The schemas lead me exaggerate the degree to which ________________________.
Reality Testing:
Even though I believe ______________________ the reality is that _______________________. The evidence in my life supporting the healthy view includes: ____________
Behavioral instruction:
Therefore even though I feel like ________________________. I could instead ____________________.
NE Trigger
EMS OriginSchema Distortion
Negative Thinking Healthy View
Negative BehaviourHealthy Behaviour
Evidence
Cognitive Strategies
Cognitive StrategiesSchema Diary
With the schema diary, patients write own healthy responses as schemas are triggered in daily life.
Before Schema Diary, the patient should be proficient in Schema Flash Card.
Cognitive StrategiesSchema Diary
Emily, 26, F. She began a job recently. Her subjugation schema made it difficult for her to manage her staff. She has difficulty with domineering subordinate Jane. When Jane behaves aggressively, she apologise. Think that “It is like she is my boss instead of I am being her boss.”
Cognitive Strategies Schema Diary
Trigger
Emotions
Thoughts
Actual Behaviour
Schemas
Healthy view
Realistic concerns
Overreactions
Healthy behaviour
Cognitive Strategies
