This is the final part of showing how my training informed my practice today and whilst it may be boring to some, there are many a few that want to read about it!
Working within a cognitive behavioural approach to therapy, I found surprisingly useful with some clients. I struggled initially with the idea of homework sheets, agendas and goals and found myself going in to the sessions to do CBT to my clients! With more experience, my practice became more relaxed; I still worked within the relationship and began working with the clients material more naturally when ‘hot cognitions’ arrived. I realised that I was beginning to practice, as opposed to force, cognitive therapy with, and not on to, my clients. I found that adopting the model worked well with one client who was agoraphobic, conceptualising his negative automatic thoughts about going out alone as being related to his underlying fear of not feeling safe. I found exposure techniques and behavioural experiments effective in working with a young man who presented with a chronic psychosomatic condition.
However, I fully agree with O’Brien and Houston (2000, p.64) when they asserted that ‘implications for the therapist who may be faced with no therapeutic movement but who adheres to a theoretical model, which emphasises, for example, working with resistance. We would suggest that therapists, like mothers with their children, would need to consider the dilemma: is it the client/child or is it the approach that needs to change?
Being exposed to different models of therapy during training and in accordance with the Competency Statement (Division of Counselling Psychology, 2005) where Chartered Counselling Psychologists ‘are accordingly in a strong position to respond appropriately and flexibly to the therapeutic needs of specific clients and/or contexts,’ I began to look to other theories to facilitate my work with the following client.
Ms E was referred for a psychosomatic complaint for which there was no biological origin. Even though there is a body of research (for a full account, the reader is referred to Hawton, Salkovskis, Kirk & Clark, 2002) on the effectiveness of CBT for somatic presentations, my client was not engaging in the process. She was arriving late to sessions and was not completing homework sheets in order for us to monitor her psychosomatic difficulties. Working within the model, I initially conceptualised this as some form of resistance where ìresistance is anything in the patientís behaviour, thinking, affective response, and interpersonal style that interferes with the ability of the patient to utilise the treatment and to acquire the ability to handle problems outside of therapy and after therapy has been terminatedî (Leahy 2003, p.11). Not completing homework tasks can also be thought of as a working alliance rupture (Safran & Muran, 1996). Following the model of CBT, I encouraged her to complete the sheets, re-iterated the model and tried to further access possible negative automatic thoughts relating to resistance. In doing so, I began to appreciate that there may be something else affecting the therapeutic process, I needed to look at whether the model (even though research states CBT is effective for her difficulties) fitted how she was as a person. I began to look at possible schemas that may be affecting the process and therapy began to progress as can be seen in the following vignette.
Schema Therapy is an integrative therapy, which ìblends elements from cognitive- behavioural, attachment, Gestalt, object relations, constructivist, and psychoanalytic schools into a rich, unifying conceptual and treatment model (Young, Klosko & Weishaar, 2003, p.1). According to the model, schemas result from unmet core emotional needs in childhood. For example, if the child did not receive the love and attention necessary for healthy development, the child may acquire an emotional deprivation schema. The schema is said to become dysfunctional in adulthood in that the individual may be removed from the original situation where the schema developed, but s/he may continue to behave in ways that perpetuate the schema. For example, they may avoid intimate relationships in an attempt to avoid rejection. In Schema Therapy, these early maladaptive schemas ìare self defeating emotional and cognitive patterns that repeat throughout life (Young, Klosko & Weishaar, 2003, p.7).
Ms E had a subjugation schema, which affected how she experienced me as a therapist. Ms E’s subjugation schema influenced her to see me (as therapist) as someone who she could not express her needs to, or explore the anger that she had learnt to control since a child. Schema Therapy (Young, Klosko & Weishaar, 2003), addressed the underlying assumptions of CBT that may be untrue of certain patients who do not respond to treatment. This was particularly relevant for my therapy with Ms E.
Standard cognitive-behavioural therapy assumes that patients are motivated to reduce symptoms, build skills, and solve their current problems however otheir motivations and approaches to therapy are complicated, and they are often unwilling or unable to comply with cognitive-behavioural therapy procedures. They may not complete homework assignments. They may demonstrate great reluctance to learn self-control strategies(Young, Klosko & Weishaar, 2003, p.3).
The approach, integrates aspects of attachment theory, Gestalt, object relations, psychoanalytic and cognitive-behavioural into a unifying conceptual model. In having this understanding of the implications of the effect of Ms E’s schema’s in the relationship, I became aware that we had to facilitate Ms E in identifying emotions that she had learnt to control for most of her life. Rather than continue with CBT and monitor her somatic presentation, changing the method allowed us to discover that when certain schemas were triggered, it resulted in her psychosomatic presentation. Schema theory was proving successful for our work together as it allowed for attention to be paid to Ms Eís childhood, during which time the predominant schemas are developed.
Reformulating Ms E’s current difficulties using Schema Therapy allowed us to trace a developmental path of how she coped with her schema. According to the model, patientís develop maladaptive coping strategies relating to their schemas which can be thought of as the early fight, flight or freeze response to threats. Individuals, when their schema is triggered, either overcompensate (fight) the threat, avoid (flight) the threat or surrender (freeze) to the threat (Young, Klosko & Weishaar, 2003). For Ms E, when her schema was triggered by, for example, anger producing situations, her subjugation schema meant that rather than feeling the anger, she experienced a ëcalming of emotions. Traditional CBT may not have allowed us to formulate her difficulties in such a way. Schema Therapy, because of the inclusion of object relations and attachment theory, allowed us to explore her early relationships where we discovered that it was necessary for Ms E not to experience anger as a child in order to protect herself from volatile relationships within her family. A subjugation schema that leads to an accumulation of anger gets manifested in maladaptive symptoms including psychosomatic symptoms (Young, Klosko & Weishaar, 2003). One of the three categories that somatic presentation of psychological problems can fall under is ìproblems where there is an observable and identifiable disturbance of bodily functioning, including involuntary muscular movements or contractions (Hawton, Salkovskis, Kirk & Clark, 2002, p.238), which was Ms Eís somatic presentation.
This gave us insight into how she was inadvertently perpetuating her schema in her adult life, which was maintaining her somatic difficulties. That is, in anger provoking situations, which trigger her subjugation of emotions schema, she copes with this by surrendering to the schema and experiences a psychosomatic presentation of her anger.
Working within this model, we began to address the impact of schemas on the therapeutic relationship. How her coping strategy of surrendering to the schema made it difficult for her to express her emotions in therapy. The therapeutic work could then progress in providing Ms E with a safe relationship in which she could experience her emotions that were previously being manifested through somatic presentations.
Concluding comments
What has been evident throughout these articles is the importance I attach to relationships, in both my personal and professional life. I had been sustained by relationships throughout the course of my training including the relationship I developed with my transpersonal therapist. The warmth and genuine respect that existed in this relationship sustained me through difficult aspects of training, my personal life as well as enabling me to engage in self-reflection.
The recent research of the effect of the amygdala system (Gerhardt, 2004) highlights the importance of the early attachments (Bowlby, 1988) we make with caregivers and the implications that this can have on our relational life. This research, when applied to the integrative philosophy of Schema Theory has produced positive implications for my practice. The concept of Young, Klosko and Weishaarís (2003) limited reparenting offered in the therapy resonates with relationship is the therapy what clients needs from therapists and what infants needs from their carers is strikingly similar (O’Brien & Houston, 2000, p.133) when consideration is given to what occurs between the infant and the caregiver and the impact this has on the amygdala system. Although the effect cannot be undone, the effect of it can be lessened, through what has been termed in Schema Therapy as limited reparenting.
Reference – this is part three of a series of three articles and all reference pertaining to it can be found here.