Underlying Schemas
Schemas are clusters of knowledge in a given area that are associated with emotions and behavioural scripts. This tacit knowledge occurs first in the course of development and relates to attachment experiences. It is a non-verbal, implicit view of the self. Tacit knowledge is the source of automatic and unconscious reactions to emotionally meaningful stimuli.
Cognitive Restructuring (from Dr Theiler’s perspective)
Stage 1 – Developing self-awareness
During this stage, the therapist attempts to help the client to identify their evaluative negative ATs, the associated processes of cognitive distortion and their underlying schemas.
Strategies for developing self-awareness:
- Revisit the specific episodes (the ABC model) using Form 2.1 to assess client’s cognition – the distorted automatic thoughts, the underlying maladaptive assumptions, the underlying negative schema; the behavior as well as interpersonal relationship of client with others.
- Explore shifts in affect (inside and outside the session)
- Free association (ask what AT comes to mind?)
- Using imagery/Role-plays
- Symptom induction using Hot Seat technique to bring in the emotions
- Discussion of the worst case scenario (how likely?)
- Look for thoughts that might explain feelings
- Dysfunctional Thought Records (DTR)
- Homework
Stage 2 - Identifying Contrasts in Thinking
The client needs to know thoughts can be different. The variations in the thoughts are determined by the schema one holds. Thoughts can be replaced and that can change feelings/mood.
Stage 3 - Evaluating and Challenging Thoughts
Terms are being defined using Semantic Technique, such as, ‘success’ in the client’s understanding and belief. (How would you define ‘success’? What is 100%, 50%, 0% success?) Therapist will conduct Cost Benefit Analysis, ie., the cost to having such assumption as well as the benefit. Examining the evidence will further help evaluate the value of holding such thought. Both therapist and client will also explore alternative explanations or other way of looking at things. Subsequently actual consequences are evaluated – So what if it happens?
Another technique is Distinguishing Behaviors from People, for e.g., if you do some things that are worthwhile, then how can you be worthless?
Double-Standard Technique is used to highlight client’s tendency to apply a different standard to self from another.
Examining evidence For and Against the assumption – What is the quality of the evidence?
Logical Analysis – E.g., How does someone’s not liking you make you worthless? If one person likes you and another doesn’t, are you worthless or worthwhile?
Challenging the ‘should’ statement and identifying the conditional rules will help client to progress in life although the therapeutic outcome may not be perfect.
Below is an example of a vertical arrow for identifying schemas:-
What if I sing the wrong key? (NAT)
People will notice
They might laugh at me
They’ll think I’m not good enough
I think I’m not good enough
Assumption: If I sing off key, people will think I’m not good enough (it means I’m not good enough)
Belief: I’m not good enough
A General Model of Cognitive Theory
Learning experience
Dysfunctional Schema formed
Critical incident
Schema activated
Negative automatic thoughts and cognitive biases
Anxiety and other affective responses
Behavioural responses
The Standard CBT approach to Depression
Assessment & formulation: Involves behavioural (e.g. withdrawal from others, rumination and social skill deficits), cognitive and interpersonal factors; suicidal risk and medical review
Socialization to treatment
Establishment of goals
Behavioural activation & other behavioural interventions (crucial first step in depression)
Cognitive interventions
Inoculation against future depressive episodes
Phasing out therapy
Developing a Cognitive-Behavioural Formulation
1. Create an all-inclusive problem list that includes major symptoms and problems in functioning
2. Propose an underlying theme that might underlie all the problems
(Client’s belief) What are the antecedents and consequences of the behaviour?
3. Hypothesize how the underlying theme might cause the problems
4. Explore the precipitants for the current problem
5. Look for the origin of the problem in the client’s early life
6. Predict obstacles in treatment based on the formulation
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