Schema-Focused Supervision1

RUNNING HEAD: SCHEMA-FOCUSED SUPERVISION

Schema-Focused Therapy:

An Integrative Approach to Psychotherapy Supervision

Michael Greenwald, Ph.D.

Allegheny Mental Health Associates,P.C.
and
Center for Cognitive Therapy
Department of Psychiatry
University of Pittsburgh
School of Medicine

and

Jeffrey Young, Ph.D.

Cognitive Therapy Centers
of New York & Connecticut
and
Department of Psychiatry
Columbia University
 Schema-Focused Supervision2

This paper presents schema-focused therapy (SFT) as an integrative approach to

psychotherapy supervision. SFT was developed to address personality dysfunction and to

assist therapists with clients for whom straightforward cognitive therapy or other brief

interventions are insufficient. It bridges cognitive-behavioral and depth-oriented

approaches, and includes developmental, interpersonal, and experiential elements. SFT

serves as a useful guide in the supervisory process, providing a methodology for

organizing case information about how clients operate.It is valuable in case

conceptualization, strategy, implementing interventions, resolving difficulties and

understanding the role of the supervisee's own schemas in the therapy process.
 Schema-Focused Supervision3

Schema-Focused Training and Supervision

Schema-focused therapy (Young, 1994a; Young & Klosko, 1993; Bricker, Young

& Flanagan, 1993; McGinn & Young, 1994) is an integrative therapy model that

incorporates cognitive, behavioral, experiential, and interpersonal interventions. SFT is

congenial with current developmental, dynamic, cognitive-behavioral, and experiential

psychotherapeutic models. It offers a practical model for assessing client difficulties,

coping styles, and client capacities. It allows conceptualization of a case and its

dynamics, and directs therapeutic interventions and strategies.

Overview of the SFT Theoretical Model

The term “schema” in this model refers to dysfunctional, enduring patterns of

thinking, feeling, acting, and relating to others, which guide perceptions, affective

responses, and self-defeating behavior patterns across a range of life situations. Young

(1994a) defines an EMS as an extremely broad and pervasive theme regarding oneself

and one’s relationships with others, developed during childhood and elaborated

throughout life, and dysfunctional to a significant degree. EMSs result from a

combination of the child’s innate temperament interacting with early childhood

experiences with significant others. Patterns of dysfunctional thinking, behavior, and

defensive processes evolve as a result of cumulative impact of negative experiences.

These persist over time and are deeply entrenched. Schemas function to minimize early

suffering, however, they also serve as guides for the interpretation of later experience and

a basis for establishing self-defeating cycles. When activated, schemas can lead to high

levels of negative affect and self-defeating consequences, and can interfere with affective

expression, attachment, social validation, and autonomy.

 Schema-Focused Supervision4

EMSs are implicit in how individuals define themselves, the choices they make in

relationships, and their capacity for adaptation. Young has proposed 18 Early

Maladaptive Schemasi (core themes), which he has grouped into five more general

Schema Domains (see Table 1 ), which can provide a useful starting framework for

identifying key client issues.

Schematic beliefs are the underlying narrative “axioms” for clients’ often painful

internal monologues; e.g., “I’m a loser and I’m never going to change” derives from the

Failure schema. EMSs are linked both to cognitive content and to styles of operating,

experiencing, and interacting with others.

Schematic processes. Akin to defense mechanisms, resistances, and cyclical

patterns described in psychodynamic theory, schematic processes operate to minimize the

experience of strong negative emotions when EMSs are activated. Unfortunately,

schematic processes prevent opportunities for corrective emotional, behavioral, and

cognitive experiences. Young identifies three primary schematic processes: schema

maintenance (surrender and act as if the schema is true), schema avoidance (escape, deny,

avoid, minimize, or detach from the schema) and schema compensation (counterattack,

overcompensate for, or externalize the schema).

Schema maintenance refers to processes, including cognitive distortions and

behavior patterns, whereby clients interpret information in their environment as

consistent with their underlying beliefs and act accordingly.

Schema avoidance is a process where clients employ cognitive, behavioral, and

emotional strategies to ward off or otherwise prevent activating schematic material.

 Schema-Focused Supervision5

Cognitive avoidance involves automatic and conscious efforts to avoid thinking about

schema-related issues. Behavioral avoidance refers to active efforts to evade schema

activation. Emotional avoidance involves blunting the affective experience of negative

feelings which would otherwise be engendered by recall or discussion of painful material.

Therapists may unwittingly contribute to processes of schema avoidance by being

unaware when avoidance is taking place, or aid in emotional avoidance by keeping the

emotional climate in the consulting room below a level in which schema activation might

take place.

Schema compensation refers to behaviors or thoughts that overcorrect,

externalize, or overcompensate for a given schema, and which appear to be the opposite

of what one would expect on the basis of the schema itself.

Schema modes. A schema mode can be thought of as a facet of the self, a persona,

or a naturally-occurring cluster of schemas, schema processes and moods, which has not

been integrated with other facets. These modes are analogous to “ego states” in

Transactional Analysis (e.g., Berne, 1961), in which one operates from one or another

stance, such as the parent, adult, or child. A number of such modes can be identified

within a given client, and modes represent a range of stances patients characteristically

take on in the face of specific emotional or environmental triggers. Table 3 provides a

listing of common modes. Patients can be said to “flip” from one mode to another,

reflecting activation of the relevant schema mode by environmental circumstances or life

events. Schema modes help to explain, for both the client and clinician, how various

“parts” of the self can be in conflict, or how problems can occur in relationships. Mood
 Schema-Focused Supervision6

states and other triggers can be seen to activate a given schema mode. The client can be

asked, “What mode is being triggered now?” as a way of understanding the various states

the client is experiencing, rather than acting them out in a therapeutic tangle.

Overall, Young’s SFT model provides a rich set of map-making tools for

depicting what is going on in a given case, helping with conceptualization of client

struggles, coping styles, and cognitive processing. It offers a catalog of mechanisms

whereby clinicians can consider how clients avoid resolution of schemas. Finally, it

offers suggestions about what activities in the various spheres (behavioral, interpersonal,

cognitive, therapeutic relationship) might lead to durable change (e.g., Young and

Klosko, 1993). From the standpoint of clinical supervision and problem-solving, SFT

provides a useful strategic guide for approaching difficult clients, particularly those with

Axis II problems, and it can be a helpful heuristic for understanding client-therapist

impasses.

Philosophical orientation. SFT is not a cookbook approach to treatment, but

instead a flexible system for conceptualizing and intervening with cases. A major aim in
utilizing the approach involves learning to describe a patient in terms of EMSs, schema

processes, and links between early development and current functioning in the four

primary modalities (cognitive, behavioral, experiential, and interpersonal), depending on

the client’s symptoms and personality make-up. Those cases with uncomplicated Axis I

presentations may require relatively less individual schema-focused conceptualization,

while those with significant impairment in relationships and high chronicity and relapse

will need relatively more emphasis on conceptualization and SFT processes.

 Schema-Focused Supervision7

Perris (1994) notes that supervision in cognitive therapy requires that the

supervisee be encouraged to: expeditiously develop a conceptualization of the client’s

problem which connects thinking, emotion, and behavior, and points to underlying

“meaning structures”; establish a secure and collaborative therapeutic relationship; define

explicit goals and adhere to these; appropriately select and apply strategies and

techniques; determine when the goals have been met; and to recognize and evaluate the

interpersonal reactions occurring in himself as well as in the patient, and understand how

to deal with them.

SFT supervision incorporates these elements, adds assessment and

conceptualization concerning schema processes and modes, and focuses supervision on

the therapy relationship and staging interventions in the areas of cognitive, behavioral,

experiential, and interpersonal change. When clinical impasses or Axis II dilemmas

appear, supervision involves careful attention to individual clients’ needs, symptoms, and

personality make-up, and the manner in which clients engage or fail to do so with the

therapist, and likewise the therapist with client.

There are three main components of the supervision process. First, case

conceptualization and treatment planning is a crucial foundation of the supervision

process. Second, role-playing with the supervisee, to improve skills in cognitive,

behavioral, interpersonal (including empathic confrontation) and affective techniques

enables the supervisee to technically implement the treatment. Finally, supervision

focuses on the therapist’s own schemas and schematic processes and how the therapy

process relates to Axis II impasses.

Elements of the Training Process in SFT

General Supervisee Prerequisites. Clinicians need to know both short-term and

longer-term treatment approaches, both to treat Axis I symptoms and underlying

personality dysfunction. Familiarity and facility in interventions deriving from cognitive,

 Schema-Focused Supervision8

experiential, behavioral, and interpersonal domains is highly desirable. SFT training and

supervision requires the capacity and willingness to integrate the clinician’s own schemas

into training and supervision efforts. Finally, the capacity to assume the appropriate

complimentary modes to the client’s challenging stances requires maturity and poise.

Content of Training. Formal training requires a thorough knowledge of DSM-IV,

Axis I and Axis II assessment and treatment, and basic cognitive therapy skills. As SFT

builds and expands on Beck’s model (e.g., A. Beck, 1976; J. Beck, 1995; Burns, 1989),

familiarity with existing cognitive therapy protocols for depression (Young, Beck, &

Weinberger, 1993; Beck, Rush, Shaw & Emery, 1979), anxiety and panic (Beck, Emery

& Greenberg, 1985), substance abuse (Beck, Wright, Newman & Liese, 1993), and

personality dysfunction (Beck et al., 1990; Young, 1994a) are important, together with a

review of individual case conceptualization (e.g., J. Beck, 1995; Persons, 1989). Training

should also review basic behavior therapy skills and knowledge of procedures for

behavioral assessment, and specific treatment procedures including graduated exposure,

behavioral rehearsal, assertion training, and programmed practice.

Familiarity with personality dysfunction from the SFT perspective (Young,

1994a), including SFT diagnosis and assessment along the four dimensions (Young &

Gluhoski,1996) is very important. Knowledge of psychopharmacology, including

common medications for various disorders and how these may be integrated in treatment,

should be incorporated into training.

While much of the above content may be mastered through reading, audiotapes, and

workshops, supervised casework with CT cases to insure mastery of basic cognitive-

behavioral skills, as measured by Cognitive Therapy Adherence Scale ratings (Young et

al., 1983; Liese et al., 1995) is most likely to lead to high proficiency.

Familiarity with SFT Resources. Young and his colleagues have developed

educational materials for client and therapist use (Bricker & Young, 1994; Young &
 Schema-Focused Supervision9

Klosko, 1993), which outline the SFT model. Familiarity with these materials serves as

an introduction to the model for clinicians in training in SFT, as well as an excellent

introduction to clinicians and supervisees seeking an orientation to the model.

Young and colleagues have also developed assessment materials to identify

schemas, developmental origins, and coping styles (referred to earlier), which improve

efficient problem identification. Combined with a life history questionnaire (e.g., Lazarus

& Lazarus, 1991), a brief, focused interview to identify behavior patterns, and simple

childhood imagery exercises, rapid and efficient case conceptualization is possible (see

Young, 1994a). A SFT conceptualization form organizes assessment information

obtained from these sources.

Training in treatment for personality dysfunction requires the development of

proficiency in empathic confrontation, as a primary means for helping clients face and

remediate the difficulties identified during the assessment phase. Young has developed a

series of videotaped demonstrations of SFT treatment sessions, incorporated into

weekend workshops which help individuals see how SFT is conducted.

The section that follows illustrates how SFT supervision might be provided, and

how it adds to conceptualization, strategy, and intervention.

The Supervision Process in SFT

In this section we will describe the eight different kinds of supervisory

experiences that we incorporate into SFT training.

(1) The first set of sessions involves the therapist and supervisee getting to know

each other. We believe that it is important to establish a high level of personal rapport

and familiarity before jumping into case supervision. In these sessions supervisees

discuss their previous training and experiences as therapists; the types of patients they

believe they are most and least effective with; areas of sensitivities that might arise in

therapy; and what they would find most helpful from the supervision process.
 Schema-Focused Supervision
10

Supervisees are also encouraged to ask their supervisors questions about the supervisors'

particular areas of expertise, the types of cases they feel most comfortable supervising,

and the supervisors' expectations of the supervisee.

Whenever possible, we urge supervisees to share their own schemas and coping

styles with supervisors, in case these become activated and create problems in therapy.

This sometimes involves the supervisee filling out and sharing the results of the schema

inventories, and doing one or two childhood imagery exercises with the supervisor.

Supervisees may also share any personal issues or problems that they think the supervisor

should be aware of that might affect their performance. Although not required, mutual

self-disclosure at this more personal level establishes a closer supervision bond that

makes it easier later for the supervisor to bring up sensitive issues that may be affecting

the therapy process. In some cases these more personal sessions can be postponed until

later, when more trust has been established.

After these early getting-acquainted sessions (which are less structured), the

supervisor and supervisee set an agenda for each session. The agenda primarily involves

deciding what type of help the supervisee wants, and which case or cases (if any) the

supervisee wants to focus on. Typically we offer seven types of help in SFT supervision:

case conceptualizing, case strategizing, case implementation, resolving technical case

problems, working on therapy relationship issues, providing support and personal help

for the supervisee, and discussing general conceptual and treatment issues. Most sessions

involve only one or two types of help from this list of seven. We will now elaborate on

these possible foci for SFT supervision.

(2) The first type of help involves refining the supervisee's conceptualization of a

specific case. Before proceeding to any of the other case-specific help discussed below,

the supervisor first insures that the supervisee is operating from a thorough and

reasonable schema-focused case conceptualization.

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11

To accomplish this, the supervisee presents the following material for each new

case: a list of presenting problems; a Multimodal Life History Inventory; the YSQ

(schema questionnaire); the YPI (parenting inventory); summaries of two childhood

imagery exercises, one with the patient's mother and one with the father; and the

supervisee's general impressions of the patient.

From this material, the supervisor and supervisee work together to clarify the

presenting problems, and to link them with childhood origins and with specific schemas

and coping styles. The end result of this discussion is an assignment for the supervisee to

complete a Schema Conceptualization Form for the case and to bring it into the next

supervisory session about the case.

(3) The next type of help involves strategizing. Once the conceptualization is

complete, the supervisor and supervisee discuss which problem to focus on first; which

schemas and coping styles to emphasize; which modes of intervention will be utilized

and in which order (cognitive, experiential, behavioral pattern-breaking, limited

reparenting). They also agree on whether to begin with traditional, symptom-oriented

cognitive-behavioral therapy; standard schema-focused therapy; or advanced schema

mode work.

After deciding on a tentative strategy, the supervisor and supervisee develop a

specific plan for the next patient session, including possible homework assignments. This

process of strategizing continues throughout the course of supervising a particular case.

Each week, the supervisee provides feedback on the progress of the case, and they agree

to either continue the current strategy, or modify it based on the feedback.

(4) After strategizing, the focus of supervision turns to implementation. A

supervisory session of this type focuses on a "micro" examination of specific interactions

between the supervisee and the patient. For these meetings, it is essential for the

supervisee to bring in a video or audiotaped segment of a session, or, if that is not

 Schema-Focused Supervision
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possible, a written transcript of a session segment that is as accurate as the therapist can

recall. The supervisor provides feedback on the segment, including as much praise as

possible, and then models ways of improving the interaction (if any) through a role-play,

in which the supervisee plays the patient. They then reverse roles, and the supervisee

practices the improvements just demonstrated by the supervisor. These implementation

sessions occur periodically with each case, and often alternate with sessions devoted to

strategizing or reconceptualizing.

(5) Many supervisory sessions are devoted solely to problem-solving difficult

cases where the therapist feels stuck. This is especially true as the supervisee gains

experience; the need for routine conceptualization, strategizing, and implementation

meetings gradually lessens over time.

In these sessions, the supervisor and supervisee try to assess why the case does

not seem to be progressing well. The supervisee first summarizes briefly the current

conceptualization and strategy for the case. Next, the supervisee gives an example of a

particular point in a session that typifies why the case is problematic; if possible, an audio

or videotape segment is very helpful in this process. Supervisees are urged to ask

patients for feedback to determine if, and why, patients believe therapy progress is

blocked. Supervisees are especially encouraged to ask the patient about personal feelings

toward the therapist, and to explore their own feelings about the patient.

After these steps have been completed, supervisors offer their opinion about why

the case is blocked, and suggest either a reconceptualization, shift in strategy, or

improvement in implementation. This may involve a shift in which life problems,

schemas, or coping styles to focus on; a change in emphasis regarding the intervention

modality (e.g., more experiential work and less behavioral work); a change in therapy

style (e.g., more confrontation); or a shift from standard schema work to an emphasis on
 Schema-Focused Supervision
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schema mode strategies. When supervisors conclude that the problem is in the therapy

relationship itself, they proceed to the next type of session, described below.

(6) Often supervisory sessions are devoted primarily to improving the therapy

relationship. These sessions begin by asking the supervisee to describe the therapist's and

patient's feelings about each other. The supervisor helps the supervisee to determine

whether either the therapist's schemas or the patient's schemas are being triggered in the

session. A knowledge of the therapist's schemas is essential at this point in order to fully

understand the interaction. It is also crucial that an actual tape segment with the patient be

played in these sessions.

If the patient's schemas have been triggered, the therapist is helped to point out

distortions to the patient. If the therapist's schemas have been activated, the supervisee is

helped to identify the relevant schemas, see how they are leading to a distorted perception

of the patient, and then correct maladaptive interactions with the patient. Sometimes

helping the therapist identify links between how the supervisee is responding to the

patient and how the supervisee felt toward his or her own parents proves valuable. One

important goal in these sessions is to guide the supervisee in maintaining a consistently

sympathetic view of the patient, regardless of the patient's behavior.

Role-playing is often helpful in practicing more adaptive interventions and

adopting a more healthy therapeutic style, or reparenting strategy, vis a vis the patient.

Throughout this process, the supervisee is urged to get ongoing feedback from the patient

about the progress of the therapy relationship, and to work together to find compromises

when the patient and therapist disagree about what would be most helpful.

(7) Occasionally we have found it useful to devote sessions to providing personal

support or limited therapy for the supervisee. This is particularly helpful when personal

problems outside the therapy are interfering with the therapist's performance. Sometimes

a few schema-focused therapy sessions are sufficient for supervisees to resolve their
 Schema-Focused Supervision
14

personal issues and regain normal functioning. If a few sessions are not sufficient,

however, we urge trainees to seek individual treatment from another therapist.

In other instances, the therapist may feel demoralized or discouraged because of a

lack of progress with one or more cases. In these sessions, it is most useful for the

supervisor to praise and reassure the therapist, pointing out successes and putting failures

in a more realistic perspective.

(8) In some instances, the supervisee may elect to devote a supervision session to

discussing general issues, including theoretical, conceptual, or practical questions that do

not pertain to just one specific case. For example, supervisees will sometimes identify

similar types of cases or problems that have arisen repeatedly, and they may want to

discuss them in broader terms, without the constraints of focusing on a single case. In our

experience, such sessions can periodically be extremely useful. However, if they become

too frequent, the supervisee may be avoiding discussing problematic cases by focusing on

more amorphous concerns. If this happens, the supervisor tactfully shifts the session to

more specific case material.

The next section illustrates the supervision process by focusing on a single

supervisory case.

SFT Supervision: A Case Example

For purposes of demonstration, the following case is presented as it would be to a

SFT supervisor (whom we will call Diane) for case consultation. The results of a

partially-completed, schema-focused assessment are summarized below for a client seen

by a supervisee (whom we will call Peter) who has made limited progress with the case.

Patient Information. The patient is a divorced mother in her mid-thirties, whom

we will refer to as Martha. She has had significant psychiatric symptomatology since

childhood, including recurrent episodes of depression, substance abuse, and a history of

 Schema-Focused Supervision
15

abusive relationships. She has been seen episodically in counseling, with lapses of weeks

or months, and appears for treatment when experiencing acute emotional difficulty.

Martha’s two primary presenting complaints were chronic depressed mood, and difficulty

with her daughter Cathy. Stressors included financial difficulty (a recurrent pattern),

Cathy’s school refusal, work stress, and dissatisfaction with her current dating

relationship. The treatment contract originally developed involved helping Martha with

her depressed mood and with limit-setting for Cathy.

Response in Treatment. Martha was initially responsive to a cognitive-behavioral

treatment trial, although finances prevented her from acquiring the bibliotherapy

materials, in favor of sports equipment for Cathy. Attendance in counseling has been

sporadic, and initial symptom relief reached a plateau after mild recovery. Since

significant biological symptoms remained, including sleep continuity problems and

weight gain, the client was started on a selective serotonin reuptake inhibitor by a

consulting psychiatrist. Sessions focused principally on helping Martha problem-solve

parenting problems and cope with her dysphoric mood. Attention was given to

dysfunctional relationship patterns, especially her pattern of poor choices in dating

partners, but this has not resulted in behavior change. Although she made initial recovery,

Martha continues to drift back toward dysfunctional behavior, such as re-establishing a

dating relationship with an abusive ex-husband, making poor financial decisions, and

getting down on herself for “never getting anywhere.”

Peter has requested help in developing a more focused approach to Martha’s

treatment. He states he is seeking greater understanding of the dysfunctional relationship

patterns which operate with Martha’s daughter as well as significant others.

Table 4 presents his partially completed Schema Conceptualization Form (Young, 1992;

adapted for this paper). The form highlights some of the key difficulties facing the client
 Schema-Focused Supervision
16

and therapist, along with possible historical antecedents; the gaps in the form suggest

areas of uncertainty in the therapist and the therapy.

Supervision process. Overall, the supervision process is parallel to the therapy,

insofar as Diane and Peter collaboratively set an agenda, which might include: a review

of assessment information, a specific consultation question, discussion of case objectives

or impasses, ideas concerning strategy, requests for feedback concerning both the client’s

and therapist’s reactions to the therapy process, rehearsal of relevant skills, and

assignment of homework for the supervisee where relevant. What is different in schema-

focused supervision compared to schema-focused therapy is that more emphasis is given

to case conceptualization, therapy process, and practice of skills and tactical strategies

for change. Relatively greater precautions are taken to protect therapist personal privacy,

keeping the supervision/therapy boundary clear. Supervision addresses schema-driven

processes in the supervisee, such as schema avoidance or activation, only to the extent

that these relate to the progress of the case, with emphasis on how these affect therapeutic

process with the client, or limit choices in treatment. Practical strategies for addressing

these situations--rather than more extensive exploration, review of personal history, or

persistent activation of schematic processes--differentiates schema-focused supervision

from personal therapy for the supervisee.

Tactical clinical considerations. Based on the description and the partially

completed materials submitted by Peter, it is apparent that, while he has done a fair job in

addressing Axis I issues and collecting schema assessment information, the therapy has

not sufficiently addressed the schemas as they present in the therapy relationship,

including Martha’s degree of engagement in the change process.

With respect to case conceptualization, missing from the list of problems is the

client’s “not following through” in key relationships and in her therapy. Diane would ask

Peter to consider targeting this behavior and its antecedents quite carefully, historically
 Schema-Focused Supervision
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and in the current therapeutic relationship. How does Peter understand what would lead

Martha to pursue or avoid relationships?

Conceptualization. Peter would be asked in supervision to describe his

conceptualization of the case, in terms of relevant schemas and coping strategies, and

then to outline his strategies for addressing these. Peter has not thought through specific

strategies for bringing about Martha’s change. He needs to review the goals of SFT in

working with each of the schema domains. Does he have a clear idea of “what makes

Martha tick?” or what changes in the domains might be important for the various EMSs?

Specifically, what is Peter’s understanding of the relationship between Martha’s

life history, her ideas about herself, and what will happen in relationships; and what skills

does she lack or possess for managing interpersonal difficulties, emotional distress, or

pursuing goals? What situations are most challenging to her and why? What experiences

in the therapy to date might be considered to be activating the Failure schema (or other

relevant schemas)? Is there a “therapeutic campaign” in Peter’s mind for bringing about

change in the various problem areas?

Structure and focus. Is there sufficient structure and opportunity for feedback in

the therapy? Has Martha been socialized into the model of treatment? Does she share a

common conceptualization of what needs to change and why? On the basis of her time

thus far in treatment, would she be able to tell us what her troubles are, how they have

developed, why change has been so difficult, and what strategies she and Peter have

planned to address these? Diane would review Peter’s audiotaped sessions with these

concerns in mind, and coach him on his use of time and focus in the sessions. He would

be directed to elicit from his client her conceptualization of her struggles, and relate the

activities of the therapy to developing skills and capabilities in the areas which have been

problems for her.

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Schematic processes are another potentially fruitful topic for this case

consultation. Have Peter and Martha understood the role of schema avoidance during the

course of therapy? Has she been gently helped to discover what might lead her to fail to

attend sessions? Has the therapist empathically pointed out what the client has failed to

talk about? Or tuned in to the presence (or absence) of affect? Are there obstacles which

block a more effective collaboration, from the standpoint of client and therapist?

Diane might ask Peter to describe the quality of relationship he has with Martha.

To highlight impasses, he might be asked to compare Martha with other clients or

personal relationships which are more intimate and more successful in achieving a

common purpose. What appears to be missing or different in this relationship? Is Peter

effectively asking for and receiving feedback concerning Martha’s experience of therapy?

Diane would ask Peter to role play with her how he is approaching sample

impasses. She would also model how to use empathic confrontation with Martha. Role-

playing impasses and Peter’s approach to schematic processes might prove revealing,

both in exposing the difficulties he is having and modeling effective skills.

Therapist schemas. Discussion of the Peter’s thoughts concerning the case will

likely highlight his schema processes. Diane will inquire about Peter’s reactions to the

possibility of activating strong affect from Martha concerning her schemas of Failure,

Vulnerability, and Abandonment? She will investigate Peter and Martha’s shared beliefs

about activating strong negative emotions. Diane will inquire about Peter’s thoughts and

feelings about Martha, her absences, how close he feels to her, whether he is able to

“level” with the patient, and if not, what stands in the way of doing so.

Therapist’s Change Strategies. Table 3 suggests possible therapeutic interventions

in the four domains for the Abandonment schema. Similar strategies can be found in

Young and Klosko (1993). Diane would probably ask Peter for his thoughts concerning

the objectives he expects to pursue in his client’s cognitive, experiential, behavioral and
 Schema-Focused Supervision
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therapy relationship areas. His proposed change strategies would be reviewed for

feasibility, timing, effectiveness to date, consideration of alternative approaches and

degree to which he and Martha are in collaboration.

In general, SFT supervision investigates whether the clinician has a conceptual

map of how to proceed, the technical skills to structure an intervention, a strategy to

begin intervening, and the sensitivity to manage the relationship processes with empathy

and persistent confrontation. In this case, discovery of parallels in Martha’s intimate

relationships and her therapy relationship with Peter could proceed to a shared conception

of what makes connecting difficult for her, and to an appreciation of her early

developmental experiences which make it understandably so. The two would discover

how Martha adapts to minimize distress, evaluating when these coping strategies are

working or not working, and develop a shared identification of both the need to change

and obstacles to development. If Peter could provide higher levels of support in the

therapeutic relationship, he might be able to maintain more complete engagement with

Martha in the treatment process. Diane can guide Peter concerning conceptual, strategic,

and technical plans for “staying schema-focused,” so that phasing and blending skills-

training and handling relationship issues can occur. Table 5 lists some of the questions

Peter (and interested readers) can ask themselves to guide their progress in learning SFT.

Recommendations and Conclusion

This paper has presented Schema-Focused Therapy as a conceptual and tactical

approach to complex cases, which has something to offer most clinicians. It is an active

approach which offers a number of practical tools and heuristic approaches for rapid and

accurate case conceptualization, together with psychoeducational materials to help clients

learn about how they operate in the world and how they resist change. Finally, the model

suggests tactics for key interventions in a number of relevant spheres.

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We have suggested a number of recommendations for training therapists in SFT,

and have outlined how SFT can be used as a model for the supervision process itself.
 Schema-Focused Supervision
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& H. Rosen (Eds.), Cognitive therapies in action (pp. 88-125). San Francisco:

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Burns, D. (1989). The feeling good handbook. New York: William Morrow.

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and Competence Scale. Unpublished instrument, Univeristy of Kansas Medical Center,

Kansas City, KS.

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Salkovskis (Ed.), Frontiers of cognitive therapy (pp. 182-207). New York: Guilford.

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Young, J.E. (1993a). Detailed schema strategies.(Available from the Cognitive

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Table 1.

Schema Domains with Early Maladaptive Schemas (1/95 Revision)

Disconnection & Rejection

1. Abandonment / Instability

2. Mistrust / Abuse

3. Emotional Deprivation

4. Defectiveness / Shame

5. Social Isolation / Alienation

Impaired Autonomy & Performance

6. Dependence / Incompetence

7. Vulnerability To Harm Or Illness

8. Enmeshment / Undeveloped Self

9. Failure

Impaired Limits

10. Entitlement / Grandiosity

11. Insufficient Self-Control / Self-Discipline

Other-Directedness

12. Subjugation

13. Self-Sacrifice

14. Approval-Seeking / Recognition-Seeking

Overvigilance and Inhibition

15. Negativity / Vulnerability To Error

16. Overcontrol / Emotional Inhibition

17. Unrelenting Standards / Hypercriticalness

18. Punitiveness

COPYRIGHT 1995 , Jeffrey Young, Ph.D.

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Table 2.

Schema Modes

Child Modes: Vulnerable Child, Angry Child, Impulsive / Undisciplined Child, Happy

Child

Maladaptive Coping Modes: Compliant Surrenderer, Detached

Protector,Overcompensator

Maladaptive Parent Modes: Punitive Parent, Demanding Parent

Healthy Adult Mode: Healthy Parent/Adult

(Abbreviated from Young (1994a))

COPYRIGHT 1996, Jeffrey Young, Ph.D. and Michael First, M.D. Unauthorized

reproduction without written consent of the author is prohibited. For more information,

write: Cognitive Therapy Center of New York, 120 East 56 Street, Suite 230, New

York,NY 10022.
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Table 3.

Illustrative Change Strategies for the Abandonment Schema

Cognitive

1.Alter belief that others will eventually leave, withdraw, or behave

unpredictably.

2.Alter expectation that significant others should always be consistent &

available.

3.Decrease exaggerated focus on significant other being there.

Experiential

1.Re-experience memories of parent who was unstable, unpredictable, left

home, or died.

2.Express anger toward “abandoning” parent in imagery.

3.Nurture “inner child” through imagery and dialogues.

Behavioral Pattern-Breaking

1.Choose partners who are stable and committed.

2.Don’t push partners away through jealousy, clinging, excessive anger, etc.

3.Gradually learn to tolerate being alone and independent.

4.Choose a secure, stable environment, even though it may feel unfamiliar or less

exciting.

Therapy Relationship

1.Therapist becomes transitional source of safety and stability. Increase

therapy contact temporarily.

2.Therapist corrects client’s distortions about likelihood of therapist abandoning

him/her.

3.Help client accept therapist’s departures, vacations, and unavailability without

overreacting.
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Table 4.

Partial Schema-Focused Case Conceptualization

Demographic Information

Therapist: Peter Patient Name: Martha Age: 36

Marital Status: Divorced Children: 1 Education: Junior

College

Occupation: Administrative Assistant

Ethnic Background: Irish Catholic

DSM-IV Diagnoses

Axis I Diagnoses: Major depression, recurrent; Dysthymic Disorder; Psychoactive

substance abuse in remission

Axis II Diagnoses: Personality disorder NOS

Current Problems With Linked Schemas & Processes

Problem 1: Depressed mood. Schema Links: Subjugation, Mistrust/Abuse,

Abandonment, Unrelenting Standards

Problem 2: Limit-setting with Cathy, 15 year old daughter with behavior problem.

Schema Links: Self-sacrifice, Subjugation, Insufficient Self-Control / Self-Discipline

Problem 3: Recurrent abusive relationships. Schema Links: Subjugation, Abandonment,

Mistrust/ Abuse

Schema Modes: Punitive Parent, Detached Self-Soother, Abandoned Child

Schema Triggers: Conflict with adolescent daughter, Onset of sexual relationship with

new dating partner

Coping Styles:

Schema Maintenance Strategies: Compliance-Dependence, Self-sacrifice, failure to set

boundaries, Subjugation to prevent Abandonment

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Schema Avoidance Strategies: Psychological withdrawal; minimizes or ignores warning

signs in relationships.

Schema Compensation Strategies: Aggression-hostility; impulsive rebellion, followed by

guilt

Severity of Schemas, Risk of Decompensation: Moderate to Severe schemas, Moderate

risk

Hypothesized Temperament/Biological Factors

Family history of depression and substance abuse.

Developmental Origins/Relevant History

Adopted at birth: Never knew biological parents. Stepmother: Physically abused patient;

substance abuser. Stepfather: Alcoholic, violent arguments with mother, neglected

patient. Suicide attempts: ages 12, 13. Physically abused as child. Overweight (r/o eating

disorder) as child. Humiliated by peers

Core Cognitive Distortions

“I’m a failure. I’m not normal. I can’t do anything right. I’m ugly, fat, lazy.” “I’m

helpless.”

“If I don’t have a man, I’m a failure” “If I stand up to others, they’ll leave.” “Being alone

is intolerable.” “If a relationship fails, I’ve done something wrong.”

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Table 5.

Self-Supervision in SFT

1. Is the client sufficiently socialized to the SFT model as an explanation for their

difficulties and a means for change?

2. Do you and the client share a common conceptualization of problems and goals for

treatment?

3. Are you alert to schema processes, such as schema maintenance and schema avoidance

and how these are operating in both the client’s life and in the therapy? Have you helped

the client to discover these as they arise in session?

4. Are the two of you able to sustain a consistent focus during therapy sessions? Do you

have an agenda, manage time well, stay on track? If not, can you trouble-shoot the

process whereby you find yourself becoming derailed?

5. Is the therapist responding to subtle affect shifts in session and schema mode flipping?

Can these events be integrated into the therapy?

6. Does the therapy activate, rather than intellectually discuss, key schemas, in a way that

allows for learning and practice of new behavior or reinterpretation of schematic

material? Does the client experience relief in session? Have they learned strategies for

tolerating and coping with strong emotional arousal?

7. Does therapy include persistent empathic confrontation, leading to homework, linked

to the SFT conceptualization and a plan for practicing alternative behavior, changing

beliefs, operating differently in relationships and in the therapy relationship itself?

8. Is the client aware of and reinforced for counter-schematic behavior? Are they attuned

to signs of progress? Can they give feedback concerning their reaction to the therapy and

therapist?
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9. Does the therapy relationship possess sufficient intimacy and collaboration for a joint

struggle? If not, is the dyad able to identify this and obstacles to achieving an optimal

climate, and address these?

10. Has sufficient attention been paid to historical and developmental origins of how

clients have developed difficulties? Has the therapist underestimated the client’s need for

validation, acceptance and valuing and favored more active change interventions

prematurely?

11. Is the therapist aware of the client’s beliefs about the change process, what actions

will be necessary to bring about and sustain changes, and over what period of time?
 i
The eighteen EMSs, as well as specific schema domains, coping styles, and schema modes, will be capitalized

when referred to in the text. General schemas, themes, and coping styles that are not drawn from these Appendices and

Tables will not be capitalized.