09 Cognitive Restructuring

Cognitive Restructuring

Clinical Prompt [For use AFTER one understands the process]

No cognitive restructuring program can be completely planned since the individual personalities of the clients are so varied. However, these are general steps that can be followed.

1. Engagement
   1. Creation of a vision statement
   2. Acceptance and validation
   3. Finding a place – relaxation techniques
2. Psychoeducation
   1. Identifying the maladaptive schema
   2. Understanding mindfulness
   3. Understanding the process of change
      1. five step cognitive process correction
      2. imagery processes
      3. homework
      4. time
   4. The role of the counselor
3. Contractual commitment to the process of change
4. Plan of change: each plan must be individualized
   1. Selecting distressing thoughts to address
      1. automatic thoughts
      2. sequencing thoughts
      3. contextual emotions
   2. Imagery exercises
   3. Skill development
   4. Selecting group or individual sessions
   5. Social family learning interventions
   6. Teacher interventions

The decision to use ‘clean language’ is predicated upon two factors: the need and willingness of the client to deal with the unsayable of his/her maladaptive contexts; and the skill of the practitioner. If the client needs extensive imagery and metaphor work and the primary clinician is not skilled in this area, s/he should identify someone who is and, with the client’s permission, add their expertise to the plan of change.

Cognitive Restructuring must be considered a long term response to a chronic thinking problem. While there is no norm, practitioners should consider at least twelve months to eighteen months for working through these difficult maladaptive contexts.

INTRODUCTION

For purposes of this protocol, we are interested in conveying a more precise definition of cognitive restructuring and to that intention, we will want to indicate the potential of changing specific types of thoughts and to indicate alternate methods to make those changes.

Thoughts are changed every day by simple observation. In fact, the human thought system can be pictured as a river, no matter when you enter a river, it is different each time. The water constantly flows by and is replaced by new water. At the same time there is a consistency over time about rivers or we could not name them. Thus, the Mississippi River is both constant and changing. So it is with our thoughts.

It is common to consider thought linguistically. However, thoughts are not words. Simply thinking of the word ‘spring’ will easily apprise you of that concept. Spring can mean many different thoughts, depending upon the context in which it is used. A thought, therefore, is something more than a language representation and includes context as well as emotional content. A belief is not a thought, since you can have a thought and not believe it. A thought also does not demand emotional content although it can contain it. A thought can be an image, which should not be considered as visual, since some people do not visualize images, but ‘sense’ them in some other way. A blind person can have an ‘image’ of something without ever having seen it.

An image is a sense of …… [something]. A thought is a meaning of ….. [something]. An image may include a meaning, so an image is more than a thought. A belief is a thought with value [plus or minus] – value can be described as emotional spin based upon utility. The most basic definition of utility is the narrow one associated with the nineteenth-century utilitarian, Jeremy Bentham: utility is the pursuit of pleasure or the avoidance of pain. The internal logic of utility becomes for each of us the starting point of decision making about value. “This is important [has plus/minus value] to me because I love/hate it. It causes me pain/pleasure in some manner which I remember. The memory of that pain/pleasure causes me to place criteria on it.” The criteria exist because of the expectations embedded in the memory of pain/pleasure. Bring it close/keep it away criteria. All of this has to do with meaning – which has as its most critical conceptual context – utility. “This is useful for …..[something].”

The consistency of our thoughts are based on our beliefs, values or criteria. These ‘meanings’ are developed over time and trial and are the patterns that we identify about how the world works and our place in it. In order to shape an understanding about the outcome of this process, we will use two separate and different analogies: the first one is architecture and the other one is banking. While no analogy fits precisely, or it would not be an analogy, these two may help to convey a new meaning of thought structure and process.

When we think of architecture, we think of building something; a structure of some sort. When we use this analogy to indicate the architecture of the mind, it helps us to get a sense of something built and maintained. This architecture of the mind is created by each individual and becomes sufficiently stable to be defined as a structure sometime after the age of four, but perhaps closer to seven years old since, according to Valent, the right brain is fully dominant until the age of three when the ‘visceral’ child first starts to think. Communication between hemispheres, he tells us, is exceedingly poor before the age of three, and limited till the age of five. Verbal dominance of information and awareness is established only after 7. At this age the left brain speech area can organise and categorise information into linguistic codes and narrative units within linear time and that may provide for the esablishment of a working Theory of Meaning. At this point, the stuctures of schemata [belief system] of self and others is in place.

An analogy for the next step might be to think of each of these thoughts, ideas, beliefs and/or values as currency [money] of different denominations. Despite their differences, they operate in similar fashion. We maintain a savings account and a checking account. Both vary in the amount of currency they hold over time, but many people hold a fairly consistent amount. The bank(s) may hold the money in various locations and even move it around fairly often, but we expect that it will all be there when we need it. The same can be said for our thoughts, they may be dispersed in the brain, but they can be brought together for immediate or long term purposes.

In the structure of our mind we hold certain beliefs to be self evident and when we use these thoughts they are of the same stuff as that which we save. Thus, we have a structure and a process. The structure consists of our savings – the thoughts we hold to consistently – and the process is the exchange [spending and receiving money] in the same manner that we use those thoughts in our day to day living . These two concepts: structure and process are interrelated by the currency [thought] and interactive, but are of different orders.

From this perspective, what is often thought of as cognitive restructuring, such as Beck’s Cognitive Therapy or Ellis’ Rational Emotive Therapy really deal only with the processes and not the structure. This is why we prefer to call these interventions Cognitive Process Correction or cognitive error correction. As with our analogy, it is true that if we spend [or collect] too much, we change the structure of our savings and in the same way Cognitive Process Correction can change the structure of beliefs, since our everyday cognitive processes are coherent with our stored beliefs. However, it is only when we go to that financial advisor and really audit and adjust our savings that actual restructure of our financial funds and accounts takes place. Thus, Cognitive Restructuring, as referred to here, will be understood to occur only when we work with a belief advisor [cognitive counselor] to look with us in depth at what we actually believe [our accounts] and the contexts [schema/funds] in which we believe them and to make specific attempts to change, not just the usable thoughts that occur day to day, but the beliefs, attitudes and values [criteria] and unsayable symbols that we have about the meaning of the world and our place in it. Just as we have financial accounts and funds we have belief accounts and funds as well, and they might be called scenarios and schema. And be sure that if we change the structure of our savings dramatically for the better, we will have more currency to spend in our day to day living. And if we change our belief structure dramatically for the better we will have much more to give to our relationships in day to day living and create much more productive and serene lives.

The two cognitive pillars [schema] of self and of others are the mainstays of our theory of meaning and maps of the world. They contain not only the obvious logical thoughts, but the mysterious symbols of our unsayable images as well. Schema is a term used to identify the network of all ideas and images that can be drawn on to describe a single domain. Thus, the schema that one has about the self are the beliefs, values and criteria that one uses to describe oneself. The mind may cross map some of the thoughts about others onto the schema of self – e.g., “other people like/don’t like me”. Thus, the schema may be best described as a network of thoughts drawn from many different parts of the brain to come together to provide a coherent notion of oneself. Using our banking analogy, we might draw on several different accounts in our savings to contribute to our retirement or college funds. Retirement and college can be thought of as schema to which we direct both thoughts and funds.

Between these two schematic pillars is expectation, e.g., a belief about or a mental picture of the future or our thoughts about how others will treat us and how we should treat others given the quality of who we believe we are. If the two pillars of self and others are strong and positive, our expectations will tend to be optimistic and our actions pleasing to self and others. Unfortunately, if our schema about self and others is maladaptive and we believe that we are helpless, hopeless and/or unworthy and that other people are better than us and that they know how ‘little’ and insignificant we are, our expectations are likely to be pessimistic and perhaps even paranoid. It is these beliefs about self and others that creates our expectations and attitudes – our personality, e.g., those persistent characteristics that personify us to ourselves and others.

The beliefs deposited in the structure of the mind are used dynamically and coherently by the individual when s/he encounters day to day situations in the world and they tend to convey a consistency in actions, responses and outcomes. When the outcomes resulting from this expenditure are distressing over time, we have varying levels of problems in living. As we have indicated, we have two methods to address this distress; we can intervene with the day to day processes or we can dig deeper and intervene with the actual makeup of the schema structure itself. In the first case, Cognitive Process [error] Correction, uses a five step intervention by:

1. making the subject aware of his/her immediate thoughts such as those articulated in self or automatic thought
2. enabling the subject to attend to those thoughts through mindfulness and the use of journals and other concrete forms of documentation throughout the day
3. helping the subject analyze these thoughts in formal and public ways so that the confirmation bias can be overcome, helping the person think creatively about –
4. alternative meanings that events might have so that they can find more balanced and rational thoughts and examine the potential consequences to find those most satisfying and gratifying, and, finally,
5. enabling the person to adapt to the new thoughts through habituation and mindfulness.

This is a valid and important process. It requires that the confirmation bias can be overcome so the person can get past their own traditional analytic outcomes allowing a creative expansion of alternative thinking to occur. The process is sufficiently powerful to help most people with problems in living, particularly when combined with specific techniques for specific problems such as phobia, panic, Post Traumatic Stress Disorder, Obsessional Compulsive Disorder, and the like.

But this is not what we mean by Cognitive Restructuring. Cognitive Restructuring is a process of auditing the savings account or ‘belief structure’ in depth, seeking areas of distress and the need for change. The automatic thought ‘I’m stupid” is a surface thought leaving a great deal unsaid [and perhaps much is unsayable]. We must find ways to ‘ladder’ down to discover the real internal messages being sent and to help the person find new ways to think, particularly about self and others, implying changes as well in future expectations. We must also help people think not just sequentially about their meanings, but simultaneously as well.

People who suffer from severe and persistent problems in living that have variously been labeled as conduct disorder, borderline personality disorder and/or as having schizophrenia, have some pretty strange ‘inner logic’ and ‘inner symbolism’ from which to operate. The outcomes they achieve are usually not very effective in gaining mutually satisfying and gratifying relationships with other people, because of the dimensions of this difference. These are usually identified as ‘chronic’ problems and change will demand something more than cognitive process correction because almost all of the processes would have to change. Cognitive Restructuring is the process that can begin to address this substantially maladaptive and confused architecture.

CREATING THE STRUCTURE

It is up to the infant animal, … to create its own categories and to use them to make sense of, to construct a world – and its not just a world that the infant constructs, but its own world, a world constituted from the first by personal meaning and reference.

Sacks – A New Vision of the Mind

“One of the deepest problems in cognitive science is that of understanding how people make sense of the vast amount of raw data constantly bombarding them from the environment” [Hofstader, 1995]. How do perceptions occur and formulate conceptions? The lowest perception occurs, of course with the reception of raw sensory information through the various sense organs, described as sensations. Out of the many sensations the mind seeks to find an orderly process by which to make sense of the world.

A newborn faces the world with few mental structures with which to interpret stimuli. S/he randomly, although with some epigenetic rules, experiences the world of objects and events and has internal responses to these events. Some objects and events are pleasant and others are not. Gradually s/he begins to build mental contexts about experiences, grouping events and objects in what we might simplistically call ‘good’ and ‘bad’, although for much of this construction our infant is not capable of speech and, therefore, the mental contexts must be built of images which may be unsayable even as s/he progresses into adolescence and adulthood. Some of these mental contexts and the thoughts, feelings and actions connected to them become so repeated and habitual, that the whole process becomes non-conscious. In fact, certain cognitive algorithms carry out much of what we do in the day to day world, just as the mysteries of direct deposit and payment may handle our banking. However, as we can bring the banking mysteries to light by exploration of banking practices, we can also bring most of our automaticity to consciousness, and as we will see, this allow us to ‘debug’ the system.

Over time, these generalizations and functional abstractions begin to lead to a hierarchy [or structure] of causes and effects and some of this hierarchy becomes no longer conscious. Gradually, the data of experiences and events are coalesced into a naive, but powerful concept of self and others much of which is not conscious. Sometime between the ages of four [04] and seven [07] years of age, this concept turns the learning and creating process upside down. Instead of continuing as a data driven ‘bottom’s up’ process, s/he now follows a theory driven ‘top down’ process in which successive events and experiences are measured against the theory [schema structure], creating what is called a confirmation bias. If you hold a theory strongly and confidently, then your search for evidence will be dominated by events that confirm your theory. Such events will even be more attractive and attention-getting. Perceptions can, therefore be influenced by belief, goals, and external context. This implies a top-down process along with the bottom-up process of the senses. In order for raw data to be shaped into a coherent whole, it must now go through a process of filtering and organization, yielding a structured representation that can be used by the mind for any number of purposes. Representations, words, symbols or images are the conclusions drawn from sensations.

The theory forms a mental context or ‘internal logic’ upon which future decisions are predicated. A mature set of theories tested over time, becomes a theory of self and others, which constitutes the essence of the person’s thoughts, feelings, expectations and attitudes; a personality. But again, much of this internal logic, which underpins the personality, is not conscious. Thus, a single word or action can have significantly different meaning to different people, even in the unlikely event of the same perception in the same circumstances, without the two persons even understanding that they have screened the information differently. If the event or experience is novel enough to one of the people to gain conscious attention as new information, it will either be rejected as not fitting the theory of self or the theory will be adapted in some manner to incorporate this new information. Finally, if the new information is powerful enough the theory of self may need to be changed or even abandoned. This is an unusual situation, but could creates a ‘crisis’ for the individual as it is essentially the message: ‘I don’t know who I am any more!’ Unless a powerful directive force is available, the person may simply break down. The psychosis of assuming new personalities [Yeshua, Napoleon, etc.] may be a most creative attempt to find ways to hold onto self, after the breakdown of the old self has occurred.

As with all theories some are more elegant than others. Elegance is a term that scientists use to describe a theory that is not only effective and useful; but also just ‘feels’ right, fit or gratifying. Thus if a person had a theory of self and others which was elegant, they would be able to predict and control future events with high levels of effectiveness and generally be considered by others to be a ‘serene’ person with few problems in living. On the other hand, if the child has developed in an invalidating environment with punishing ambiguities, the theory may be crude or gauche – resulting in an ‘inner logic and symbolism’ which is out of touch with the cognitive adaptions of most of their ecosystem.

The distinguishing mark of high-level perception is that it is semantic: it involves drawing meaning out of situations. The more semantic the processing involved, the greater the role played by concepts in this processing, and thus the greater the scope for top-down influences, since it taps either the knowledge base or the theories, ideologies and/or belief systems of the individual.

The way we learn is contingent on pattern perception, extrapolation and generalization. These activities are descriptive of analogical thought. The quality of an analogy between two situations depends almost entirely on one’s perception of the situation. Analogical thought provides one of the clearest illustrations of the flexible nature of our perceptual abilities. People are constantly interpreting new situations in terms of old ones. It is this process that allows for the enlargement of our understanding of the world. Analogy-making is going on constantly in the background of the mind, helping to shape our perceptions of everyday situations. One could suggest that it is the breakdown of analogy-making and the onslaught of automatic thoughts which most constitutes the difficulties that people have in using cognition effectively in personal and interpersonal domains. The use of automatic thoughts keeps the person recycling old information instead of learning new information.

On the other hand, analogy-making leads to metaphor. Analogy is ‘this is like that’ and metaphor is ‘this is that’. Thus, there are similarities of analogy to thought and metaphor to belief. People use metaphors all them time – “S/he stabbed me in the back” – to convey displeasure with another persons betrayal. However, metaphors are also used in the mind nonconsciously because they can capture the essence of a context which may not be expressible in words.

HOW DOES MALADAPTATION OCCUR?

While we are all products of self creation, others, particularly significant others contribute to our organization processes. This often happens in unsayable ways. There is much ambiguity in the world and thus what may be considered abusive by one child may be considered constructive by another. Nonetheless, it is not what the significant adults in the child’s life do, it is the interpretations that are made of these experiences that count. This does not mean that we, as adults, cannot make appropriate judgement of such actions, only that the child does not always do so. So we have the usual parental suspects:

• Physically, sexually or emotionally abusive
• Absent through death or an inability to provide consistent parental nurturing and empathy
• Critical and rejecting
• Unable to separate their own needs from their child’s needs, leading to a suppression of the individual needs and feelings of the child.

Marsha M. Linehan has coined two valuable terms based on a bio-social theory of personality disorder which can be very helpful descriptive terms for us. Linehan hypothesizes the individual growing up within a particular set of environmental circumstances. She refers to this environment as the ‘Invalidating Environment’ referring essentially to a situation in which the personal experiences and responses of the growing child are disqualified or ‘invalidated’ by the significant others in his/her life.

The child’s personal communications are not accepted as an accurate indication of his/her true feelings and it is implied that, if they were accurate, then such feelings would not be a valid response to circumstances. Furthermore, an Invalidating Environment is characterized by a tendency to place a high value on self-control and self-reliance. Possible difficulties in these areas are not acknowledged and it is implied that problem solving should be easy given proper motivation. Any failure on the part of the child to perform to the expected standard is, therefore, ascribed to lack of motivation or some other negative aspect of his/her character.

The other term Linehan uses is ’emotionally vulnerable’. This person in the sense identified by Linehan is someone whose autonomic nervous system reacts excessively to relatively low levels of stress and takes longer than normal to return to baseline once the stress is removed. An emotionally vulnerable child can be expected to experience particular problems in an invalidating environment. S/he will neither have the opportunity to accurately label and understand his/her feelings nor will s/he learn to trust his/her own responses to events.

Neither is s/he helped to cope with situations that s/he may find difficult or stressful, since such problems are not acknowledged. It may be expected then that s/he will look to other people for indications of how s/he should be feeling and to solve his/her problems. However, it is in the nature of such an environment that the demands that s/he is allowed to make on others will tend to be severely restricted. The child’s behavior may then oscillate between opposite poles of emotional inhibition in an attempt to gain acceptance and extreme displays of emotion in order to have his/her feelings acknowledged. Erratic response to this pattern of behavior by those in the environment may then create a situation of intermittent reinforcement resulting in the behavior pattern becoming persistent.

The characterization of problems in living stemming from a distorted environment combined with the personal vulnerability of an individual child seems to us to make a great deal of sense, although we surmise that the invalidation outcome may affect multiple vulnerabilities. People with differences in temperament and/or neurological or biological makeup must make sense of a very chaotic world when the messages being sent by those people upon whom the child is reliant for nurturance are unclear, distorted or punishing in some way. Paradoxes abound – from the parent who metes out physical punishment in order to teach the child not to be physically punishing to the emotional and language hijacking of double binds.

Our behaviors – effective or not – are learned. We do not develop in a vacuum. Rather, we learn to act and respond within a given context, and within that context our behaviors make sense. If we continue to use those same behaviors in new contexts the behaviors may seem frivolous or ineffectual; they may even be labeled as abnormal. Yet the behaviors did make sense within the context in which they were developed such as a dysfunctional family environment. Psychotraumatizing creates a person whose emotions are crippled by fear, anger and/or sadness and whose mind is often confused and impulsive. Dysfunctional family interactions directly produce psychotraumatic childhood exposures that trigger a cascade of aversive experiences and brain changes that lead to severe and persistence problems in living by late adolescence.

A psychotraumatic experience is an aversive experience that triggers a fear response capable of causing a person to become concerned about his or her psychological or physical safety while effectively inhibiting the person’s ability to protect him or herself by terminating or escaping the aversive event. The magnitude of the event must be intense and chronic enough to have a lasting effect on a person’s functioning.

While physical and sexual abuse are the epitome of dysfunction, they are but the tip of the iceberg. This is not to underestimate their powerful negative impact, but we are always drawn to the earthquakes and volcano eruptions and their terrible and traumatic impact upon the shape of the world and seem to be oblivious to the much more dramatic effects of wind and water, which work their erosive qualities much more secretively. Words matter! Whether intentional or not, the way we communicate to our children is a powerful influence on their creation of themselves.

MESSAGES

Children are natural mimics – they act like their parents in spite of every effort to teach them good manners. – Unknown

Adults socialize children through the way they communicate to them. As a child attempts to learn to predict and control the world, s/he is required to find patterns and make analogies about those patterns [this is like that], and finally to generalize the patterns into a broad theory or perspective of the world and his/her place in it. Since adults are primarily responsible for the first four years of input, the messages they send are magnified in importance.

Child Management Strategies	Concept Type	Concept Impact	Emotional Spin	Emotional Impact
Authoritarian	Power assertions, commands, demands	Disrespect, demeaning	Bullying, shaming, belittling	Fear, anger
Authoritarian	Balanced and rational direction, instruction, requests	Acceptance, value	Respect, courtesy	Caring
Laissez-Faire	Easy going, ignoring, rejection	Loss, worthlessness	Flippant, seems not to care	Sadness, anger

 

As the table above indicates, psychologists have identified these three basic modes or strategies for communicating to children; but to suggest that these are carried out in ‘pure’ form would be unwise. For the most part, adults trend toward one or the other, but often mix modes of communication to the detriment of the child. The more variation in modal theme an adult has, the more confusing it is to the child – and since confusion results in uncertainty, the child’s personal style becomes uncertain. Depending on the temperament of the child, the child is likely to become anxious and fearful, angry and/or sad. While this may be the worst of all worlds, two of the three child management strategies, even in a ‘pure’ state, are rather problematic. While the child may feel more clear on the pattern that s/he is experiencing, s/he may still have difficulty with the message.

Temperament is that aspect of our personalities that is presumed to be genetically based, inborn, there from birth or even before. According to C. George Boeree , the issue of personality types, including temperament, is as old as the ancient Greeks, who came up with two dimensions of temperament, leading to four ‘types’, based on what kind of fluids (called humors) of which they had too much or too little.

The sanguine type is cheerful and optimistic, pleasant to be with, comfortable with his or her work.

The choleric type is characterized by a quick, hot temper, often an aggressive nature.

Next, the phlegmatic temperament characterized by slowness, laziness, and dullness.

Finally, people with a melancholy temperament tend to be sad, even depressed, and take a pessimistic view of the world.

These four types are actually the corners of two dissecting lines: temperature and humidity.

Boeree goes on to tell us how Ivan Pavlov, of classical conditioning fame, used the humors to describe his dogs’ personalities. One of the things Pavlov tried with his dogs was conflicting conditioning – ringing a bell that signaled food at the same time as another bell that signaled the end of the meal.

Some dogs took it well, and maintain their cheerfulness.

Some got angry and barked like crazy.

Some just laid down and fell asleep.

And some whimpered and whined and seemed to have a nervous breakdown.

Pavlov believed that he could account for these personality types with two dimensions:

On the one hand there is the overall level of arousal (called excitation) that the dogs’ brains had available.

On the other, there was the ability the dogs’ brains had of changing their level of arousal – i.e. the level of inhibition that their brains had available.

Lots of arousal, but good inhibition: sanguine.

Lots of arousal, but poor inhibition: choleric.

Not much arousal, plus good inhibition: phlegmatic.

Not much arousal, plus poor inhibition: melancholy.

Arousal would be analogous to warmth, inhibition analogous to moisture!

However, the question of temperament is a difficult one to assess. How much is innate and how much is learned [if even in the womb]? And this leads us back to the question at hand, for regardless of whether temperament exists or not, it merely provides one aspect of interpreting messages. It is still the message that counts.

When speaking of the ‘message’, we must be aware that we are talking about several different levels of perception. First, there is the intent of the sender. This intent may be clear to the sender, but not to the receiver. However, the intent is often conveyed, not by the ‘message’ itself, but by the demeanor of the sender. Demeanor (bearing, deportment, mein) is conveyed by many nonverbal actions and by some of the verbal actions such as tone and emphasis. The quote at the beginning of this section indicates that often the child takes an intent that is not ever expressed in words and runs with it. The intent being expressed is manifested more by the way the adult behaves than what the adult says. The intent also conveys one of the modes to the child. But be aware, the child perceives and interprets the demeanor, the child may or may not be right. So a child manager may be laissez-faire about managing the child and the child may interpret this as a wonderful gift of the authority to do what s/he wants – a reinforcement of the adult’s trust in the wisdom of the child OR s/he may interpret this as an adult ignoring him/her, an adult wishing the child did not exist or would go away – leading to a sense of nonpersonhood and ultimately worthlessness. So it is not just the concept type that is important, but the emotional spin that goes with it. And often the emotional spin can be perceived through the demeanor of the sender – even though the words contradict. A parent who conveys love, even with a very authoritarian strategy may end with a child with a positive connotation for commands.

So the receiver (child) must judge the meaning of the demeanor and the concepts of the message. Thus, a group of words such as – “Will you please stop doing that” – might convey a mild request for the child to alter his/her behaviors (including a polite respect) or if said harshly, with an emphasis on STOP and a reddening of the face – might be perceived as a threat to bodily harm if s/he does not stop. How does the child determine which interpretation is the ‘truth’. It may be based on the emotional spin and partially it may be based upon the prior experiences. What patterns have been perceived in the past in relationship with this individual or with other adults that can be brought to bear on the judgement? If the child has experienced harsh commands and demands combined with bullying and belittling most often in the past, s/he may respond with fear of anger at a command that is not disrespectful or demeaning as though it was. “Stop that” may be a simple directive, but perceived as a bullying command. If given by a peer, it may open an opportunity for a response which leads to an opportunity to operationalize the anger as aggression, which might not be possible with the adult who set the pattern.

From the chart we can see that the Authoritative mode is the best selection a parent can make for gaining a positive impact. It is most likely that the child will develop positive beliefs about him/herself and others if s/he experiences a caring authoritative adult. However, even this mode can run into trouble with a child who already has identified patterns of adult communication that makes him/her anxious, fearful, sad and/or angry. For giving directions and instructions can be interpreted as commanding and demanding. And some children, because of their prior pattern of experiences are sensitive to such interpretations. On the other hand, direction and instruction may be seen as impinging on the child’s autonomy if the child has been pleasantly ignored and sees him/herself as setting her own directions. It is important to note that communication is a feedback system, in which the receiver receives feed back from his/her own prior experiences and then gives feedback to the original sender.

An additional difficulty with communication is that we don’t just send one message to one receiver. We send multiple messages – often contradictory – at the same time AND we get a response, which we interpret in the same manner as the child and to which we then respond. Each response also is embedded in a demeanor that either correlates with or doesn’t correlate with the conceptual content [words].

Thus, communication [multiple messages in multiple verbal and nonverbal, concept and emotional modes] leads us to believe that something is happening which is consistent with our experiences of the past. A well intended adult sending messages with a kind and caring intent can get a rebuff. What is a person to think? Is this child ungrateful, ignorant or incorrigible? And if so, how do I respond?

We use the term transactional communication to convey the use of the notions articulated in the theory of Transactional Analysis. There is the Child Schema – “I want what I want when I want it”. There is the Parent Schema – “You will do it because I told you to do it”. Note that both of these are power assertions. Power assertions almost always result in a push back, unless the person is so worn down by power assertions that are supported by punishment that they have learned helplessness. Power assertions are not recommended. The recommended response to a power assertion is a balanced and rational statement. The use of balanced and rational statements demands patience, persistence and probably a positive self image. The reason for patience and persistence is that people using power assertions are unlikely to immediately accede to balanced and rational discussion. The reason for the positive self image is that one is required to ignore what can appear to be a threat to one’s person and territory.

Thus, a child who has learned to mimic a profane adult may suggest that you – the person who sent with kind intent the message that was rebuffed – are a ”#&%@*& (jackass)’. Now generally, this will tend to get you irritated and when irritated the response is likely to be one of defensiveness or aggression. This is not helpful. What we need to find out is what the child is thinking and defensiveness or aggression is not likely to achieve this purpose. Therefore, a more appropriate response might be inquiry. “Gee, I have acted like a jackass on occasion [notice we change the metaphor “you are a jackass” to an analogy, “like a jackass”], but I don’t see it here, “what do you think I am doing that makes me like a jackass”. That seems to be balanced and rational. And what is the response likely to be. One might at first expect the child to be confused – s/he made an irrational statement in anger – meant more to convey the anger than a concept – and received an acceptance rather than a rebuff. More than likely, s/he really hadn’t thought about what s/he meant. The response is likely to continue to convey the anger without making any more sense. Possibly, “You know what I mean” [anger combined with some feeling of confusion that you are somehow being manipulative].

Since the child’s meaning theory is oriented around beliefs about self, others and future prospects, s/he may perseverate in trying to get an appropriate response from you [anger, authoritarian statements] for some time. This is what s/he has predicted and s/he believes that s/he can control in some fashion. For these kids, the balanced and rational response results in confusion and uncertainty. You are challenging the basic beliefs about self and others – a profound experience. Depending on the strength of the child’s theory, you may dent the surface causing him/her to put your response into some kind of acceptable format so that it can be assimilated into the theory – ”this is just a ploy to get me off guard – go along, but stay alert”. Or, you may actually puncture a child’s mildly held theory and require a change – “this adult does not fit the pattern – s/he is the exception to the rule – meaning that there are exceptions and perhaps I should reconsider my beliefs” – before s/he can accommodate the idea – meaning to modify the belief itself so that the response makes sense within it.

We are always fine tuning our theory of meaning through assimilation and accommodation. However, people with severe and persistent problems in living often have very rigid beliefs and, therefore, make it difficult for such fine tuning to occur. For some situations, you may actually communicate something that shatters the belief system – leaving the person with no way to cope – and providing an opportunity for real change to occur.

You will note that this communication process is the equivalent of the authoritative child management strategy. Thus, the strategy can be used developmentally or remedially. In other words, when the child is first collecting data on patterns, analogies, generalizations and other higher level abstractions, this process can be used to provide the most fertile soil for the development of positive [balanced and rational] beliefs about self, others and future prospects. And as we have indicated, this strategy has specific remedial merit for the child whose theory of meaning is distorted. This is not to imply that balanced and rational conversations are not also powerful tools for communicating with adults; it merely contends that use of such communication strategies reinforces positive emotional spin and impact, thereby enhances the child’s potential to develop a positive pattern of identification and ultimately to create a theory of meaning which has balanced and rational beliefs about self, others and future prospects.

After the primary caretaker’s and other adults in the child’s community of interest have provided a pattern of messages which have been used to create a workable theory of meaning, the child’s socialization process is taken over by peers. The unfortunate part is that once the child has created a distorted theory of meaning, his/her communications are likely to reap the most negative of responses, thus reinforcing the negative beliefs already abounding in his/her belief system. Thus, if the child does not trust other people because s/he believes that s/he is worthless and therefore unlikable, s/he will tend to convey a morose, negative attitude to those around. Most of us respond negatively to these kinds of attitudes, thus reinforcing the person’s assumptions that s/he is worthless and unlikable.

Peer rejection is the single most vital indicator of future problems in living. A pattern of negative relationships is set very early, and without someone to create a crack in the theory, it is likely to continue with self fulfilling confirmations. The one area of possible interpersonal relations is to align oneself with other people with the same belief system. Thus, children with negative theories often become members of a ‘victims’ group where all of the member agree with the negative values – thus reinforcing each other with the rightness of their anger, fear and sadness – although mostly it will be the anger – the emotion of justification – that is the one that provides the ‘glue’ that holds the group together. All the members believe that they have been violated and, therefore, have the right to strike back. They are all justifiably angry at a world that has rejected them.

This, of course, makes change even more difficult as it would require a repudiation of the only sources of solace that the child has. Even if s/he were to suddenly believe that his/her theory of meaning was wrong, s/he would need to abandon his/her friends or try, perhaps, to change them. Such an attempt might be the way the break is finally made, since others with the old theories are likely to turn on the newly ordained ‘do gooder’.

What we are trying to articulate is that children create their own personalities out of organizing the pattern of their experiences and trying to make sense out of them. If the communication patterns of significant adults are negative, distorted or do not make sense – the resulting theories are likely to be unable to provide good skills in predicting and controlling the world. The ‘inner logic’ of the child is then reinforced by the way people react to the child’s own communication patterns and a cycle of ‘bad vibes’ and reinforcement continues.

We can label such behaviors anything we want – conduct disorder, oppositional defiant disorder, etc., but we miss the point in doing so. These are the golems or Frankensteins of our own making. Certainly the child has participated in this process, interpreting messages in his or her own unique way, and possibly with many errors. However, it is hard to believe that a child who has arrived at the conclusion that s/he is worthless and unlikable, that others are not to be trusted and that the future holds no hope, has purely invented these notions.

The most unfortunate aspect of this whole process is that many of these kids become parents and need to manage the development of their own child’s theory of meaning. What strategies might they choose?

“The apple does not fall far from the tree.”

CONFLICTING CONDITIONING

But let us return to the subject of invalidating environments and emotionally vulnerable children and the messages they received. Plalov, as noted above, tried conflicting conditioning and found differing responses from his dogs. This seems to be some justification of the constructs developed by Linehan. But let us pursue the conflicting conditioning process a little further.

In Steps to an Ecology of Mind, Gregory Bateson discusses a theory of schizophrenia which was the result of a research project undertaken by Bateson, Don D. Jackson, Jay Haley, and John H. Weakland. The theory looks at the behavior of the person with the label schizophrenia within the context of his or her family. They suggest that schizophrenic behaviors ‘make sense’ when viewed from this perspective. In other words, as we have been suggesting, behaviors do not develop in isolation, but as a result of interactions.

Bateson et al. suggest that a person caught in a “double bind” – a situation in which no matter what a person does, s/he “can’t win” – may develop symptoms. In the double bind there are two conflicting levels of communication and an injunction against commenting on the conflict. The following is an often-quoted example from their paper, “Toward a Theory of Schizophrenia,” which demonstrates this bind:

A young man who had fairly well recovered from an acute schizophrenic episode was visited in the hospital by his mother. He was glad to see her and impulsively put his arm around her shoulders, whereupon she stiffened. He withdrew his arm and she asked, “Don’t you love me any more?” He then blushed, and she said, “Dear, you must not be so easily embarrassed and afraid of your feelings.” The patient was able to stay with her only a few minutes more, and following her departure he assaulted an aide and was put in the tubs. (Watzlawick)

In this scenario, the mother is giving her son conflicting verbal and nonverbal messages and he seems unable to respond to the discrepancy. According to Bateson’s theory of logical types, the person with schizophrenia cannot comment about the meaning of his mother’s communication. “The ability to communicate about communication, to comment upon the meaningful actions of oneself and others, is essential for successful social intercourse.” In normal relationships we continually comment about the actions and communications of others, saying such things as, “I feel uncomfortable when you look at me that way”, “Are you kidding me?” or “What do you mean by that?”. In order for us to accurately discriminate the meaning of our own or another’s communication we must be able to comment on the expression – but the person with schizophrenia is effectively enjoined from such commentary.”

Carlos Sluzki has suggested that the double bind has the following characteristics:

1. two or more persons
2. repeated experience
3. a primary negative injunction
4. a secondary injunction conflicting with the first at a more abstract level, and like the first enforced by punishments or signals which threaten survival
5. a tertiary negative injunction prohibiting the victim from escaping from the field
6. finally, the complete set of ingredients is no longer necessary when the victim has learned to perceive his universe in double bind patterns

This pattern is, of course, exacerbated when the person causing the double bind is the same person on whom the child is reliant for protection and nurturance.

Paul Watzlawick has described four variations on the double bind theme. The first and probably the most frequently used is what he calls the “Be spontaneous” paradox. The wife who wants her husband to surprise her with flowers is experiencing this sort of dilemma. She is asking him to do something which by its nature must be spontaneous. “It is one of the shortcomings of human communication that there is no way in which the spontaneous fulfillment of a need can be elicited from another person without creating this kind of self-defeating paradox,” says Watzlawick.

A second variation involves a situation in which a person is chastised for a correct perception of the outside world. In this situation the child will learn to distrust his/her own sensory awareness in favor of the parent’s assessment of the situation. One example would be the child who is raised in a violent household but is expected to see the parents as loving and peaceful. In later life this person may have a difficult time determining how to behave appropriately in a variety of situations. Indeed, this person may spend an inordinate amount of energy trying to decipher exactly how s/he “should” interpret the situation.

The third variation is one in which a person is expected to have feelings other than those s/he actually experiences. The mother who wants her child to “want” to do his or her homework falls into this category. The child will often end up feeling guilty when s/he cannot achieve the “proper” feelings.

The fourth variation, according to Watzlawick, occurs when we demand and prohibit at the same time. The parent who demands honesty while encouraging winning at any cost is placing the child in this kind of bind. The child is placed in a position of having to disobey in order to obey.

The key to how a person will be affected by growing up in such an environment is directly connected to the fact that s/he cannot comment on these perceived discrepancies and that the child is totally reliant on the communicator. The child, trapped in this manner, may eventually learn to trust only one part of their experience and to deny or distrust the rest.

A team of researchers in 1967 proposed that the operational component of the double bind is its pattern of disqualification – the means by which one person’s experience is invalidated as a result of the imposed bind. They cited five methods for disqualifying the previous communication.

Evasion or a change of subject is the first method of disqualification. If the previous statement (a) does not clearly end a topic of discussion, and the next statement (b) does not acknowledge the switch in topic, then the second statement disqualifies the first statement:

a. Son: Can we go to the park and play soccer?
b. Father: What a beautiful day for working in the garden.

The second method of disqualification is sleight-of-hand. Sleight-of-hand occurs when the second response (b) answers the first (a) but changes the content of the previous statement:

a. Daughter: We have always gotten along well.
b. Mother: Yes, I’ve always loved you. . .

In the above example, the mother has responded to her daughter but has switched the issue from getting along well to love.

Literalization, the third type of disqualification, occurs when the content of the previous statement (a) is switched to a literal level in the second statement (b) with no acknowledgment of the change of frame:

a. Son: You treat me like a child.
b. Father: But you are my child.

The fourth method, status disqualification, happens when a person uses either personal status or superior knowledge to imply that the previous message is not valid:

a. Mother: I have observed that he doesn’t play very well with the other children.
b. Son: But I do, Mama!
a. Mother: He doesn’t realize because he is so little . . .

Redundant questions are used to imply doubt or disagreement without openly stating it:

a. Daughter: I get along well with everybody.
b. Mother: With everybody, Cathy?

The authors conclude their paper with the following observation:

We are consistently finding, in families with a member with schizophrenia, disqualifications followed by special types of sequences, such as the ones described, which tend to consolidate the bind and hence reinforce idiosyncratic modes of interaction. In this process, which implies a whole style of relation with the world and in which certain stimuli are systematically denied, certain meanings are systematically repressed, lack of recognition is reinforced and rewarded, and clarification is punished – in this, we concur in believing, might rest the context of schizophrenia.

Jay Haley discusses a basic rule of communications theory which maintains that it is virtually impossible for a person to “avoid defining, or taking control of the definition of, his relationship with another”. In any relationship, one of the first things that needs to be addressed is what kind of relationship it will be.

Relationships are defined as complementary or symmetrical. A symmetrical relationship is one in which the two parties match behaviors. If one person tells about a vacation s/he has had, the second person responds by telling of a vacation s/he has just taken. What is emphasized here is the symmetry, how they are alike. These relationships tend to be competitive.

A complementary relationship is one in which the behaviors complement each other. One person teaches and the other learns; there is a give and take between behaviors. After listening to the first person tell about his/her vacation the second person would press for further information.

Over time the nature of relationships will shift. As a child matures s/he evolves from a complementary relationship with his parents to a more symmetrical relationship.

A complementary relationship usually exists between a teacher and the student. But, when the student asks a question which implies that s/he knows more than the teacher s/he is maneuvering to shift that relationship. The teacher can choose to re-establish the old relationship or allow the interaction to shift. “Such maneuvers are constantly being interchanged in any relationship and tend to be characteristic of unstable relationships where the two people are groping toward a common definition of their relationship.”

It has been suggested that people with schizophrenia, as children, experienced a great deal of confusion in regard to defining their relationships as complementary or symmetrical. In other words, there was a great deal of mismatch between child and caretaker regarding the definition of their relationship. An example is the child who perceives the relationship as complementary and responds accordingly – only to have the caretaker switch to a symmetrical relationship.

The results of this interaction on a child is to grow up attempting to avoid defining relationships by negating any or all of these four elements. S/he can:

(a) deny that s/he communicated something
(b) deny that something was communicated
(c) deny that it was communicated to the other person
(d) deny the context in which it was communicated

There are many kinds of mixed messages in the world.

The man who responds to his wife’s request that he help her in the kitchen by saying “Sure, I’ll be happy to help you,” as he settles deeper into his easy chair, is at once accepting her request for assistance and simultaneously communicating that he will not help her.

The woman who says “I would love to help you but I have a headache,” is defining her relationship as cooperative, while using her headache to negate the relationship.

Similarly, how is a person to make sense of the communication “I love you” when it is said in a flat voice while gazing in the other direction?

The man says, “This subject is fascinating,” while checking his watch.

The woman asks her child if s/he wants to give her a hug as she pulls him/her toward her for a hug.

These sorts of interactions are common in everyday life. Much of our ability to make sense out of the world depends on our being able to recognize and comment upon the conflicting messages we receive. When the child is faced with the dilemma of deciphering to which part of the message s/he can safely respond, since commenting upon the discrepancy is not in the repertoire of behaviors available, this escalates the impact of the bind. It is much like living in a battle zone, particularly where every communication is a threat to personal safety. Faced with the task of discovering the meaning of another person’s communication while being prohibited from commenting on or acknowledging one’s own confusion seems like a terrifying proposition.

It appears that, because of the early influence of repeatedly being caught in double binds, children develop a defensive approach to communication which is tenacious in its ability to say something and say nothing at the same time. Their goal in life is not to be pinned down on any front. Unfortunately, they are as trapped in their web of confusion as the people who come in contact with them.

BEHAVIORAL OUTCOMES

James Masterson contends that as a result of childhood influences a person can develop a “false self” in order to protect the “real self” from further trauma. He suggests that the child begins with an orientation toward mastering reality, but once those efforts have been thwarted the false self shifts the orientation from that of mastering the environment to one of avoiding bad feelings.

Jerold J. Kreisman, M.D., and Hal Straus identify five dilemmas created by such avoidance. They call the first “Damned if you do and damned if you don’t”. An example is a woman who asked her boyfriend about his impressions of her amateur public performance about which she had misgivings. He replied “do you really want my honest opinion?” She insisted that she did. But when he told her his assessment of the performance – which was not particularly encouraging – she responded by telling him how wrong his perceptions actually were. Her communication was typical of the kind of confusing message that plagues the borderline’s relationships.

A second tendency cited is “feeling bad about feeling bad”. Rather than attempt to understand or cope with feelings, the person tries to get rid of unwanted feelings. The person who “should” be happy adds additional layers of guilt and other difficult emotions to an already depressed or angry persona – contributing to a seemingly endless spiral of feeling bad about feeling bad.

The perennial victim is a third pattern observed. The person perceives him/herself as at the mercy of the events and people around her. The woman whose happiness depends on her husband’s financial success is one example of victim. The person who organizes his/her life such that the solutions to his/her problems lie in other people’s hands is exhibiting a borderline tendency. “If only s/he understood me better …” is one way that the victim puts the responsibility for his or her happiness on another person.

Fourth is the quest for meaning in life. Some continually search for that which will fill the emptiness they experience. Relationships and drugs are two common solutions for filling this void.

The perennial search for constancy is the fifth behavior observed. The person exists in a world that is untrustworthy and inconsistent. Friendships, jobs, and skills are always in question. The person lacks the ability to experience consistency and predictability. It is as if all their experience is for naught.

The sixth and last element is what the authors characterize as the “rage of innocence”. Such rage is unpredictable and intense when it surfaces. Sparked by seemingly insignificant events, it can appear without warning and often carries the threat of real violence.

In considering the roots of the personality, Masterson suggests that John Bowlby’s research into the infant-caretaker attachment is significant. Bowlby studied the mourning process that children aged 13-32 months experienced when they were separated from their mothers as a result of hospitalization for physical illness.

Bowlby noted three stages of mourning that these children went through as a result of the separation from their caretaker. The first stage is protest and can last a few hours up to several weeks. In the second stage, hopelessness, the child sinks into despair and may even stop moving. He tends to cry monotonously or intermittently, and becomes withdrawn and more inactive, making no demands on the environment as the mourning state deepens.

In the third stage, detachment, the child no longer rejects nurses, but when the mother returns to visit, the strong attachment to the mother typical of children this age is strikingly absent. Instead of greeting her, he may act as if he hardly knows her; instead of clinging to her he may remain remote and apathetic; instead of dissolving in tears when she leaves, he will most likely turn listlessly away. He seems to have lost all interest in her.

Masterson realized that these same three stages of mourning and the defenses they produced are evident in adolescent and adult borderline personalities: when they go through a separation experience that they have been defending themselves against all their lives, they seem to react just like Bowlby’s infants in the second stage of despair. The separation brings on a catastrophic set of feelings, which are called an abandonment depression. To defend against this mental state, the person may retreat into the defensive patterns encouraged by the false self, which they have learned over the years will ward off this abandonment depression.

In adults without a sense of their real self, the abandonment depression symbolizes a replaying of an infantile drama: the child returned for support and encouragement, but the mother was unavailable or unable to provide it. The acknowledgment and approval, so crucial to developing the capacities of expression, assertiveness and commitment, were simply not there. Masterson suggests that what characterizes the borderline personality is an over-reliance on primitive defense mechanisms learned in early childhood: denial and clinging, avoidance and distancing, projection and acting out.

“In order to establish a coherent sense of self, the child in the first three years of life must learn that s/he is not a fused, symbiotic unit with the mother” says Masterson. In his book, A Secure Base, Bowlby discusses the elements he considers most necessary to allow this process to take place in children:

. . . the ordinary sensitive mother is quickly attuned to her infant’s natural rhythms and, by attending to the details of his behavior, discovers what suits him and behaves accordingly. By so doing she not only makes him contented but also enlists his cooperation.

This brings us to a central feature of the concept of parenting – the provision by both parents of a secure base from which a child or an adolescent can make sorties into the outside world and to which s/he can return knowing for sure that s/he will be welcomed when s/he gets there, nourished physically and emotionally, comforted if distressed, reassured if frightened. In essence this role is one of being available, ready to respond when called upon to encourage and perhaps assist, but to intervene actively only when clearly necessary.

Masterson suggests that many borderline clients had mothers who themselves had an impaired sense of self. Consequently, the mothers are not able to provide the secure base from which the child can venture out and explore the world. He cited one example of a mother with low self esteem and a fear of separation who tended to foster this fear of separation in her child. She encouraged him to remain dependent on her in order to maintain her own emotional equilibrium:

She seemed to be overwhelmingly threatened by her child’s emerging individuality, which sounded as a warning that he was destined to leave her eventually forever. Not being able to handle what she perceived as abandonment, she was unable to support the child’s efforts to separate from her and express his own self through play and exploration of the world. Her defensive maneuvers to avoid her own separation anxieties entailed clinging to the child to prevent separation and discouraging his moves toward individuation by withdrawing her support.

It looks like the ultimate double bind – a world that expects one to grow up and become self sufficient while the caretaker is rewarding that same person for remaining dependent and helpless.

DISTORTED MESSAGE AND PROBLEMS IN LIVING

Twenty years after the double bind theory of schizophrenia was published, one of the authors, John Weakland, published a paper in which he suggested that perhaps they had focused too closely on schizophrenia. He suggests that the real significance of the theory was its viewpoint that behavior and communication are closely tied. Perhaps, he suggested, the double bind has far reaching effects in many kinds of emotional disturbance, and its explorations should not be limited to cases with a diagnosis of schizophrenia.

Carlos Sluzki seems to have come to the same conclusion in his paper with the provocative title “The Double Bind as a Universal Pathogenic Situation.”

Sluzki notes that a child passes through three evolutionary stages:

1. infantile dependence, marked by a relative lack of differentiation between the self and the non-self and a preponderance of the incorporation or the “taking” of objects
2. transition
3. mature dependency, characterized by “relations between two independent beings who are completely differentiated; and by a predominance of giving” in object relations”

The transitional stage ushers in the core dilemma of all mental development: dependence versus independence.

The child’s developmental task is to balance the need for security and dependence with his or her need to move toward independence. If the parents are to facilitate the child’s emergence from dependence to independence they will need “to stimulate the impulse towards independence and to neutralize the needs for dependency.” Without the parents’ encouragement, it is difficult for the child to face the uncertainty and risks along the road to independence.

Sluzki describes three modes of relationship between parent and child; this includes those areas of a child’s life where he is dependent, independent or moving from dependence to independence with parents’ help and supervision. For example, dependence is when a child cannot get to school without his parents’ assistance. Independence is when the child can get himself to school without assistance. The third area entails that point in time where perhaps the child, with parents’ assistance and encouragement, is learning the route to and from school but is not ready to do it for himself.

As a child proceeds through life s/he and the parent(s) must constantly redefine where those boundaries are. At best this is a very complex task; if parents are unclear themselves about these boundaries, then their children will have to contend with a great deal of confusion about what they can and cannot do.

One example of a double bind that inhibits the child’s growth toward independence is a parent who is in conflict about the desire for the child to be independent and the desire for the child to “be perfect.” A child’s ability to think and behave creatively will become increasingly limited if, for example, s/he is told to think for him/herself and then second-guessed as to his choice of actions. This pitfall is illustrated by an otherwise responsible young man who spilled paint thinner and just walked away from it because he didn’t know what he should use to clean it up. He seemed to be caught in a “damned if I do, damned if I don’t” kind of experience. He seemed to think it would be better to walk away from the mess than to be criticized for using the wrong implement to clean it up. He has found it safer to retreat into helplessness and dependence rather than risk making a mistake on his road to independence.

Exploring these kinds of common binds may give us useful insights into the behavior of people with chronic serious and persistent problems in living. These outcomes may include a temperament and/or an emotional vulnerability aspect, but the key is not pathology. The key is the messages sent or not sent, received and incorporated into a theory of meaning about self and others. While all of us ‘chunk’ learned knowledge into schemata, people who have been unable to develop clear patterns or themes about themselves and others often have maladaptive schema which permeates their personalities. Mere Cognitive Process Correction here would be inefficient, for we must audit the accounts of the inner logic and find ways to help these sufferers rearrange their accounts in order to be able to tap their resources effectively and efficiently.

This is a simple, although not easy process. We are dealing with highly protective emotions of fear, anger and sadness which have demonstrated effectiveness over time. There are two critical elements to change: trust and hope – and people who have been confused and tormented over time are not long on either of these characteristics. Part of the process of developing trust and hope is to find ways to ‘emotionally shock’ the person by responding differently than expected – ‘to turn the other cheek’.

CONDUCTING THE BELIEF AUDIT

Because one’s beliefs, attitudes and values have not been created in a vacuum, it is important that a ‘community of interest’ be identified and assessed. We have addressed this elsewhere [CBAT#01 – Functional Cognitive Behavior Assessment] and will not address this process here. However, we would emphasize that without understanding and intervening with the ecosystem, it is unlikely that you can have an optimal impact on the individual child. Unlike adults, they cannot simply walk away from debilitating influences and even adults with severe and persistent problems in living have difficulty doing this.

CHANGE

Changing the mind of someone who has significant maladaptive themes [schema] will take two different perspectives: thought and imagery.

Thought

Touch your finger to your nose. How did you do that? You may be surprised to learn that nobody really knows.

A neuroanatomist can tell us the area of the brain where the first nerve impulses fire to begin that movement. We can also trace the chain of nerves that conduct impulses from the brain to the appropriate muscles. But no one knows how you go from thinking about touching your nose to firing the first cell in that chain. You just decide to do it and you do it, without having to worry about the details.

Thoughts are not just psychological in nature, they are physiological – electrochemical triggers that direct and affect the chemical activity. When given an electrical command – a thought – the brain immediately does several things: It responds to the thought by releasing appropriate control chemicals into the body, and it alerts the central nervous system to any required response or action.”
Shad Helmstetter

This is at least true for those things which are under our immediate control, such as raising your arms or touching your nose.

Now make yourself salivate.

You probably didn’t find that as easy, and you may not have been able to do it at all. That’s because salivation is not usually under our conscious control. It is controlled by a different part of the nervous system than the one that governs movement. While the central nervous system governs voluntary movement, the autonomic nervous system regulates physiologic functions, such as salivation, that normally operate without conscious control. The autonomic nervous system doesn’t readily respond to ordinary thoughts like “salivate.” But this does not mean that it cannot be controlled.

Imagery

Relax for a moment and imagine you are holding a juicy yellow lemon. Feel its coolness, its texture, and its weight in your hand. Imagine cutting it in half and squeezing the juice of one half into a glass. Perhaps some pulp and a seed or two drop into the glass. Imagine raising the glass to your lips and taking a good mouthful of the tart juice. Swish it around in your mouth, taste its sourness, and swallow.

Now did you salivate? Did you pucker your lips or make a sour face when you imagined that? If you did, that’s because your autonomic nervous system responded to your imaginary lemon juice.

Imagery is a thought process which can initiate what are normally automatic processes – and thoughts, as we have seen, have power. Imagery is a flow of thoughts you can see, hear, feel, smell, or taste. An image is an inner representation of your experience or your fantasies – a way your mind codes, stores, and expresses information. Imagery is the currency of dreams and daydreams; memories and reminiscence; plans, projections, and possibilities. It is perhaps because of this context, that we relate ‘magic’ to imagery and ignore the magic of thought which controls our everyday actions. And it is this illusory ‘magic’ which causes doubt in the serious mind.

Imagery is a window on your inner world, a way of viewing your own ideas, feelings, and interpretations – a means of transformation and liberation from distortions in the realm that may unconsciously direct your life and shape your health.

Imagination, in this sense, has not been greatly valued in our culture. The imaginary is often equated with the fanciful, the unreal, the impractical and the magical. The premium is on the practical, the useful, the real, as it should be – but imagination nurtures human reality as a river brings life to a desert. Imagination is the language of emotion and as Daniel Goleman in his book, Emotional Intelligence, has pointed out “emotion matters for rationality. In the dance of feeling and thought the emotional faculty guides our moment-to-moment decisions, working hand-in-hand with the rational mind, enabling – or disabling – thought itself.”

In the last twenty years, however, we have learned that imagery is a natural language of a major part of our nervous system. Critical to this understanding is the Nobel-prize-winning work of Dr. Roger Sperry and his collaborators at the University of Chicago and later at the California Institute of Technology. They have shown that the two sides of the human brain think in very different ways and are simultaneously capable of independent thought. In a real sense, we each have two brains. One thinks, as we are accustomed to thinking, with words and logic. The other, however, thinks in terms of images and feelings. And both types of thought have the power to make things happen with the body.

In most people, the left brain is primarily responsible for speaking, writing, and understanding language; it thinks logically and analytically and identifies itself by the name of the person to whom it belongs. The right brain, in contrast, thinks in pictures, sounds, spatial relationships, and feelings. It is relatively silent, though highly intelligent. The left brain analyzes, taking things apart, while the right brain synthesizes, putting pieces together. The left is a better logical thinker, the right is more attuned to emotions. The left is most concerned with the outer world of culture, agreements, business, and time, while the right is more concerned with the inner world of perception, physiology, form, and emotion.

The essential difference between the two brains is in the way each processes information. The left brain processes information sequentially, while the right brain processes it simultaneously. Imagine a train coming around a curve in the track. An observer is positioned on the ground on the outside of the curve, and he observes the train to be a succession of separate though connected cars passing him one at a time. He can see just a little bit of the cars ahead of and behind the one he is watching. This observer has a ‘left-brain’ view of the train.

The “right-brain” observer would be in a balloon several hundred feet above the tracks. From here he could not only see the whole train but also the track on which it was traveling, the countryside through which it was passing, the town it had just left, and the town to which it was headed.

Lest we become confused about the special merits of the right brain and enamored by the left, it should be pointed out that the left or logical brain is limited by Godel’s Theorem of Uncertainty. As articulated by Bateson:

…Logic is precisely unable to deal with recursive circuits without generating paradox and that quantities are precisely not the stuff of complex communicating systems.

In other words, logic and quantity turn out to be inappropriate devices for describing organisms and their interactions and internal organization.

When the sequence of cause and effect becomes circular [or more complex than circular], then the description or mapping of those sequences into timeless logic becomes self-contradictory. Paradoxes are generated that pure logic cannot tolerate.

Spell out the cycle onto a causal sequence, we get the following:

If contact is made at A, then the magnet is activated.
If the magnet is activated, then contact A is broken.
If contact at A is broken, then the magnet is inactivated.
If magnet is inactivated, then contact is made.

This sequence is perfectly satisfactory provided it is clearly understood that the if…then junctures are causal. But the bad pun would move the if and thens over into the world of logic, which will create havoc:

If the contact is made, then the contact is broken.
If P, then not P.

The if …then of causality contains time, but the if …then of logic is timeless. It follows that logic is an incomplete model of causality. Logic can often be reversed, but the effect does not precede the cause. Bateson

The ability of the right hemisphere to grasp the larger context of events is one of the specialized functions that make it invaluable to us in healing. The imagery it produces often lets a person see the “big picture” and experience the way an illness is related to events and feelings you might not have considered important. You can see not only the single piece but also the way it’s connected to the whole. This change of perspective may allow you to put ideas together in new ways to produce new solutions to old problems. A right-brain point of view may reveal the opportunity hidden in what seems to be a problem.

Language continually asserts by the syntax of subject and predicate that ‘things’ somehow ‘have’ qualities and attributes. A more precise way of talking would insist that the ‘things’ are produced, are seen as separate from other ‘things’, and are made ‘real’ by their internal relations and by their behavior in relationship with other things and with the speaker. Bateson

The right brain has a special relationship not only to imagery but also to emotions. This is another of the major strengths it brings to the healing adventure. Many studies have shown that the right brain is specialized to recognize emotion in facial expressions, body language, speech, and even music. This is critical to healing because emotions are not only psychological but physical states that are at the root of a great deal of illness and disease. Rudolph Virchow, a nineteenth century physician and founding father of the science of pathology, remarked that “Much illness is unhappiness sailing under a physiologic flag.” Studies in England and the United States have found that from 50 to 75 percent of all problems presenting to a primary care clinic are emotional, social, or familial in origin, though they are being expressed by pain or illness.

Emotions themselves are, of course, not unhealthy. On the contrary, they are a normal response to certain life events. Failure to acknowledge and express important emotions, however, is an important factor in physical illness and psychological distress; one that is widespread in our society. In many ways we are emotional illiterates, lacking clear guidelines and traditions for expressing emotions in healthy ways. It is difficult to know what to do with distressing emotions such as grief, fear, and anger, so we cope as best we can. We may unconsciously build layer upon layer of inner defenses to protect us from feeling unpleasant feelings. But strong emotion has a way of finding routes of expression. If not recognized and dealt with for what it is, it may manifest as psychological distress or physical pain or illness.

Social and family relationships to some extent depend on our ability to process emotions internally. We don’t need to express every emotion we feel. But strong, persistent emotions need to be expressed or resolved, as their chronic denial may lead to physiologic imbalance and disease as well as psychological distress.

When there is inner conflict, the body is the battleground. It may pay dearly for prolonged, serious struggle. Bringing the conflicting sides, whether sides of the brain or sides of the argument, to the bargaining table may be the beginning of healing. The goal, after all, is not to become a ‘left-brain’ or ‘right-brain’ person, but a ‘whole-brain’ person.

In any successful arbitration, both sides must have the opportunity to express themselves, to state their grievances, their desires, their needs, and what they can offer in the interest of peace. If they speak different languages, there must be an impartial translator willing to listen and speak for both sides, or the two must attempt to learn each other’s languages. This is why imagery is important—it is a major language of the right brain. Imagery can indicate what the person cannot ‘say’ in words – the unspeakable.

Six Step Reframing is a process used in NeuroLinguistic Programming through which a problematic behavior is separated from the positive intention of the internal program or ‘part’ that is responsible for the behavior. New choices of behavior are established by having the ‘part’ responsible for the old behavior take responsibility for implementing other behaviors that satisfy the same positive intention but don’t have the problematic by-products. The most important concept of six step reframing is that every behavior or feeling, no matter how bizarre or stupid it seems, has some useful and important positive intention or purpose.

When we speak in terms of ‘parts’ of a person, it is important to understand that we are not talking about a particular body part or in ascribing human attributes to a part of the body. ‘Parts’ is just a convenient way of talking about the experience we all have when we are ambivalent, divided or in conflict; we kind of want to do one thing and also want to do another at the same time. Such behaviors range from excessive television watching to compulsive spending, from nail biting to driving too fast, from eating too much to procrastination. A bad habit is any recurring behavior that you can’t seem to stop doing, even though you have come to realize that it has a negative impact on your life.

As a sample of the process, the counselor would first, have the client turn inward and apologize to this part for not appreciating it in the past. This is the part that you now realize wants to do something important and positive for you in continuing the behavior, even though you don’t yet know what this positive intention is. The more kind and gentle s/he is with this part of him/herself, the more willing this part will be to communicate with him/her. Once having achieved a positive focus the client should close his/her eyes and ask a question inside: “Will the part of me that makes me do this behavior, communicate with me in consciousness now?” After the question has been asked, the client should notice what s/he sees, hears or feels. This will often seem a little strange, but that’s okay – just concentrate on what happens.

People get a wide variety of signals from their right brain parts. S/he may get an image of a person, or an animal nodding its head; s/he may see a color or shape. S/he may hear sounds or words. Many people feel a body sensation – a tingling in the spine, warmth in the hands or face, an increase in heart rate or something else. Note that all of these responses are not ‘logical’, but are symbolic. They are also not ‘mystical’ responses from some unknown source. They are the responses of the mind/body of the person asking the questions. They prompt the person to explore deeper and to make some decisions about how they might make changes in their lives in unique ways.

Most of us understand and use left-brain language and logic every day. We are relatively familiar with our conscious needs and desires. Imagery gives the silent right brain a chance to bring its needs to light and to contribute its special qualities to the healing process.

Calling verbal or logical thinking ‘left-brained’ and symbolic, and imaginal thinking ‘right-brained’ is an oversimplification, but it is a useful model for thinking about some uses of imagery. Imagery allows you to communicate with your own silent mind in its native tongue. Imagery is a rich, symbolic, and highly personal language, and the more time you spend observing and interacting with your own image-making brain, the more quickly and effectively you will use it to improve your health.

Mental images that are formed long before we learn to understand and use words lie at the core of who we think we are, what we believe the world is like, what we believe we deserve, and how motivated we are to take care of ourselves. They strongly influence our beliefs and attitudes about how we fall ill, what will help us get better, and whether or not any medical and/or psychological interventions will be effective.

Imagery also has powerful physiological consequences that are directly related to the healing systems of the body. Research on the omnipresent placebo effect, the standard to which we compare all other modalities (and we find relatively few more powerful), has provided some of the strongest evidence for the power of the imagination in healing. It is well documented that from 30-55% of all people given inactive placebos respond as well or better than those given active treatments or agents.

If people can derive not only symptomatic relief, but actual physiologic healing in response to treatments that primarily work through beliefs and attitudes, then learning to better mobilize this phenomenon in a purposeful, conscious way becomes an important, if not critical, area of investigation. While all responses to imagery are not placebo responses, imagery offers an entrance into this important arena.

In addition to its potential for stimulating physical healing, imagery provides a powerful window of insight into unconscious processes, rapidly and graphically revealing dynamics that may support either health or illness. To the clinician, this window is invaluable for quickly identifying opportunities for change, as well as resistance to change, and ways to work effectively with both.

“Guided imagery” is a term variously used to describe a range of techniques from simple visualization and direct imagery-based suggestion through metaphor and storytelling. Guided imagery is used to help teach psychophysiologic relaxation, to relieve symptoms, to stimulate healing responses in the body, and to help people tolerate procedures and treatments more easily.

Imagery can also be used “interactively” to evoke imagery dialogue where the unconscious [or a part of the unconscious or the body] is invited to tell its own story such as in the Six Step Reframing process. This gives people a way to draw on their own inner resources to support healing, to make appropriate adaptations to changes in health, and to find creative solutions to challenges that they previously thought were insoluble.

The use of association and dissociation allows the individual to “metaperceive” or visualize several different levels of an experience. These terms indicate that we can imagine being in the situation in an associated way, being dissociated or outside the situation watching ourselves or others in the situation, as though watching a movie, or placing ourselves in the role of another person in the situation. These degrees of involvement [first, second and third person] are helpful in either experiencing the emotional impact of a situation or of protecting ourselves from the full impact while still experiencing the occurrence. Metaperception is also used to change timelines, so that an experience can be thought of to be, for example, in the future instead of the past, allowing the subject to prepare.

Cognitive psychology began to utilize imagery in a variety of ways to address problems with anxiety. Phobias became a particular focus since the behavioral approach of habituation was often rejected for its strong emotions. Metaperception techniques allowed the person to experience the phobic situation while controlling the degree of emotional intensity through degrees of dissociation. Only recently have practitioners begun to understand the value of imagery in use with people with severe and persistent problems in living – the ability to work through ‘double binds’ and other anomalies may be impossible without imagining oneself in a safe place with people you can trust.

The founders of NeuroLinguistic Programming, John Grinder and Richard Bandler, made extensive use of imagery, particularly in their discovery of the use of submodalities [sensory qualities, such as contrast, color, tone, movement, etc.]. What they discovered is that by changing the submodalities in a memory of an experience through imagery, they could change the emotions of the memory. What may seem like magic is merely the use of the mind’s own healing qualities to effect neurological change.

Imagery, visualization and metaperception are now standard tools in helping people change their mental states, and through those changes a potential change in their somatic states as well.

Although no one really knows what ‘consciousness’ is, we believe that it is critically related to the process of attention, for what we attend to is what we experience.¬ Over the years, most of us learn to give our major attention to the conscious, verbal part of our mind that narrates a linear, logical, rational, analytic monologue, describing its perspective of the world and how we think about it.

However, we are much more than what we think.¬ We are also the richness of intuitions, emotions, feelings, memories, drives, goals, appetites, aspirations, ambitions, values, beliefs, and sensations. Any or all of these aspects of self may require and even demand attention, finding ways to intrude on everyday consciousness through physical, emotional, or behavioral symptoms if need be. By focusing attention on these signals in a relaxed state of mind and inviting imagery to arise, we have the potential to reconnect with these important resources and improve the quality of our lives. Imagery is essentially a way of thinking that uses sensory attributes and, in the absence of competing sensory cues, the body tends to respond to imagery as it would to a genuine external experience.

Imagery has been shown in many research studies to be able to affect almost all major physiologic control systems of the body including respiration, heart rate, blood pressure, metabolic rates in cells, gastrointestinal mobility and secretion, sexual function, and even immune responsiveness.

Emotions motivate us to action, and they also produce characteristic physiologic changes in the body including varying patterns of muscle tension, blood flow, respiration, metabolism, and neurologically and immunologically active peptide secretions. ¬¬Modern research in psychoneuroimmunology points to the emotions as key modulators of neuroactive peptides secreted by the brain, gastrointestinal, and immune systems. Imagery has a significant influence on bodily functions – from emotions to the immune system and more. Tapping into such potent resources of the body makes guided imagery a valuable tool to promote healing.

Imagination is a powerful mental function that allows us to review the past, imagine possible futures, and do things that we sometimes can’t do in the outer world. The imagination is the source of creativity, problem-solving, planning, and of setting our course in this world if we use it correctly. Aristotle called it “the window to the soul,” since it always represents our internal reality. Einstein, late in life, said, “Imagination is more important than knowledge.”

Few of us are educated in the use of imagination, though it is one of our most powerful mental functions. Our educational system is geared toward teaching us logical, linear thinking, which is invaluable in life, but we are generally discouraged from using too much imagination and are certainly not trained in how to focus it and use it well. Fortunately, we use imagination instinctively, since it is a normal, natural way for our brains and nervous systems to store, process, and retrieve information.

Imagery is important in healing because it seems to have a much more direct link to bodily functions than spoken words. Imagery involves thinking in thoughts that have sensory qualities, in other words, with thought that you see, hear, smell, or feel inside. This body/mind connection, mediated largely through the emotions, is one of the powers of imagination that closely links it to healing. When you shift your state of being from anxious, depressed, or uncomfortable, to one that is quieter, happier, and more comfortable, there are physiologic changes that accompany this shift. The calmer, more relaxed, and yet often more energized state that follows this shift is one that is often associated with healing. It allows the body to focus its attention on healing rather than spending its energy combating imagined worries and woes.

Many studies indicate that focusing the imagination in specific ways can be calming, encouraging, mood modulating, pain relieving, and may even speed up, or allow physical as well as mental healing. It is certainly a better use of your mental energy than imagining all the possible bad things that can happen.

Imagery can be thought of as one of the brain’s two higher-order encoding systems. Imagery utilizes a simultaneous information processing mode, which underlies the holistic, synthetic, pattern thinking of the unconscious mind. However, the system we are most familiar with is the sequential information processing system that underlies linear, analytic, and conscious verbal thinking.

THOUGHT

We do not intend, despite the powerfulness of imagery to ignore the other encoding system of thought, words and logic. We have already identified a five step process which included awareness, attention, analysis, alternative and adaptation as a logical, left brain process of addressing automatic thoughts. This process continues to be valid and can be incorporated within the use of imagery. But now the process is directed more at themes of thought rather than ‘snapshots’. Two powerful systems of cognitive interventions with such themes have been developed by Linehan and Young. While we will address some of the specifics of these interventions, we suggest that they are useful beyond the original purposes of working with borderline personality disorder and also suggest that they could incorporate more imagery for increased effectiveness.

There are two ways to identify prevalent themes: asking and inferring. The asking process is called ‘laddering’. Laddering is a way of analyzing your internal monologue statements by looking for more and more basic underlying assumptions and predictions until you arrive at statements of core belief. The technique is called laddering because it proceeds step by step. Laddering has only two rules. Rule number 1 is to question yourself with the following format, and Rule number 2 is don’t answer with a feeling. The format is to ask:
‘What if ________________________?
What does it mean to me?’
In the blank space the client writes a self-statement from his/her internal monologue. Then s/he writes the answer to the question. Having done that, have the client use the answer to fill in the blank and ask the question again. After using this sequence a few times, the client will arrive at a core belief – at least as logically understood – because s/he will no longer be able to put into words what it would mean. The answers must be confined to statements that express conclusions, beliefs or assumptions – not descriptions of feelings.

The idea is that the client will work his/her way down the levels of abstraction to get to the root conceptual understanding of what the idea – “I am stupid” really means to them. Beyond a certain point it becomes unsayable, although through imagery, one may find analogies that one can use to ‘say’ something new.

There are other variations on this theme, for example, the worst case scenario statements, such as:

“If this were true [being stupid], what does it mean to me?”

And again, use the answer to reframe the question. Sometimes called the Vertical Arrow – instead of disputing negative thoughts, have the subject ask “if this thought were true, why would it be upsetting to me? Start by writing the negative thought and drawing an arrow down to the next item which is the answer to the question. Then ask the question again and draw an arrow down to the next answer. This will generate a series of negative thoughts which will lead to more clearly defined core beliefs.

Part of the concern is that clinicians, particularly those in cognitive arenas create ‘demand characteristics’. The term demand characteristics was coined by Martin T. Orne as an extension of Kurt Lewin’s “field theory” of personality to the analysis of behavioral motivation in a social context. Originally applied to the ecological validity of experimental research on human behavior, the concept has become increasingly relevant to contemporary issues regarding the assessment and intervention of psychological disorders. In research design, the term demand characteristics refers to the sum total of cues that convey an experimental hypothesis to subjects and influence their behavior. In counseling, the term may refer to the sum total of cues that convey the counselor’s wishes, expectations, and worldviews to clients and influence their behavior.

One way to address the issue of demand characteristics is to use ‘clean language’: an elegant and non-leading questioning techniques. – which combines avoidance of demand characteristics and an exploration of metaphor – thus it integrates both the left and right brain techniques. Clean Language is most often used in Metaphor Counseling which has the goal of helping the individual bring into cognitive awareness his/her metaphors and to urge them to put them into words.

The Art of Clean Language

In the early 1980’s, David Grove wondered what it would be like to fully preserve and honor a client’s experience with minimal interference. He achieved this by identifying a number of very simple questions with a particular syntax and a unique delivery method. He discovered that the more he used Clean Language, the more clients naturally used metaphor to describe their symptoms. When Clean Language questions were then directed to the metaphors and symbols, unexpected information became available to the client, often with profound results. He found that the less he attempted to change the client’s model of the world, the more they experienced their own core patterns, and organic, lasting changes naturally emerged from ‘the system’. By interfering with a client’s description of their symptoms, Grove asserts that well-meaning clinicians can rob clients of the very experience needed to resolve their unwanted behaviors.

Information-Centered

The aim of Metaphor Counseling [See CBT#37] is for the client to gather information about his/her own subjective experience, not necessarily for the clinician to understand it. Attempting to understand the client’s experience is replaced with tracking the inherent symbolic process and structure.

The counselor asks questions on behalf of the information sources, staying strictly within the metaphor or the client’s ‘inner symbolism’ instead of their ‘inner logic’. Thus, this process is not client-centered, it is information-centered.

The reason that clean language is so valuable is that we seem to be biologically programmed to attempt to make sense of whatever another person communicates. For example, when we are asked a question we have to “mentally do” whatever is asked before we can answer. To do this we have to presuppose or infer much more information than is given in the ‘surface structure’ of the question. When another person makes even minute changes to a client’s words the implications can be significant. Clients often have to go through additional translation processes and mental gymnastics to reorient themselves to the other’s presuppositions. Thus, the process subtly goes in a direction determined by the counselor’s map of the world.

In Clean Language, the clinician aims to ask the question the client’s information suggests to be asked. Each response is then utilized by the counselor in the next question. Thus, the counselor follows the natural direction of the process rather than leads it.

METAPHORS:

• are generated entirely from within the client’s experience
• are represented as an internal construct within Visual, Auditory and Kinesthetic (VAK) modalities and submodalities
• are coded with symbolic attributes that are containers of meaning and significance for the client

For example, if a client says “I keep running up against a brick wall”, then the attributes of that wall (how high, how long, how many bricks, what the bricks are made out of, etc.) will be highly significant and correlate with the characteristics of the presenting problem. In addition, the location of the wall in relation to the speaker, the direction of their run, and the sequence of events within the metaphor will also be part of the inherent structure that keeps the behavior repeating or, as Grove calls it, the replicating mechanism.

Grovian metaphors are idiosyncratic and very personal to the client, and, require no interpretation by either the clinician or the client. ‘Real’ memories and imagined memories are treated the same within the Metaphor Model. It’s the symbolic meaning of their representations that is important, not whether they really happened. People cannot produce images, sounds and feelings that have no symbolic meaning – even if they try! Often the more a client is surprised by their own metaphors, the more valuable the information embedded in the symbols.

For this process to be successful, it is not important to have any idea whatsoever of the meaning of these symbols, only that they were deeply significant for the client. The Metaphor Model can work without the client describing real events. You may notice how valuable this can be for people who have suffered ‘unspeakable’ trauma.

For this intervention and all interventions that are used to work cognitively with a client, it is vital that the counselor work within the client’s sphere of thoughts; his/her inner logic or inner symbolism. While the following two interventions do not specifically detail this aspect, it must be held as a principle of the intervention that the information the client is conveying is true to them, and we will never be able to understand that truth, until we understand the logic behind that belief. If a client says that “There are spiders falling down from the ceiling” – the counselor cannot deny that this is true. The counselor must ask more about the spiders and the ceiling in order to understand what the belief system really is. A client who ‘hears voices’ cannot be denied. Tell me about the voices. How do you know that it is God? Would God do these things? Is the beginning of an inner logic dialogue which the client has the resources to work through if we allow him or her to use those resources.

DIALECTIC BEHAVIOR COUNSELING [See CBT#38]

In the late 1970s, Marsha M. Linehan (1993) attempted to apply standard Cognitive Behavior Therapy to the problems of adult women with histories of chronic suicide attempts, suicidal ideation, urges to self-harm, and self-mutilation. Three concerns were particularly troublesome:

1. Clients found the unrelenting focus on change invalidating. Clients responded by withdrawing from engagement, by becoming angry, or by vacillating between the two. This resulted in a high drop-out rate.
2. Clients unintentionally reinforced their counselors for ineffective intervention while punishing their counselors for effective services. In other words, counselors were unwittingly under the control of consequences outside their awareness. For example, the research team noticed through its review of audiotaped sessions that counselors would ‘back off’ pushing for change of behavior when the client’s response was one of anger, or emotional withdrawal, or shame, or threatened self-harm. Similarly, clients would reward the counselor with interpersonal warmth or engagement if the counselor allowed them to change the topic of the session from one they didn’t want to discuss to one they did want to discuss.
3. The sheer volume and severity of problems presented by clients made it impossible to use the standard format. Individual counselors simply did not have time to address both the problems presented by clients – suicide attempts, urges to self-harm, urges to quit treatment, noncompliance with homework assignments, untreated depression, anxiety disorders, etc, — AND have session time devoted to helping the client learn and apply more adaptive skills.

Adding Validation and Dialectics

In response to these key problems, Linehan and her research team made significant modifications. They added in new types of strategies and reformulated the structure of the intervention. In the case of new strategies, Acceptance-based interventions, frequently referred to as validation strategies, were added. Adding these communicated to the clients that they were both acceptable as they were and that their behaviors, including those that were self-harming, made real sense in some way.

Further, counselors learned to highlight for clients when the client’s thoughts, feelings and behaviors were “perfectly normal”, helping clients discover that they had sound judgment and that they were capable of learning how and when to trust themselves. The new emphasis on acceptance did not occur to the exclusion of the emphasis on change: clients also must change if they want to build a life worth living. Thus, the focus on acceptance did not occur to the exclusion of change based strategies; rather, the two enhanced the use of one another.

In the course of weaving in acceptance with change, Linehan noticed that a third set of strategies – dialectics – came into play. Dialectical strategies gave the counselor a means to balance acceptance and change in each session and served to prevent both counselor and client from becoming stuck in the rigid thoughts, feelings, and behaviors that can occur when emotions run high, as they often do in the services of clients with severe and persistent problems in living. Dialectical strategies and a dialectical world view, with its emphasis on holism and synthesis, enable the counselor to blend acceptance and change in a manner that results in movement, speed, and flow in individual sessions and across the entire process.

Restructuring the Services

As noted above, very significant changes were also made to the structure of the intervention protocol and philosophy in order to solve the problems encountered in the standard application. Below we discuss how DBT is organized by Functions and Modes and by Stages and Targets.

Functions and Modes.

Briefly, Linehan hypothesizes that any comprehensive service must meet five critical functions. It must:

• enhance and maintain the client’s motivation to change
• enhance the client’s capabilities
• ensure that the client’s new capabilities are generalized to all relevant environments
• enhance the counselor’s motivation to treat clients while also enhancing the counselor’s capabilities
• structure the environment so that treatment can take place

It is typically the individual counselor who maintains the client’s motivation for services, since the individual counselor is the most salient individual for the client. Skills are acquired, strengthened, and generalized through the combination of

• skills groups
• phone coaching (clients are instructed to call counselors for coaching prior to engaging in self harm)
• in vivo coaching
• homework assignments

Counselors’ capabilities are enhanced and burnout prevented through weekly consultation team meetings.

Stages and Targets.

DBT also organizes the process into stages and targets and, with very few exceptions, adheres strictly to the order in which problems are addressed. The organization into stages and targets prevents the counselor from week after week, addressing the crisis of the moment. Further, it has a logical progression that:

• first addresses behaviors that could lead to the client’s death
  then behaviors that could lead to premature termination
• to behaviors that destroy the quality of life
• to the need for alternative skills

In other words,

• the first goal is to ensure the client stays alive
• so that the second goal (staying in service)
• results in meeting the third goal (building a better quality of life)
• partly through the acquisition of new behaviors (skills)

We have just described the targets found in Stage I. To repeat, the first stage of treatment focuses, in order, on decreasing life threatening behaviors, behaviors that interfere with continuing service, quality of life threatening behaviors and increasing skills that will replace ineffective coping behaviors. The goal of Stage I is for the client to move from behavioral dyscontrol to behavioral control so that there is a normal life expectancy.

In Stage II, DBT addresses the client’s inhibited emotional experiencing. It is thought that the client’s behavior is now under control but the client is suffering “in silence”. The goal of Stage II is to help the client move from a state of quiet desperation to one of full emotional experiencing.

Stage III focuses on problems in living, with the goal being that the client has a life of ordinary happiness and unhappiness.

Stage IV is specifically for those clients for whom a life of ordinary happiness and unhappiness fails to meet a further goal of spiritual fulfillment or a sense of connectedness of a greater whole. In this stage, the goal is for the client to move from a sense of incompleteness toward a life that involves an ongoing capacity for experiences of joy and freedom.

Modes Of Service Delivery

There are four primary modes of service provided:

1. Individual counseling
2. Group skills training
3. Telephone contact
4. Consultation

While keeping within the overall model, group work and other modes of intervention may be added at the discretion of the counselor, providing the targets for that mode are clear and prioritized.

The individual counselor is the primary counselor. The main work is carried out in the individual sessions.

Between sessions the client should be offered telephone contact with the counselor including out of hours telephone contact. Each counselor has the right to set clear limits on such contact and the purpose of telephone contact is also quite clearly defined. In particular, telephone contact is not for the purpose of counseling. Rather it is to give the client help and support in applying the skills that s/he is learning to real life situations between sessions and to help him/her find ways of avoiding self-injury. Calls are also accepted for the purpose of relationship repair where the client believes that s/he has damaged the relationship with the counselor and wants to put this right before the next session. Calls after the client has injured him/herself are not acceptable and, after ensuring his/her immediate safety, no further calls are allowed for the next twenty four hours. This is to avoid reinforcing self-injury.

Intervention Strategies

Within the framework of stages, target hierarchies and modes a wide variety of intervention protocols and specific techniques can be applied.

The core strategies are ‘validation’ and ‘problem solving’. Attempts to facilitate change are surrounded by interventions that validate the client’s behavior and responses as understandable in relation to his/her current life situation, and that show an understanding of the difficulties and suffering.

Problem solving focuses on the establishment of necessary skills. Having the skills, s/he may be prevented from using them in particular situations either because of environmental factors or because of emotional or cognitive problems getting in the way. To deal with these difficulties the following techniques may be applied in the course of counseling:

1. Contingency management
2. Cognitive Process Correction
3. Exposure based interventions

The principles of using these techniques are precisely those applying to their use in other contexts and will not be described in any detail. However, they are used in a relatively informal way and interwoven into the service delivery.

Problem solving and change strategies are again balanced dialectically by the use of validation strategies. It is important at every stage to convey to the client that his/her behavior, including thoughts, feelings and actions are understandable, even though they may be maladaptive or unhelpful.

Significant instances of targeted maladaptive behavior occurring since the last session (which should have been recorded on the daily card) are initially dealt with by carrying out a detailed ‘behavioral analysis’.

In the course of a typical behavioral analysis, a particular instance of behavior is first clearly defined in specific terms and then a ‘chain analysis’ is conducted, looking in detail at the sequence of events and attempting to link these events one to another. In the course of this process, hypotheses are generated about the factors that may be controlling the behavior. This is followed by, or interwoven with, a ‘solution analysis’ in which alternative ways of dealing with the situation at each stage are considered and evaluated. Finally, one solution should be chosen for future implementation.

A particular approach is taken in dealing with the network of people with whom the client is involved personally and professionally. These are referred to as ‘case management strategies’. The basic idea is that the client should be encouraged, with appropriate help and support, to deal with his/her own problems in the environment in which they occur. Therefore, as far as possible, the counselor does not do things for the client but encourages the client to do things for him/herself.

SUMMARY AND CONCLUSIONS

Dialectical Behavior Counseling is a comprehensive compendium of service built on a formal model. The service is clearly structured in stages and at each stage a clear hierarchy of targets is defined. The techniques used are extensive and varied, addressing essentially every aspect of service and they are underpinned by a dialectical philosophy that recommends a balanced, flexible and systemic approach to the work of counseling. Techniques for achieving change are balanced by techniques of acceptance. The client is helped to understand his/her problem behaviors and then deal with situations more effectively. S/he is taught the necessary skills to enable him/her to do so and helped to deal with any problems that s/he may have in applying them in his/her natural environment. Generalization is not assumed but encouraged directly. Advice and support is available between sessions and the client is encouraged and helped to take responsibility for dealing with life’s challenges.

The strength of the process is its thorough delineation of the structure and philosophy of a comprehensive service delivery process, and it is strongly recommended that any program of cognitive restructuring look closely at how best to use these structural and philosophical elements. The weaknesses include the failure to work with the members of the ecosystem, particularly if you plan to do this work with children. However, it must be noted that the design was specifically created and carried out with adults. For working with children and adolescents, we are specifically concerned about providing social learning family interventions, which we will discuss later. We might also hope that the service delivery would include more imagery based techniques to help clients address the unsayable aspects of their experiences. Even with these deficits, the model provides for a comprehensive restructuring of the way the clients think about themselves, in particular, and other people, at least to the extent of the clinical staff.

This process may also be enhanced by the inclusion and use of the conceptual structures that help people understand, interpret, and remember incoming information. These conceptual structures are based on schema theory, which lays out a picture of how people organize the truly astounding amount of background knowledge which they accumulate about the world. This theory asserts that such knowledge is organized into mental units called ‘schema’. When people learn, when they build knowledge, they are either creating new schemata, or linking together preexisting schemata in new ways. Most of the schemata which people develop are idiosyncratic. Everyone has different experiences, so everyone develops a somewhat different view of the world and their place in it. However, we also share many common experiences. Most Americans have seen a baseball game, know who the President is, and have eaten at McDonald’s. So, many of the schemata which people develop are shared, others have developed them as well. Shared schemata constitute an important part of our shared cultural knowledge.

All human beings possess categorical rules or scripts that they use to interpret the world. New information is processed according to how it fits into these schematic rules. Information that does not fit into these schema may not be comprehended, or may not be comprehended correctly.

Most schema theorists postulate that there is not just one body of knowledge available to learners at any given stage of development, but rather a network on context-specific bodies of knowledge that learners apply to specific situations.

Situation-specific schema helps to explain the difference between expert and novice interpretation of knowledge; experts, with more complex developed schema in a particular subject area can function better in any given domain than a novice with no schema or an inadequate schema to help them interpret and react to new information. Since these schemata are context specific, they are dependent on an individual’s experience with and exposure to a subject area rather than simply “raw intelligence.”

The way that learners acquire knowledge under schema theory is quite similar to Piaget’s model of the process of development. In essence, there are three different reactions that a learner can have to new information: accretation, tuning, and restructuring. In accretation, learners take the new input and assimilate it into their existing schema without making any changes to the overall schema. Tuning is when learners realize that their existing schema is inadequate for the new knowledge and modify their existing schema accordingly. Restructuring is the process of creating a new schema by addressing the inconsistencies between the old schema and the newly acquired information.

An important aspect of the organization of schemata is that simpler schemata can be “embedded” within more complex schemata. Or, to put it another way, schemata can be hierarchically structured. The most idiosyncratic of the schemata are those that are most personal: schema about self and others. And the expectations that such thoughts engender. It is these schemata and the distortion of the hierarchy of thoughts that make up these schema which are the subject of schema focused cognitive counseling.

Gregory Bateson has identified the issue of context in an interesting way that may help us characterize schema. He examines the concept of ‘play’ and notes that play as a label does not limit or define the acts that make up play. Play is applicable only to certain broad premises of the interchange. In ordinary parlance, ‘play’ is not the name of an act or action; it is the name of a frame for action. What is characteristic of ‘play’ is that this is a name for contexts in which the constituent acts have a different sort of relevance and organization from that which they would have had in non-play. It may even be that the essence of play lies in a partial denial of the meaning that the actions would have had in other situations.

The difficulty of terms such as ‘play’, ‘crime’, or ‘explore’ is that they are the name of a way of organizing action and that a change in an individual act will not change the nature of the context. In this same way, the personal schema – the schema that defines the personality of the individual is a way of organizing actions. At any given time, the act may be legitimate, but it is interpreted ‘in context’ – in the same manner that a nondescript act interpreted as ‘play’ can suddenly cause laughter and fun.

The lateness of a friend can now be interpreted ‘in the context’ of abandonment and has an entirely different meaning than if it is interpreted as lateness. The emotional charge is entirely different as is the nature of change.

Bateson discusses the difficulty of change as he considers the nature of the concept of ‘crime’.

We act as if crime could be extinguished by punishing parts of what we regard as criminal action, as if ‘crime’ were the name of a sort of action or of part of a sort of action. More correctly ‘crime’ like ‘exploration’, is the name of a way of organizing action. It is, therefore, unlikely that punishing the act will extinguish the crime.

…There is a very profound difference between a serious attempt to change the characterological state of an organism and trying to change that organism’s particular actions. The latter is relatively easy; the former, profoundly difficult.

Thus we can change the acts [thoughts, feelings and behavior] of an early maladaptive schema through cognitive process correction but we have not changed the characterological state of the organism. This will require a much more stringent regimen of cognitive reconstruction.

SCHEMA FOCUSED COGNITIVE COUNSELING [See CBT#39]

This is an approach developed by Dr. Jeff Young, who originally worked closely with Dr. Aaron Beck, founder of Cognitive Counseling. Dr. Young and his colleagues found a segment of people who had difficulty in benefiting from the standard approach – people typically with long-standing patterns or themes in thinking and feeling – and consequently in behaving or coping – that required an expanded means of intervention. Dr. Young’s attention turned to ways of helping these clients to address and modify these deeper patterns or themes, also known as “schemata”. Schematic knowledge is vital to the growth, development and functioning of human beings. However, like all human knowledge, there are some schema that are distressing.

The schemata that are targeted by schema focused counseling are those enduring and self-defeating patterns that typically begin early in life under invalidating circumstances. These patterns consist of negative/ dysfunctional thoughts, feelings and behaviors, have been repeated and elaborated upon, and pose obstacles for accomplishing one’s goals and getting one’s needs met. Some automatic thought examples of thematic beliefs are: “I’m unlovable,” “I’m a failure,” “People don’t care about me,” “I’m not important,” “Something bad is going to happen,” “People will leave me,” “I will never get my needs met,” “I will never be good enough,” and so on. These thoughts and beliefs are usually supported imaginally through metaphor and other symbols.

Eighteen [18] early maladaptive schemata have been identified through clinical observation. Like the list of cognitive errors used in cognitive process correction, they provide a model to watch for although individual clients may group their thoughts differently. These include:

Emotional Deprivation Abandonment
Mistrust/Abuse Defectiveness
Social Isolation Vulnerability
Dependence/Incompetence Enmeshment/Undeveloped Self
Failure Subjugation
Self-Sacrifice Approval-Seeking/Recognition-Seeking
Emotional Inhibition Negativity/Pessimism
Unrelenting Standards Punitiveness
Entitlement/Grandiosity
Insufficient Self-Control/Self-Discipline

One could easily expect that the clients being served by the Linehan model could be identified as having one or more of these maladaptive schema. In fact, it is the intertwining of the emotionally laden schema that makes them so difficult to deal with. Consider the following thought process:

Thought Schema

I failed the test. Incompetence
I fail Failure
I always fail Failure/Negativity/Pessimism
I never succeed Negativity/Pessimism
I just don’t have what it takes Incompetence
I’m worthless Defectiveness

This is more than a habituated thought, it is an habituated thought process covering many areas of life. If one is to seek evidence and dispute one element, the next one is likely to take over. Thus, the process requires time and patience to address all of the areas of the chain of thinking that has been honed over a long period of time, and may not even touch the part of the mind that imagines incompetence, failure, pessimism and defectiveness, but cannot say it.

An Early Maladaptive Schema [EMS] has been defined as ‘a broad pervasive theme or pattern regarding oneself and one’s relationship with others, developed during childhood and elaborated throughout one’s lifetime, and dysfunctional to a significant degree’.

Therefore EMS began with something that was done to the child or perceived by the child to be done, by the family or by other children, which damaged them in some way. S/he might have been abandoned, criticized, overprotected, emotionally or physically abused, excluded or deprived and, consequently, the thematic thoughts can becomes part of the schema.

Long after leaving home, the person with EMS continues to create situations in which they are mistreated, ignored, put down or controlled and in which we fail to reach desired goals.

Schemata are perpetuated throughout one’s lifetime and become activated under conditions relevant to the particular domain.

Changing early maladaptive schemata

It is important to realize that schemata can be functional or dysfunctional and are core cognitive constructs in what is typically referred to as our personality style. Even when presented with evidence that disproves the schema, individuals distort data to maintain its validity. To indicate the impact of a schema on one’s ability to respond, imagine sitting down in a restaurant and being handed a menu by a waitperson who then asks “whether you would rather sing?”. Such an experience would be disconcerting to most people. In fact, the usual response would be ‘What?’ – for you may not even be able to hear the words since they do not fit into the core of the schema. Your schema, therefore, have a powerful influence not only on how you behave, but on what you perceive.

The most dominant early maladaptive schemata are the ones developed in the preverbal stage. It is these preverbal schemata that tend to be entrenched and absolute, while the later ones tend to be conditional.¬ Most important to this entrenchment is the fact that the preverbal encoding is symbolic rather than logical, making identifying it cognitively and acting on it consciously much more difficult. This may make it more resistant to cognitive process correction and other approaches. Such embedded schema are self perpetuating, very resistant to change and usually do not change without specific and lengthy input.

One major effort is to help the person become mindful of his/her thinking, emotions and behavior. Mindfulness is a term which implies an ability to separate oneself in one’s mind and to observe oneself in thought, word and deed. Western culture may be familiar with the construct of Adam Smith, eighteenth century Scottish philosopher, who developed the concept of the ‘impartial and well-informed spectator’. He defined the impartial spectator as the capacity to stand outside yourself and watch yourself in action, which is essentially the same mental action as the ancient Buddhist concept of mindful awareness.

Trying to observe your own thoughts, feelings and behavior as if you were observing the experiences of another person implies a degree of dissociation to a second person level. As in the use of metaperception, this ‘step back’ allows for a diminishment of emotional involvement. The person is then able to observe him/herself in highly emotional situations without becoming infected by the emotions. The idea is neither to suppress emotions nor to act upon them, but simply to be aware and acknowledge them. A mindful person focuses on the process of awareness without getting caught up in the content of awareness.

Bennett-Goleman suggests that there are two dimensions to mindfulness: the calming aspect and the investigatory aspect. The calming approach would be to say to yourself the moment you have the distressing thought: I know what this is and how I respond to it. The investigative approach allows you to notice how you emotionally judge and compare while you are doing it. With an observing awareness, you notice how you are being affected – while not getting pulled deeper into the reaction or its story line. You see the process as a learning opportunity. Bennett-Golman reports that Nyanaponika Thera in The Power of Mindfulness offers a rule of thumb for being mindful of varying intensities of our inner turbulence: put the least effort into dealing with a disturbing feeling that will do the job. A brief act of noticing the distressing thoughts and feelings, just an acknowledgement, like an inner nod – can sometimes suffice.

Investigating schema in this way can lead to a more precise understanding of these effects. Among the psychological understandings to be gained are a sense of what triggers your responses, a recognition of the emotional patterns that go with it and hold it in place, and memories of early event in life that may have shaped or given rise to the schema. This extension of mindful investigation may help a client sustain a clearer awareness in situations that otherwise might be more disturbing.

Unlike metaperception as normally used in cognitive behavior management, mindfulness, has a notion of continuity. In the best of circumstances, the mind’s eye is always open and watching one’s own internal performance. One become habituated to observing oneself impartially. This is never more important than when one is in crisis.

Bennett-Goleman reports that Buddhist psychology distinguishes among several varieties of suffering, and she includes schemata in the category of suffering due to conditioning and learned habits. She also outlines the Four Noble Truths which describe how we experience suffering and how it can end.

The first of these truths is simply to recognize our suffering, which is what we do when we acknowledge and accept our schemata. This acceptance is a critical feature of change, for not only does the person need validation that what they are feeling is real, they need to affirm this aspect of themselves. Upon validating themselves in this way, they then, and only then, can be prepared to change.

The second truth is the cause of our suffering. This is the process of bringing the schema into cognitive space either through imagery or psychoeducation and identifying the distress that is the outcome and the elements of thinking, feeling and behaving that we would like to change.

The third truth, she reports, is that we can free ourselves from suffering by becoming mindfully aware of how these schema operate and by challenging them.

Finally, the fourth truth provides the details of the path to nonsuffering and, for our purposes would include the reconstruction of the schema to include a balanced and rational frame of reference as well as thought.

When one talks about making any changes in emotion laden behavior, mindfulness become a necessary component in the maintenance of that change. From the beginning of the five step process, as the subject becomes aware that s/he is experiencing distressing thoughts and emotions which are driving behavior, there is a need to help the subject practice ‘mindfulness’; first, in absorbing deeply the emotions without responding to them, and then to mentally attend to the diminishment of emotional content. The process of attendance is not just the keeping of journals or doing homework, but of being mindful enough to catch the thoughts and emotions as they are happening and being able to comment on them in an impartial way.

The Schema Focused model is designed to help people break these maladaptive coping styles which perpetuate negative patterns of thinking, feeling and behaving, so that individuals can get their core needs met. The process continues on the awareness, attendance, analysis, alternative and adaptation process, but is not limited to single thought phrases, but expands to cover themes. By switching between past events and current problems, using imagery and role playing, higher levels of affect are activated. Using Interactive Imagery the client is helped to talk to his inner child as s/he experiences early life as remembered, comforts the child, changing the submodalities, and finding alternative meanings in the experience. [Along with CBT#22 Six Step Reframing, See CBT#14 Testing Core Beliefs and CBT#15 Changing Core Beliefs with Visualization]

As a psychoeducational process to enable cognitive change, clients are helped to understand conceptually where the dysfunctional schema originated and how it is being maintained. However, because insight rarely leads to change, schema-focused counseling utilizes cognitive, behavioral and interpersonal techniques including empathetic reality testing, whereby, the counselor fully acknowledges and validates distressing feelings and beliefs, while pointing out another more balanced and rational view.

This process serves to challenge and modify negative thoughts and behaviors, which are rigidly intact.

Schema focused counseling deals with life patterns rather than current situations, which have arisen. It is this aspect that requires a Cognitive Restructuring approach.

Since schema have the tendency to group into patterns, the eighteen [18] identified early maladaptive schemata have been organized into five themes known as domains. Each of the five domains contain categories of schemata which represent an important component of a child’s core needs. When these needs are not met negative schemata may develop, resulting in unhealthy life patterns:¬

Domain I: DISCONNECTION & REJECTION

Schemata in this domain result from early experiences of a detached, explosive, unpredictable, or abusive family environment. People with these schemata expect that their needs for security, safety, stability, nurturence, and empathy in intimate or family relationships will not be met in a consistent or predictable way.

Abandonment/Instability

This schema refers to the expectation that one will soon lose anyone with whom an emotional attachment is formed. The person believes that one way or another close relationships will end imminently. This schema usually occurs when the parent has been inconsistent in meeting the¬ child’s needs.

Mistrust

This schema refers to the expectation that others will intentionally take advantage in some way. People with this schema expect others to hurt, cheat, or put them down.

Often significant others were abusive emotionally or sexually and betrayed the child’s trust.

Emotional Deprivation

This schema refers to the belief that others will never meet one’s primary emotional needs.

These needs include nurturance, empathy, affection, protection, guidance and caring from others. Often significant others were emotionally depriving to the child.

Social Isolation/ Alienation

This schema refers to the belief that one is isolated from the world, different from others, and/or not part of any community. This belief is usually caused by experiences in which children see that either they, or their families, are different from other people.

Defectiveness/ Shame

This schema refers to the belief that one is internally flawed, and that, if others get close, they will realize this and withdraw from the relationship. This feeling of being flawed and inadequate often leads to a strong sense of shame. Generally, parents were very critical of their children and made them feel not worthy of being loved.

Social Undesirability

This schema refers to the belief that one is outwardly unattractive to others. People with this schema see themselves as physically unattractive, socially inept, or lacking in status. Usually there is a direct link to childhood experiences in which children are made to feel, by family or peers, that they are not attractive.

Failure to Achieve

This schema refers to the belief that one is incapable of performing as well as one’s peers in areas such as career, school, or sports. These clients may feel stupid, inept, untalented, or ignorant. People with this schema often do not try to achieve, because they believe that they will fail. This schema may develop if children are put down and treated as if they are a failure in school or other spheres of accomplishment. Usually the parents did not give enough support, discipline, and encouragement for the child to persist and succeed in areas of achievement such as schoolwork or sports.

Domain II: IMPAIRED AUTONOMY & PERFORMANCE

Schemata in this domain have to do with expectations about oneself and the environment that interfere with one’s ability to separate and function independently and one’ s perceived ability to survive alone. The typical family of origin is enmeshed, undermining of the child’s judgement, or overprotective.

Dependence/Incompetence

This schema refers to the belief that one is not capable of handling day-to-day responsibilities competently and independently. People with this schema often rely excessively on others for help in areas such as decision making and initiating new tasks. Usually parents did not encourage these children to act independently and develop confidence in their ability to take care of themselves.

Vulnerability to Harm and Illness

This schema refers to the belief that one is always on the verge of experiencing a major catastrophe (financial, natural, medical, criminal, etc.). It may lead to taking excessive precautions to protect oneself. Usually there was an extremely fearful parent who passed on the idea that the world is a dangerous place.

Enmeshment/Undeveloped Self

This schema refers to the sense that one has too little individual identity or inner direction. There is often a feeling of emptiness or of floundering. This theme is usually developed from parents who are so controlling; abusive, or overprotective that the child is discouraged from developing a separate sense of self.

Failure

This schema refers to the belief that one has failed, will fail, or is fundamentally inadequate compared to others. Parents, who did not give enough support, expected the child to fail, treated him/her as stupid and/or never taught the child the discipline to succeed, usually cause this belief.

Domain III: IMPAIRED LIMITS

Schemata in this domain relate to deficiencies in internal limits, respect and responsibility to others, or meeting realistic personal goals. The typical family origin is permissiveness and indulgence.

Entitlement/Self-Centeredness

This schema refers to the belief that you should be able to do, say, or have whatever you want immediately, regardless of whether that hurts others or seems unreasonable to them. You are not interested in what other people need, nor are you aware of the long-term costs to you of alienating others. Parents who overindulge their children and who do not set limits about what is socially appropriate, may promote the development of this schema. Alternatively, some children develop this schema to compensate for feelings of emotional deprivation, defectiveness, or social undesirability.

Insufficient Self-Control/Self-Discipline (Low Frustration Tolerance)

This schema refers to the inability to tolerate any frustration in reaching one’s goals, as well as an inability to restrain expression of one’s impulses or feelings. When lack of self-control is extreme, criminal, or addictive behavior rule your life. Parents who did not model self-control, or who did not adequately discipline their children, may predispose them to have this schema as adults.

Domain IV: OTHER-DIRECTNESS

Schemata in this domain relate to an excessive focus on meeting the needs of others, at the expense of one’s own needs. The typical family origin is based on conditional acceptance, whereby children suppress normal needs and emotions in order to gain attention, approval and love.

Subjugation

This schema refers to the belief that one must submit to the control of others in order to avoid negative consequences. Often these clients fear that, unless they submit, others will get angry or reject them. Clients who subjugate ignore their own desires and feelings. In childhood there was generally a very controlling parent.

Self-Sacrifice

This schema refers to the excessive sacrifice of one’s own needs in order to help others. When these clients pay attention to their own needs, they often feel guilty. To avoid this guilt, they put others’ needs ahead of their own. Often people who self-sacrifice gain a feeling of increased self-esteem or a sense of meaning from helping others. In childhood the person may have been made to feel overly responsible for the well being of one or both parents.

Approval-Seeking

This schema refers to an excessive emphasis on gaining approval and recognition from others at the expense of one’s own ideas. This may involve an overemphasis on status, money, and achievement.

Usually parents who were concerned with social status, appearance by others, or offered conditional acceptance, etc., influenced this belief.

Domain V: OVERVIGILANCE & INHIBITION

Schemata in this domain involve an excessive focus on controlling, suppressing, or ignoring of one’s emotions and spontaneous feelings in order to avoid making mistakes, or meeting rigid internalized rules. Typical family origins are domination and suppression of feelings, or a bleak environment where performance standards and self-control take priority over pleasure and playfulness

Negativity/Vulnerability to Error

This schema refers to an exaggerated expectation that things will go wrong at any moment, an inordinate fear of making mistakes that could lead in that direction. “That which can go wrong, will!” This may involve financial loss, humiliation, making mistakes leading to excessive worrying. Parents were pessimistic, worried, or expected the worst outcome.

Overcontrol/Emotional Inhibition

This schema refers to the belief that you must inhibit emotions and impulses, especially anger, because any expression of feelings would harm others, or lead to loss of self-esteem, embarrassment, retaliation, or abandonment. You may lack spontaneity, or be viewed as uptight. Usually parents discourage the expression of feelings often bring on this schema.

Unrelenting Standards/Hypercriticalness

This schema refers to two related beliefs. Either you believe that whatever you do is not good enough, that you must always strive harder; and/or there is excessive emphasis on values such as status, wealth, and power, at the expense of other values such as social interaction, health, or happiness. Usually these clients’ parents were never satisfied and gave their children love that was conditional on outstanding achievement.

Punitiveness

This schema refers to the belief that one must be angry and harshly punishing with those people (including oneself) who do not meet one’s (high) expectations or standards. Usually, these parents blamed, punished, or were verbally abusive when mistakes were made.

We must remind the reader that individual children may not group any of these schema into these domains. The development of ‘chunks’ of knowledge is an idiosyncratic process based on random experiences. One should not try to ‘fit’ a child into a category. On the other hand, it is reasonable to look for other maladaptive schema in these domains to check areas for concern.

SUMMARY & CONCLUSIONS

If one examines the functional distortions outlined in this material, we would obtain a list something like the following:

• suicide attempts
• suicidal ideation
• parasuicidal behavior [self mutilation]
• urges to self harm
• avoidance of confrontation of problems: resulting in confrontations of counselors, failure to complete homework and or dropping out of the service
• distancing
• denial
• clinging
• sadness
• anxiety
• invalidation [nonpersonhood] – identifiable sense that perceptions and emotions are not appropriate; impaired judgement in many areas; emotional inhibition; and self-invalidation
• rigid thoughts, feelings and behaviors – escalated in intense situations
• ambivalence to change
• lack of connectedness; detachment
• blaming others; projection
• feeling bad about feeling bad
• perennial victim
• shame and/or anger for failure to meet goals
• inhibited grieving
• perennial search for constancy
• rage of innocence
• protest
• hopelessness
• active passivity – finding others to solve your problems
• quest for meaning of life
• extreme mood dependence
• lack of interpersonal skills
• lack of emotional modulation
• lack of distress tolerance
• lack of problem solving skills
• frequent psychiatric hospital admissions

These characteristics along with the specific early maladaptive schema are obviously not limited only to people identified as having personality disorders. Many children with serious and persistent problems in living could reasonably be identified as having many of these functional problems, even if no diagnosis exists which identifies a personality disorder.

The content of the protocol

It is our contention that many of these children could benefit from a protocol which includes:

• the use of the philosophy, structure, focus and range of interventions of dialectical behavior counseling
• the content of schema focused cognitive counseling
• the use of interactive and metaperceptive imagery techniques
• the provision of social learning family intervention strategies

Cognitive Restructuring is a deeper and more intense level of counseling that deals with core beliefs which are usually arranged schematically in the person’s mind. As the domains indicate, several themes can intertwine to create the inner logic and inner symbolism of the client. When this logic and symbolism are distorted, many different kinds of problems in living are likely to occur. Since we are primarily concerned with children, it would seem important to identify some of these trends early even though a diagnosis may not be appropriate. Since the EMS that are created in preverbal childhood are most personal and pervasive, it should not be difficult to expect that assessments done in schools could identify traces of difficulty and proceed to respond quickly and effectively.

There is little clarity as to the length of time required for children whose EMS are not as entrenched as adults, but may be operationally more intense, since they may still be dealing with ongoing nurturance issues. When dealing with conduct disorders, which are considered a chronic problem in living and which require intensive work with the family and school, a year is not an unlikely expectation. Therefore, one might expect to shape the services for twelve [12] months and then evaluate to determine further responsibility.

Social learning family intervention

We are concerned with supplying a full range of services for the child, which may include individual and group counseling and skill building sessions for the child and other services for the parents and teachers. In CBP#07 – Conduct Disorders, we outline the issues concerning family. We indicate there that in a comprehensive review of research on intervention for childhood aggressive and antisocial behavior, Kazdin [1987] identified structured family intervention based on behavioral social learning principles as the most promising approach tested. The central assumption behind this approach is that conduct disorder is acquired and maintained primarily through social learning processes in the family. As Lineham, Young and Bateson, et al., have contended, this is also true for people with severe and persistent problems as well.

An ecological approach to family intervention goes beyond intra-familial or intra-individual factors and views maladjustment as a problem across entire ecosystems [Haley, 1973]. The aim is to change transactions within and between all pertinent environmental systems that serve to maintain, or to be maintained by, a child’s deviant behaviors. Multimodal intervention is directed at four ecological domains:

• individual adjustment factors
• interactions in the family
• extrafamilial systems- connections among micro systems such as home, school and neighborhood
• cultural community systems – includes values, laws and customs [Miller & Prinz, 1990]

A child develops within a complex system of relationships affected by multiple levels of the surrounding environment. Further, it is clear that these various influences have differing levels of influence at different points of development. While the family has the earliest and most profound effect on the emerging person, there are really several interrelated affectional systems that influence [shape] and maintain [reinforce] behavior. These include the mother-infant affectional system that is sustained or terminated in varying degrees and include the onset of father affection and the age group or peer affectional system that concludes with the heterosexual affectional system. Holistic perspectives may be helpful in creative design of corrective interventions.

As the person with early maladaptive schema proceeds through childhood, s/he is likely to attract adverse responses and potential isolation from others. Intervention at an early stage can help these children to grow into productive citizens.

REFERENCES:

Allmon, D., Armstrong, H. E., Heard, H. L., Linehan, M. M., &.Suarez, A. (1991). Cognitive-Behavioral Treatment of Chronically Parasuicidal Borderline Patients. Archives of General Psychiatry, 48, 1060-1064.

Bennett-Goleman, T., Emotional Alchemy: How the Mind Can Heal the Heart, Harmony Books, New York, 2001.

Bateson, Gregory, Mind And Nature: A Necessary Unity, 1979.

Bateson, Gregory, Steps to an Ecology of Mind.

Conner, Mary, Understanding Borderline Personality Disorder, Department of Family Practice & Community Health, Issue 9, February 2000.

Gilovich, Thomas, How We Know What Isn’t So: The fallibility of human reason in everyday life, The Free Press, 1991.

Hofstadter, D., Fluid Concepts and Creative Analogies: Computer Models of the Fundamental Mechanisms of Thought, Basic Books, 1995.

Kiehn, Barry & Swales, Michaela, An Overview of Dialectical Behavior Counseling in the Treatment of Borderline Personality Disorder.

Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., Bishop, G. K., Butterfield, M. I., & Bastian, L. A. (2001). Efficacy of Dialectical Behavior Counseling in Women Veterans with
Borderline Personality Disorder. Behavior Counseling, 32, 371-390.

Linehan, M. M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.

Linehan, M. M., Schmidt, H., Dimeff, L. A., Kanter, J. W., Craft, J. C., Comtois, K. A., & Recknor, K. L. (1999). Dialectical Behavior Counseling for Patients with Borderline Personality Disorder and Drug-Dependence. American Journal on Addiction, 8, 279-292.

Linehan, M.M. (1993b) Skills Training Manual for Treating Borderline Personality Disorder. The Guilford Press, New York and London.

Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D. & Heard, H.L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.

Linehan, M.M., Heard, H.L. & Armstrong, H.E. (in press) Dialectical behavior counseling, with and without behavioral skills training, for chronically parasuicidal borderline patients.

Santoro, Joseph, The Angry Heart: An Interactive Self-Help Guide to Overcoming Borderline and Addictive Disorders, MJF Books, New York, 1997.

Stone, M.H. (1987) The course of borderline personality disorder. In Tasman, A., Hales, R.E. & Frances, A.J. (eds) American Psychiatric Press Review of Psychiatry. Washington DC; American Psychiatric Press inc. 8, 103-122.

Tompkins, P. & Lawley, J., Less is More … The Art of Clean Language, First published in Rapport Magazine, Issue 35, February 1997.

Tompkins, P. & Lawley, J., Meta, Milton and Metaphor: Models of Subjective Experience, First published in Rapport magazine, Issue 36, August 1996.

Verheul, R., Van Den Bosch, L. M. C., Koeter, M. W. J., De Ridder, M. A. J. , Stijnen, T., & Van Den Brink, W. (2003). Dialectical Behavior Counseling for Women with Borderline Personality Disorder, 12-month, Randomised Clinical Trial in The Netherlands. British Journal of Psychiatry, 182, 135-140.

Young, J. (1999) Cognitive counseling for personality disorders: A schema-focused approach. Professional Resource Press, Sarasota, FL.

Young, J. and Klosko, J. (1993) Reinventing your life: The breakthrough program to end negative behavior and feel great again.

Dialectical Behavior Counseling
http://www.behavioraltech.com/downloads/DBT_FAQ.pdf.
© 2003, Behavioral Tech, LLC [Sanderson, C.J.]