Professional Documents
Culture Documents
a cutting-edge evidence-based
framework for mental health pro-
fessionals seeking to more effect-
ively address the myriad interper-
sonal problems that individuals
seeking psychotherapy face in their
daily lives. It is the first book of its
type to bridge the more cognitive
notions of schemas with newer
mindfulness and acceptance-based
behavior therapies such as accept-
ance and commitment therapy. The
authors know both worlds intim-
ately, and offer a straightforward
approach that gets to the heart of
patterns of unhelpful interpersonal
behavior that ultimately damage
significant social bonds. The book is
full of practical exercises, work-
sheets, and even a full-length pro-
tocol outlining its use in either an
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CHAPTER 7: CONDUCTING
EXPOSURE WITH DEFUSION
CHAPTER 8: WORKING WITH SIX
KEY PROCESSES
Appendix A: Schema Questionnaire
Appendix B: Research Outcomes
Appendix C: Group Protocol (Written with
Koke Saavedra)
References
Foreword
Inflexible
Patterns of maladaptive coping behaviors
in relationships are inflexible because they
were formed during early childhood experi-
ences and continue to be reinforced in adult
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▪ Interpersonal psychotherapy:
a time-limited form of psychother-
apy, originally developed for the
treatment of depression, that fo-
cuses on maladaptive relational
patterns
▪ Transference-focused psycho-
therapy: a form of psychoanalytic
psychotherapy, developed by Otto
Kernberg, that treats borderline
personality disorder using
transference-based interpretations
▪ Schema-focused therapy: a
cognitive behavioral therapy treat-
ment targeting borderline and nar-
cissistic personality disorders that
identifies core maladaptive schem-
as and schema-avoidance behavi-
ors that damage relationships
▪ Self-expression. In a nurturing
environment, children are encour-
aged to express their needs and de-
sires. When this self-expression is
discouraged, children are made to
feel that their needs and feelings
matter less than those of their par-
ents. Often these children are pun-
ished and made to feel “less than.”
When self-expression isn’t encour-
aged and supported, children may
develop a subjugation schema or
an unrelenting standards and hy-
percriticalness schema.
Understanding Early
Maladaptive Schemas
• Deprivation of nurturance:
the absence of attention
Deprivation of empathy:
the absence of
understanding
Deprivation of protection:
the absence of guidance
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Schema Questionnaires
The Young Schema Questionnaire has
been widely used to identify the eighteen
early maladaptive schemas. In appendix A,
we’ve adapted the Young Schema Question-
naire, with the permission and assistance of
Jeffrey Young, PhD, to specifically identify
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Thought Logs
A simple thought log can be a gateway to
understanding clients’ schemas. Over a peri-
od of one to two weeks, have clients keep a
record of their thoughts using the Thought
Log. Instruct them to use the log after exper-
iencing strong emotional reactions, such as
sadness, anxiety, shame, or anger, and ask
that they record all significant thoughts ex-
perienced during the period of high affect,
describing triggering situations in the left-
hand column, emotional reactions in the
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Imagery
To use imagery to trigger and identify
schemas, start by identifying a recent situ-
ation that created high affect and might be
related to a schema. Ask clients to visualize
the scene, noticing what they saw, heard, and
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Schema Triggers
Overcompensation
Manipulation or exploitation: If
you use this coping behavior in re-
sponse to a schema-triggering event,
you’ll find yourself trying to meet
your own needs without letting
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Passive-aggressiveness or rebel-
lion: If you use this coping behavior
in response to a schema-triggering
event, you’ll appear to be compliant
but will rebel by procrastinating,
complaining, being tardy, pouting, or
performing poorly.
Surrender
Avoidance
Creative Hopelessness
Mindful Focusing
The following simple focusing exercise is
an easy way to teach mindfulness in session
and also a good practice to assign for home-
work between sessions. To begin, have cli-
ents observe their breath, all the way from
their nose down to stretching sensations in
their diaphragm. Then have them notice
when private events arrive, labeling them
simply as “thought,” “emotion,” or “sensa-
tion.” If you wish, you can also make an au-
dio recording of the guided practice for cli-
ents to use at home. Here’s a sample script
for a five-minute practice (adapted from
McKay, Davis, & Fanning, 2011):
Therapist: Close your eyes and take a deep
breath, noticing the experience of
breathing. Observe perhaps the
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Mindful Activities
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▪ Noticing schema-relevant
thoughts: observing thoughts
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Interpersonal Experi-
ences Diary
Event: ___________
___________
Schema emotions: ___________
___________
Schema-related thoughts:
___________
___________
Physical sensations: ___________
___________
Schema-driven urges: ___________
___________
Event: ___________
___________
Schema emotions: ___________
___________
Schema-related thoughts:
___________
___________
Physical sensations: ___________
___________
Schema-driven urges: ___________
___________
Event: ___________
___________
Schema emotions: ___________
___________
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Schema-related thoughts:
___________
___________
Physical sensations: ___________
___________
Schema-driven urges: ___________
___________
Labeling Barriers
The first step in dealing with barriers is to
label what they are. The mere act of describ-
ing the obstacles to values-based behavior
can make them seem less overwhelming. To
do this, use the Assessing Barriers Work-
sheet to help clients identify specific emo-
tional and cognitive barriers that are likely to
show up for each values-based intention.
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Facing Barriers
As clients move toward values-based in-
terpersonal behavior, emotional and cognit-
ive barriers are likely to emerge. An excellent
way to recognize and work with them is
through the monsters on the bus metaphor
(Hayes & Smith, 2005). Hold this metaphor
in reserve for exploring a value or intention
of great importance to clients, then devote
about half a session to developing the meta-
phor. It provides a powerful explication of
the key ACT concept that avoiding
uncontrollable schema-related pain results
in dysfunctional and damaged relationships,
whereas willingly facing and accepting the
pain opens the door to creating functional
relationships based on core interpersonal
values.
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Rebecca: (Nods.)
Therapist: What happens then?
Rebecca: I screw up my relationships at
work. I get isolated and angry. This
has happened at other jobs.
Therapist: Okay. That doesn’t work. You’ve
gone that direction with your bus
before and bad things happened.
But the monsters are still jumping
up and down, blocking your way.
What are you going to do?
At this point, let clients struggle to figure
this out. After you’ve given clients some time
with this conundrum—that experiential
avoidance and SCBs don’t work but the bar-
riers are formidable—reveal the solution:
The answer is to let the monsters on the bus
and keep driving in a valued direction.
Therapist: What if you opened the bus door?
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Awareness and
Willingness
Watching Thoughts
The starting point of defusion is learning
how to watch the mind. There are several ef-
fective methods for teaching this. In this pro-
tocol, we use Mindful Focusing (see chapter
5) and the White Room Meditation. As you
introduce defusion, we recommend that you
start with the White Room Meditation.
MINDFUL FOCUSING
Once clients have explored the first pro-
cess for watching thoughts (the White Room
Meditation), revisit Mindful Focusing, from
chapter 5. Guide clients in Mindful Focusing
for four to five minutes, encouraging them
not to pay a lot of attention to the thoughts.
Ask them to simply label each one (“There’s
a thought”) and then observe their breath
until a new thought shows up. For at least
two weeks, give clients a homework assign-
ment of doing five minutes of Mindful Fo-
cusing each day. As they get more experience
observing cognitive processes, discuss
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Labeling Thoughts
Building on observing thoughts, the defu-
sion skill of labeling thoughts emphasizes
that cognitions are products of the mind
(Hayes et al., 1999). They aren’t real or a pri-
ori truths. They are just thoughts.
In ACT, a key approach to thought la-
beling is to teach clients the phrase “I’m hav-
ing the thought that ___________ .” Here
are some examples: “I’m having the thought
that Linda will leave me.” “I’m having the
thought that I can’t be honest.” “I’m having
the thought Bill is distant because he sees
how screwed up I am.”
Alternatively, clients can use the phrase
“Now my mind is having a ___________
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Letting Go of Thoughts
Once clients have practiced observing
and labeling thoughts, you can teach them a
variety of techniques to help release thoughts
and let them go. Recommend that they
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OBJECTIFYING THOUGHTS
One way to shrink the power of painful
thoughts is by objectifying them, imagining
them as physical objects (Hayes et al., 1999).
To use this technique, ask clients to imagine
the thought as an object, then tell you its
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CARD CARRYING
In this defusion technique, clients carry
index cards on which they write down
schema-driven thoughts as they come up.
Then, whenever these painful cognitions re-
cur, clients can remind themselves, “It’s on
the card,” and let it go.
WEARING LABELS
Painful self-judgments that show up re-
peatedly can be defused by actually wearing
them. Do this exercise together with clients
so you can model the process and share
some of the embarrassment. Each of you
should write a recurring self-judgment on a
sticky note or name tag and wear it for the
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▪ “Has anything
about the emotion
changed? Does it
feel more or less
intense? Has it
transformed into a
different
emotion?”
how they’re
different.”
Client: Green.
Therapist: Can you read the first thought
backward?
Client: Wrong it doing I’m.
Therapist: Okay, can you have these fourteen
green letters and observe them?
Can you have them just as they are,
just letters and lines on the paper?
What’s that like after a while?
Client: They kind of lose their meaning.
Therapist: What’s happening with your sad-
ness and anger?
Client: They are still there.
Therapist: That’s fine. This schema-related
pain—the sadness and anger, and
the thoughts (tapping the pa-
per)—what has this pain kept you
from doing in your relationships?
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▪ Values-based planning
▪ Defusion
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▪ Exposure
2. Discussing Defusion
As mentioned, chapter 6 provides a wide
variety of techniques for cognitive defusion,
and working with these will go a long way to-
ward helping clients understand and cultiv-
ate this skill. In addition, call attention to
mental activity, thoughts, and stories
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2. Discussing Exposure
When clients accept that the problem
isn’t schema-related pain, but rather at-
tempts to eliminate or avoid that pain, they
are in a position to experience and explore
creative hopelessness. That sets the stage for
discussing exposure. Explain that part of the
solution is to get closer to the pain and relate
to it differently, rather than running away
from it. As ever, highlight the many costs of
emotional avoidance and suggest acceptance
and willingness as an alternative.
You can use various techniques from
chapter 7, such as the exercise Exploring the
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6 = Describes me perfectly
___________ 7. I am inept.
Failure (fa)
Entitlement (en)
Subjugation (su)
___________ 6. I go to great
lengths to avoid conflict or confront-
ations with others.
___________ 9. I am very
competitive.
Procedures
1. Administer a Pre-Treatment
Assessment
Have clients fill out a schema question-
naire before the session. (We recommend
the Young Schema Questionnaire, which you
can purchase at schematherapy.com; see ap-
pendix A for an example.) The schema ques-
tionnaire is used to identify members’
schemas, not as an assessment measure. The
purpose is to identify which schemas are
most salient for each member. Group mem-
bers can then choose which schemas reson-
ate with them the most and which they
would like to focus on. Also administer any
outcome measures you’d like to use, such as
the Valued Living Questionnaire (VLQ;
Wilson, Sandoz, Kitchens, & Roberts, 2010),
the Automatic Thoughts Questionnaire
(ATQ; Hollon & Kendall, 1980), the Accept-
ance and Action Questionnaire–II (AAQ-II;
Bond et al., 2011), or the Inventory of
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3. Provide Psychoeducation on
Schemas
Give the group members their results
from the schema questionnaire you admin-
istered, along with the handout Ten Key
Schemas. Have members circle the three
schemas where they scored highest and ask
them whether these schemas seem to correl-
ate with their experience. Then discuss the
concept of schemas and how they arise.
Here’s a script showing how you might do so:
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• Deprivation of nurturance:
the absence of attention
Deprivation of empathy:
the absence of
understanding
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Deprivation of protection:
the absence of guidance
5. Provide Psychoeducation on
Schema Coping Behaviors
Take some time to explain schema coping
behaviors (SCBs), perhaps starting with the
metaphor of a popcorn machine to illumin-
ate how thoughts are generated spontan-
eously and continuously:
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Overcompensation
Manipulation or exploitation: If
you use this coping behavior in re-
sponse to a schema-triggering event,
you’ll find yourself trying to meet
your own needs without letting
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Passive-aggressiveness or rebel-
lion: If you use this coping behavior
in response to a schema-triggering
event, you’ll appear to be compliant
but will rebel by procrastinating,
complaining, being tardy, pouting, or
performing poorly.
Surrender
Avoidance
7. Assign Homework
Educate group members about the im-
portance of following through with home-
work assignments and explain that home-
work is a core mechanism for promoting
change and making progress in therapy.
Homework provides clients with an oppor-
tunity to practice new skills in their relation-
ships and explore workability. Then assign
the following homework to group members
to be practiced throughout the week:
Procedures
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2. Review Homework
Ask group members to share what they
noticed when their schemas were triggered
over the past week.
5. Assign Homework
Assign the following homework to be
practiced throughout the week:
Procedures
2. Review Homework
Ask group members to share moments
over the past week when their schemas were
triggered and to describe how they reacted.
6. Assign Homework
Assign the following homework to be
practiced throughout the week:
Procedures
2. Review Homework
Ask group members to share their experi-
ence in watching for the moment of choice.
Ask whether they were able to notice when
their schemas were activated and any associ-
ated urges to engage in old coping behaviors.
Also ask whether they were able to identify
this as the moment of choice.
7. Assign Homework
Assign the following homework to be
practiced throughout the week:
Procedures
2. Review Homework
Ask group members to share their experi-
ence in following through on their valued in-
tention. Ask whether they were able to notice
the moment of choice. Explore any barriers
that came up and brainstorm strategies to
deal with those barriers, then have them set
a new intention for the following week. For
those who didn’t follow through, it’s best to
continue working on the previously identi-
fied intention unless they have determined
that the intention doesn’t genuinely reflect
their values.
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3. Provide Psychoeducation on
Defusion
Begin by explaining that this session will
continue the work of exploring values. Re-
mind the group that thoughts and feelings
can function as barriers to valued action and
that in order to change how they interact
with others, they may need to learn to relate
to their internal experiences differently. Use
the monsters on the bus metaphor to explore
the idea of relating to thoughts differently.
The sales representative metaphor from
chapter 6 (Vuille, 2006a) can also be helpful.
Here’s an example of how you can weave
these two metaphors together to set the stage
for defusion:
Defusion Skills
9. Objectifying, or thinking of
thoughts as physical objects.
Imagine what physical characteristics
your thought might have—size, col-
or, texture, shape, density, consist-
ency, weight, flexibility, temperat-
ure, and so on. This technique is also
very useful for disentangling yourself
from emotions and other internal
experiences.
6. Assign Homework
Assign the following homework to be
practiced throughout the week:
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Procedures
1. Review Homework
Ask group members to share their experi-
ence in following through on their valued in-
tention. Explore any barriers that came up
and brainstorm strategies to deal with those
barriers, then have them set a new intention
for the following week. For those who didn’t
follow through, it’s best to continue working
on the previously identified intention unless
they have determined that the intention
doesn’t genuinely reflect their values.
4. Explore Self-Evaluations
The work on evaluations helps set the
stage for exploring self-evaluations. You can
simply continue with the previous line of
thought and describe applying defusion tech-
niques to self-evaluations:
5. Cultivate Self-as-Context
Work on defusing from self-evaluations
overlaps and leads naturally to cultivating
self-as-context, or the observer self. An
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6. Assign Homework
Assign the following homework to be
practiced throughout the week:
Procedures
1. Review Homework
Ask group members to share their experi-
ence in following through on their valued in-
tention. Explore any barriers that came up
and brainstorm strategies to deal with those
barriers, then have them set a new intention
for the following week. For those who didn’t
follow through, it’s best to continue working
on the previously identified intention unless
they have determined that the intention
doesn’t genuinely reflect their values.
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2. Explore Willingness
To help group members develop willing-
ness to face emotional pain, begin by ex-
plaining that emotional pain is unavoidable
in important relationships:
7. Assign Homework
Assign the following homework to be
practiced throughout the week:
Procedures
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1. Review Homework
Ask group members to share their experi-
ence in following through on their valued in-
tention. Explore any barriers that came up
and brainstorm strategies to deal with those
barriers, then have them set a new intention
for the following week. For those who didn’t
follow through, it’s best to continue working
on the previously identified intention unless
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8. Assign Homework
Assign the following homework to be
practiced throughout the week:
Procedures
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1. Review Homework
Ask group members to share their experi-
ence in following through on their valued in-
tention. Explore any barriers that came up
and brainstorm strategies to deal with those
barriers, then have them set a new intention
for the following week. For those who didn’t
follow through, it’s best to continue working
on the previously identified intention unless
they have determined that the intention
doesn’t genuinely reflect their values.
Here’s an example:
6. Assign Homework
Procedures
7. Administer post-treatment
assessments.
2. Review Homework
Ask group members to share their experi-
ence in following through on their valued in-
tention and discuss any barriers that came
up. (Later in the session, you’ll conduct a
thorough discussion of potential future bar-
riers and strategies to deal with them and
also ask members to commit to a new
intention.)
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7. Administer Post-Treatment
Assessments
If you chose to administer any pre-treat-
ment assessments for use as outcome meas-
ures, have group members complete those
questionnaires again at the end of the
session.
References
http://acbs.dharmatech.org/
thoughts_as_sales_representatives