The Official Publication of the International Society of Schema Therapy
In This October IssueThis Issue - Schema Therapy in Healthcare Settings
Using the Schema Therapy Model to Help Patients Cope with a Cancer Diagnosis
Schema Therapy in Medical Settings
"I am trapped in a body I can't trust": Working with Patients who have Chronic Illness
Schema Therapy in Dermatology
Meet the ISST Board - Eckhard Roediger
Public Affairs Corner
Newly Formed: Schema Therapy Association of Ireland
Schema Therapy Association of Ireland (STAI) has been established at an inaugural meeting in Dublin. Several new members attended. There is a growing awareness of schema therapy throughout Ireland and, with the society's launch, the group hopes to serve as a valuable resource by making information about schema therapy more accessible and available to the general public as well as to other professionals. Although still in our early days, the group also plans to establish schema therapy training programs throughout Ireland in the not too distant future.
Interested in joining STAI? email Cathy: EMAIL
We must be particularly careful to find the balance between time dedicated to meeting the emotional needs of the child while encouraging healthy alternatives
Recent Book/ Chapter Schema Therapy Releases
Schema Therapy with Couples: A Practitioner's Guide to Healing Relationships (2015) Simeone-DiFrancesco, C., Rodiger, E., Stevens, B, Wiley.
Good Enough Parenting: An In-Depth Perspective on Meeting Core Emotional Needs and Avoiding Exasperation. Lewis, J. & Lewis, K. (2015), Morgan James Publishing.
"I am trapped in a body I can't trust": Working with Patients who have Chronic Illness
by Elizabeth Lacy, LCSW, USA
Lisa walks in to my office, tense, underweight and tearful. She tells me that she has had Chronic Lyme for about 6 years… she can barely swallow most days because of the almost constant burning in her mouth and throat. She has been to so many doctors she can’t even count them and she just read an article in my waiting room that talked about the mind-body connection of illness. She starts blaming herself harshly “I don’t think I’m doing enough. I know it isn’t all in my head but I’m afraid it is. I’ve been sick since I was a kid, but this is ridiculous”…Monica, a 20 year old who is obese, has terrible panic attacks in college and has had severe rheumatoid arthritis since age 3. As Monica tells me about her anxiety, I can barely hear her through her flat affect. She has no idea what she thinks about anything, only that she can’t tolerate the feeling of her anxiety. She describes how she gets a “wooshy feeling in my head like there is a Plexiglas window between me and everyone else” and this scares her to the point of not being able to drive alone, go to a store or see a friend. She said she has felt this out of body experience since she was young and in pain but never this severely. Her mother hands me a four inch thick stack of CBT skills and tools that she has been trying to get Monica to use. Mom says it’s been the same with her RA since she was a child: “she just won’t do anything about it. I give her lists but she never follows through!”
Treating people who have chronic illnesses is challenging to say the least. Back when I was treating people with more traditional CBT, patients who were extremely sensitive to physical sensations and the threat, whether real or imagined, of serious illness would hit walls that seemed impenetrable with exposure therapies, cognitive reattribution or any other more traditional CBT. Schema Therapy helps break through the “walls” of shame and fear by offering more than cognitive-behavioral strategies. By modelling and ultimately promoting the constructed enhancement of a healthy adult care-taking mode, changes occur deep at the root of the emotional system. The healthy adult facilitates the process of getting the core unmet needs of the vulnerable child (the one who implicitly experiences the longstanding shame and/or fear linked with early life issues) met, in an adaptive manner. Self-defeating patterns, and biased emotional beliefs gradually heal as schema links weaken, and become reorganized in the cotext of healthier and more effective outcomes.
Not surprisingly, people start to feel better physically. Suffering, if not pain, lessens. Symptoms are less frequent. People go back to having more balance…a life worth living.
There are some core profiles of schemas that emerge with most of the patients I have treated with chronic illnesses such as RA, chronic Lyme, HIV, Lupus and the like: Vulnerability, Defectiveness/Shame and Negativity/Pessimism. These are frequently activated in conjunction with the presentation of a new symptom or sensation in the body. With these patients, it’s very important to help them differentiate between schema activation and what are normal and reasonable responses to current and predictable illness-related experiences. Schema mode work can be a critical asset in the differentiating work. The question becomes: “Is the mode helping or is it creating more suffering?”
How people cope with illness is often interestingly linked with their coping styles and modes from childhood: Lisa, mentioned earlier, spent hours each day researching new homeopathic or alternative treatments, even right after she just started a new protocol. She was stuck in an overcompensating mode, very common for people who have suffered and experienced a loss of control over an extended period of time. The modes which tend to be most active in people with chronic illness are Detached Protector and Controlling Over-Compensator; these may show up as substance abuse, shopping, numbing, shutting down, endless research, unhealthy doctor-shopping or insistence on endless rumination about the illness.
As always, it’s imperative to take a thorough history because primary schemas and modes that become activated during flair ups are almost always informed by earlier life experiences where schemas and modes formed. For example, Lisa grew up with a highly narcissistic father who had no trust for the medical profession insisting, “doctors poison people”. If a person became sick his mantra was, “you should only depend on yourself to get well”. If Lisa got sick it was her own fault. So when she became sick all of her schemas and modes became reinforced and highly active, especially since her illness was initially difficult to diagnose. She couldn’t trust anyone to help and had to do it all herself, feeling trapped and mistrustful as she was made to feel as a child.
Monica’s pain was so intense that she began to shut down as a young child, depending on her fearful mother to take care of her because she could not even walk at times. Her mother was a controlling over-compensator and Monica’s pain coupled with her mother’s almost constant OC mode resulted in the development of a detachment that was more of a dissociative state, frightening her even further.
The modes that are most active during flair ups, and may prevent the patient from healthily coping with their illness, need to be persistently confronted or there may be little hope of the patient finding adaptive emotional or physical relief. The effect of these self-critical, perfectionistic, detached or dependent modes is the perpetuation of the vulnerable-frightened child reliving early experiences (through their illness) of not getting their needs met— ones that could help alleviate some of their current suffering.
For Lisa that could mean trust—allowing someone to care for her, and for Monica—to feel more of a sense of competency when she is away from her mother. Through imagery and other experiential strategies, in addition to re-parenting and re-scripting, the schema therapist can help patients experience what it would be like to feel better, to depart from their dysfunctional modes. They learn to label the “illness mode” and dialogue between this mode and others, “What do other parts say to it? What does the illness say? What does the pain say?”
Simultaneously, we must be particularly careful to find the balance between time dedicated to meeting the emotional needs of the child while encouraging healthy alternatives in mode coping and decision making regarding medical care and health preservation. Modes, especially avoidance, will fight hard for sustenance acting as protectors. And, while thoughtful time is sometimes necessary for good medical care to be rendered, avoidance and detachment need to be differentiated from careful scrutiny and appraisals of health care providers.
Some of our patients who suffer with chronic illness may face other co-existing obstacle in their journey to get their needs met. Some family members, practitioners, even friends may eventually develop compassion fatigue with your highly avoidant or help-rejecting patient; while others or may find the illness an opportunity to control your patient or to feel needed. Doctors who become frustrated when illness is complex and diagnoses are not easily configured can be sometimes guilty of suggesting, “it’s all in your head” thus invalidating the patient and perhaps activating core schemas and maladaptive responses.
Mode dialogues and imagery are important and vital strategies for linking the patient’s schemas and modes with the “obstacles” that occur during diagnosis and treatment phases related to chronic health issues, keeping the patient consistently and keenly apprised of what they are up against; strengthening healthy responses to implicit and explicit (harmful/hurtful) inputs from others past and present; while also reducing anxiety, hopelessness, and unwarranted fears. In so doing, our patients with chronic health issues can get the care they need…and have a life worth living.
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