The British Pyschological Society Health & Care Professions council

Schema Focused A Case Study

Working with young people experiencing psychological problems through the challenging period of adolescence is always professionally stimulating and rewarding.  This is particularly the case when working with adolescents who have experienced physical, sexual and emotional abuse or neglect.  Working with adolescents who have experienced maltreatment and are suffering emotional difficulties as a consequence of psychological trauma forms a significant part of my professional psychological work.  I specialize in working with both young people and adults who have experienced significant social difficulties during their childhoods.  Many of the young people and adults I provide psychological therapy to have been emotionally scarred by witnessing or being directly involved in severe conflict between parents or parent figures.  They have often not had their emotional needs met as parents or carers have suffered significant personal difficulties with mental health, personality, substance abuse or other problems.  Or simply parents and primary caregivers have prioritised their own needs above those of the young person. Many of my adolescent clients have had an unsettled childhoods and spent several months or years in residential, foster or kinship care.  Sometimes young people may have been institutionalized within secure settings or in-patient mental health units due to psychological problems that have stemmed from their childhood experiences.

One psychological approach that I have found particularly useful in my work with adolescents in emotional crisis is schema focused therapy.  Schema focused therapy was developed by the American Psychologist Dr Jeffery Young in the 1980s.  Young initially specified the early maladaptive schemas which alternatively can be described as the self-defeating thoughts, feelings and behaviour which influence people.  Early maladaptive schemas develop as a consequence of both their innate temperament and negative life experiences with relatives, peers and other important people within their lives.  I have found schema therapy to be a particularly revolutionary way of helping adolescents to resolve the psychological problems that they have experienced.  Schema therapy uses powerful psychological techniques which really help people to move forward in their lives.  The best way to describe the power of schema therapy is to discuss my work with a client which demonstrates some of the techniques of schema therapy.

 

Dear Elspeth*

You and your mother Patricia* sought psychological help from me 4 months ago at a time of psychological crisis.  You had taken an overdose of paracetamol and were experiencing difficulties in your relationships with relatives, peers and teachers.  You live with your mother Patricia but have important relationships with your maternal Aunt Julie* and father Jack*.   

You described your aims for therapy as to help you improve the quality of your relationships with relatives and peers.  You also said that you wanted help with the way you manage yourself commenting that you are often in trouble both at home and at school for not conforming to school rules of getting into conflict with your Mum.

It became clear during the initial psychological session that we had together that you had not actually wished to end your life but have a very emotionally over-involved, enmeshed relationship with your mother Patricia.  The context of your overdose had been your Mum insisting for the first time in your life that she was going to go out with an adult friend without you and leave you in the care of your Aunt Julie whom you see regularly.  Previously you have been able to persuade your Mum not to separate from you except for attending school and you had become enraged when your Mum had on this occasion insisted that she needed to have some space to have quality time with an adult female friend separate from you.  Like many teenagers that I work with you had not appreciated the seriousness of taking an overdose and did not recognise that having taken 8 paracetamol could have proved fatal.

It was apparent that you had become very angry when your Mum had insisted on going out with her adult female friend despite your pleas for her not to do so.  You had taken an overdose on the night that she went out stating that you knew this would force her to return home to attend to your needs.  It is clear that you and your Mum find it very hard to separate from each other and your Mum had chosen to go out because she had become aware that the overly close relationship that the two of you have is emotionally unhealthy.

Your mother Patricia is very critical of your behaviour and is particularly embarrassed by your rule-breaking behaviour in public such as at school which she regards as “letting the side down”.  She is primarily concerned about the perception that outside agencies have of your family rather than individual family members’ emotional wellbeing. Your mother is in denial about her own issues with alcoholism.  You leave for school each morning with your Mum still asleep after becoming intoxicated the previous night having consuming excessive amounts of vodka.  She rises at noon and earns some money from her home based self-employment as a psychic medium.  You describe having often witnessed her giving psychic readings over the telephone to unsuspecting clients whilst intoxicated.   Sadly when you return home from school your Mum is often drinking again and you have described being very fearful that you will return to find her unconscious under the influence of alcohol and this influences your emotionally close relationship with her.

Your father Jack is serving a 16 year prison term having been convicted of leading an international gang smuggling hundreds of thousands of pounds worth of heroin and cocaine.  He was imprisoned when you were aged only ten and you previously had a very close relationship with him.  As a consequence his imprisonment is a major loss for you.  You now only see your father monthly and are not permitted by your mother to talk about him with either family members or peers because his imprisonment is regarded by your Mum as very shameful despite her having been previously well aware of his criminal activities and her welcoming the financial rewards his conduct brought to your family.   It was after your father was imprisoned that your mother and you developed an emotionally over-involved, enmeshed relationship which primarily met your mother’s needs and allowed her to experience a confiding relationship with you to compensate for your father’s loss.  Your mother intentionally kept you very young and dependent and now finds your clingy, childlike behaviour over-whelming when she has now separated from your father and wishes to pursue an adult, independent life.

We have worked together in therapy on your early maladaptive schemas which stem from your childhood experiences which centre on dependence, enmeshment, entitlement and emotional inhibition.  Your psychological issues with emotional dependence and enmeshment are most evident in your family relationships.  Your family has always been very secretive because of your father’s criminal activities and your mother’s alcoholism and you were raised to form close attachments only with relatives.  You developed a particularly enmeshed relationship with your mother after your father’s imprisonment which particularly met your mother’s needs rather than your own.  You had developed emotionally inhibited relationships with your family and other young people because of the way in which you had been conditioned by your family not to acknowledge even to yourself your feelings about your father’s criminal behaviour and mother’s alcoholism and the negative consequences that your parent’s problems have for you with both of them often being physically and emotionally unavailable to you.   Finally you have psychological difficulties with entitlement and often engage in impulsive, thrill seeking behaviour as a way of having your emotional needs met.  Your family economically over-compensate by being very extravagant in meeting your material needs.  However, you have had psychological issues with compulsive shop-lifting of clothes, stationary and other items.  You were shop-lifting several times a week and had been banned from several shops as a consequence.  Your mother was very fearful that criminal prosecution for your shop-lifting would eventually result in you receiving a custodial sentence and damage the public image of your family.

When you begun schema therapy you displayed many traits of borderline personality disorder particularly with regards to your repetitive self-harming behaviour, emotionally unstable relationships with peers and relatives, compulsive shop-lifting and other impulsive behaviour, fear of abandonment by your parents and other close relatives and your intense rages and mood swings particularly towards relatives.  In schema therapy we have worked through your angry child mode which drives your impulsive, self-harming and other destructive behaviour and worked through the demanding parent mode that you have internalized as a consequence of your parents’ overly high expectations. 

We have begun working through these issues in therapy by using powerful imagery techniques which have helped you to identify your central schemas and to connect with them emotionally in therapy.  I have been really impressed by the way in which you have been able to recognise through guided imagery the childhood experiences which have contributed to your problems with anger and mood swings and recognised that “Angry Elspeth” developed because your emotional needs were unmet within your family.  You are beginning to recover from the angry child mode with the limited re-parenting provided by me during schema therapy in which your emotional needs have been met.  We have also begun working through the demanding parent mode you have internalized from your parents’ unreasonably high expectations of you through guided imagery, chair work in which you have been able to speak to the demanding parent in schema therapy sessions and through the limited re-parenting offered to you in schema therapy in which I have supported you in confronting your demanding parents in therapy, offered praise and professional care.  You have begun making changes and have reduced the frequency of your self-harming behaviour and have not shop-lifted for one month.  You have also begun separating positively from your mother and begun relating more to your peer group.  I am really impressed with the changes you have made and look forward to you continuing to make changes with the help of schema therapy in the future.

Best Wishes

Dr Dorothy Ojarikri

Clinical Psychologist