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Chapter
8.
Case Formulation
and
Cognitive Schemas
in
Cognitive Therapy
for
Psychosis
177
Anthony
P.
Morrison
Chapter
9.
Maladaptive
Schemas
and
Core
Beliefs
in
Treatment
and
Research With Couples
199
Mark
A.
Whisman
and
Lisa
A.
Uebelacker
Afterword
221
Lawrence
P.
Riso
Index
225
About
the
Editors
239
viii
CONTENTS
CONTRIBUTORS
Samuel
A.
Ball, PhD, Associate
Professor
of
Psychiatry,
Yale
University
School
of
Medicine, Division
of
Substance Abuse,
New
Haven,
CT
Pieter
L. du
Toit,
MA,
Psychologist, National
Health
Service
in the
United Kingdom, Cambridge, England
Peter
Farvolden,
PhD, Assistant
Professor
of
Psychiatry,
Centre
for
Addiction
and
Mental Health, Toronto, Ontario, Canada
Matt
J.
Gray,
PhD, Assistant Professor
of
Psychology, University
of
Wyoming,
Laramie
Helen
Kennerley, PhD, Consultant
and
Clinical Psychologist, Oxford
Cognitive
Therapy
Centre,
Warneford Hospital, Oxford, England
Brett
T.
Litz, PhD,
Professor,
Boston Veterans
Affairs
Health Care
System
and
Boston University
School
of
Medicine, Boston,
MA
Rachel
E.
Maddux,
MA,
Georgia
State
University,
Atlanta
Shira
Maguen,
PhD, Psychologist,
San
Francisco Veterans
Administration Medical Center,
San
Francisco,
CA
Carolina
McBride, PhD, Research Director, Interpersonal Psychotherapy
Clinic, Department
of
Psychiatry, University
of
Toronto, Ontario,
Canada
Anthony
P.
Morrison,
PhD, Senior Lecturer, University
of
Manchester,
Manchester, England
Vartouhi
Ohanian,
PhD, Lakeside Mental
Health
Unit,
West
London
Mental Health
NHS
Trust, West Middlesex University Hospital,
Middlesex,
England
Gilbert
Pinard,
MD,
Professor
of
Psychiatry,
McGill
University
Health
Centre, Montreal, Quebec, Canada
Lawrence
P.
Riso,
PhD, Associate
Professor,
American
School
of
Professional
Psychology, Argosy University/Washington,
DC
Noelle
Turini
Santorelli,
MA,
Georgia
State
University, Atlanta
IX
Debbie Sookman, PhD, Associate
Professor
of
Psychiatry
and
Director,
Obsessive—Compulsive
Disorder Clinic, McGill University Health
Centre, Montreal, Quebec, Canada
Dan J.
Stein,
MD,
PhD,
Professor
and
Chair, Department
of
Psychiatry
and
Mental
Health,
University
of
Cape
Town; Director, Medical
Research
Council
Unit
on
Anxiety Disorders, Cape Town, South
Africa;
Mt.
Sinai
School
of
Medicine,
New
York,
NY
Stephen
R.
Swallow, PhD, Psychologist, Oakville
Centre
for
Cognitive
Therapy, Oakville, Ontario, Canada
Lisa
A.
Uebelacker,
PhD, Brown University Medical
School
and
Butler
Hospital, Providence,
RI
Glenn
Waller, PhD,
Professor,
Eating Disorders Section, Institute
of
Psychiatry,
King's College London; Vincent Square
Clinic,
Central
and
North West London Mental Health Trust, London, England
Mark
A.
Whisman, PhD, Associate
Professor,
Department
of
Psychology,
University
of
Colorado, Boulder
Jeffrey
E.
Young, PhD, Founder
and
Director, Cognitive Therapy
Centers
of New
York
and the
Schema Therapy Institute,
New
York,
NY;
Department
of
Psychiatry, Columbia University College
of
Physicians
and
Surgeons,
New
York,
NY
CONTRIBUTORS
ACKNOWLEDGMENTS
The
editors would like
to
thank
and
acknowledge
Ms.
Tiffany
L.
Klaff
for
her
help
in
preparation
of the
manuscript.
XI
Cognitive Schemas
and
Core
Beliefs
in
Psychological
Problems
1
INTRODUCTION:
A
RETURN
TO A
FOCUS
ON
COGNITIVE SCHEMAS
LAWRENCE
P.
RISO
AND
CAROLINA
McBRIDE
More
than
30
years ago, Aaron
T.
Beck (1967, 1976) emphasized
the
operation
of
cognitive schemas
as the
most fundamental factor
in his
theories
of
emotional disorders. Schemas, accordingly, played
a
principal role
in the
development
and
maintenance
of
psychological disorders
as
well
as in the
recurrence
and
relapse
of
episodes.
Despite
the
central place
of
cognitive schemas
in the
earliest writings
of
cognitive therapy,
the
cognitive techniques
and
therapeutic approaches
that
later emerged tended
to
address cognition
at the
level
of
automatic
negative
thoughts,
intermediate
beliefs,
and
attributional style.
In a
similar
way,
the
psychotherapy protocols
that
developed tended
to be
short term.
Relatively
less
attention
was
paid
to
schema-level processes.
In
most accounts
of
clinical cognitive theory, cognition
can be
divided
into
different
levels
of
generality (Clark
&
Beck, 1999). Automatic thoughts
(ATs)
are at the
most
specific
or
superficial
level. Automatic thoughts
are
moment-to-moment cognitions
that
occur without
effort,
or
spontaneously,
in
response
to
specific
situations.
They
are
readily accessible
and
represent
conscious
cognitions.
Examples
of ATs
include
"I'm going
to
fail
this
test," "She thinks
I'm
really
boring,"
or
"Now I'll never
get a
job."
ATs
are
often negatively distorted, representing,
for
instance, catastrophizing,
personalization,
or
minimization.
They
are
significant
in
that
they
are
tightly
linked
to
both
the
individual's mood
and his or her
behavioral
responses
to
situations.
Beliefs
at an
intermediate level (termed
intermediate
beliefs
or
conditional
assumptions)
are in the form of
"if.
. .
then"
rules. Examples
of
intermediate
beliefs
include
"If 1 do
whatever people want,
then
they
will
like
me" and
"If
I
trust others, I'll
get
hurt."
At the
highest level
of
generality
are
cognitive schemas. Negative
automatic thoughts
and
intermediate
beliefs
are
heavily influenced
by
under-
lying
cognitive schemas, particularly
when
these
schemas
are
activated.
In
cognitive psychology,
the
notion
of
cognitive schemas
has
played
an
impor-
tant
role
in the
understanding
of
learning
and
memory.
For
clinical contexts,
A. T.
Beck (1967) described
a
cognitive schema
as "a
cognitive structure
for
screening,
coding,
and
evaluating
the
stimuli
that
impinge
on the
organism
. . ." (p.
283).
A
number
of
authors have returned recently
to
Beck's original notions
of
the
need
to
conceptualize patients
in
terms
of
their
cognitive schemas
(see,
for
instance, Young, 1995,
and
Safran, Vallis, Segal,
6k
Shaw, 1986).
Jeffrey
Young (1995; Young, Klosko,
6k
Weishaar, 2003)
has
been
one of
the
more influential proponents
of a
schema-focused clinical approach.
Noting limitations
of
traditional cognitive therapy, Young (1995) suggested
that
a
focus
on
schemas
was
often necessary because some patients have
poor access
to
moment-to-moment changes
in
affect,
making
a
primary
focus
on ATs
unproductive.
Other
patients
are
readily able
to
recognize
the
irrationality
of
their thoughts
in
therapy,
but
then
report
that
they still
"feel"
bad.
Still
others
are
unable
to
establish
a
productive
and
collaborative
working
alliance
that
is
required
for
more symptom-focused work. Finally,
Young
noted
that patients seen
in the
community
are
often much more
complex
and
chronic than
are
those enrolled
in
clinical trials with
3-month
cognitive therapy protocols.
As a
consequence,
the
need
to
focus
on
underly-
ing
schemas
has
begun
to
influence
the
practice
of
cognitive therapy.
In
this volume,
we
have compiled work
by a
number
of
authors
who
tailor
the
schema-focused
approach
to the
understanding
and
treatment
of
specific
clinical
problems.
The
increased interest
in
cognitive schemas parallels
the
search
for
underlying
dimensions
of
vulnerability
to
psychopathology.
The
search
for
these
underlying processes includes factors such
as
temperament, personality,
and
personality disorders. Schema-focused approaches also represent
a
return
to an
interest
in
developmental antecedents
of
psychopathology.
The
concept
of
schemas
has a
rich ancestry
in
psychology deriving
from
cognitive psychology, cognitive development, self-psychology,
and at-
tachment
theory.
Within
the
cognitive therapy literature,
the
term
cognitive
schema
has had
multiple meanings (James, Southam,
6k
Blackburn, 2004;
4
RISO
AND
McBRIDE
Segal, 1988; Young
et
al., 2003).
These
definitions
vary
in the
extent
to
which
schemas
are
accessible
or
inaccessible cognitive structures. Nearly
all
definitions, however, maintain
that
cognitive schemas represent highly
generalized
superordinate-level cognition,
that
schemas
are
resistant
to
change,
and
that
they
exert
a
powerful influence over
cognition
and
affect.
As
in
psychoanalytic theory,
the
notion
of
cognitive schemas suggests
the
power
of
unconscious processes
in
influencing thought,
affect,
and
behavior.
However,
unlike
the
psychodynamic
unconscious,
schemas
exert
their
influ-
ence through unconscious information processing, rather
than
through
un-
conscious motivation
and
instinctual drives.
Early
attempts
to
study cognitive schemas used paper-and-pencil mea-
sures
such
as the
Dysfunctional Attitudes
Scale
(Weissman
&
Beck, 1978).
Numerous
studies found
that
currently
ill
individuals consistently scored
higher
on
self-report inventories purportedly measuring dysfunctional
sche-
mas
than
did
control participants
who
were never depressed (see Segal,
1988,
for
review). However, subsequent research demonstrated
that
these
elevated scores normalized with symptomatic recovery (Blackburn, Jones,
&
Lewin, 1986; Giles
&
Rush, 1983; Haaga, Dyck,
&
Ernst, 1991;
Hollon,
Kendall,
&
Lumry, 1986,
Silverman,
Silverman,
&
Eardley,
1984).
The
explanation
for
these
findings,
from
a
schema-theory perspective,
was
that
following
recovery, cognitive schemas became dormant
and
thus
difficult
to
detect.
Therefore,
the
next generation
of
research examined cognitive schemas
using
information-processing tasks.
It was
assumed
that
information tasks
would
be
less prone
to
reporting biases
and
more able
to
detect
latent
schemas, particularly when
these
tasks were accompanied
by an
effort
to
prime
or
activate
the
schema.
In one
such task, individuals made judgments
of
whether
a
number
of
positive
and
negative personal adjectives were
self-
descriptive,
followed
by an
incidental recall test. Results indicated
that
not
only were individuals with depression biased toward recall
of
negative
self-
referent
information (Derry
&
Kuiper,
1981; Dobson
&
Shaw, 1987)
but
also,
and
perhaps more importantly, these
formerly
depressed individuals
were biased
in
their
recall
after
undergoing
a sad
mood
induction
(Hedlund
&
Rude, 1995; Teasdale
&
Dent,
1987).
In
other
work, individuals
who
had
recovered
from
depression made more tracking errors during dichotic
listening
tasks
than
did
control
participants,
who
were
never
depressed,
after
they underwent
a sad
mood induction (Ingram, Bernet,
&
McLaughlin,
1994). Finally, Miranda
and
colleagues (Miranda, Gross, Persons,
&
Hahn,
1998; Miranda, Persons,
&
Byers, 1990) assessed dysfunctional attitudes
in
formerly
depressed versus never depressed individuals. Although
the
groups
exhibited similar levels
of
dysfunctional attitudes
before
any
mood induction,
following
the
mood induction procedure only
the
formerly
depressed group
showed increases
in
their reporting
of
dysfunctional attitudes.
These
and
INTRODUCTION
other studies substantiated
the
notion
that
schemas
are
latent during non-
symptomatic periods
and
become accessible
and
impact cognitive processing
when they
are
activated.
The
importance
of
schemas
in the
development
and
maintenance
of
psychopathology,
as
well
as the
role
of
schemas
in
treatment resistance,
has
much
in
common with
the
Diagnostic
and
Statistical
Manual
of
Mental Disor-
ders
(4th ed.;
DSM-IV;
American Psychiatric Association, 1994) Axis
II
personality disorders. Like personality disorders, schemas represent purport-
edly
stable generalized
themes
that
develop early
in
life
and are
important
considerations
for
understanding
and
treating
a
wide range
of
psychopatho-
logical conditions. Unlike personality disorders, however, schemas
are di-
mensional rather
than
categorical,
are
more cognitive-affective
than
behav-
ioral,
and
were derived
from
the
traditions
of
personality psychology
and
cognitive phenomenology, rather
than
the
traditions
of
operationalized psy-
chiatric nomenclature
and
descriptive psychopathology.
Given
the
accelerating interests
in
personality, temperament,
and de-
velopmental antecedents
of
psychopathology
as
well
as
schema theory,
we
thought
that
a
volume devoted
to
schema theory
and
schema-focused
ap-
proaches
to
clinical problems would
be a
timely
and
important
contribution.
Our
volume examines
how the
general principles
of
schema theory
can be
applied
to
specific
clinical problems.
The
chapters
in
this volume cover
several
major
psychological problems including depression, eating disorders,
posttraumatic stress disorder, substance
use
disorders, obsessive-compulsive
disorder,
and
schizophrenia,
as
well
as
couple distress. Each chapter begins
with basic research
on
schema processes
and
issues
in the
assessment
of
schemas
for
that
particular disorder,
followed
by a
description
of the
clinical
application
of the
schema-focused approach. Each chapter describes
the
implications
of a
schema-focused approach
for
theory, research,
and
practice.
Thus,
this
volume
is
intended
for
either
a
scholar-practitioner
or a
practitioner-scholar with
at
least some
familiarity
with
the
cognitive therapy
literature.
The
contributing authors range
from
clinic directors
to
faculty
members
at
universities
and
university medical schools,
and all
have devel-
oped innovative treatment models
that
combine science with practice.
In
this
volume, several
of the
chapters (i.e.,
chaps.
1, 2, 5, 6, and 8)
draw
heavily
on
Young's (1995; Young
et
al., 2003) notion
of
early maladap-
tive schemas (EMS). Young (1995) described
EMS as
"extremely stable
and
enduring themes
that
develop during childhood
and are
elaborated upon
throughout
an
individual's lifetime"
(p. 9).
EMS, which
contain
underlying
life
themes
and are
assessed with self-report instruments,
differ
somewhat
from
other
definitions
of
schemas
that
emphasize
an
implicit structure
and
organization
of
cognitive
and
affective
elements (Segal, 1988; Segal, Gemar,
Truchon, Guirguis,
&
Horowitz, 1995). According
to the
more "structural"
RISO
AND
McBRIDE
perspective,
the
existence
of a
cognitive schema
can be
demonstrated only
with information-processing tasks.
By
contrast,
the 16
rationally derived
EMS are
assessed with
the
Young
Schema
Questionnaire
(YSQ; Young,
1995).
Examples
of EMS
include
failure
to
achieve, vulnerability
to
harm,
and
emotional deprivation.
There
is
generally good support
for the
YSQ's factor structure (Lee, Taylor,
&
Dunn, 1999; Schmidt, Joiner, Young,
&
Telch,
1995)
and
long-term stability
(Riso
et
al.,
in
press).
EMS
capture
the
verbal
content
of
schemas
and
are
therefore more accessible
than
are
some other definitions primarily
emphasizing
structure.
The
accessibility
of EMS is a
desirable quality
from
a
clinical standpoint
as
they
are
available
for
scrutiny
in
psychotherapy
(Elliot
&
Lassen, 1997).
As
accessible structures
that
reside
at the
level
of
awareness,
EMS fit
closely with
the
notion
of
core
beliefs,
which have been
described
as the
cognitive
content
or
verbal representation
of
schemas
(J.
S.
Beck, 1995; Clark
&
Beck, 1999;
James
et
al., 2004). Both core
beliefs
and
schemas
are
defined
as
stable, overgeneralized belief structures. They
influence
both
the
selection
and
interpretation
of
incoming information,
have varying levels
of
prepotence
or
activation,
and
contain stored
affects
and
cognition. Because
of a
lack
of
adequate theoretical
and
empirical work
to
justify
a
sharp distinction between them,
the
terms
are
sometimes used
interchangeably.
We
refer
to
both
terms
in the
title
of
this volume
and
both
are
used
in the
chapters herein.
The
concept
of
cognitive schemas
was
initially developed
and re-
searched
in the
effort
to
understand depressive disorders. Thus, this volume
begins with
a
chapter
on
cognitive
schemas
and
major depressive disorder.
A
chapter
on
chronic depression (chap.
2) is
included because there
is now
considerable research documenting important
differences
between chronic
and
nonchronic
depression. Moreover,
as
described
in
chapter
2,
there
is
now
good evidence
that
dysfunctional schemas
are
particularly related
to
chronic
forms
of
depression.
Other
chapters adapting Young's (1995) general approach
to
specific
clinical problems include chapter
6 in
which
the
activation
of
painful
EMS
is
described
as a
risk factor
for
relapse
in
substance-related disorders.
In
chapter
7,
Waller
and
colleagues describe
how the
reaction
to EMS can in
part
determine
the
form
of an
eating pathology. Chapter
8
describes
how
underlying
schemas
may
impact
the
form
of
psychotic symptoms.
A
method
of
case formulation
and
specific
interventions
are
then
described
for
individu-
als
with schizophrenia
and
other
forms
of
psychosis.
Chapters
4, 5, and 9 (on
posttraumatic stress disorder, obses-
sive-compulsive disorder,
and
couple distress, respectively)
focus
more
on
theoretical issues
and
directions
for
future
research
as
there
has
been less
effort
to
translate theory
and
research into clinical guidelines
in
these areas.
INTRODUCTION