Structured summary of events
Once some narrative episodes have been collected and the patient has started to grasp the links connecting events to thoughts, emotional and behavioural aspects of experience, the next step is forming a structured summary of events. The elements in the story should be placed in a sequence starting from the wish and core self-images, followed by descriptions of the other’s response and the self’s reaction, and terminating in the perception that one’s goal will remain unfulfilled.
At this stage it is not yet possible to talk about unravelling a person’s schema, but rather of analysing one or a few episodes that do not necessarily reflect general modes of functioning. A particular schema can be confirmed only if demonstrated in a variety of different episodes across a range of contexts and, if possible, involving different persons.
The structured summary of events initially develops in therapists’ mind, in the form of hypotheses. Once hypotheses can be coherently articulated, therapists will attempt to involve the patient: “Look, let’s try and see if I’ve grasped what you told me.” Therapists start to reconstruct the story, while continuously asking the patients if they perceive themselves as reflected in their words. This is a cognitive strategy that benefits from experiential techniques.
Experiential work makes the links among events, thoughts, emotions and behaviour emerge with greater richness and clarity, which provides clinicians with higher quality information. During an experiential practice the patient feels the emotions, and when the therapist refers back to them in the summary, they resonate with the patient.
Evoking associated autobiographical memories
Before moving on to the next stage one or more narrative episodes need to be retrieved. The goal is to continue collecting material that can be used to theorise about patients’ interpersonal schemas. Multiple episodes are necessary to be analysed in order to confirm the presence of a schema. We say jokingly during our training sessions that, the first key MIT question is “Can you give me an example?”, and the second key question is “Can you give me another example?”
The way we evoke associated memories is rigorous, by: a) summarising the narrative episode by reconstructing the experience in a manner that reflects the schema structure. Therapists communicate their formulation in simple language that makes it possible for patients to identify themselves in the reconstructed narrative; and by b) asking if patients remember having experienced something similar in the past.
This is an example:
So you wanted to act independently, according to your own wishes, but when you saw your partner suffering, you thought you had no right to follow your chosen path and you felt guilty. A part of you, however, rebelled because you considered that it was your right to pursue your plan. Can you recall other episodes from the past where you experienced a situation like this, where you sought your independence yet the other opposed or even obstructed you by communicating that your plans were causing them to suffer? Or situations where, when faced with a suffering other, you felt guilt, anger, frustration, or a mixture of these emotions?
The therapist started from the patient’s wish and presented various aspects of the patient’s experience which the patient could relate to. It is then up to the patient to direct her mind towards scenes she feels to correspond to this summary. Following this stage, the therapist asks for feedback to further hone her formulation to a version the patient agrees with.
If necessary, and often it should be done by default, therapists validate the patients’ experiences: “I can understand why you felt forsaken and angry.” Then, once she has ensured that the patient feels welcomed, she goes on to ask for associated memories: "Do any other episodes come to mind where you hoped to be welcomed and the person you were expecting to be supportive or welcoming failed to provide guidance and abandoned you or made you angry?”
Alternatively, if a patient is aware that the feelings and thoughts described in the episode are typical of him or, better still, if he realises that it is a problematic experience he would like to free himself of, the therapist can pose more direct questions: “How did you come to believe that your need or your wish would not be satisfied? Where does this strong sensitivity to signs of being abandoned come from?”
When confronted with such questions, patients very often recall relevant memories, allowing for a shared formulation of schemas. Memories of one’s developmental history are welcome, but not indispensable; if patients have difficulty retracing distant memories, therapists look elsewhere!
Even if remote memories do not surface, it is possible to help patients understand their experiences are schema-driven. The therapist will quietly accept it is not always possible to recall the past. MIT is not based on a systematic reconstruction of patients’ life stories. Nor is it interested in the origins of a disorder, which often remain unknown. The useful thing is for patients to arrive at understanding that their ways of thinking, feeling and acting are schema-driven and do not necessarily reflect an accurate interpretation of reality. A requirement to achieving this is the collection of narrative episodes with a recurring structure. It is of little importance whether they are recent or distant. Therefore, if patients lack memories from their early years, which are often not effortfully processed for long-term retention, therapists ask them to pay attention to any moments over the next week that resemble, to a lesser or greater extent, the same patterns of maladaptive emotions, thoughts and actions. Therapists ask patients to note down their experience, either mentally, in writing, or through a voice memo, in order to relate this new narrative episode in the next session. Over time, patients manage to perceive that certain intrapsychic and relational functioning experiences constitute repetitive patterns that are schema-driven.
A range of techniques can be very helpful during this stage. While reviewing a recent memory, therapists can use body-focused techniques (Chapter 7) and stimulate an experiential connection with emotional and somatic states, which become the focal point that resonates with the patients the most in the here and now. A therapist uses these somatic states to trigger related memories: “Now you feel this sensation of anxiety and can sense that it is accompanied by a tightening of your stomach. Does some image from the past come to mind? Can you remember yourself experiencing this sensation, your stomach feeling tight?” If a patient describes details of the expressions, tones of voice and gestures of the person he interacted with, the therapist can suggest that he concentrate on these details and ask him if they recall someone in particular.
Enrico was 40 years old and suffered from covert narcissism with depressive personality traits. During guided imagery he was reliving a board meeting, when he presented a report to his colleagues in the data processing firm where he worked. The therapist asked him to describe the faces he noticed. Enrico scanned the situation and then concentrated on the face of one colleague.
T: “What’s the face like?”
E: “Impenetrable. Hard, stern, eyes covered by glasses, as if it were a screen.”
T: “How do you feel when you see that face?”
E: “Ill. Tense.”
T: “Can you help me define this tension? Where do you feel it physically?”
E: “On my shoulders, like a weight.”
T: “Like a feeling of disappointment?”
E: “Hmm.... Yes, kind of. It’s wearing me down. I’m feeling less confident in my report.”
T: “Can you tell me anything else about this face?”
E: “It’s harsh, cold. I know she won’t like anything that I’m saying.”
T: “How do you feel now?”
E: “The tension’s increased. A bit of anxiety too now.”
When the guided imagery was over, the therapist asked Enrico to focus again on the face.
T: “And how’s your muscular tension now?”
E: “It comes back as soon as I pay attention to my colleague’s face.”
T: “What emotion could it be? What might happen? What would you like to do in the presence of that face?”
E: “Get away.”
T: “What could your colleague do to you?”
E: “Perhaps... anxiety, I’m afraid she would criticise me.”
T: “Excellent. Now you’re faced with a face that’s cold, stern and impenetrable, and you’re afraid that some criticism is to be expected. Is this a scene familiar to you? Is there any face from your past that looks at you in the same way?”
Enrico grimaced and the therapist noticed this immediately.
T: “Enrico, your face changed, as if it were twitching with pain. Is that right? Has something come to mind?”
E: “I didn’t think we’d get this far. I can see my mother’s face. That expression where she pretends everything’s going well and you know very well that, whatever you do, she won’t like it.”
The therapist asked Enrico to describe a situation where he was interacting with his mother while she wore this expression. Lots of memories surfaced. Enrico chose the one when he told her he wanted to enrol in a data processing course instead of law school. This episode helped him reconstruct how his expectation of being obstructed and criticised if he expressed independent drives and desires was rooted in his mother’s invalidating and judgemental attitude towards him.
Using the psychological knowledge accrued from narrative episodes first related in detail and then relived in-session, for example during a guided imagery exercise, it is possible to collaboratively redefine a schema for patients to recognise as their own. A patient might narrate an initial episode, communicating she desired approval but instead felt criticised, and sharing a relevant memory, drawn from her developmental history, of her mother criticising her and making her feel guilty. Let us imagine that with guided imagery she relives an episode with her mother. Anger surfaces, because she feels the criticism to be unfair, and feelings of solitude are evoked at the realisation of her mother’s inability to listen to her and accept her. These thoughts and emotions remain impressed in her memory.
The therapist therefore redefines the schema in a way that resonates with the patient:
You hold on to your wish to be appreciated, which is normal as it is one of the most powerful engines driving us in adult life. However, it’s as if you’ve learnt that, when you expose yourself to the other’s gaze, their reaction will be judgemental, sometimes harsh and disdainful, as in the episode with your mother. At this point you feel a sense of disappointment and defeat, because for a moment you really believe you’re worthless. Then you rebel, you feel you deserve appreciation. In the end, you’re end up with feelings of solitude, related to the fact that your mother did not accept you for who you were. You still have these sensations, which you experienced so vividly during our imagery game today. You think the hope of being appreciated is remote and that criticism will prevail.
Patients will feel such a formulation as their own and are more likely to memorise it.
Reconstructing dysfunctional coping and self-regulation strategies
In addition to providing a reconstruction of schemas, therapists show to patients that part of their suffering is due to processes preceding, accompanying, or following schema-activating situations.
Such processes may include repetitive thought, such as worry or rumination (Chapter 2). Patients are likely to adopt these strategies while in the midst of interactions activating their schemas. For example, paranoid and avoidant patients will monitor relational threats during their conversations: “How am I to understand if he’s going to criticise or cheat me? However, if I behave in a certain way, I can deceive him myself or hide my flaws. But he’s attentive and might still find a way to uncover my defences. Let me try to understand what he really means. Maybe he’s setting up a trap.”
Very often patients activate strategies based on relational avoidance, like a person with Obsessive-Compulsive PD who spent decades avoiding asking his employer for a promotion or a raise he deserved, because he felt morally unworthy. Just as common is the adoption of dysfunctional behavioural coping: alcohol and drug abuse, risky behaviour, workaholism, compulsions/rituals, a persistent search for reassurance, manipulation and so on. The list of coping/self-regulation behavioural strategies is long and therapists should understand in collaboration with patients which strategies are activated in response to schema-related suffering. We help the patients understand how in the long term such strategies amplify the negative emotions they would like to avoid, activate other negative emotions and reduce the likelihood they will fulfil their wishes.
Once the schema has been reconstructed and links between maladaptive strategies and long-term distress have been established, there is often a germ of differentiation, with the patient being able, almost on her own, to admit to herself: “But is it then me that’s still trying to come to terms with my mother’s views?” This is the first step towards steering away from views of oneself as worthless or of others being unfair to oneself. This awareness is one of the pillars for progressing to the stage of change promoting.