Even if the techniques described here are successful in improving patients’ understanding of their own functioning, they deploy their full power when put to the service of change. At the peak of the shared formulation stage the therapist and patient have collaboratively reconstructed the latter’s main schemas. They now perceive clearly what the patient is driven by and what self-images underlie the activation of a wish: “I wish to be loved. I feel unlovable, even if at some moments I can see that others would give me attention and it would be reasonable to expect it.” They now have a definite image of the expected or perceived response by the
The decision-making procedure 119 other: “He’s not interested in me, even if I still have a slight hope he could pay attention to me.”
Therapist and patient have also reconstructed the self’s response to the other’s response with much detail: “I think it’s normal for her to leave me, because I do not have qualities, and this makes me feel terribly alone.” The response may further include the full range of behavioural reactions, more or less dysfunctional forms of mastery over the patient’s distressing state: “I withdraw to avoid further distress I am likely to experience when she won’t pay me any attention.”
The formulation of functioning includes the way in which coping schemas get activated when confronted with the other’s response (Chapter 2). “As I can’t be loved for what I am, I hope that, by improving my performance, the other will at least appreciate me." This marks the shift to the social rank motive with perfectionist tendencies.
In the renewed decision-making procedure, our formulation includes the initial awareness of healthy parts: a sense of competence, self-worth and of being lovable, curiosity, dynamic drive and interests. Of course, their presence in a patient’s mind is limited: he may have accessed these healthy parts in-session, perhaps whilst applying a technique, but negative representations of himself and others may persist in his day-to-day life. This is, therefore, the point at which to move on to promoting change.
At this stage we aim to broaden patients’ healthy parts, increase their ability to take a critical distance from maladaptive interpersonal schemas and tolerate suffering, and to interrupt the dysfunctional strategies they use to handle distress, such as rumination to behavioural avoidance. At this stage, patients manage to form a more complex understanding of the other’s mind and, eventually, the impact their actions have on others and how these contribute to relational dysfunctions they demonstrate, that is, how they themselves contribute to forming interpersonal cycles. The techniques stimulate change in many ways.
In MIT we establish change operation hierarchies (Dimaggio, Montano et al., 2015). The first goals are: 7a) to differentiate and 7b) to widen experiential connection with heathy parts. These are separate yet synergistic. On the one hand, acquiring a critical distance from maladaptive schemas requires OR involves assimilating ideas outside one’s schemas and accepting one’s healthy self-parts. For example, recognising that the view of oneself as worthless traces back to one’s development history can almost automatically lead to question its truth and, consequently, to becoming open to the idea, at least embryonically, that one is worthy. On the other hand, accessing healthy parts allows one to review maladaptive representations from a different angle.