Schema Therapy

Schema Therapy in London

Schema-Focused Cognitive Therapy - Treatment for Lifelong Patterns

This cognitive-development model is based on the assumption that many negative cognitions have their roots in past experiences.

Schema-Focused Cognitive Therapy proposes an integrative systematic model of treatment for a wide spectrum of chronic, difficult and characterological problems. Jeffrey Young developed the schema-focussed approach to deliberately address lifelong, self-defeating patterns called early maladaptive schemas. Over a period of 15 years, Young and associates identified 18 early maladaptive schemas through clinical observation, as opposed to the concept of unconscious phantasy, or unproven theory.

A basic premise of Jeffrey Young’s approach is that individuals with more complex problems have one or more early maladaptive schemas. He felt that the more pure form of cognitive therapy he had learned during his training with Aaron Beck was insufficient for treating these types of problems.

What is an Early Maladaptive Schema (EMS)?

An early maladaptive schema has been defined by Jeffrey Young as ‘a broad pervasive theme or pattern regarding oneself and one's relationship with others, developed during childhood and elaborated throughout one's lifetime, and dysfunctional to a significant degree’. Schemas are extremely stable and enduring patterns, comprising of memories, bodily sensations, emotions, cognitions and once activated intense emotions are felt. When a person has an EMS like abandonment, they have all the memories of early abandonment, the emotions of anxiety or depression, which are attached to abandonment, bodily sensations and thoughts that people are going to leave them. An Early Maladaptive Schema, therefore, is the deepest level of cognition that contains memories and intense emotions when activated.

What is the origin of early maladaptive schemas?

The three basic origins are:

1. Early childhood experiences. 2. The innate temperament of the child.3. Cultural influences.

It is believed that the combination of these three lead to early maladaptive schemas.

What type of early childhood experiences lead to the acquisition of schemas?

The child who does not get his/her core needs met. The child needed affection, empathy and guidance but didn’t get it etc.

The child who is traumatised or victimised by a very domineering, abusive, or highly critical parent.

The child who learns primarily by internalising the parent’s voice. Every child internalises or identifies with both parents and absorbs certain characteristics of both parents, so when the child internalises the punitive punishing voice of the parent and absorbs the characteristics they become schemas.

The child who receives too much of a good thing. The child who is overprotected, overindulged or given an excessive degree of freedom and autonomy without any limits being set.

Therefore Early Maladaptive Schemas began with something that was done to us by our families or by other children, which damaged us in some way. We might have been abandoned, criticised, overprotected, emotionally or physically abused, excluded or deprived and, consequently, the schema becomes part of us.

Schemata are essentially valid representations of early childhood experiences, and serve as templates for processing and defining later behaviours, thoughts, feelings and relationships with others.

Early maladaptive schemas include entrenched patterns of distorted thinking, disruptive emotions and dysfunctional behaviours. These schemata become fixed when they are reinforced and/or modelled by parents.

Long after we leave the home we grew up, we continue to create situations in which we are mistreated, ignored, put down or controlled and in which we fail to reach our desired goals.

Schemata are perpetuated throughout one’s lifetime and become activated under conditions relevant to that particular schema.

Schema domains and developmental needs:

A schema domain is a grouping of schema resulting from the frustration of related developmental needs. The schemas are grouped into five categories, the notion is that children have certain developmental needs, and each of the five domains relates to one grouping of childhood needs, and then the schemas are grouped into these five broad areas of needs, so, for example disconnection and rejection domain has to do with the child’s need for love, attention, connection and acceptance and schemas that are learned and frustrate those needs, e.g. when a child doesn’t get enough attention or love they develop an emotional deprivation schema which is part of disconnection and rejection domain.

Changing early maladaptive schemas

One of the reasons that schemas are hard to change is because they are not stored through logic, but in an emotional part of the brain called the amygdala, as opposed to a part of the brain that’s readily amenable to logical analysis or discourse. They are self-perpetuating, very resistant to change and usually do not go away without therapy.

Schema-Focused Cognitive Therapy utilises encompasses a variety of techniques to address the varied psychological and behavioural problems presented by clients, including experimental, cognitive, behavioural and interpersonal (object relations) techniques. Another recent development in the treatment of trauma is Eye Movement Desensitisation and Reprocessing (EMDR). When used as an adjunct to Schema-Focused Cognitive Therapy, EMDR processing, can often be helpful in changing the meaning of early painful memories, which have resulted in negative core beliefs and schemas. (see EMDR)

It is important to realise that schemas can be functional or dysfunctional and are core cognitive constructs in what is typically referred to as our personality style.

For example, someone may have a schema of personal incompetence, from which his or her actions are consistently interpreted as “not good enough". Someone else may have a schema of mistrust, from which all interpersonal actions by others are seen as suspicious. A third person may have a dependency schema and feel unable to function alone without help. Even when presented with evidence that disproves the schema, individuals distort data to maintain its validity. Some schemas are developed in the preverbal period and therefore the most central core early maladaptive schemas are the ones developed in the preverbal stage. It is these preverbal schemas that tend to be entrenched and absolute, whilst the later ones tend to be conditional.

Early maladaptive schemas are typically unconditional themes (entrenched beliefs and feelings) held by individuals, which are often linked to the individual’s self-concept and that of the environment. Because of this concept, together with the fact that schemata begin so early in life, people feel secure in knowing who they are and what their world is like. This sense of secureness and predictability is comfortable and familiar, making it difficult to change without therapy.

How are schemas maintained?

Once a childhood pattern is established we tend to repeat it over and over. Freud called this 'repetition compulsion'. It refers to the universal tendency of individuals to repeat in their lives distressing or even painful situations without realising they are doing so, or even understanding they are bringing about the recurrence and repeating in their current situations the worst times from the past. Somehow people manage to create, in adult life, conditions remarkably similar to those that were so destructive in childhood. An example is a woman who took emotional care (self-sacrifice or subjugation) of her father who was emotionally depriving. Later in life the tendency could be to go after a man who in one way was unavailable or emotionally unstable, unaware of the similarity with her father. A schema is all the ways in which we recreate these patterns.

The above example explains why individuals are likely to be drawn to partners where there is a high degree of chemistry, as this triggers their schemas, even when they are not objectively healthy for them. People with (EMS) tend to be drawn to partners who trigger their core schemas and that maladaptive partner selection is another strong mechanism through which schemas are maintained.

There are three broad coping styles, which ultimately reinforce the schemata through avoiding experiencing painful emotions associated with schema activation. These coping styles are processes that overlap with the psychoanalytical concepts of resistance and defence mechanisms:

Schema surrender

– everything the person does to keep the schema going, by remaining in the situation and doing things to keep the schema going, e.g. if someone has a defectiveness schema and they stay in a relationship with someone who has criticised them, they are surrendering to the schema, they are staying in the situation but allowing themselves to be criticised thus enhancing the schema.

Schema avoidance

is avoiding the schema either by avoiding situations that trigger the schema or by psychologically removing yourself from the situation so you don’t have to feel the schema. An example of avoidance might be the person with a mistrust schema who avoids making friendships because of the fear of being hurt or taken advantage of. This action only tends to reinforce the belief when others pick up the coolness and distance themselves.

Schema overcompensation

is an excessive attempt to fight the schema by trying to do the opposite of what the schema would tell you to do. So if someone has a subjugation schema, they might rebel against the people who are subjugating them. If the overcompensation is too extreme it ultimately backfires and reinforces the schema. A form of overcompensation is externalising the schema, by blaming others and becoming aggressive. Another way can be achieving at a very high level, whereby, a person who feels defective works 80 hours a week to overcompensate.

The Schema-Focused model of treatment is designed to help people break these maladaptive coping styles which perpetuate negative patterns of thinking, feeling and behaving, so that individuals can get their core needs met.

How does schema-focused cognitive therapy differ from traditional cognitive therapy?

In comparison with standard cognitive therapy, schema therapy probes more deeply into early life experiences. It utilises experimental, cognitive, behavioural and interpersonal (object relations) techniques, which promotes higher levels of affect in sessions and is somewhat longer-term.

A greater use is placed on the therapy relationship as a means for change with the therapist working directly and collaboratively with the client, in identifying and modifying any schema driven thoughts and feeling that are activated in or outside of the session.

By switching between past events and current problems, using imagery and role playing, higher levels of affect are activated. Using imagery and elaborate discussion of early life experiences, clients are able to understand where the dysfunctional schema originated from and how it is being maintained.

However, because insight rarely leads to change; schema-focussed therapy utilises cognitive, behavioural and interpersonal techniques including empathetic reality testing, whereby, the therapist fully acknowledges and validates distressing feelings and schema-driven beliefs, while pointing out another more accurate view. This process serves to challenge and modify negative thoughts and behaviours, which are rigidly intact.

Is schema-focused therapy right for you?

Schema-focused therapy deals with life long patterns rather than current situations, which have arisen. Because schemas are dimensional it is not whether you have it or you don’t have it that’s relevant but how much do you have it. In other words how intense is the schema when it’s activated and how pervasive and broadly does it affect your life.

Some of these problems and signs that could indicate you probably have an early maladaptive schema influencing your life include being stuck in some area of your life which you don’t seem to be able to change, feelings of inadequacy, loneliness, relapsing depression, dependency on others, problems choosing appropriate partners, and being out of touch with one's feelings. Presenting problems, which are chronic or long-term, eating disorders, drug abuse, relapsing depression, ridged thinking and behaviour patterns.

Those with presenting problems, which are vague but pervasive and those with existential problems such as feeling life has no meaning - I don’t know what life is about - Feeling slightly down on a regular basis. Other signs include those with long-term relationship problems. Choosing the wrong partners, getting into relationships where you always feel criticised, deprived, controlled, always fighting and feeling angry - displaying repetitive patterns.

Cognitive therapy is often combined with schema therapy and focuses on exactly what traditional therapies tend to leave out — how to achieve beneficial change, as opposed to mere explanation or “insight.” Because understanding the past is rarely curative without change, both traditional cognitive therapy and schema focussed cognitive therapy are structured and systematic, helping clients to identify, challenge and change core cognitive schemas.

The main goals of schema-focussed therapy are:

identifying early maladaptive schemas which are maintaining the client’s presenting problem and seeing how they are played out in everyday situations

changing dysfunctional beliefs and building alternative beliefs, which can be used to fight the schemas

breaking down maladaptive life patterns into manageable steps and changing the coping styles, which maintain the schemas, one step at a time

providing clients with the skills and experiences that create adaptive thinking and healthy emotions

empowering clients and validating their emotional needs that were not met, so that their needs will be met in everyday life.

The 18 identified early maladaptive schemas have been organised into five themes known as domains. Each of the five domains contain categories of schemata which represents an important component of a child’s core needs. When these needs are not met negative schemas may develop, resulting in unhealthy life patterns:

Domain i: DISCONNECTION & REJECTION

Schemas in this domain result from early experiences of a detached, explosive, unpredictable, or abusive family environment. People with these schemas expect that their needs for security, safety, stability, nurturance, and empathy in intimate or family relationships will not be met in a consistent or predictable way.

Abandonment/Instability

This schema refers to the expectation that one will soon lose anyone with whom an emotional attachment is formed. The person believes that one way or another close relationships will end imminently. This schema usually occurs when the parent has been inconsistent in meeting the child's needs.

Mistrust

This schema refers to the expectation that others will intentionally take advantage in some way. People with this schema expect others to hurt, cheat, or put them down. Often significant others were abusive emotionally or sexually and betrayed the child's trust.

Emotional Deprivation

This schema refers to the belief that others will never meet ones primary emotional needs. These needs include nurturance, empathy, affection, protection, guidance and caring from others. Often significant others were emotionally depriving to the child.

Social Isolation/ Alienation

This schema refers to the belief that one is isolated from the world, different from others, and/or not part of any community. This belief is usually caused by experiences in which children see that either they, or their families, are different from other people.

Defectiveness/ Shame

This schema refers to the belief that one is internally flawed, and that, if others get close, they will realize this and withdraw from the relationship. This feeling of being flawed and inadequate often leads to a strong sense of shame. Generally, parents were very critical of their children and made them feel not worthy of being loved.

Social Undesirability

This schema refers to the belief that one is outwardly unattractive to others. People with this schema see themselves as physically unattractive, socially inept, or lacking in status. Usually there is a direct link to childhood experiences in which children are made to feel, by family or peers, that they are not attractive.

Failure to Achieve

This schema refers to the belief that one is incapable of performing as well as one's peers in areas such as career, school, or sports. These clients may feel stupid, inept, untalented, or ignorant. People with this schema often do not try to achieve, because they believe that they will fail. This schema may develop if children are put down and treated as if they are a failure in school or other spheres of accomplishment. Usually the parents did not give enough support, discipline, and encouragement for the child to persist and succeed in areas of achievement such as schoolwork or sports.

Domain ii: IMPAIRED AUTONOMY & PERFORMANCE

Schemas in this domain have to do with expectations about oneself and the environment that interfere with one's ability to separate and function independently and one' s perceived ability to survive alone. The typical family of origin is enmeshed, undermining of the child's judgement, or overprotective.

Dependence/Incompetence

This schema refers to the belief that one is not capable of handling day-to-day responsibilities competently and independently. People with this schema often rely on others excessively for help in areas such as decision making and initiating new tasks. Usually parents who did not encourage these children to act independently and develop confidence in their ability to take care of themselves.

Vulnerability to Harm and Illness

This schema refers to the belief that one is always on the verge of experiencing a major catastrophe (financial, natural, medical, criminal, etc.). It may lead to taking excessive precautions to protect oneself. Usually there was an extremely fearful parent who passed on the idea that the world is a dangerous place.

Enmeshment/Undeveloped Self

This schema refers to the sense that one has too little individual identity or inner direction. There is often a feeling of emptiness or of floundering. This theme is usually developed from parents who are so controlling; abusive, or overprotective that the child is discouraged from developing a separate sense of self.

Failure

This schema refers to the belief that one has failed, will fail, or is fundamentally inadequate compared to others. Parents, who did not give enough support, expected the child to fail, treated him/her as stupid and/or never taught the child the discipline to succeed, usually cause this belief.

Domain iii: IMPAIRED LIMITS

Schemas in this domain relate to deficiencies in internal limits, respect and responsibility to others, or meeting realistic personal goals. The typical family origin is permissiveness and indulgence.

Entitlement/Self-Centeredness

This schema refers to the belief that you should be able to do, say, or have whatever you want immediately, regardless of whether that hurts others or seems unreasonable to them. You are not interested in what other people need, nor are you aware of the long-term costs to you of alienating others. Parents who overindulge their children and who do not set limits about what is socially appropriate, may promote the development of this schema. Alternatively, some children develop this schema to compensate for feelings of emotional deprivation, defectiveness, or social undesirability.

Insufficient Self-Control/Self-Discipline (Low Frustration Tolerance)

This schema refers to the inability to tolerate any frustration in reaching one's goals, as well as an inability to restrain expression of one's impulses or feelings. When lack of self-control is extreme, criminal, or addictive behaviour rule your life. Parents who did not model self-control, or who did not adequately discipline their children, may predispose them to have this schema as adults.

Domain iv: OTHER-DIRECTNESSSchemas in this domain relate to an excessive focus on meeting the needs of others, at the expense of one’s own needs. The typical family origin is based on conditional acceptance, whereby children suppress normal needs and emotions in order to gain attention, approval and love.

Subjugation

This schema refers to the belief that one must submit to the control of others in order to avoid negative consequences. Often these clients fear that, unless they submit, others will get angry or reject them. Clients who subjugate ignore their own desires and feelings. In childhood there was generally a very controlling parent.

Self-Sacrifice

This schema refers to the excessive sacrifice of one's own needs in order to help others. When these clients pay attention to their own needs, they often feel guilty. To avoid this guilt, they put others' needs ahead of their own. Often people whom self-sacrifice gain a feeling of increased self-esteem or a sense of meaning from helping others. In childhood the person may have been made to feel overly responsible for the well being of one or both parents.

Approval-Seeking

This schema refers to an excessive emphasis on gaining approval and recognition from others at the expense of one’s own ideas. May involve an overemphasis on status, money, and achievement. Usually parents who were concerned with social status, appearance by others, or offered conditional acceptance etc.

Domain v: OVERVIGILANCE & INHIBITION

Schemas in this domain involve an excessive focus of controlling, suppressing, or ignoring of one's emotions and spontaneous feelings in order to avoid making mistakes, or meeting rigged internalised rules. Typical family origins are domination and suppression of feelings, or a bleak environment where performance standards and self-control take priority over pleasure and playfulness

Negativity/Vulnerability to Error

This schema refers to an exaggerated expectation that things will go wrong at any moment, an inordinate fear of making mistakes that could lead in that direction. “That which can go wrong, will!” This may involve financial loss, humiliation, making mistakes leading to excessive worrying. Parents who were pessimistic, worried, or expected the worst outcome.

Overcontrol/Emotional Inhibition

This schema refers to the belief that you must inhibit emotions and impulses, especially anger, because any expression of feelings would harm others, or lead to loss of self-esteem, embarrassment, retaliation, or abandonment. You may lack spontaneity, or be viewed as uptight. Usually parents who discourage the expression of feelings often bring on this schema.

Unrelenting Standards/Hypercriticalness

This schema refers to two related beliefs. Either you believe that whatever you do is not good enough, that you must always strive harder; and/or there is excessive emphasis on values such as status, wealth, and power, at the expense of other values such as social interaction, health, or happiness. Usually these clients' parents were never satisfied and gave their children love that was conditional on outstanding achievement.

Punitiveness

This schema refers to the belief that one must be angry and harshly punishing with those people (including oneself) who do not meet one’s (high) expectations or standards. Usually these parents blamed, punished, or were verbally abusive when mistakes were made.

The Schema Therapy Model

The four main concepts in the Schema Therapy model are: Early Maladaptive Schemas, Schema Domains, Coping Styles, and Schema Modes.

The 18 Early Maladaptive Schemas are self-defeating, core themes or patterns that we keep repeating throughout our lives.

The Schema Domains define 5 broad categories of emotional needs of a child (connection, mutuality, reciprocity, flow and autonomy). When these needs are not met, schemas develop that lead to unhealthy life patterns. The 18 schemas are grouped into these 5 categories, that correspond to specific emotional needs. Coping Styles refer to the ways a child adapts to damaging childhood experiences. For example, some surrender to their schemas; some find ways to block out or escape from pain; while others fight back or overcompensate.

Schema Modes are the moment-to-moment emotional states and coping responses that we all experience. Our maladaptive schema modes are triggered by life situations that we are oversensitive to (our "emotional buttons"). Many schema modes lead us to over or under react to situations and, thus, to act in ways that end up hurting us or others.

The goal of schema therapy is to help patients get their core emotional needs met. Key steps in accomplishing this involve learning how to:

Stop using maladaptive coping styles and modes that block contact with feelings

Heal schemas and vulnerable modes through getting needs met in and outside of the therapeutic relationship

Incorporate reasonable limits for angry, impulsive or overcompensating schemas and modes

Fight punitive, overly critical or demanding schemas and modes

Build healthy schemas and modes

Early Maladaptive Schemas

The most basic concept in Schema Therapy is an Early Maladaptive Schema. We define schemas as: "broad, pervasive themes regarding oneself and one's relationship with others, developed during childhood and elaborated throughout one's lifetime, and dysfunctional to a significant degree."

Schemas develop in childhood from an interplay between the child's innate temperament, and the child's ongoing damaging experiences with parents, siblings, or peers.

Because they begin early in life, schemas become familiar and thus comfortable. We distort our view of the events in our lives in order to maintain the validity of our schemas. Schemas may remain dormant until they are activated by situations relevant to that particular schema.

DISCONNECTION & REJECTION

(Expectation that one's needs for security, safety, stability, nurturance, empathy, sharing of feelings, acceptance, and respect will not be met in a predictable manner. Typical family origin is detached, cold, rejecting, withholding, lonely, explosive, unpredictable, or abusive.)

1. ABANDONMENT / INSTABILITY (AB)

The perceived instability or unreliability of those available for support and connection.

Involves the sense that significant others will not be able to continue providing emotional support, connection, strength, or practical protection because they are emotionally unstable and unpredictable (e.g., angry outbursts), unreliable, or erratically present; because they will die imminently; or because they will abandon the patient in favor of someone better.

2. MISTRUST / ABUSE (MA)

The expectation that others will hurt, abuse, humiliate, cheat, lie, manipulate, or take advantage. Usually involves the perception that the harm is intentional or the result of unjustified and extreme negligence. May include the sense that one always ends up being cheated relative to others or "getting the short end of the stick."

3. EMOTIONAL DEPRIVATION (ED)

Expectation that one's desire for a normal degree of emotional support will not be adequately met by others. The three major forms of deprivation are:

A. Deprivation of Nurturance: Absence of attention, affection, warmth, or companionship.B. Deprivation of Empathy: Absence of understanding, listening, self-disclosure, or mutual sharing of feelings from others.C. Deprivation of Protection: Absence of strength, direction, or guidance from others.

4. DEFECTIVENESS / SHAME (DS)

The feeling that one is defective, bad, unwanted, inferior, or invalid in important respects; or that one would be unlovable to significant others if exposed. May involve hypersensitivity to criticism, rejection, and blame; self-consciousness, comparisons, and insecurity around others; or a sense of shame regarding one's perceived flaws. These flaws may be private (e.g., selfishness, angry impulses, unacceptable sexual desires) or public (e.g., undesirable physical appearance, social awkwardness)

5. SOCIAL ISOLATION / ALIENATION (SI)

The feeling that one is isolated from the rest of the world, different from other people, and/or not part of any group or community.

IMPAIRED AUTONOMY & PERFORMANCE

(Expectations about oneself and the environment that interfere with one's perceived ability to separate, survive, function independently, or perform successfully. Typical family origin is enmeshed, undermining of child's confidence, overprotective, or failing to reinforce child for performing competently outside the family.)

6. DEPENDENCE / INCOMPETENCE (DI)

Belief that one is unable to handle one's everyday responsibilities in a competent manner, without considerable help from others (e.g., take care of oneself, solve daily problems, exercise good judgment, tackle new tasks, make good decisions). Often presents as helplessness.

7. VULNERABILITY TO HARM OR ILLNESS (VH)

Exaggerated fear that imminent catastrophe will strike at any time and that one will be unable to prevent it. Fears focus on one or more of the following: (A) Medical Catastrophes: e.g., heart attacks, AIDS; (B) Emotional Catastrophes: e.g., going crazy; (C) External Catastrophes: e.g., elevators collapsing, victimized by criminals, airplane crashes, earthquakes.

8. ENMESHMENT / UNDEVELOPED SELF (EM)

Excessive emotional involvement and closeness with one or more significant others (often parents), at the expense of full individuation or normal social development. Often involves the belief that at least one of the enmeshed individuals cannot survive or be happy without the constant support of the other. May also include feelings of being smothered by, or fused with, others OR insufficient individual identity. Often experienced as a feeling of emptiness and floundering, having no direction, or in extreme cases questioning one's existence.

9. FAILURE (FA)

The belief that one has failed, will inevitably fail, or is fundamentally inadequate relative to one's peers, in areas of achievement (school, career, sports, etc.). Often involves beliefs that one is stupid, inept, untalented, ignorant, lower in status, less successful than others, etc.

IMPAIRED LIMITS

(Deficiency in internal limits, responsibility to others, or long-term goal-orientation. Leads to difficulty respecting the rights of others, cooperating with others, making commitments, or setting and meeting realistic personal goals. Typical family origin is characterized by permissiveness, overindulgence, lack of direction, or a sense of superiority -- rather than appropriate confrontation, discipline, and limits in relation to taking responsibility, cooperating in a reciprocal manner, and setting goals. In some cases, child may not have been pushed to tolerate normal levels of discomfort, or may not have been given adequate supervision, direction, or guidance.)

10. ENTITLEMENT / GRANDIOSITY (ET)

The belief that one is superior to other people; entitled to special rights and privileges; or not bound by the rules of reciprocity that guide normal social interaction. Often involves insistence that one should be able to do or have whatever one wants, regardless of what is realistic, what others consider reasonable, or the cost to others; OR an exaggerated focus on superiority (e.g., being among the most successful, famous, wealthy) -- in order to achieve power or control (not primarily for attention or approval). Sometimes includes excessive competitiveness toward, or domination of, others: asserting one's power, forcing one's point of view, or controlling the behavior of others in line with one's own desires -- without empathy or concern for others' needs or feelings.

11. INSUFFICIENT SELF-CONTROL / SELF-DISCIPLINE (IS)

Pervasive difficulty or refusal to exercise sufficient self-control and frustration tolerance to achieve one's personal goals, or to restrain the excessive expression of one's emotions and impulses. In its milder form, patient presents with an exaggerated emphasis on discomfort-avoidance: avoiding pain, conflict, confrontation, responsibility, or overexertion -- at the expense of personal fulfillment, commitment, or integrity.

OTHER-DIRECTEDNESS

(An excessive focus on the desires, feelings, and responses of others, at the expense of one's own needs -- in order to gain love and approval, maintain one's sense of connection, or avoid retaliation. Usually involves suppression and lack of awareness regarding one's own anger and natural inclinations. Typical family origin is based on conditional acceptance: children must suppress important aspects of themselves in order to gain love, attention, and approval. In many such families, the parents' emotional needs and desires -- or social acceptance and status -- are valued more than the unique needs and feelings of each child.)

12. SUBJUGATION (SB)

Excessive surrendering of control to others because one feels coerced -- usually to avoid anger, retaliation, or abandonment. The two major forms of subjugation are:A. Subjugation of Needs: Suppression of one's preferences, decisions, and desires.B. Subjugation of Emotions: Suppression of emotional expression, especially anger.Usually involves the perception that one's own desires, opinions, and feelings are not valid or important to others. Frequently presents as excessive compliance, combined with hypersensitivity to feeling trapped. Generally leads to a build up of anger, manifested in maladaptive symptoms (e.g., passive-aggressive behavior, uncontrolled outbursts of temper, psychosomatic symptoms, withdrawal of affection, "acting out", substance abuse).

13. SELF-SACRIFICE (SS)

Excessive focus on voluntarily meeting the needs of others in daily situations, at the expense of one's own gratification. The most common reasons are: to prevent causing pain to others; to avoid guilt from feeling selfish; or to maintain the connection with others perceived as needy. Often results from an acute sensitivity to the pain of others. Sometimes leads to a sense that one's own needs are not being adequately met and to resentment of those who are taken care of. (Overlaps with concept of codependency.)

14. APPROVAL-SEEKING / RECOGNITION-SEEKING (AS)

Excessive emphasis on gaining approval, recognition, or attention from other people, or fitting in, at the expense of developing a secure and true sense of self. One's sense of esteem is dependent primarily on the reactions of others rather than on one's own natural inclinations. Sometimes includes an overemphasis on status, appearance, social acceptance, money, or achievement -- as means of gaining approval, admiration, or attention (not primarily for power or control). Frequently results in major life decisions that are inauthentic or unsatisfying; or in hypersensitivity to rejection.

OVERVIGILANCE & INHIBITION

(Excessive emphasis on suppressing one's spontaneous feelings, impulses, and choices OR on meeting rigid, internalized rules and expectations about performance and ethical behavior -- often at the expense of happiness, self-expression, relaxation, close relationships, or health. Typical family origin is grim, demanding, and sometimes punitive: performance, duty, perfectionism, following rules, hiding emotions, and avoiding mistakes predominate over pleasure, joy, and relaxation. There is usually an undercurrent of pessimism and worry -- that things could fall apart if one fails to be vigilant and careful at all times.)

15. NEGATIVITY / PESSIMISM (NP)

A pervasive, lifelong focus on the negative aspects of life (pain, death, loss, disappointment, conflict, guilt, resentment, unsolved problems, potential mistakes, betrayal, things that could go wrong, etc.) while minimizing or neglecting the positive or optimistic aspects. Usually includes an exaggerated expectation -- in a wide range of work, financial, or interpersonal situations -- that things will eventually go seriously wrong, or that aspects of one's life that seem to be going well will ultimately fall apart. Usually involves an inordinate fear of making mistakes that might lead to: financial collapse, loss, humiliation, or being trapped in a bad situation. Because potential negative outcomes are exaggerated, these patients are frequently characterized by chronic worry, vigilance, complaining, or indecision.

16. EMOTIONAL INHIBITION (EI)

The excessive inhibition of spontaneous action, feeling, or communication -- usually to avoid disapproval by others, feelings of shame, or losing control of one's impulses. The most common areas of inhibition involve: (a) inhibition of anger & aggression; (b) inhibition of positive impulses (e.g., joy, affection, sexual excitement, play); (c) difficulty expressing vulnerability or communicating freely about one's feelings, needs, etc.; or (d) excessive emphasis on rationality while disregarding emotions.

17. UNRELENTING STANDARDS / HYPERCRITICALNESS (US)

The underlying belief that one must strive to meet very high internalized standards of behavior and performance, usually to avoid criticism. Typically results in feelings of pressure or difficulty slowing down; and in hypercriticalness toward oneself and others. Must involve significant impairment in: pleasure, relaxation, health, self-esteem, sense of accomplishment, or satisfying relationshipsUnrelenting standards typically present as: (a) perfectionism, inordinate attention to detail, or an underestimate of how good one's own performance is relative to the norm; (b) rigid rules and &qout;shoulds&qout; in many areas of life, including unrealistically high moral, ethical, cultural, or religious precepts; or (c) preoccupation with time and efficiency, so that more can be accomplished.

18. PUNITIVENESS (PU)

The belief that people should be harshly punished for making mistakes. Involves the tendency to be angry, intolerant, punitive, and impatient with those people (including oneself) who do not meet one's expectations or standards. Usually includes difficulty forgiving mistakes in oneself or others, because of a reluctance to consider extenuating circumstances, allow for human imperfection, or empathize with feelings.