Journal of Psychotherapy Integration, Vol. 11, No.

2, 2001

Case of Silvia: A Schema-Focused Approach

John J. Cecero1,3 and Jeffrey E. Young2

This case study systematically addresses the components and sequence of a

Schema-Focused cognitive therapy approach to the assessment, formulation,
and treatment of Silvia’s anxious and depressive symptoms and enduring life
problems. Following a description of the major tools and procedures involved
in collecting the evidence that is required to generate a Schema-Focused case
conceptualization, a comprehensive formulation of this case is presented as
a guide for treatment intervention. A Schema-Focused Therapy approach is
then applied to this case, highlighting the four essential strategies—cognitive,
experiential, behavioral, and the therapy relationship—used to change Silvia’s
maladaptive schemas. Adjunctive interventions and potential problems with
this therapy approach are also proposed for consideration.
KEY WORDS: schema-focus; cognitive; assessment; psychotherapy case.

INTRODUCTION AND OVERVIEW OF SCHEMA-FOCUSED

THERAPY

Short-term cognitive therapy has been applied to a broad range of psy-

chological problems, including depression, anxiety (Beck, Rush, Shaw, &
Emery, 1979), and more recently personality disorders (Beck et al., 1990). In
this model, schemas are conceptualized as maladaptive cognitive biases and
distortions that may be identified and corrected with cognitive interventions.
Young (1990/1999) argues that this conceptualization of schemas is incom-
plete, especially when working with difficult and challenging patients (e.g.
1 Department of Psychology, Fordham University, New York, New York.
2 CognitiveTherapy Centers of New York and Connecticut, Department of Psychiatry,
Columbia University.
3 Correspondence should be addressed to John J. Cecero, PhD, Department of Psychology,
Fordham University, 113 W. 60th Street, New York, New York 10023.

217

1053-0479/01/0600-0217$19.50/0 °
C 2001 Plenum Publishing Corporation
218 Cecero and Young

treatment refractory, chronic anxiety or depression or both, long-term rela-

tionship problems, personality disorders, etc.), because it ignores the pres-
ence and function of early maladaptive schemas (EMSs). Schema-focused
therapy (Young, 1990/1999) combines cognitive, behavioral, interpersonal,
and experiential techniques to assess and modify these EMSs, and places
greater emphasis on the childhood origins and developmental processes in-
volved in the genesis and maintenance of these schemas.
Young defines an early maladaptive schema4 as an extremely broad,
pervasive theme regarding oneself and one’s relationships with others, de-
veloped during childhood and elaborated upon throughout one’s lifetime,
and dysfunctional to a significant degree (Young and Behary, 1999). More-
over, as schemas originate in dysfunctional experiences with parents, sib-
lings, or peers in the first few years of life, their presence and strength often
result in high levels of disruptive affect and chronic dysfunctional patterns
of interaction throughout one’s lifetime.
Young (1990/1999) identifies 18 specific schemas. In the case of Silvia,
the primary schema appears to be Subjugation, and the other important
schemas include Emotional Deprivation, Defectiveness, and Dependence/
Incompetence (see Table I).
Given these schemas, the schema-focused therapist would proceed in
two phases: (1) Assessment and Education and (2) Change. In the first phase,
we would identify and educate Silvia about her central life schemas, her dys-
functional life patterns, and their developmental origins. Then, we would link
these schemas and the emotions surrounding them to her presenting prob-
lems. In the second phase, we would employ four kinds of change strate-
gies: (1) cognitive techniques (e.g., reality testing, reframing), to restruc-
ture her thinking related to the schemas; (2) experiential techniques (e.g.,
imagery, dialogues with parents), to express anger and grieve for early pain,
and to empower her to validate her own needs and feelings; (3) the thera-
peutic relationship, to provide limited reparenting. The therapist creates an
atmosphere through the therapy relationship; this serves as a partial antidote
to the patient’s harmful early experiences as a child. In this case, the ther-
apist becomes like a parent to the patient, within the limits of the therapy
relationship; and (4) behavioral pattern-breaking, to change self-defeating
behavior patterns.
A considerable amount of research is either completed or in progress
to test schema theory through validating the Young Schema Questionnaire
(Lee, Taylor, & Dunn, 1999; Schmidt, Joiner, Young, & Telch, 1995). Fur-
thermore, outcome studies are also in progress to test the effectiveness of
schema-focused treatment with various disorders (e.g., Ball, 1998).
4 For
the remainder of this paper, the term “schema” will be used to mean Early Maladaptive
Schema (EMS).
Case of Silvia 219

Table I. Definitions of Early Maladaptive Schemas in the Case of Silvia

A. Subjugation: Excessive surrendering of control to others because one fears their anger,
retaliation, or abandonment. The two major forms of subjugation are
Subjugation of needs: Suppression of one’s preferences, decisions, and desires
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)
B. Emotional Deprivation: 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
Deprivation of nurturance: Absence of attention, affection, warmth, or
companionship
Deprivation of empathy: Absence of understanding, listening, self-disclosure,
or mutual sharing of feelings from others
Deprivation of protection: Absence of strength, direction, or guidance from
others
C. Defectiveness: 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).
D. Dependence/Incompetence: 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

PRESENTING PROBLEMS

A schema-focused approach would categorize the presenting problems

into symptoms and life problems, the latter being the primary focus of
schema-focused therapy (Young & Gluhoski, 1996). For Silvia, her present-
ing symptoms include all of the markers of a DSM-IV diagnosis of major
depressive disorder (depressed mood most of the day, nearly every day;
diminished interest or pleasure in most activities, loss of libido, sleep prob-
lems, tiredness, retardation and agitation, feelings of worthlessness, inability
to concentrate, suicidal ideation), as well as many symptoms of generalized
anxiety disorder5 (unsteadiness, nervousness, sleep disturbance, worry, and
physical symptoms including palpitations, tension, and dizziness), and other
psychogenic symptoms (e.g., headaches).
5 Concerning the DSM Axis I diagnosis of Generalized Anxiety Disorder and Axis II diagnosis
of Dependent Personality Disorder, we do not have enough information to make definitive
diagnoses and would need additional screening measures, that is, the Structured Clinical In-
terview for DSM Axis I and Axis II Diagnoses (SCID I and SCID II respectively) to do so.
220 Cecero and Young

Silvia also presents three significant life problems. First, she reports that
she experiences a lack of attention, empathy, and support from her husband,
and that this lack of emotional nurturance is exacerbated by her husband’s
alignment with his mother against her. Second, Silvia reports that she is
upset because of her difficulty with controlling and disciplining her children.
Third, Silvia is distressed by her low self-esteem and lack of confidence in
her ability to cope with daily demands on her own, consistent with a DSM-IV
diagnosis of dependent personality disorder.

SYMPTOM REDUCTION WITH COGNITIVE THERAPY

Prior to the direct focus on schema assessment and education with Silvia,
we would address the presenting high levels of depression and anxiety with
standard cognitive therapeutic techniques (Beck et al., 1979; Beck & Emery,
1985). We would employ activity schedules to challenge her lack of activity
(staying in bed all day). We might also use mastery and pleasure schedules,
which are frequently helpful to depressed and anergic clients (Beck et al.,
1979), whereby Silvia would be encouraged to identify specific activities in
which she feels pleasure and a sense of mastery, and then regularly to sched-
ule those activities according to a behavioral plan agreed upon by her and her
therapist. We would also employ a Daily Record of Dysfunctional Thoughts
(Beck et al., 1979) to teach Silvia to identify those cognitive distortions that
generate depression and anxiety in her life (e.g., Everyone is trying to control
me and will retaliate if I disagree; I am a bad, useless wife/mother/person; I
can’t cope with daily demands; No one will ever be there to meet my emo-
tional needs) and to generate alternative, more reality-based thoughts to
counter those distortions and alleviate her painful affect. Once her present-
ing symptoms of depression and anxiety were reduced in intensity to the
mild to moderate range, we would begin a comprehensive schema-focused
assessment.

SCHEMA-FOCUSED ASSESSMENT AND CONCEPTUALIZATION

We would employ several methods to determine which of the 18 schemas

are most relevant to Silvia, the links between those schemas, their develop-
mental and historical origins, and the relationship between those schemas
and her presenting life problems (see Table II).
In the first place, we would assist Silvia in presenting a detailed descrip-
tion of her current life problems and symptoms, both within the session and
by completing the Multimodal Life History Inventory (Lazarus & Lazarus,
Case of Silvia 221

Table II. Schema Conceptualization

Patient’s name: Silvia
Age: 27
Marital status: Married
Children (ages): 6 1/2 ; 4; 2
Occupation: Housewife
Schema group
Subjugation
Emotional Deprivation
Defectiveness
Dependence/Incompetence
Problem 1. Lack of attention, empathy, and support from husband (especially regarding
mother-in-law); feeling controlled and put down by her husband and mother-in-law
Schema links: Subjugation—Emotional Deprivation—Defectiveness
Problem 2. Feels like a failure because of her difficulty controlling and disciplining
her children
Schema links: Subjugation—Defectiveness
Problem 3. Low self-esteem; lack of confidence in her ability to cope with daily demands
and function on her own
Schema links: Dependence/Incompetence—Defectiveness
Schema triggers
Having decisions imposed on her by others
Disobedient or demanding children or both
Being criticized by others
Husband not paying attention to her feelings
Severity of schemas and risk of decompensation: Subjugation severe; Emotional
Deprivation, Defectiveness, and Dependence moderate; Moderate risk
of decompensation (depression, suicidal ideation)
Developmental origins
Mother: demanding, forced her to do things, passive
Father: controlling, critical, verbally abusive, strict, not loving or affectionate
Childhood memories
Parents quarreling and blaming her for things that went wrong
Being forced by parents to stay home and take care of younger siblings
Father’s verbal and physical threats when she wanted to leave home
Core cognitive distortions
Everyone is trying to control me and will retaliate if I disagree
I am a bad, useless wife/mother/person
I can’t cope with daily demands
No one will ever be there to meet my emotional needs
Coping behaviors: Expresses anger covertly
Therapeutic relationship: Came across as dependent, compliant, and childlike in sessions.
As the therapeutic alliance increased, she was able to disagree with the therapist and
express her own opinions

1991). This information frequently provides evidence for initial, tentative

hypotheses about the predominant schemas in one’s life. We expect that
Silvia would endorse problems that are consistent with specific schemas: (1)
in her relationship with her husband, feeling controlled (Subjugation), put
222 Cecero and Young

Table III. Schemas and Their Evidence in Silvia’s Life Problems

Schemas Life problems
Subjugation Marrying in order to find freedom from controlling parents
Feeling controlled by her husband and mother-in-law
Difficulty asserting her wishes and needs with her children
Emotional Deprivation Her expectation that her husband will never meet her
needs for emotional support
Defectiveness Low self-esteem
Feeling continually put down by her husband
Dependence/Incompetence Feeling unable to cope with daily responsibilities
on her own
Her overreliance on her husband to defend her from her
mother-in-law’s accusations
Her reluctance to consider a divorce for fear of not being
able to take care of herself

down (Defectiveness), and emotionally ignored (Emotional Deprivation);

(2) being unable to discipline her children (Subjugation); and (3) in general
having low self-esteem (Defectiveness) and an overall sense of inability to
cope with daily responsibilities (Dependence/Incompetence) (see Table III).
Next, in order to strengthen our confidence in the hypothesized sche-
mas, we would link the childhood origins of these schemas to the adult
dysfunctional life-patterns. The typical family origin for the Subjugation
schema is one in which (1) the child is treated as if her opinions or de-
sires didn’t count; (2) parents did what they wanted, regardless of the child’s
needs; (3) parents controlled the child’s life, so that she had little freedom of
choice; and (4) everything had to be on the parent(s)’ terms. In her family,
Silvia was repeatedly “forced to do things” by her mother, and controlled
by a strict, verbally abusive father. She was not permitted to pursue her
own interests, but instead was coerced into staying home to take care of her
younger siblings. She felt trapped in her family of origin and looked forward
to marriage as a means of freedom.
The typical childhood origins for Emotional Deprivation include paren-
tal failures to (1) love the child and treat her as someone special; (2) spend
time with and pay attention to her; (3) give her helpful guidance and di-
rection; (4) listen to her, understand her, and share feelings with her; and
(5) give her warmth and physical affection. This schema is consistent with
Silvia’s experience of her parents as not loving or affectionate, leaving her
feeling deprived of nurturance. For Defectiveness, the typical family of ori-
gin involves parents who (1) criticized the child a lot; (2) made the child feel
unloved or rejected; (3) treated the child as if there was something wrong
with her; and (4) made the child feel ashamed of herself in important re-
spects. In the case of Silvia, her repeated experiences of being blamed for
things that went wrong in the family are consistent with this schema’s origins.
Case of Silvia 223

Finally, the childhood origins of Dependence/Incompetence involve parents

who (1) made the child feel that she could not rely on her decisions or judg-
ment; (2) did too many things for the child instead of letting her do things
on her own; and (3) treated the child as if she were younger than her age.
In the case of Silvia, this schema probably came about as a result of her
parents’ undermining of her decisions and judgments in everyday situations.
She was never permitted to develop a sense of her own competence and
adequacy.
Another component of schema-focused assessment is the administra-
tion of the Young Schema Questionnaire (YSQ; Young, 1990/1999), which
is a 205-item self-report measure designed to assess most of the 18 schemas.
Each item reflects a thought, feeling, or behavior that corresponds to a par-
ticular schema. Participants are instructed to rate each item on a Likert scale
ranging from 1 to 6, where 1 is completely untrue of me and 6 describes me
perfectly. Items are clustered by schema; the severity of a given schema is
assessed by identifying how many items were given high ratings (5 or 6) by
the patient within a schema cluster. In the case of Silvia, we would expect
high severity ratings on most or all of the Subjugation schema items, as this
schema appears to be her primary one (e.g., I let other people have their
way because I fear the consequences; In relationships, I let the other person
have the upper hand; I worry a lot about pleasing other people so they won’t
reject me; I get back at people in little ways instead of showing my anger).
We would also expect high ratings on some of the items corresponding to
the other three schemas identified in her case: Emotional Deprivation (e.g.,
In general, people have not been there to give me warmth, holding, and
affection); Defectiveness (e.g., I am inherently flawed and defective); and
Dependence/Incompetence (e.g., I don’t feel confident about my ability to
solve everyday problems that come up).
A second instrument, the Young Parenting Inventory (YPI, Young,
1994), would be administered to identify and confirm the childhood origins
of the identified schemas. The YPI is a 72-item self-report measure. Each
item assesses a particular parental behavior corresponding to the hypothe-
sized childhood origins of that schema. Patients who complete the measure
are instructed to rate each item for both their mother and father. Items are
rated on a Likert scale ranging from 1 to 6, where 1 is completely untrue and
6 describes mother/father perfectly. We expect that Silvia would give high
ratings to many of the Subjugation items for both her mother and father.
We would also expect high severity scores6 on some of the Emotional De-
privation items for both parents. On the Defectiveness items, Silvia would

6 The Emotional Deprivation items on the YPI are reverse scored, so that lower scores on these
items represent a higher severity of the schema.
224 Cecero and Young

probably rate her father in the severe range (e.g., Criticized me a lot; Made
me feel unloved or rejected; Made me feel ashamed of myself in important
respects), whereas her mother would probably be rated low because she was
not openly critical and verbally abusive like her father. Finally, we expect that
Silvia would rate her parents highly on Dependence/Incompetence schema
items (i.e., Made me feel I couldn’t rely on my decisions or judgment), as both
parents stressed compliance with their demands over personal initiative.
In addition to a thorough discussion of the results of the two inventories,
we would invite Silvia to generate still more confirming evidence of the
identified schemas, through separate childhood imagery exercises involving
her mother and father. We would ask Silvia to imagine herself as a child
with her mother or father, and to recall an upsetting memory. In her case,
Silvia might recall her father blaming her for something that went wrong. We
would ask her to describe her thoughts and feelings in the scene, and then
to express them to her father in the imagery. We expect that Silvia would
report thinking that she is trapped, and feeling controlled and angry, just as
she feels in her relationship with her husband and children. We would later
point out the link between her actual childhood experience of Subjugation
and its present manifestation in her current life.
As an ongoing component of schema assessment, we would also iden-
tify characteristic in-session behavior for each schema. For example, her
therapist described her as dependent, compliant, and childlike in sessions
(personal communication, 1999), and this behavior is consistent with the
Subjugation and Dependence schemas. On the other hand, as the therapeu-
tic alliance increased, Silvia began to assert herself more in sessions and
even to disagree with the therapist. Her decreasing fear of anger, retalia-
tion, or abandonment by the therapist appears to correspond to her growth
in assertiveness, and may explain in part her differentiation between the op-
timistic, carefree, and energetic person that she is with her peers, where she
does not perceive the threat of retribution, and the pessimistic, fearful, and
anergic person that she is with her family.
At the completion of the formal assessment phase of schema-focused
therapy, we would complete the Schema Conceptualization Form (see
Table II) and present an abbreviated summary and formulation to Silvia,
to elicit her feedback and to revise it as necessary. This case conceptualiza-
tion would then guide the treatment.

TREATMENT STRATEGIES

The change phase of Schema-Focused Therapy corresponds to the four

essential strategies of treatment for schemas: (1) cognitive restructuring of
Case of Silvia 225

her schemas; (2) experiential exercises to elicit anger and empowerment;

(3) behavioral pattern-breaking; and (4) the use of the therapy relationship.
We would begin by focusing on her primary Subjugation schema, because
it is the one that is most severe and pervasive in regard to her present-
ing problems; later, we would work on the other three schemas. In this
paper, because of space limitations, we are focusing primarily on the treat-
ment of Subjugation and will only briefly review the treatment for the other
schemas.
As a function of her Subjugation schema, Silvia appears dispropor-
tionately focused on her responsibilities to others (husband, children) and
not adequately attentive to the satisfaction of her own needs in these re-
lationships. We would educate Silvia about her right to reciprocity in re-
lationships, and that she needs to practice confronting people instead of
accommodating so much. We would question her core cognitive distortion
related to this schema, namely that healthy people (i.e. not subjugating ones
like her father) will retaliate or hurt her if she asks for emotional support or
if she disagrees with them. We would likewise challenge her view that she is
a bad, useless wife, mother, or person, if she puts her own needs first some
of the time. We would assist her in weighing the pros and cons of always
taking care of others. We would help her to develop a list of her own needs
and preferences in individual situations.
One of the techniques that we would employ as a cognitive intervention
is to foster a dialogue between the schema side and the healthy side of herself.
For example, we might ask Silvia to speak from the subjugated side of herself,
which feels she is trapped, controlled, and angry. Then, we would ask her
to change seats to speak from the healthy side, which thinks that she has
choices and feels empowered and happy. We would coach her in building up
the healthy side to fight the schema side.
Two other cognitive strategies would also be useful with Silvia: schema
flashcards and schema diaries (Young & Behary, 1999). The purpose of the
flashcards is to provide patients with a healthy response to utilize when a
schema is triggered. An abbreviated version of a flashcard with Silvia would
read as follows:

1. Acknowledgment of Current Feeling: Right now I feel angry because

someone criticized me.
2. Identification of Schema: However, I know that this is probably my
Subjugation schema, which I learned through repeated experiences
of my father’s control and domination. This schema leads me to ex-
aggerate the degree to which others are trying to control me.
3. Reality Testing: Even though I believe others are trying to control
me through their criticism, the reality is that the other person simply
226 Cecero and Young

had a strong position of his/her own and I am free to have an opinion

of my own.
4. Behavioral Instruction: Therefore, even though I feel like withdraw-
ing and harboring resentment, I could instead assert my freedom to
disagree with the other person’s criticism.

Later in the therapy, once Silvia’s healthier side is stronger, she would
be instructed to complete schema diaries on her own, without the therapist’s
help, in order to identify the triggers, emotions, thoughts, and behaviors
associated with the activation of a schema in specific life situations, and to
generate healthier interpretations and behavioral responses to those triggers.
The experiential strategies would include an imagery exercise to link
a current situation in which Silvia subjugates (e.g., passively withstanding
the control of her mother-in-law) to a childhood memory with her father
(e.g., his threats at her attempt to leave home). In this exercise, the therapist
would model the response of a Healthy Adult side of herself in both scenes,
expressing anger toward her mother-in-law and father, asserting that they
should have taken her needs and feelings into account instead of controlling
her. In a follow-up exercise, Silvia would play the Healthy Adult, modeled
after the therapist.
Another experiential strategy would be to ask Silvia to write a letter to
her parents, in which she explains how damaging it has been to her that her
father did not respect her needs and her mother did not protect her from him
or model standing up to him. Silvia would be instructed to read this letter in
the therapy session, but (in most cases) not actually to send it to her parents
because of potential negative consequences.
Behavioral pattern-breaking strategies would include having Silvia list
everyday situations in which she subjugates her needs unnecessarily and
ranking these situations on a hierarchy of difficulty to change. She would
then be asked to do homework assignments whereby she practices asserting
her needs in each of those situations. For example, she would be encouraged
to ask people to meet her needs when appropriate, and to practice con-
fronting people instead of accommodating to them. Through role-playing
and imagery, we would help her to stop behaving in a passive-aggressive, re-
bellious, or avoidant (e.g., retreating to bed) manner (see Table II for Coping
Behavior). Finally, we would encourage her to pull back from or leave rela-
tionships with people who are too controlling to take her needs into account,
even after she asserts her needs appropriately.
Within the therapy relationship, we would practice limited reparenting
by relating to Silvia in a noncontrolling, nonsubjugating manner, offering her
as many choices as possible in the session. We would be less directive and
Case of Silvia 227

structured than usual, and would ask her to come up with her own homework
assignments. We would likewise point out when she appears overly compliant
or passive in sessions, and practice helping her to disagree with the therapist
when appropriate.
With respect to the remaining three schemas, we would use similar treat-
ment strategies. In order to modify her Emotional Deprivation schema, we
would change her cognitive distortion that no one will ever be there to meet
her emotional needs. We would also employ imagery to assist her in express-
ing anger and pain at her depriving parents, and to give her the opportunity
to ask to have her needs met by her parents in imagery. We would help her
to monitor her feelings of deprivation in her relationship to her husband
and teach her to ask appropriately for what she needs from him emotionally
in that relationship. Finally, in the therapy relationship, the therapist would
provide a nurturing atmosphere characterized by empathy, guidance, and
attention. The therapist would help Silvia to express her feelings of depriva-
tion without overreacting or remaining silent.
In treating the Defectiveness schema, we would help alter her distorted
view of herself as a bad, useless wife, mother, and person, and instead focus
on her assets. The therapist would assist her in role-plays to vent anger at
her critical father, as well as to dialogue with the critical schema. We would
teach her not to overreact to this schema’s trigger, that is, being criticized by
others. In the therapy relationship, the therapist would directly praise her to
help promote her self-acceptance.
Finally, with respect to the Dependence/Incompetence schema, we
would alter her cognitive distortion that she cannot cope with daily demands.
The therapist would use imagery to assist her in expressing anger at her par-
ents for undermining her decisions and judgments. The therapist would also
set up graded assignments for her to handle everyday tasks alone, with-
out assistance from others. In the therapy relationship, the therapist would
resist her attempts to take on a dependent role and encourage Silvia to
make her own decisions and choices, all the while praising her judgment and
progress.

ADJUNCTIVE INTERVENTIONS

In addition to individual schema-focused therapy, Silvia might well ben-

efit from group therapy (e.g., assertiveness training) to promote the cognitive
and behavioral changes related to the modification of her schemas. In addi-
tion, couples therapy to focus on helping Silvia to express appropriately to
her husband her needs for emotional support, as well as family therapy to
228 Cecero and Young

identify her parenting deficits and to teach her appropriate skills may each
be useful adjuncts to individual treatment.

POTENTIAL PROBLEMS

A serious complication of Silvia’s problems is that she is subjugated to

the husband on whom she is at the same time financially dependent. Conse-
quently, as Silvia becomes more assertive, it is possible that her controlling
husband might threaten to leave her, and she might not feel adequately com-
petent to withstand this threat. Likewise, if she decides to leave the marriage
as a way to break free from her subjugation and dependence, she may at least
temporarily become even more dependent on her family of origin, given her
unemployed status and financial vulnerability.
There is also some risk of suicide, given her past attempts. However, as
these attempts appear linked to her Subjugation thoughts and feelings (i.e.,
controlled, trapped, and angry), it is likely that as she becomes more assertive
and feels more empowered to choose from a wider behavioral repertoire of
responses to dysphoric affect, her risk for suicide will be attenuated through
therapy.

EXPECTED OUTCOME

Overall, the prognosis for Silvia is positive, as her schemas generally

respond well to schema-focused therapy. She is motivated for treatment,
actually engages in the therapeutic process, and already demonstrates some
capacity to challenge her Subjugation schema by asserting her wishes within
the less-threatening therapy relationship. A practical obstacle to treatment
progress, however, remains her financial vulnerability, which may be exac-
erbated in the course of treatment and recovery.

SUMMARY

Schema-focused therapy is an integrative treatment approach that pro-

vides a systematic set of procedures for the assessment and modification of
EMSs in two phases: (1) the Schema Assessment and Education phase, where
the goal is to identify the patient’s primary dysfunctional life patterns and
EMSs and (2) the Change phase, in which the goal is to integrate four types
of strategies (cognitive, experiential, behavioral, and the therapy relation-
ship) systematically to change these schemas and patterns. Schema-focused
therapy offers significant potential for change with patients like Silvia.
Case of Silvia 229

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