Phase 4: Identifying and Helping the Patient to Modify Irrational Beliefs and Contradictions in Schemas of Self

Once the maladaptive phenomena and shifting states of mind are clear and defensive obscurities reduced, the long middle phase of therapy can concentrate on changing behavioral patterns by identifying and modifying irrational beliefs. These beliefs often concern the self and also involve contradictions between various internalized models of relationships between the self and others. A first step stems from the individualized list of states of mind of the patient. A goal of clarification and interpretation becomes answering questions about each recurrent state: What views of self and others characterize a state, and how do shifts in these person schemas occur within the context of various social challenges and opportunities?

The theatrical, self-displaying, and exaggerating state that is sometimes itself called a histrionic state of mind will often be found to contain a role-relationship model in which the self becomes the center of interest for another person on the display of some kind of appeal. Sex appeal, as in flagrant machismo (male) or glamour (female), is common, but disability or waiflike helplessness may also be used. The role of a distressed and abused victim may be exaggerated in order to deserve rescue from a gallant savior.

A maladroit and impulse-ridden use of derivatives of such role-relationship models often leads the patient with a histrionic personality disorder to disaster rather than the desired satisfaction of real interest, attention, care, love, or friendship. Instead of a courting suitor, devoted rescuer, or protector and avenger against aggressors, the patient may attract people who will use, exploit, and then abandon the patient. It is not surprising that the person then enters into a dreaded state of mind in which the self is experienced as degraded, unworthy, desperate, and needy but alone.

Roles may be exchanged. The idealized rescuer becomes another aggressor, and the self is again a victim looking for a different rescuer. A variety of transference enactments can place either the patient or the therapist, or both, in each of these common roles as various scripts or scenarios of enactment unfold, leading to the sudden changes in emotionality already described. Now, however, in the middle phase of therapy, the patient is better able to sustain working states and reduce avoidances. This enables the therapist-patient pair to identify the differences between such transference-based expectations of seduction and later accusations of manipulation and abandonment of the self and the realities of the therapeutic arrangement and supportive environment.

A common sequence of transitions between different states and role-relationship models can start with a wish and go through a cycle of states of mind, only to repeat the entire cycle again. For example, a patient may wish for an intimate relationship with another person who can provide loving care and attentive reflection that will bolster a developing but immature (girl-like or boy-like) self. In such a relationship, the self would feel pride, dignity, and love for the other. In order to realize this wish, the self offers aspects of itself that are of likely interest to the other.

In response to this display of self, the other does become interested. The self reacts to that interest by becoming too enmeshed or enthralled in this script of sequential role shifts. The other exploits the enthralled and needy self, then loses interest and leaves the self. The self feels degraded, ashamed, or afraid of worse things that may happen or enters a state of despair at being unable to care for the self alone.

Because the wish for attention and closeness is too entangled with scripts of that closeness leading to manipulation or loss, the self instead shifts into a defensive stance of both wanting and anxiously resisting closeness. The other becomes ambiguous in this role-relationship model: aggressor or rescuer, selfish manipulator or available for intimacy or friendship? Inhibitions, anxiety, and phobic withdrawals may occur in this “mousy” state. It is a problematic compromise, containing such feelings and symptoms, and it is preferable to shift to a different self-image, that of having some kind of dramatic quality that can attract attention, even if that does not feel internally authentic as a real identity.

With this shift, the person may enter a theatrical display state that mimics what is desired but without any deep relationship quality. This histrionic state of mind may start a new relationship or a new part of the cycle in an existing relationship, but the patient remains unsatisfied because of the felt inauthenticity. This hollowness motivates activation of the desired role-relationship model of really getting care, and that starts the cycle just described into another repetition.

Such role-relationship models and scripts for going through a cycle of states are seldom consciously known at the beginning of therapy. What can lead to change is recognition of maladaptive patterns, reasons for them, and development of new schemas. One aspect of reschematization is integration of contradictions that are present in existing schemas of self and relationships. Conscious and focused thought and trials of new behaviors lead to such reschematizations when enough repetitions have occurred. The therapist’s encouragement of these more adaptive ways may be important to getting enough repetitions for reschematization to occur.

Contradictions, as mentioned above, include discrepancies between what is ideally desired and what is realistically possible and also between excessively weak self-concepts and ones that are realistically possible. The person may believe he or she has to make a prepayment of gratification to others in order to get attention or care. This may even include submission to the manipulation and exploitation of the self by others as a masochistic surrender to them in return for occasional or fantasized states of love. This scenario is contradictory to the development of a dignified, worthwhile, and competent self-concept.

Features of the personality that could lead to a positive sense of identity should be bolstered. Through practice, such features can be further developed. For this reason, identification and counteraction of self-degradations, abnegations, and harshly unrealistic self-criticisms are as important as identification and counteraction of excessive idealizations of self and others, and support for a mourning process in which unrealistic hopes for ideal parents in adulthood, or for better bodily attributes, are given up.

The obligatory scripts in which desired states and role-relationship models lead to dreaded ones can be identified in the here and now and the sources of their development in the past identified. The goal is to change the patient’s attitude toward the near future, so that the very next experiences and behaviors of the patient are dictated less by stereotypes and based more on observant attention to things as they are and could become. Some of these techniques of integrative psychotherapy are summarized in

Table 84-5.