The identification of core schemas marks the point in treatment when cognition becomes object rather than subject—when the client can think about their thinking (Beck, 2011; Young et al., 2003). Neuroimaging shows that when clients observe thoughts nonjudgmentally, activation shifts from limbic regions to prefrontal regulatory circuits (Goldin et al., 2013). Here are the keys that mark this stage of the therapeutic process when productive self-awareness is in full bloom:

• Increased awareness of thought patterns (Dimaggio et al., 2007; Wells, 2009).
• Identify recurring roles as schema activations (Karpman, 1968; Rafaeli et al., 2010).
• Replace global self-judgment with functional analysis

transforming personality

As previously noted, Cain experienced an episode of severe anxiety on a train ride to therapy. This manifested physiologically as “knots” in his stomach. When he arrived in session, this point of contact with the embodied traumatic material revealed a repressed story, one that Cain has processed in subsequent sessions.

At first, Cain was entirely overwhelmed by the memory. He was assisted in holding space for this story by grounding himself in the presence of a compassionate other, the therapist, which is a primary mechanism of healing (Norcross & Lambert, 2019; Rogers, 1957). At this stage of therapy, he’s processed the memory a few times, each time feeling less overwhelmed than the time before. The therapist will have noted how the trauma has been embodied in each session, and now is the time to bring those observations to Cain’s awareness.

While recounting the memory, Cain has presented the following: tension in his shoulders, avoidance of eye contact by looking down and to the left, turning his body toward the exit, and self-reported knots in his stomach. The therapist shares these observations with Cain for the purpose of a self-observation study that the work of transforming Cain’s personality hinges on.

Cain is asked to observe and note each and every situation between sessions when these physiological manifestations arise.

This is important for three reasons. First, the body remembers everything it’s ever been through and Cain is likely responding to present-day circumstances, such as the train ride, with a hyper-aroused nervous system trying to protect itself from unresolved, repressed psychological trauma. His body believes the trauma is ongoing because it hasn’t been fully processed.

Secondly, becoming conscious of the tension and aversion to eye contact will present Cain with ample opportunity to explore alternative behaviors, such as relaxing and holding eye contact long enough to say hello. It’s imperative that the therapist not mention this work, yet, as it comes later in the process. It’s likely Cain will begin doing some of this on his own without the therapist’s recommendation, and this is much preferred, as it’s patient-driven.

Thirdly, paying attention to the physiological manifestations of unconscious trauma in Cain’s day-to-day life will allow him to begin thinking about how he thinks of himself and others. This is the relational aspect of healing psychological trauma, interpersonal metacognitive therapy, assessing how he perceives himself and others during moments of trauma activation (Dimaggio, Montano, Popolo, & Salvatore, 2015; Dimaggio & Lysaker, 2010).