Schema therapy is a distinct and integrative therapeutic approach that was conceptualized by Dr. Jeffrey Young in the 1980s and is rooted in cognitive behavioral therapy. It integrates aspects of gestalt therapy, attachment theory, and object relations, intending to treat personality disorders and chronic mental health disorders.
Schema psychotherapy aims to break the cycle of schema activation, thereby facilitating behavioral change and emotional healing. The theory behind it posits that unmet needs during childhood and adolescence lead to the development of maladaptive schemas, deeply ingrained patterns in thinking and behavior.
Core Concepts in Schema Therapy
Schema therapy encompasses several foundational elements that work in concert to treat complex psychological conditions. It specifically addresses enduring patterns, known as schemas, that people form about themselves and the world, which can be maladaptive and deeply ingrained.
Early maladaptive schemas are self-defeating emotional and cognitive tendencies that emerge from childhood and persist throughout life. They may consist of emotional recollections of prior hurt, tragedy, fear, abuse, neglect, unmet safety needs, abandonment, or a general lack of basic human attachment.
Early maladaptive schemas may also involve physiological sensations connected with these emotional experiences. They can vary in severity and pervasiveness: the more severe the schema, the more intense and prolonged the unpleasant emotion when the schema is triggered; the more pervasive the schema, the more situations trigger it.
Coping Styles
Coping styles in schema therapy refer to the ways individuals adapt to maladaptive schemas. There are generally three coping styles:
- Surrender: where the individual acts in ways that conform to the schema.
- Avoidance: where the individual tries to escape or circumvent the schema.
- Overcompensation: where the individual fights against the schema in an excessive manner.
Maladaptive methods of coping (overcompensation, avoidance, or surrender) frequently reinforce schemas. For example, after imagining a fear of desertion in a relationship and feeling sad and anxious, a person employing an avoidance coping style may behave in ways that limit the closeness in the relationship in order to protect themselves from being abandoned. The accompanying loneliness, or even the termination of the connection, might easily reinforce the individual’s Abandonment schema.
Schema Modes
Schema modes are the moment-to-moment emotional states and coping responses that individuals exhibit. They are fluid and can change in response to situations, acting as a temporary “mode of being”.
For example, the Detached Protector mode leads to emotional withdrawal to avoid pain, while the Angry Child mode involves the expression of unmet core emotional needs or feelings of victimization.
Young, Klosko, and Weishaar, in their 2003 book, defined ten schema modes, which Jacob, Genderen, and Seebauer in 2015 classified into four distinct categories. There are four categories are child modes, dysfunctional coping modes, dysfunctional parent modes, and healthy adult modes.
Schema therapists attempt to assist patients in achieving a long-term state of well-being known as the Healthy Adult mode. The Healthy Adult is at ease making decisions, is a problem solver, thinks before acting, is appropriately ambitious, sets limits and boundaries, nurtures self and others, forms healthy relationships, accepts all responsibility, sees things through, enjoys/participates in enjoyable adult activities and interests with boundaries enforced, cares for their physical health, and values themselves.
In this schema mode, the patient focuses on the present day with optimism and strives for the best tomorrow imaginable. The Healthy Adult forgives the past, sees themselves as a survivor rather than a victim, and expresses all emotions in healthy and non-harmful ways.
Maladaptive Schemas
Maladaptive schemas, a broader term often used synonymously with early maladaptive schemas, are the pervasive themes or patterns of memories, emotions, cognitions, and bodily sensations.
These themes are dysfunctional to a significant degree and often result in maladaptive coping responses or patterns of behavior. They are core issues that schema therapy aims to identify, challenge, and modify to support an individual’s recovery and growth.
Schema Domains
Based on the emotional needs of children during development, Jeffrey Young, along with Janet Klosko, and Marjorie Weishaar identified 18 early maladaptive schemas under five major types of unfulfilled needs known as schema domains. In 2020, Yalcin, Lee, and Correia conducted a primary and higher-order factor analysis using data from a large clinical sample and a smaller non-clinical population.
Their higher-order factor analysis revealed four schema domains — Emotional Dysregulation, Disconnection, Impaired Autonomy/Underdeveloped Self, and Excessive Responsibility/Overcontrol — that coincide with the five domains established previously by Young, Klosko, and Weishaar.
Impaired Autonomy and Performance
This domain encompasses schemas related to expectations about oneself and the environment regarding the ability to separate, perform successfully, and function independently.
Two specific examples include failure, where an individual expects to fail and views themselves as fundamentally inadequate compared with peers, and dependence/incompetence, where they believe they cannot handle daily responsibilities without considerable assistance.
Disconnection and Rejection
Within this domain, schemas are of a nature that anticipate an unstable relationship with others, predicting that one’s needs for security, safety, and empathy will not be met.
Defectiveness/shame is a key schema here, causing an individual to feel intrinsically flawed and expecting disapproval from others. Another is social isolation/alienation, which breeds feelings of isolation from the world, perceiving oneself as different and not part of any community.
Overvigilance and Inhibition
Schemas under this domain place an excessive emphasis on suppressing one’s spontaneous feelings and impulses to avoid making mistakes or being criticized. This can manifest as an enmeshment/undeveloped self schema, where individuals feel excessively emotionally involved with and controlled by their family or significant others, including their needs and emotions.
Furthermore, there’s a strong focus on rigid rules and standards at the cost of happiness, termed as overcontrol, leaving little room for error and relaxation.
The Therapeutic Process
The initiation of therapy involves a careful assessment to identify a client’s early maladaptive schemas. Through tools like the schema diary and interviews, therapists gain insight into the pervasive life themes that underpin emotional distress.
During case conceptualization, therapists create a personalized treatment plan that correlates the client’s life history with their present maladaptive schemas, highlighting triggers and unhealthy coping mechanisms.
Cognitive techniques in this type of therapy challenge the beliefs underpinning harmful schemas, while experiential techniques like imagery or role-playing create new emotional experiences. Behavioral techniques are employed to practice adaptive behaviors in real-life situations, fostering a move from old patterns to healthier ones.
Limited reparenting is central to Schema Therapy, where therapists provide the nurturing support that clients may have missed in childhood. This helps patients foster their healthy adult mode, which is a state of mind where patients can address their needs effectively and with self-compassion. The activation of the healthy adult mode is crucial for clients to autonomously maintain emotional well-being and navigate through life’s challenges post-therapy.
Treatment of Personality Disorders
Schema therapy has been established as a significant advancement in the treatment of various personality disorders, offering a unique and well-structured approach to individuals who struggle with pervasive patterns of thoughts, feelings, and behaviors.
Schema therapy is particularly effective for treating Borderline Personality Disorder (BPD), a condition characterized by difficulty in regulating emotions, impulsivity, and unstable interpersonal relationships. This form of therapy provides a framework for understanding the intense emotional responses and offers strategies to manage them.
It has been demonstrated that schema therapy can lead to substantial improvement in BPD symptoms, with a focus on addressing unresolved needs and maladaptive coping mechanisms. One study showed this approach to be more successful than some traditional therapies in reducing BDP symptoms and improving quality of life.
Not only is it applicable to BPD, but schema therapy is also flexible enough to address a spectrum of other mental health conditions. It’s been adapted for use with conditions that often co-occur with personality disorders, such as chronic depression, eating disorders, and posttraumatic stress.
Given the complex nature of personality disorders, schema therapy’s integrative methodology that encompasses cognitive, behavioral, and experiential techniques is particularly valuable. As a versatile treatment option, it addresses the broad array of symptoms and behaviors associated with various personality disorders, demonstrating clinical effectiveness across different contexts.
References:
- Giesen-Bloo, Josephine; van Dyck, Richard; Spinhoven, Philip; van Tilburg, Willem; Dirksen, Carmen; van Asselt, Thea; Kremers, Ismay P; Nadort, Marjon; Arntz, Arnoud (2006). Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Archives of General Psychiatry. 63 (6): 649–658. doi: 10.1001/archpsyc.63.6.649
- Jacob, Gitta; Genderen, Hannie van; Seebauer, Laura (2015). Breaking negative thinking patterns: a schema therapy self-help and support book. Chichester, UK; Malden, MA: John Wiley & Sons ISBN 9781118877722
- Taylor, C. D. J., Bee, P., & Haddock, G. (2017). Does schema therapy change schemas and symptoms? A systematic review across mental health disorders. Psychology and psychotherapy, 90(3), 456–479
- van Vreeswijk, Michiel; Broersen, Jenny; Nardort, Marjon, eds. (2012). The Wiley-Blackwell handbook of schema therapy: theory, research, and practice. Chichester, West Sussex; Hoboken, NJ: John Wiley & Sons ISBN 9780470975619
- Yalcin, Ozgur; Lee, Christopher; Correia, Helen (2020). Factor structure of the Young Schema Questionnaire (Long Form‐3). Australian Psychologist. 5 (5): 546–558. doi:10.1111/ap.12458
- Young, Jeffrey E; Klosko, Janet S; Weishaar, Marjorie E (2003). Schema therapy: a practitioner’s guide. New York: Guilford Press. ISBN 9781593853723