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Schema Therapy, pioneered by Jeffrey Young in the 1990s, is a talk therapy that combines elements of cognitive behavioral therapy, gestalt therapy, attachment theory, and emotion-focused therapy to effectively treat personality disorders, particularly borderline personality disorder. The goal of schema therapy is to help patients identify and understand their early maladaptive schemas - self-defeating patterns that often arise when core emotional needs are not met in childhood. These schemas can trigger maladaptive coping modes, leading individuals to act in ways that end up hurting themselves or the needs of others.
Schema Therapy was specifically designed for individuals who have not benefited from other therapies or who have experienced a relapse.
In Schema therapy, the therapist and patient work together to identify and understand the patient's schemas through the use of a schema questionnaire. The therapy session then involves a combination of talk therapy, cognitive therapy, and behavioural techniques to change these maladaptive coping styles. Schema therapy aims to help patients achieve a healthy adult mode, where their emotional states and coping responses are more balanced and less likely to trigger the schema. The effectiveness of schema therapy, particularly in the treatment of borderline personality disorder, has been demonstrated in a trial of schema-focused therapy vs. transference-focused psychotherapy.
The International Society of Schema Therapy recognises 18 early maladaptive schemas, divided into five schema domains. These schemas become problematic when they lead to maladaptive coping styles - either by surrendering to their schemas, overcompensating, or avoiding them. Schema therapy includes techniques to heal schemas by diminishing the intensity of the schema and the emotional memories comprising the schema. It's worth noting that different schemas and coping styles may require different therapeutic techniques. Ultimately, schema therapy is about helping patients meet their core emotional needs in a healthier way, without resorting to maladaptive coping modes.
The main issues targeted by this therapy include:
In the context of Schema Therapy, the core needs of a child are fundamental emotional and psychological necessities that need to be met for healthy development and emotional well-being. These needs are central to understanding Schema Theory, as unmet or poorly met needs in childhood can lead to the formation of early maladaptive schemas. These schemas are self-defeating patterns that can persist into adulthood and trigger maladaptive coping styles, causing distress and dysfunction.
The core needs of a child, as identified by schema therapy
- secure attachments to others (including safety, stability, nurturance, and acceptance),
- autonomy
- competence
- a sense of identity
- freedom to express valid needs and emotions
- spontaneity and play
- realistic limits and self-control
When these needs are not met, children may develop schemas that lead them to overreact to negative aspects of life and end up hurting themselves or the needs of others. The goal of schema therapy is to help patients understand these schemas and, through a therapeutic relationship, learn healthier ways of having their core emotional needs met, thereby reducing the impact of maladaptive schemas and promoting healthier coping mechanisms.
Schema domains are broad categories under which the 18 early maladaptive schemas fall. These domains provide a framework for understanding how unmet emotional needs in childhood can lead to maladaptive schemas and coping styles in adulthood. The five schema domains are:
This domain relates to the expectation that one's needs for security, safety, stability, nurturance, empathy, sharing of feelings, acceptance, and respect will not be met in a consistent or predictable manner. Schemas in this domain can lead to feelings of isolation, instability, and a lack of self-worth.
This domain reflects beliefs that one is incapable of functioning independently, leading to dependence on others, vulnerability to harm or illness, and a sense of failure.
This domain involves the inability to set internal limits, respect others' boundaries, and understand the repercussions of one's actions. It can lead to entitlement and a lack of self-discipline or self-control.
This domain centres on an excessive focus on the desires, feelings, and responses of others at the expense of one's own needs. This can lead to a lack of self-identity and unhealthy relationships.
This domain reflects a focus on suppressing one's feelings, impulses, and preferences to avoid making mistakes, maintain control, or meet high internalised standards of behaviour. This can result in rigidity, perfectionism, and a negation of positive experiences.
The goal of schema therapy is to help patients identify their schemas within these domains and work towards healthier ways of meeting their core emotional needs. This involves using various techniques to change maladaptive coping styles, heal schemas, and ultimately lead a more fulfilling and balanced life.
Schemas can lead to certain coping styles, which are strategies that individuals use in an attempt to protect themselves from the intense emotions they experience when their schemas are triggered. The three primary maladaptive coping styles are surrender, avoidance, and overcompensation. These coping styles, while providing temporary relief, are maladaptive as they end up reinforcing the schemas and leading to further distress.
This coping style involves individuals giving in to their schemas. Instead of challenging or trying to change the schema, they behave in ways that perpetuate it. For example, someone with an abandonment schema might stay in unhealthy relationships, fearing that being alone is worse.
This coping style involves individuals going to great lengths to avoid situations or stimuli that might trigger their schemas. This can take many forms, including physical avoidance, psychological avoidance, and numbing one's feelings. For example, an individual with a mistrust/abuse schema might avoid intimate relationships altogether to prevent potential hurt.
This coping style involves individuals acting in ways that are completely opposite to what their schemas would predict. They are, in effect, going overboard in their efforts to prevent the schema from being triggered. For example, a person with a defectiveness/shame schema might become excessively perfectionistic and set unrealistically high standards for themselves to avoid feelings of shame and worthlessness.
Schema modes are moment-to-moment emotional states and coping responses that we all experience. Many schema modes lead us to overreact or act in ways that end up hurting ourselves or not meeting the needs of others. These modes are triggered by life situations that we perceive as threatening or challenging, particularly when they resemble situations from our past that were associated with unmet emotional needs.
Schema modes are categorised into four main types.
These reflect the emotional states and reactions that we experienced during childhood when our basic emotional needs were not met. They include the vulnerable child mode (feeling sad, lonely, or abandoned), the angry child mode (feeling angry, frustrated, or impatient), and the impulsive/undisciplined child mode (acting on impulses or desires without considering consequences).
These are maladaptive coping responses that we learned in childhood to survive difficult experiences. They include surrender to their schemas, avoidance (avoiding situations that trigger schemas), and overcompensation (behaving in ways that oppose the schema).
These reflect the internalised voices of critical or demanding parents. They can be punitive (punishing oneself for doing things wrong) or demanding (pressuring oneself to meet high standards).
This mode is the ultimate goal of schema therapy. It represents a state in which an individual's emotional needs are being met in a balanced way, without resorting to maladaptive coping modes.
Schema therapy aims to help patients strengthen their healthy adult mode to meet their core emotional needs and heal schemas by diminishing the intensity of the schema and the emotional memories comprising the schema.
The goal of schema therapy is to assist individuals in meeting their core emotional needs (listed above) that were not met in childhood.
The primary goal of Schema Therapy is to help patients identify, challenge, and alter their early maladaptive schemas and the associated maladaptive coping styles, which often result from unmet core emotional needs in childhood. This form of therapy aims to reduce the distress, dysfunction, and self-defeating patterns caused by these schemas and promote healthier ways of having emotional needs met.
A central objective of this therapy is to strengthen the 'Healthy Adult Mode'. This means helping the patient develop skills and behaviours that allow them to get their needs met in an adaptive manner. This includes learning to set and maintain personal boundaries, assertively express and meet emotional needs, tolerate distress and frustration, and engage in self-care.
Another significant goal of schema therapy is to help patients heal their 'Child Modes'. This involves identifying and accessing the vulnerable, angry or impulsive child modes, and providing the safety, acceptance, and nurturing that was lacking in their childhood.
In addition, schema therapy works to diminish the influence of 'Dysfunctional Parent Modes', which are often internalised by critical or demanding parents and can lead to self-punishment or high self-expectations.
Moreover, schema therapy also aims to reduce maladaptive coping modes, which can involve surrender, avoidance, or overcompensation, and instead promote healthier coping mechanisms.
Schema therapy utilizes a variety of therapeutic techniques drawn from cognitive, behavioural, emotive, and interpersonal therapies. These techniques are used to identify, challenge, and alter maladaptive schemas and coping styles, ultimately aiming to meet the patient's core emotional needs in healthier ways.
These techniques aim to access and change the emotional memories associated with schemas. They can include imagery rescripting, where the patient visualises a past distressing event and then imagines it with a more positive outcome, and chair work, where the patient has a dialogue with different aspects of themselves (e.g., their vulnerable child mode and healthy adult mode) to elicit and process emotions.
These focus on the relationship between the patient and the therapist, using it as a model for healthier relationships. Techniques may include limited reparenting, where the therapist provides the support, validation, and care that the patient lacked in their childhood, and empathic confrontation, where the therapist gently but assertively challenges the patient's maladaptive behaviours and attitudes.
These involve helping the patient identify and understand their schemas, and then challenge the beliefs and assumptions associated with them. This could involve cognitive restructuring, where the therapist helps the patient to challenge and change their maladaptive thoughts and beliefs, and psychoeducation, where the therapist educates the patient about schemas and their impact.
These are used to help patients change the behaviours associated with their schemas and coping styles. This could involve role-playing, in which the patient and therapist act out scenarios to practice new behaviours, and behavioural experiments, where the patient tests out new behaviours in real-life situations and then discusses the outcomes with the therapist.
These techniques are flexibly applied based on the patient's needs and the schemas and coping styles at play, making schema therapy a highly individualised form of therapy.
While Schema Therapy has proven to be effective in treating personality disorders and other chronic psychological conditions, it does have several limitations:
Schema Therapy is typically a long-term treatment, taking several months to years. This may not be suitable or feasible for everyone, particularly those who cannot commit to regular, long-term therapy due to time constraints or financial limitations.
The process of revisiting and working through past traumas and emotional memories can be distressing and emotionally intense for some individuals. This requires a high level of motivation and resilience from the patient.
While there is growing evidence supporting the effectiveness of schema therapy, particularly in treating borderline personality disorder, more research is needed to establish its effectiveness for other disorders and populations.
Schema Therapy requires therapists to have specialised training and skills to effectively apply its techniques and strategies. Not all therapists may have these skills or be able to provide this type of therapy.
The limited reparenting component of schema therapy, where the therapist provides the nurturing, validation, and care that the patient lacked in childhood, may potentially lead to a dependence on the therapist. While this is managed within the model, it requires careful navigation by the therapist.
Schema Therapy may not be suitable for individuals with severe mental conditions such as psychosis or bipolar disorder, or for those who are currently in crisis. It’s essential that a thorough assessment is carried out to determine the most appropriate type of therapy for each individual.
If you're considering schema therapy, the first step is to find a trained and experienced schema therapist. Once you've found a potential therapist, you should schedule an initial consultation to discuss your needs and ascertain whether schema therapy might be a good fit for you.
During the initial consultation, the therapist will likely conduct a thorough assessment. This includes understanding your current concerns, history, and the patterns you've noticed in your life. They may also use tools like the Young Schema Questionnaire, which is designed to identify your early maladaptive schemas.
Following the assessment, the therapist will provide you with feedback and discuss whether schema therapy is the best approach for you. If you both agree to proceed with schema therapy, you and your therapist will outline a treatment plan. This typically involves regular therapy sessions where you'll work on identifying and changing your schemas and coping styles.
Remember, schema therapy is often a long-term commitment and it's important to be prepared for the journey. It can be emotionally intense as it requires exploring past traumas and deep-seated patterns. However, with a qualified therapist and your commitment, schema therapy can lead to significant improvements in your emotional well-being and relationships.
If at any point you feel that schema therapy is not working for you, it's crucial to discuss these concerns with your therapist. They can adjust your treatment plan, try different techniques, or recommend other types of therapy that may be more effective for you. The key is to stay open and communicative with your therapist throughout the process.
The Psych Collective has a range of clear, easy-to-understand videos on YouTube explaining schema therapy. Below are two good videos to start with.
See Imagery Rescripting (ImRS)
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