Schema therapy


Schema therapy was developed by Jeffrey E. Young for use in treatment of personality disorders and chronic DSM Axis I disorders, such as when patients fail to respond or relapse after having been through other therapies. Schema therapy is an integrative psychotherapy combining theory and techniques from previously existing therapies, including cognitive behavioral therapy, psychoanalytic object relations theory, attachment theory, and Gestalt therapy.

Introduction

Four main theoretical concepts in schema therapy are early maladaptive schemas, coping styles, modes, and basic emotional needs:
  1. In cognitive psychology, a schema is an organized pattern of thought and behavior. It can also be described as a mental structure of preconceived ideas, a framework representing some aspect of the world, or a system of organizing and perceiving new information. In schema therapy, a schema specifically refers to an early maladaptive schema, defined as a pervasive self-defeating or dysfunctional theme or pattern of memories, emotions, and physical sensations, developed during childhood or adolescence and elaborated throughout one's lifetime. Often they have the form of a belief about the self or the world. For instance, a person with an Abandonment schema could be hypersensitive about their perceived value to others, which in turn could make them feel sad and panicky in their interpersonal relationships.
  2. Coping styles are a person's behavioral responses to schemas. There are three potential coping styles. In "avoidance" the person tries to avoid situations that activate the schema. In "surrender" the person gives into the schema, doesn't try to fight against it, and changes their behavior in expectation that the feared outcome is inevitable. In "counterattack", also called "overcompensation", the person puts extra work into not allowing the schema's feared outcome to happen. These maladaptive coping styles very often wind up reinforcing the schemas. Continuing the Abandonment example: having imagined a threat of abandonment in a relationship and feeling sad and panicky, a person using an avoidance coping style might then behave in ways to limit the closeness in the relationship to try to protect themself from being abandoned. The resulting loneliness or even actual loss of the relationship could easily reinforce the person's Abandonment schema. Another example can be given for the Defectiveness schema: A person using an avoidance coping style might avoid situations that make them feel defective, or might try to numb the feeling with addictions or distractions. A person using a surrender coping style might tolerate unfair criticism without defending themself. A person using the counterattack/overcompensation coping style might put extra effort into being superhuman.
  3. Modes are mind states that cluster schemas and coping styles into a temporary "way of being" that a person can shift into occasionally or more frequently. For example, a Vulnerable Child mode might be a state of mind encompassing schemas of Abandonment, Defectiveness, Mistrust/Abuse and a coping style of surrendering.
  4. If a patient's basic emotional needs are not met in childhood, then schemas, coping styles, and modes can develop. Some basic needs that have been identified are: connection, mutuality, reciprocity, flow, and autonomy. For example, a child with unmet needs around connection—perhaps due to parental loss to death, divorce, or addiction—might develop an Abandonment schema.
The goal of schema therapy is to help patients meet their basic emotional needs by helping the patient learn how to:
Techniques used in schema therapy including limited reparenting and Gestalt therapy psychodrama techniques such as imagery re-scripting and empty chair dialogues. See, below.
There is a growing literature of outcome studies on schema therapy, where schema therapy has shown impressive results. See, below.

Early maladaptive schemas

Early maladaptive schemas are self-defeating, emotional and cognitive patterns established from childhood and repeated throughout life. They may be made up of emotional memories of past hurt, tragedy, fear, abuse, neglect, unmet safety needs, abandonment, or lack of normal human affection in general. Early maladaptive schemas can also include bodily sensations associated with such emotional memories. Early maladaptive schemas can have different levels of severity and pervasiveness: the more severe the schema, the more intense the negative emotion when the schema is triggered and the longer it lasts; the more pervasive the schema, the greater the number of situations that trigger it.

Schema domains

Schema domains are five broad categories of unmet needs into which are grouped 18 early maladaptive schemas identified by :
  1. Disconnection/Rejection includes 5 schemas:
  2. # Abandonment/Instability
  3. # Mistrust/Abuse
  4. # Emotional Deprivation
  5. # Defectiveness/Shame
  6. # Social Isolation/Alienation
  7. Impaired Autonomy and/or Performance includes 4 schemas:
  8. # Dependence/Incompetence
  9. # Vulnerability to Harm or Illness
  10. # Enmeshment/Undeveloped Self
  11. # Failure
  12. Impaired Limits includes 2 schemas:
  13. # Entitlement/Grandiosity
  14. # Insufficient Self-Control and/or Self-Discipline
  15. Other-Directedness includes 3 schemas:
  16. # Subjugation
  17. # Self-Sacrifice
  18. # Approval-Seeking/Recognition-Seeking
  19. Overvigilance/Inhibition includes 4 schemas:
  20. # Negativity/Pessimism
  21. # Emotional Inhibition
  22. # Unrelenting Standards/Hypercriticalness
  23. # Punitiveness

    Schema modes

Schema modes are momentary mind states which every human being experiences at one time or another. A schema mode consists of a cluster of schemas and coping styles. Life situations that a person finds disturbing or offensive, or arouse bad memories, are referred to as "triggers" that tend to activate schema modes. In psychologically healthy persons, schema modes are mild, flexible mind states that are easily pacified by the rest of their personality. In patients with personality disorders, schema modes are more severe, rigid mind states that may seem split off from the rest of their personality.

Identified schema modes

identified 10 schema modes grouped into four categories. The four categories are: Child modes, Dysfunctional Coping modes, Dysfunctional Parent modes, and the Healthy Adult mode. The four Child modes are: Vulnerable Child, Angry Child, Impulsive/Undisciplined Child, and Happy Child. The three Dysfunctional Coping modes are: Compliant Surrenderer, Detached Protector, and Overcompensator. The two Dysfunctional Parent modes are: Punitive Parent and Demanding Parent.
Treatment plans in schema therapy generally encompass three basic classes of techniques: cognitive, experiential, and behavioral. Cognitive strategies expand on standard cognitive behavioral therapy techniques such as listing pros and cons of a schema, testing the validity of a schema, or conducting a dialogue between the "schema side" and the "healthy side". Experiential and emotion focused strategies expand on standard Gestalt therapy psychodrama and imagery techniques. Behavioral pattern-breaking strategies expand on standard behavior therapy techniques, such as role playing an interaction and then assigning the interaction as homework. One of the most central techniques in schema therapy is the use of the therapeutic relationship, specifically through a process called "limited reparenting".
Specific techniques often used in schema therapy include flash cards with important therapeutic messages, created in session and used by the patient between sessions, and the schema diary—a template or workbook that is filled out by the patient between sessions and that records the patient's progress in relation to all the theoretical concepts in schema therapy.

Schema therapy and psychoanalysis

From an integrative psychotherapy perspective, limited reparenting and the experiential techniques, particularly around changing modes, could be seen as actively changing what psychoanalysis has described as object relations. Historically, mainstream psychoanalysis tended to reject active techniques—such as Fritz Perls' Gestalt therapy work or Franz Alexander's "corrective emotional experience"—but contemporary relational psychoanalysis is more open to active techniques. It is notable that in a head to head comparison of a psychoanalytic object relations treatment and schema therapy, the latter had significantly better outcomes.

Outcome studies on schema therapy

Schema therapy vs transference focused psychotherapy outcomes

Dutch investigators, including Josephine Giesen-Bloo and Arnoud Arntz, compared schema therapy with transference focused psychotherapy in the treatment of borderline personality disorder. 86 patients were recruited from four mental health institutes in the Netherlands. Patients in the study received two sessions per week of SFT or TFP for three years. After three years, full recovery was achieved in 45% of the patients in the SFT condition, and in 24% of those receiving TFP. One year later, the percentage fully recovered increased to 52% in the SFT condition and 29% in the TFP condition, with 70% of the patients in the SFT group achieving "clinically significant and relevant improvement". Moreover, the dropout rate was only 27% for SFT, compared with 50% for TFP.
Patients began to feel and function significantly better after the first year, with improvement occurring more rapidly in the SFT group. There was continuing improvement in subsequent years. Thus investigators concluded that both treatments had positive effects, with schema therapy clearly more successful.

Less intensive outpatient, individual schema therapy

Dutch investigators, including Marjon Nadort and Arnoud Arntz, assessed the effectiveness of schema therapy in the treatment of borderline personality disorder when utilized in regular mental health care settings. A total of 62 patients were treated in eight mental health centers located in the Netherlands. The treatment was less intensive along a number of dimensions including a shift from twice weekly to once weekly sessions during the second year. Despite this, there was no lessening of effectiveness with recovery rates that were at least as high and similarly low dropout rates.

Pilot study of group schema therapy for borderline personality disorder

Investigators Joan Farrell, Ida Shaw and Michael Webber at the Indiana University School of Medicine Center for BPD Treatment & Research tested the effectiveness of adding an eight-month, 30-session schema therapy group to treatment-as-usual for borderline personality disorder with 32 patients. The dropout rate was 0% for those patients who received group schema therapy in addition to TAU and 25% for those who received TAU alone. At the end of treatment, 94% of the patients who received group schema therapy in addition to TAU compared to 16% of the patients receiving TAU alone no longer met BPD diagnostic criteria. The schema therapy group treatment led to significant reductions in symptoms and global improvement in functioning. The large positive treatment effects found in the group schema therapy study suggest that the group modality may augment or catalyze the active ingredients of the treatment for BPD patients. As of 2014, a collaborative randomized controlled trial is under way at 14 sites in six countries to further explore this interaction between groups and schema therapy.

Professional literature