Schema Therapy provides a new system of psychotherapy that is especially well suited to patients with entrenched, chronic psychological disorders who have heretofore been considered difficult to treat.
Schema Therapy (ST) was developed by Jeffrey Young in the 1980s with the goal of improving interventions for individuals who had personality disorders and more complex, chronic and characterological difficulties. Dr. Young found traditional CBT to be less helpful for patients with chronic characterological problems.
ST originates from cognitive behavioral therapy (СBT). In comparison with CBT, ST definitely focuses on three areas:
problematic emotions, which come to the fore with the cognitive and behavioral aspects of the patient's symptoms
negative childhood experience. The ST therapist processes information about the childhood of the patient and helps him to understand how his past could cause the current problems.
therapeutic relationships play an important role in ST. They are conceptualized as relations of repeated fatherhood. The idea is that the therapist takes on a parental role, showing warmth and care for the patient - of course, within therapeutic relationships. The style of these relationships is always individual.
However, a great number of techniques from other psychotherapeutic approaches, for instance Gestalt, psychoanalysis, psychodrama, CBT, were integrated into one framework emphasizing the strength of each method.
In 1990s the first Schema Therapy Institute was established by J. Young in Manhattan. In 2008 the International Society of Schema Therapy was founded.
2. Description
There are four main concepts that are central to ST: early maladaptive schemas, coping styles, schema domains and schema modes (Young et al., 2003).
Early maladaptive schemas (EMS) are at the heart of model. Currently, there are eighteen EMS and they are described as extremely stable and enduring themes, comprised of memories, emotions, cognitions, and bodily sensations regarding oneself and one’s relationship with others, that develop during childhood and are elaborated on throughout the individual’s lifetime, and that are dysfunctional to a significant degree (Young et al., 2003). These EMS develop when there is a mismatch between a child’s basic needs and their environment, traumatic experiences and unhealthy parental attitudes. Actually, EMS are the main causes of psychopathology.
Universal basic emotional needs that are supposed to be met in every person, are the needs of:
safety and care;
unconditional acceptance and emotional warmth;
permission for authenticity and development of “internal space”;
support in the development of self-control, self-discipline, healthy conscience;
the autonomy and the development of the “outside world”.
Early maladaptive schemas include: abandonment, mistrust, emotional deprivation, defectiveness, social isolation, dependence, vulnerability to harm or illness, enmeshment, failure, entitlement, insufficient self-control, subjugation, self-sacrifice, approval-seeking, pessimism, emotional inhibition, unrelenting standards and punitiveness (Young et al. 2003).
Maladaptive schemas can be hidden until they are cause by any psychotraumatic situation. There are three mechanisms of reactions (seen as dysfunctional) on the negative emotions created by maladaptive schemas: schema avoidance, schema surrender and schema compensation.
Coping styles refer to the ways a child adapts to these environments and experiences. There are three main coping strategies that these children adopt: (1) overcompensation (fighting the schema and acting as though the opposite were true), (2) surrendering (or giving in to the schema) and (3) avoidance (trying to avoid schema activation) (Young et al., 2003).
Schema modes are the most recent addition to the ST model. Modes reflect the moment-to-moment emotional and behavioural state of a person at a given time. Modes comprise of clusters of schemas, for example, defectiveness (the belief that one is flawed or defective) and emotional deprivation (the belief that you will never be understood and that your needs will never be met by others) are both part of the Vulnerable Child mode (Young et al., 2003).
Eighteen schemas are put in five broad developmental categories of schemas that are call schema domains. Each of the five domains represents an important component of a child's core needs.
Disconnection and Rejection
Abandonment/instability
Mistrust/Abuse
Emotional Deprivation
Defectiveness/Shame
Social Isolation/Alienation
Impaired Autonomy and Performance
Dependence/Incompetence
Vulnerability to harm or illness
Enmeshment/Undeveloped Self
Failure
Impaired Limits
Entitlement/Grandiosity
Insufficient Self-Control/Self-Discipline
Other-Directedness
Subjugation
Self-Sacrifice
Approval-Seeking/Recognition-Seeking
Overvigilance and Inhibition
Negativity/Pessimism
Emotional Inhibition
Unrelenting Standards/Hypercriticalness
Punitiveness
3. Indications
Personality Disorders
Depression
Bipolar Affective Disorder
Eating Disorders
Anxiety Disorders
Post-Traumatic Stress Disorder
Forensic Applications
Addictions
A Systematic Review of the Evidence Base for Schema Therapy
Samantha A. Masley, David T. Gillanders, Susan G. Simpson & Morag A. Taylor (2011): A Systematic Review of the Evidence Base for Schema Therapy, Cognitive Behaviour Therapy, DOI:10.1080/16506073.2011.614274
4. Efficacy
Schema therapy has been found to be effective in the treatment of borderline personality disorder as well as other personality disorders.
In a meta-analysis study, it was determined that schema therapy was significantly effective in reducing symptoms in depressive disorders (Malogiannis, 2014) and chronic depression. Schema therapy has been indicated to be a new and effective method for the treatment of anxiety disorders (e.g. Young & Mattila, 2002).
Some initial studies have been conducted on eating disorders and Schema Therapy. These include single case studies (e.g. Ohanian, 2002 and Simpson & Slowey, 2011) and larger scale studies (e.g. George et al., 2004).
New findings suggest that ST is more effective than usual forensic treatment in psychopathic offenders, and that these patients may be more amenable to change than believed possible (M. Keulen-de Vos, 2013).
ST is an effective adjunctive psychotherapy option that attenuates emotional reactivity, reduces symptoms and improves quality of life (D. Hawke, D. Provencher, V. Parikh, 2012).
Given the prevalence of co-morbidity and complex personality traits in this population, Schema Therapy has been identified as a potentially viable treatment option. (F Calvert, E. Smith, R. Brockman, S Simpson, 2018)
Young, J.E. & Klosko, J.S. (1993, 1994). Reinventing your life. New York: Plume Books
M. Vreeswijk, J. Broersen & M. Nadort (Eds.) (2012). The Wiley‐Blackwell handbook of schema therapy, theory, research, and practice. Oxford, UK: Wiley‐Blackwell
Eshkol Rafaeli, David P. Bernstein, & Jeffrey Young (2010). Schema Therapy: Distinctive Features.
Joan Farrell, Neele Reiss and Ida Shaw (2014). The Schema Therapy Clinician's Guide: A complete resource for building and delivering individual, group and integrated mode treatment programs. Wiley-Blackwell
a master’s degree in psychology or a medical degree with psychiatric residency and the license to practice
complete 25 didactic hours, 15 hours of supervised role-playing, and 20 supervision sessions
use of a schema therapy approach in at least two cases of at least 25 therapy hours each
provision of a minimum of 80 sessions
Self-therapy and peer supervision are strongly recommended
9. Comment from an expert
“The primary characteristic that differentiates ST from other therapies is that ST is truly integrative. Every therapy model has its strengths, but most other therapies primarily utilize only one or two modalities. ST is broader, both conceptually and in terms of techniques. Comparing it to psychoanalysis, ST is similar in going “deeper”, and ST focuses on feelings and thoughts that are out of the people’s awareness. But it does this in a much more active way, and it uses many more strategies. ST is more structured in how we assess the patient and guide the therapist to core themes. The typical analyst is much more detached and interprets needs, whereas reparenting in ST gratifies many of the needs of the patient.”
Jeffrey Young
Schema therapy contains a great "composition" of techniques in a holistic bouquet of a modern model of understanding of basic psychological needs, as well as modern data of the developmental neurobiology. It emphasizes the importance of interpersonal relations in human life, on such relationships, which give a sense of trust, safety, acceptance and understanding.
Oleh Romanchuk
Children psychiatrist, CBT, ST psychotherapist and supervisor, EMDR therapist, the President and the founder of Ukrainian Institute of Cognitive Behavioral Therapy
10. Comment from a trainee
In my psychotherapeutic practice, I noticed a tendency, that usually patients with, for example, depression or anxiety disorders have many destructive personality characteristics. Such character traits are not sufficient for the diagnosis of personality disorder. Sometimes Cognitive-Behavioral Psychotherapy is not enough at the final stage of the work with such patient`s core beliefs and conditional assumptions. Schema Therapy, skillfully complementing the techniques of Cognitive-Behavioral Psychotherapy, has become an excellent assistant in my psychotherapy practice. Practicing Schema therapy for half a year, I came to the conclusion that it is a unique method that combines both rationality and emotionality, works up patient`s childhood traumatic experience and helps to implement new beliefs in everyday life. ST helped me “to look deeper into each patient`s soul” and never give up, no matter what diagnosis my patient has.
Affiliations
Dr. Sofiia Lahutina, Psychiatric trainee, Ukraine, 1st year intern of Schema Therapy project, 3d year intern of CBT project.
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