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It was originally designed to treat clients with personality disorders, chronic depression and anxiety, and other difficult problems that were not responding well to traditional cognitive-behavioral therapy (CBT).

Schema therapy focuses on identifying and modifying early maladaptive schemas (self-defeating emotional and cognitive patterns) and schema modes (moment-to-moment emotional states) that are thought to underlie chronic psychological disorders.

The goal is to help patients develop healthier schemas and coping strategies to improve their interpersonal relationships and overall functioning.

Early Maladaptive Schemas

The main premise is that psychological problems arise from unmet core emotional needs in childhood and adolescence, which lead to the development of early maladaptive schemas (EMS).

EMSs are pervasive patterns of memories, emotions, cognitions, and bodily sensations regarding oneself and relationships with others (Young et al., 2003). They are self-perpetuating and resistant to change.

Schemasstrongly influence individuals’ views of themselves (e.g., “I am a terrible person”), their relationships to others (e.g., “Others will leave me anyway”), and the world as a whole (e.g., “The world is a dangerous place”).

Schema therapy aims to identify and modify EMSs and maladaptive coping styles so that core emotional needs can be met in healthy, adaptive ways.

Early maladaptive schemas are the core pathological themes or patterns that develop from unmet emotional needs, traumatic experiences, or toxic interactions with parents and peers during childhood (Young et al., 2003).

Unmet Core Childhood Needs

EMSs are dimensional – they range from mild to severe. More pervasive EMSs cause greater distress and life impairment. EMSs develop from an interplay between the child’s innate temperament and the early environment.

18 EMSs have been identified, grouped into 5 domains based on the core needs they relate to:

Early Maladaptive Schemas and Unmet Core Childhood Needs

Coping Styles

Coping styles are automatic ways of responding to schema activation. While adaptive in childhood as survival mechanisms, coping styles often become rigid and maladaptive in adulthood, perpetuating rather than healing the schemas.

These coping strategies develop in childhood to help the child adapt to and lessen painful emotions in a distressing environment. But over time, they often become rigid, automatic, and maladaptive, impairing relationships and self-regulation and perpetuating difficulties in key life areas.

The rigid coping prevents childhood needs from being met in adulthood and maintains the maladaptive schema.

Three broad coping styles are described (Young et al., 2003):

For Example

When the mistrust schema is activated in interpersonal situations, patients experience intense anxiety, a sense of threat, and mistrust. They cope with this schema in three main ways:

Schema Modes

A schema mode, or simply “mode,” combines an activated schema and a coping strategy, describing the momentary emotional-cognitive-behavioral state active at a given time. Patients can quickly switch from one mode to another, whereas a schema is rigid and enduring (i.e., schema = trait, mode = state).

This concept is convenient in clinical practice, as it helps patients and therapists track and explain the frequent and sometimes sudden shifts in emotion, cognition, and behavior. Specific treatment strategies and goals for each dysfunctional mode have been developed to help patients learn healthier coping methods.

The concept of modes was necessary to explain the rapidly shifting symptoms of borderline personality disorder (BPD) patients.

The complexity of the possibilities (18 schemas × 3 coping styles = 54 possibilities) made it challenging for both the patient and therapist to maintain an overview.

Moreover, the schema concept was not optimal for explaining and working with these patients’ rapid mood and behavior changes.

To address this, Young extended the schema theory with the mode model approach, which was initially developed specifically for BPD and later fornarcissistic PD.

Four main categories of modes have been identified:

3. Dysfunctional Parent modes (Demanding/punitive inner critic modes): Internalized negative aspects from significant others (e.g. parents, teacher, siblings or peers). Includes punishing and harsh messages (punitive critic) and setting unreachable expectations and standards (demanding critic)

4. Healthy Adult mode: Adaptive functioning modes that are associated with a sense of fulfillment and well-being

The Healthy Adult mode serves an “executive” role to nurture the Vulnerable Child, set limits for the Angry and Impulsive Children, and counter the Maladaptive Coping modes. Well-functioning people have a strong, active Healthy Adult mode. A major goal of schema therapy is to help clients develop their Healthy Adult.

Treatment Strategies

Schema therapy integrates cognitive, experiential, relational and behavioral interventions. The therapist’s general stance is one of empathic confrontation – empathizing with the client’s schemas and coping responses while encouraging change (Young et al., 2003).

The ultimate goal of ST is to help patients find adaptive ways to get their emotional needs met and cope with frustration when needs cannot be met. This involves changing maladaptive schemas, coping styles, and modes underlying symptoms and problems.

Treatment focuses on healing schemas and breaking patterns of maladaptive coping.

By integrating three channels of change – experiential, cognitive, and behavioral – ST provides a holistic approach to treatment that targets both the underlying schemas and modes that drive patients’ problems, as well as the thoughts, emotions, and behaviors that maintain them. This comprehensive approach is designed to lead to lasting change and improved functioning for patients with a range of psychological disorders.

1. Cognitive strategies

Empirically testing and challenging the validity of schemas; identifying cognitive distortions and reframing early experiences

Cognitive techniques in ST include traditional cognitive-behavioral therapy (CBT) techniques, such as Socratic dialogue and challenging negative thoughts.

However, ST also places a strong emphasis on psychoeducation, which involves teaching patients about:

By providing this information, patients can better understand the origins of their problems and develop a more compassionate and understanding stance towards themselves.

Other cognitive techniques used in ST may include:

2. Therapeutic Relationship Techniques

Early maladaptive schemas often develop through childhood interpersonal traumatization, especially from parents.

Therefore, the therapeutic relationship is a central focus throughout schema therapy, serving as an antidote to those adverse experiences.

The therapeutic relationship aims to provide corrective interpersonal and emotional experiences to change the early maladaptive schemas.

3. Experiential strategies

Using imagery, dialogue work, and trauma processing to link schemas to early experiences and facilitate emotional change

The goal is to help patients access and process emotions on a deeper level, going beyond cognitive insight. This is particularly important for patients with personality disorders who may intellectually understand a concept but not feel it emotionally.

Experiential techniques allow therapists to work with patients at the developmental level of the child who experienced the negative events that contributed to their current problems.

By providing corrective experiences and information at a developmentally appropriate level, patients can better integrate these new experiences into their memory representations of past events.

4. Behavioral pattern-breaking

Replacing maladaptive coping behaviors with healthier behavioral responses through exposure, skills training, and homework assignments

Behavioral techniques in ST are similar to those used in traditional CBT and may include:

One specific behavioral technique emphasized in ST is behavioral pattern breaking. This typically occurs towards the end of treatment when patients are encouraged to identify and change dysfunctional patterns in their behaviors and choices.

The goal is to help patients break free from repeating unhealthy cycles and to experiment with new, more functional ways of living.

Empirical Support

Research on mechanisms of change in schema therapy (ST) is still in its early stages. The therapeutic alliance appears important, with better patient-rated alliance predicting less dropout and more clinical improvement in borderline personality disorder (BPD) (Spinhoven et al., 2007).

Imagery rescripting has been shown effective as a stand-alone technique across disorders like PTSD, social anxiety, and depression (Arntz et al., 2007; Grunert et al., 2007; Raabe et al., 2015; Brewin et al., 2009; Frets et al., 2014; Nilsson et al., 2012; Wild & Clark, 2011; Wild et al., 2008; Wheatley et al., 2007).

A meta-analysis supported its transdiagnostic use for aversive memories (Morina et al., 2017). Qualitative studies highlighted imagery rescripting as a powerful change process (de Klerk et al., 2017; Tan et al., 2017).

Other experiential ST techniques, like chair dialogues, need more research, though one study found no differences from present-focused CBT for non-BPD PDs (Weertman & Arntz, 2007).

AnRCTon schema therapy-based art therapy showed large effects (Haeyen et al., 2018). Component analyses testing different ST technique combinations could clarify mechanisms further.

References

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Arntz, A., & Weertman, A. (1999). Treatment of childhood memories: Theory and practice.Behaviour Research and Therapy, 37(8), 715–740.

Arntz, A., Klokman, J., & Sieswerda, S. (2004). An experimental test of the schema mode model of borderline personality disorder.Journal of Behavior Therapy and Experimental Psychiatry, 36, 226–239.

Arntz, A., Tiesema, M., & Kindt, M. (2007). Treatment of PTSD: A comparison of imaginal exposure with and without imagery rescripting.Journal of Behavior Therapy and Experimental Psychiatry, 38(4), 345-370.

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Required Readings

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Olivia Guy-Evans, MSc

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

Saul McLeod, PhD

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.