Schema Therapy was developed by Dr. Jeffrey E. Young for use in treatment of personality disorders and chronic Axis I disorders, such as when patients fail to respond or relapse after having been through other therapies (for example, traditional cognitive behavioral therapy). Schema Therapy is a newer, integrative psychotherapy combining theory and techniques from existing therapies, including cognitive behavioral therapy, psychoanalytic object relations, attachment Theory, and Gestalt therapy (Young, 2003, p. 6).
- 1 Introduction
- 2 Definition of maladaptive schemas
- 3 Schema modes
- 4 Technique in Schema Therapy
- 5 Discussion of some outcome studies on Schema Therapy
- 5.1 Schema Therapy vs transference focused psychotherapy outcomes (Archives of General Psychiatry 2006)
- 5.2 Less intensive outpatient, individual schema therapy (Behaviour Research and Therapy 2009)
- 5.3 Pilot study of group Schema Therapy for BPD (Journal of Behavior Therapy and Experimental Psychiatry 2009)
- 5.4 Cost effectiveness of Schema Therapy
- 6 Conclusion
- 7 Notes
- 8 References
- 9 External links
The main theoretical concepts in Schema Therapy are Early Maladaptive Schemas (or just "schemas"), Coping Styles, Modes, and basic emotional needs. (Young, 2003, p. 7, 9, 32, 37)
In most of psychology, schemas describe an organized pattern of thought or 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.However, schemas according to Young, refer to early maladaptive schemas, and are defined as "self-defeating life patterns of perception, emotion, and physical sensation". (Young, 2003, p. 6) For instance, a person with an Abandonment schema could be hypersensitive (have an "emotional button") to their perceived value to others, therefore being prone to leaving them which in turn could make them feel sad and panicky in those relationships.
Coping styles are our behavioral responses to the schemas in hopes of making things better, but in fact they very often wind up reinforcing the schema. (Young, 2003, p. 32) Continuing the Abandonment example, having over-perceived possibilities of abandonment in a relationship and feeling sad and panicky, someone with an avoidance coping style might then behave in ways to limit the closeness in the relationship in order to try to protect themselves from being abandoned. The resulting loneliness or even actual loss of the relationship could easily reinforce the person's Abandonment schema.
Modes are mind states that we can shift into quickly or more stably that cluster schemas and coping styles into a temporary "way of being." (Young, 2003, p. 37) 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 (to the schemas).
If basic emotional needs are not met in childhood, schemas, coping styles, and modes can result. (Young, 2003, p. 9) Some basic needs that have been identified are: connection, mutuality, reciprocity, flow, and autonomy. (Young, 2003, p. 9) For example, a child with unmet needs around connection, say from parental loss to death, divorce, or addiction, might develop an Abandonment schema.
The goal of Schema Therapy is to help patients get their core emotional needs met. Key steps in accomplishing this involve learning how to:
- Stop using maladaptive coping styles and modes that block contact with feelings
- Heal schemas and vulnerable modes through getting needs met in and outside of the therapeutic relationship
- Incorporate reasonable limits for angry, impulsive or overcompensating schemas and modes
- Fight punitive, overly critical or demanding schemas and modes
- Build healthy schemas and modes
Some distinctive techniques in Schema Therapy are Limited Reparenting and Gestalt psychodrama techniques, such as imagery re-scripting and empty chair dialogues. See Technique section below.
There is a growing literature of outcome studies on Schema Therapy, where Schema Therapy has shown impressive results. See the Outcomes Studies section below for further detail.
Definition of maladaptive schemas
Young uses the concept of Schemas as it is defined in Cognitive Psychology, and, as such, schemas can be either healthy or maladaptive. In a sense, Schema Therapy ultimately seeks to replace maladaptive schemas with more healthy schemas.
Maladaptive schemas, according to Young, are defined as and relate mainly to the lack of basic emotional needs met in childhood and a lack of appropriate relationships, bonds, and behaviors of the parents, caretakers, and others involved in the life of a growing child.
Maladaptive schemas are considered a pattern of established (from childhood) unstable reactions/behaviors to any given situation in life. Maladaptive schemas may be made up of revisited (sometimes obsessively) memories of past hurt, tragedy, fear, abuse, neglect, unmet safety needs, abandonment, or lack of normal human affection in general. Thus, as an adult, Schema "modes" may become nearly reflexes as the patient is seeking approval due to unmet childhood needs.
Maladaptive schemas can also be bodily sensations associated with such traumas (and/or flashbacks such as with PTSD). The ways of which a person may view him or herself in combination with difficulties establishing one's true identity, body image, and/or one's ability (or lack thereof) to properly or happily socialize with others (as they were never taught/never learned as children) can be considered "Schemas", as well. Schemas may also cause feelings of inadequacy leading to seemingly dramatic, inappropriate, dysfunctional, or generally disruptive behaviors in response to what a "healthy adult" may deem as every day scenarios or situations.
Schema Modes are defined as emotional states and ways of coping which every human being experiences at one time or another. Life situations that we find disturbing, arouse bad memories, or offend us, or personal topics/situations to which we are sensitive, are referred to as "triggers" that tend to bring out the somewhat explosive behaviors of patients involved in this type of therapy.
According to Young, people suffering with personality disorders especially tend to be hypersensitive and may be "triggered" by a simple image, word of offense, sound, etc. These "triggers" may produce states of being which often lead to reactions perceived as inappropriate and/or overreaction by the general public. Reflection upon a schema of their own dislike instinctively and often brings about the "Flight or fight" response. Schema Therapy's Philosophies of caring and comfort help to step in when someone is "triggered", replacing a self-destructive reaction with a healthy coping skill.
Schema Therapy works with such emotional individuals by focusing on identifying roots of lack of personal self-control, impulsivity, lack of attachments with peers or family, and to positively help a patient build self confidence and to eliminate any self-destructive reactions effectively, as the patient gains healthier coping methods.
Some of the identified Schema modes of which patients and clients are educated about via therapy are as follows
- Angry child - This mode is fueled mainly by feelings of victimization or bitterness, leading towards negativity, pessimism, jealousy, and rage. While experiencing this schema mode, a patient may have urges to yell, scream, throw/break things, or possibly even self-injury/harming others. The "angry child" is enraged, anxious, frustrated, self-doubting, feels unsupported in ideas, and vulnerable.
- Impulsive Child - This is the mode where anything goes. Theoretically if an individual is having an "identity crisis" or moments of depersonalization this mode might come into play. Behaviors of the "impulsive child" may include: reckless driving, substance abuse, cutting oneself, suicidal thoughts, gambling, or fits of rage, such as punching a wall when "triggered" or laying blame of circumstantial difficulties upon innocent people. Unsafe sex, rash decisions to run away from a situation without resolution, tantrums perceived by peers as infantile, and so forth are a mere few of the behaviors of which an "impulsive child" might display. "Impulsive Child" is the rebellious and careless schema mode and can lead to conscious suicidal thoughts if not stopped.
- Detached Protector - This schema mode is based in escape. Individuals in "detached protector" withdraw, dissociate, alienate, or hide in some way. This may be triggered by numerous stress factors or feelings of being overwhelmed. The lack of coping skills when a person is in a life situation involving high-demand or a chain of thoughts/emotions revolving obsessively often can trigger "detached protector." Stated simply, patients become numb in order to protect themselves from the harm or stress of what they fear is to come, or fear of the unknown in general. Mistrust is often a culprit in "triggering" such fears.
- Abandoned Child - The "abandoned child" is a schema mode in which a person may feel defective in some way, thrown aside, unloved, obviously alone, or may be in a "me against the world" mindset. Feeling as though peers, friends, family, and even the entire world have abandoned a person are the things which make up this schema mode. Behaviors of individuals stuck in "abandoned child" include, but are not limited to: falling into major depression, pessimism, feeling unwanted, inferiority complexes arising, feeling unworthy of love, and personality traits perceived as unchangeable flaws. In this mode suicidal ideation, suicidal tendencies, hypersensitivity to criticism/compliments, stubbornness, avoidant behavior, and the "why bother?" attitude all make up "abandoned child."
Rarely, a patient's personal perceived flaws may be intentionally withheld on the inside. When this occurs, instead of showing one's true self, the patient may appear to others as "egotistical", "attention-seeking", selfish, distant, and may exhibit behaviors unlike their true nature. In this mode, the patient might create a narcissistic alter-ego/persona in order to escape or hide the insecurity from others. Due to fear of rejection, of feeling disconnected from their true self and poor self-image, these patients (who truly desire companionship/affection) may end up pushing others away. This rare behavior can also be a self-soothing (yet unhealthy) self-therapy technique. It feeds the "abandoned child" delusion and becomes hazardous in the end.
- Punitive Parent - The Punitive Parent schema mode is identified by beliefs of a patient that they should be harshly punished perhaps due to feeling "defective", or making a simple mistake. They may feel that they should be punished for even existing when "punitive parent" takes over the psyche. Sadness, anger, impatience, and judgmental natures come out in "punitive parent" and are directed to the patient and from the patient. Even a small and solvable issue or unrealistic perfectionist expectations and "black and white thinking" all bring forth the "punitive parent." The "punitive parent" has great difficulty in forgiving oneself even under average circumstances in which anyone could fall short of their standards. The "Punitive Parent" does not wish to allow for human error or imperfection, thus punishment is what this mode seeks and what it desires.
- Healthy Adult - The "Healthy Adult" schema mode is what Schema Therapy strives to help a patient achieve as the long-lasting state of well-being. The "healthy adult" is good with decision making, nurturing, comforting, ambitious, sets limits and boundaries, forms healthy relationships, takes on all responsibility, sees things through, and enjoys/partakes in enjoyable adult activities and interests with boundaries enforced, takes care of his/her physical health as well, is rational, a problem-solver, someone who thinks before acting, someone aware of their self-worth, well-balanced mentally, emotionally, and physically. The "healthy adult" is grown up and loves his/herself. In this schema mode the person focuses on the present day with hope and strives towards the best tomorrow possible. The "healthy adult" forgives the past, no longer sees oneself as a victim (but as a survivor), and expresses all emotions in ways which are healthy and cause no harm.
Technique in Schema Therapy
Some techniques in Schema Therapy draw on and expand standard CBT techniques in making primarily cognitive interventions (Young, 2003, ch. 3), such as traditional pros and cons or expanding into an imagery dialogue between the "schema side" and the "healthy side." Some Schema Therapy Techniques are more experiential and emotion focused (Young, 2003, ch. 4) and draw much on psychodrama and Gestalt techniques. Another type of Schema Therapy intervention is behavioral (Young, 2003, ch. 5), such as role playing an interaction and then assigning the interaction as homework. The behavioral interventions also draw on and expand standard CBT techniques. One of the most distinctive and central areas of technique in Schema Therapy is the use of the therapy relationship, specifically Limited Reparenting (Young, 2003, ch. 6).
From a psychotherapy integration perspective, Limited Reparenting and the experiential interventions, particularly around changing modes, could be seen as actively changing what psychoanalysis has described as object relations, or as the psychoanalyst Thomas Ogden clarified, internal subject relations. Historically, mainstream psychoanalysis has tended to reject active interventions around changing object relations, such as Fritz Perls Gestalt work or Alexander's "corrective emotional experience"[original research?] (However, movements in contemporary Self Psychology are revisiting or reinventing some of these areas in terms of "optimal responsiveness") It is notable that in a head to head comparison of a psychoanalytic object relations treatment, Kernberg's Transference Focused Psychotherapy, and Schema Therapy, Schema Therapy had significantly better outcomes, one possible inference from that being that traditional psychoanalytic fears around active interventions ("something more than interpretation") are unfounded (see Outcome Study section of this article).
(Young, 2003, p. 177)
The Heart of Schema Therapy
The process of limited reparenting is the heart of the treatment in Schema Therapy and is one of its most unique and defining elements. Its centrality and power has been gaining strong empirical support through the results of two randomized control trials of Schema Therapy. These outcome studies have found that a large percentage of patients with Borderline Personality Disorder can achieve full recovery across the complete range of symptoms. The dropout rate in these studies was notably extremely low. The patients in these studies attributed a great deal of the effectiveness of the treatment and the low dropout rate to limited reparenting.
Meeting Needs and Establishing a Secure Attachment
Limited reparenting flows directly from Schema Therapy's assumption that early maladaptive schemas and modes arise when core needs are not met. Schema Therapy’s aim is to meet these needs by helping the patient find the experiences that were missed in early childhood that will serve as an antidote to the damaging experiences that led to maladaptive schemas and modes. Limited reparenting, paralleling healthy parenting, involves the establishment of a secure attachment through the therapist, within the bounds of a professional relationship, doing what he/she can to meet these needs. Research spanning a wide range of disciplines supports the notion that secure attachment is at the root of adaptive functioning, well-being and flourishing.
The Broad Range of Limited Reparenting
The focus of limited reparenting spans a broad range of needs including early connection, joy, adequate limits, and autonomy. Just as the process of parenting takes widely different forms, limited reparenting may involve warmth and nurturance, firmness, self-disclosure, confrontation, playfulness, and setting limits amongst other things. It takes the form of simultaneous tenderness and firmness through what is called “empathic confrontation.” It will also vary depending upon the phase of treatment. For this reason, Schema Therapy cannot be typified by a particular stance such as neutrality, firmness or nurturance. It is best typified by the broad range of responses and inclinations on the part of the therapist it incorporates, its flexibility, and the organization of these responses around the core needs of the patient.
Limited Reparenting and Trusting Needs
The limited reparenting approach to early needs for connection sets Schema Therapy apart from most other approaches to psychotherapy. The prevailing view is that autonomy is most effectively promoted by teaching patients skills to regulate their affect or remaining therapeutically neutral and thus keeping the patient from becoming dependent upon the therapist for this regulation. The process of limited reparenting involves welcoming and encouraging this dependency. The therapist’s regulation of the patient’s affect becomes internalized by the patient and forms a healthy adult mode modeled on the therapist’s. This healthy adult mode becomes a strong foundation for the establishment of autonomy. In this way limited reparenting is based upon more trust of these early dependency needs and a belief that is more effective to gratify than fight them.
The Key steps in Limited Reparenting
Limited reparenting involves reaching the Vulnerable Child Mode and reassuring, being firm with or setting limits on the avoidant and compensatory modes or coping styles that block access to the Vulnerable Child Modes or schemas. In the midst of this, the therapist helps to provide constructive outlets for what is called the Angry Child Mode. In addition, it often requires that the therapist help the patient fight punitive, demanding, or subjugating parent modes or schemas. These steps are usually facilitated by the use of guided imagery, an experiential technique that allows the therapist to establish more direct contact with the various modes and schemas.
(Young, 2003, p. 111)
The right hemisphere of the brain is the dominant hemisphere during early childhood and, consequently, the hemisphere through which a young child experiences her formative relationships. For this reason, most early maladaptive schemas are believed to be experienced and stored within the patient’s right hemisphere. The right hemisphere has the strongest links with the limbic part of the brain (the seat of our emotions) and, consequently, is directly connected to our deepest and most powerful feelings. Imagery is a primary means by which the right hemisphere organizes and processes information about self, others and affect and, therefore, is often an important means of gaining direct access to the “vulnerable child part” of the patient in relation to significant others and the associated “gut level” feelings that make up schemas.
Guided imagery is often used early in Schema Therapy to more clearly and deeply understand schemas and modes. This is accomplished by:
1. Eliciting upsetting childhood memories in the form of images of experiences with mother, father and other significant people
2. Asking the patient to carry on dialogues with these people
3. Asking the patient what she needs from significant others and understanding these needs in terms of the associated schema
4. Asking the patient to identify which current situations have the same emotions as the images from early childhood and, thus, clarifying the links between early memories and current triggers of schemas and modes
Through this process a resonance is established between the therapist’s right hemisphere as she imagines the imagery the patient is describing by way of her vulnerable child mode and the patient’s right hemisphere. This right hemisphere to right hemisphere resonance is believed to deepen and intensify the emotional connection between therapist and patient.
Imagery is also often an important element of the change phase. This involves a process called “imagery rescripting” through which painful memories are revised in ways that allow for the patient to get their needs met. In instances where parents or significant others were, and remain, unable to meet the patient’s needs, this involves the therapist entering into an image and serving as a transitional source of healthy parenting. This leads to a secure attachment developing between the patient and therapist, a form of attachment that is known to lead growth and integration. Imagery during the change phase also involves the patient being encouraged to express anger towards the individuals that have hurt them and helped to assert her rights. This will occur within an image or role-play during a session and not necessarily with significant others. Imagery is also used to help patients grieve for the losses in their life and to overcome trauma. In the case of trauma, imagery rescripting involves a reworking of the traumatic memories in the direction of needs such as safety and protection being met rather than primarily a process of exposure and desensitization. Later in therapy, as the patient’s healthy adult mode becomes stronger, she will enter images that include the vulnerable child mode and take the lead in meeting needs.
(Young, 2003, p. 104)
Flash cards are written statements referred to by the patient in-between sessions. They are developed by the therapist or a co-creation of therapist and patient and are statements that would be similar to those made by a parent to a young child at the developmental age that the patient currently experiences their Vulnerable Child mode. They serve as links to the therapist and, as such, as transitional objects, especially in the early phases of treatment of work on problems rooted in early attachment. The messages and sentiments expressed in the cards are gradually internalized and, thus, are very helpful in developing the Healthy Adult mode. Patients who suffer from problems such as borderline personality disorder often find flash cards to be especially powerful. Flash cards are often developed for each type of challenging situation and phase of treatment. They can take various forms such notes or poems, depending of the creativity of the therapist and the developmental level of the Vulnerable Child mode, and may be carefully thought out or spontaneous gestures.
(Young, 2003, p. 100)
Chair work involves the patient moving between two chairs as she dialogues between different parts of herself such as a schema side and the healthy side or a Detached Protector Mode and the Healthy Adult Mode. Dialogues can also take place between the patient and imagined significant others for such purposes as reaching closure or practicing assertiveness. Imagery work and chair work are frequently blended with one another.
(Young, 2003, p. 107)
A Schema Therapy Diary is a form filled out in-between sessions that provides a guide for the patient to organize their experience when schemas or modes are triggered in terms of what they have been learning in the therapy. Schema driven reactions are sorted out in terms of thoughts, feelings, behaviors, underlying schemas, healthy perspectives and realistic concerns, overreactions, and healthy behavior. It is a summary of all the major elements and stages of the therapy process and, as such, provides an important template. For some patients and therapists the Schema Diary is internalized and not used explicitly, especially at later stages in the therapy. For other therapist-patient pairs it becomes an important tool to further the internalization of healthy adult processes.
Discussion of some outcome studies on Schema Therapy
Schema Therapy vs transference focused psychotherapy outcomes (Archives of General Psychiatry 2006)
Dutch investigators, including Dr. Josephine Giesen-Bloo and Dr. Arnoud Arntz (the project leader), compared Schema Therapy (also known as Schema Focused Therapy or SFT) with Transference Focused Psychotherapy (TFP) in the treatment of Borderline Personality Disorder. 86 patients were recruited from 4 mental health institutes in the Netherlands. Patients in the study received two sessions per week of SFT or TFP for 3 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. 
Free full text of study article available at: http://archpsyc.ama-assn.org/cgi/content/full/63/6/649
Less intensive outpatient, individual schema therapy (Behaviour Research and Therapy 2009)
Dutch investigators including Dr. Marjon Nadort and Dr. Arnoud Arntz assessed the effectiveness of schema therapy in the treatment of BPD when utilized in regular mental health care settings. A total of 62 patients were treated in 8 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 BPD (Journal of Behavior Therapy and Experimental Psychiatry 2009)
Investigators Dr. Joan Farrell, Ida Shaw and Dr. Michael Webber at the Indiana University School of Medicine Center for BPD Treatment & Research tested the effectiveness of adding an eight-month, thirty-session schema therapy group to treatment-as-usual (TAU) for BPD 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. A collaborative randomized controlled trial with 14 sites in six countries is in development to further explore this productive interaction between groups and Schema Therapy. 
Cost effectiveness of Schema Therapy
Even the most intensive version of Schema Therapy mentioned in the first study was found to be cost effective. An economic analysis conducted by the authors of the study indicated that, for each year Schema Therapy patients were in the study, Dutch society benefited from a net gain of 4,500 Euros per patient (the equivalent of about 5,700 US dollars), despite the cost-intensive treatment.
The ultimate goal of Schema Therapy is to help patients get their core needs met. Schema Therapy does this by changing maladaptive schemas, coping styles and modes, using tools such as imagery, limited reparenting, cognitive challenges and behaviorally changing maladaption.
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