Schema Therapy

Schema Therapy was created by psychologist Jeffrey Young in 1990. He was trained in cognitive-behavioral therapy (CBT) but found that while CBT was good at alleviating symptoms associated with axis I disorders (e.g, depression and anxiety), it was not as effective with characterological problems. As a result, he set out to develop a new therapy that could address deep-seated personality issues. 

What is Schema Therapy? 

Schema Therapy mixes the concepts of CBT with psychodynamic, experiential, and attachment theories. It can be brief or long-term, depending on the needs of the client. In addition to examining thought patterns, it emphasizes exploring childhood experiences, the therapist-patient relationship, and ineffective coping styles. It is a truly integrative approach. 

The premise behind Schema Therapy is that maladaptive schemas develop because the emotional needs of childhood are not met.

Young and his colleagues identified 18 commonly held schemas and grouped them into five broader domains: 

1. Disconnection/Rejection: This domain encompasses beliefs that others cannot be relied upon for support, or that one is isolated and rejected by other people.

2. Impaired autonomy/Performance: Beliefs that one is not equipped to handle daily responsibilities and is likely to fail. 

3. Impaired limits: Believing that one is superior to others and entitled to special treatment.

4. Other-directedness: Beliefs that other people are more deserving of good fortune and you should suppress your needs in exchange for their desires. 

5. Overvigilance/Inhibition: Believing that expressing your true thoughts and emotions leads to failure rather than success. Strict internal rules must be adhered to, even when they don’t result in well-being.  

These schemas lead to maladaptive coping styles, such as surrender, avoidance, and overcompensation. The goal of therapy is to identify these core schemas and work to change negative coping styles through different therapeutic techniques. 

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Schema Therapy concepts and techniques

Schema Therapy works under two primary treatment concepts:

Empathic confrontation. The therapist helps the client identify their schemas and how they have caused harm. Through empathy and understanding, they help the client recognize the need to change.

Limited reparenting. The therapist, through validation, compassion, and respect, helps fulfill the emotional needs of the client that weren’t met in childhood.

The following techniques are used to satisfy these concepts: 

Chair Work 

Chair work has roots in Gestalt therapy and is a specialized type of role-play. It is often used to help clients express emotions to family, friends, and partners. Some of these chair “interactions” may be practice for real future conversations but it is also a vehicle for expressing emotions to people that may no longer be a part of the client’s life. For example, an individual might express their feelings toward a dead caregiver while sitting in one chair and then move to the other chair to play the role of that caregiver. In this way, they work through emotional issues that may have led to maladaptive schemas and poor coping behavior. 

Imagery 

Imagery is a powerful tool for both assessment and intervention. The therapist typically asks the client to imagine a situation that is a cause of concern and then picture themselves overcoming the negative coping strategies they have used to address the situation in the past. For example, a female client might have been abused as a child, causing her to have poor self-esteem and feeling that she does not deserve the love of another human being. As a result, whenever she dates, she finds herself sabotaging the relationship because she feels she is not good enough. The therapist may ask the client to push through her feelings of inadequacy and visualize herself avoiding the sabotaging behavior, leading to a long-term and meaningful relationship. 

Keeping a diary 

Similar to a thought journal in CBT, individuals in Schema Therapy are often asked to keep a diary of situations associated with maladaptive schemas and coping styles. Diaries help illustrate patterns of negative thoughts and behavior and are a starting point in assisting clients to learn how to embrace more beneficial behavior. Keeping a consistent diary can also show the client their progress over time. 

Flashcards

Flashcards are used to create messages for caregivers who failed to meet clients’ childhood needs. These messages can take the form of poems, notes, or letters. The client can express these messages directly to their caregivers if they choose but this is not a mandatory part of therapy. The client is asked to review the flashcards regularly throughout their treatment. Flashcards help clients express suppressed feelings and learn how to make effective statements about their emotional needs to important people in their lives.

Pros and cons of Schema Therapy

• Personality disorders are notoriously difficult to treat. Schema Therapy is effective in treating many of the most treatment-averse, including borderline personality disorder, narcissistic personality disorder, and dependent personality disorder. However, Schema Therapy is relatively new to the field and has not undergone extensive review.

• There is no recommended time limit for Schema Therapy. For difficult cases, it could take years. Insurance companies might balk at paying for so many sessions but may also be convinced that treating personality disorders takes considerable time. 

• Schema Therapy can be difficult for the client, as they need to confront long-held belief systems. They also need to stay motivated over a long time and be willing to try new ways of doing things. Change is hard and Schema Therapy asks a lot of the client. 

Training Resources

• Proper training in Schema Therapy is a lengthy process that can take months, if not years. It includes didactic learning, experiential learning, and supervision. It is not so easy to find; most formal certification occurs through Schema Therapy institutes dotted around the country. Because of Covid-19, much of the didactic parts can now be done online. 

• In addition to the U.S., Schema Therapy has a strong international presence. The International Society of Schema Therapy provides training worldwide and has valuable resources, including relevant research, books, and articles. 

• PESI is offering an online course that, while extensive, is not so demanding as the training found through Schema Therapy institutes. 

• PositivePsychology has a comprehensive guide to Schema Therapy exercises and techniques that therapists can use with their clients.

• Here is a video of a psychotherapy session with Schema Therapy founder Jeffrey Young, Ph.D.