Schema Therapy

Suppose you have experienced repeated unwanted behaviors or patterns in your life. In that case, you might be experiencing what's known as a "schema," a core theme that might seem to occur without reason. For many individuals, a scheme might be entering into unhealthy relationships, navigating the challenges of substance use, or having negative thoughts that repeat throughout your day.  

A significant degree of adult dysfunctional coping modes develop in early childhood. Negative feelings and thoughts may be developed in childhood and morph into deep-seated patterns that cycle multiple times until they are changed. For those experiencing multiple distressing schemas, schema therapy may be beneficial.

Cognitive-behavioral therapy (CBT) is often used to treat mental health symptoms related to behaviors. However, the schema therapy model focuses more on the importance of therapeutic relationships and a patient's emotions while utilizing some core concepts of CBT. Schema therapy may also integrate behavioral techniques such as exposure therapy or activity planning. 

Jeffrey Young developed schema therapy for people whose mental health concerns were not solved using cognitive therapy. Schema therapy is often used to treat personality disorders, with a core belief that personality disorders may stem from unmet emotional needs during childhood. 

Mental health myths and stigmas are often targeted toward personality disorders. Although many people may believe that personality disorders "can't be treated," schema therapy focuses on the idea that they can and that treatment can assist this process. With schema therapy, the therapeutic relationship between the patient and the therapist may create a safe and trusting dynamic to support clients with any diagnosis. 

Negative patterns in schema therapy

A maladaptive schema is a continuing negative pattern that starts during childhood. For instance, a child may have experienced bullying in school and developed low self-esteem throughout life. Schemas are often strengthened by actions, core beliefs, relationships, and thoughts throughout a person's life experiences. 

Unhelpful schema beliefs may include phrases like, "no one loves me," "I will never succeed," "I'm ugly," or I'm a failure," among others. Some schema beliefs might develop during adulthood. However, the premise of schema therapy focuses heavily on childhood. 

According to schema theories, maladaptive schemas form because of harmful childhood experiences. Maladaptive schemas can also be explained as how people interpret life occurrences, other people's behaviors, and their effect on later events or choices. Maladaptive schemas might cause individuals to engage in unhealthy relationships, poor social skills, or harmful behaviors and experience low self-esteem or worthlessness. These maladaptive modes may profoundly affect an individual or cause insufficient skills. 

Schema therapists may assist people in addressing and fulfilling their unmet needs. This form of therapy can help clients modify deep-rooted challenging emotions or patterns. Unlike cognitive-behavioral therapy (CBT), which shows the patient how to reduce negative thought patterns, schema therapy uses techniques based on focus and acceptance. One therapy that may help symptoms of maladaptive coping styles is dialectical behavior therapy (BDT), which includes a mindfulness module. DBT has been effective in treating maladaptive coping skills in children and adults.

Standard techniques used in schema therapy

Schema therapy references CBT techniques and experiential and emotion-focused techniques during treatment. It dwells on specific core needs, including a sense of safety and attachment, self-compassion, freedom, and the ability to play and enjoy life. In a session, a therapist may use various techniques to assist clients in meeting their adult needs through compassionate therapeutic care. 

Flashcards

During a schema therapy session, a therapist might provide a schema therapy flashcard for the client to fill out questions about their current feelings and the schema they think they may be experiencing. The client may continue to read the flashcards to come up with positive ways they or others can meet their needs in the present. 

Diaries

Schema diaries are also recommended for patients. They guide the patients to understand their experiences when the schemas are triggered. The patient can record their progress compared to the theoretical concepts they are introduced to during schema therapy treatment sessions. 

Imagery

Imagery allows people to explore adverse childhood events and better understand how their maladaptive schemas might have developed. 

During childhood, the right side of the brain is dominant, and through this, a child's experiences are created. Researchers believe maladaptive schemas are stored in the right hemisphere, which primarily rules creativity and emotion. Suppose someone has an adverse experience as a child. In that case, these maladaptive schemas may be stored in the right hemisphere and lead to emotional dysregulation throughout an individual's lifetime. 

During imagery practices, clients may be asked to imagine images or scenes of anything involved with their memories or experiences. For example, they might imagine a dialogue with the individuals who harmed them or pretend that the ideal circumstances were met, imagining what that would look like. The imagery might provide mental freedom from distressing memories.  

In a scheme therapy session, the therapist may take the following approaches: 

1. Assessment And Identification: The therapist gets to know the client to understand their schemas and the effect they may have. They discuss the client's life and provide a systemic review of their lifetime schemas and coping strategies.
2. Emotional Awareness: The client is assisted in developing emotional awareness to understand their schemas and behaviors. They might use flashcards, role-playing, or imagery to imagine these. 
3. Correction: The schema mode inventory of maladaptive coping schemas is replaced with healthy schemas for emotional control and healing. This may include rewarding adaptive behavior. 

Young also developed a schema questionnaire designed to help clients and their therapists determine what early maladaptive schemas they may have developed throughout their life. The following 18 schemas are commonly seen in schema therapy:

1. Emotional Deprivation: The belief that others will not give you empathy or that others cannot meet adequate emotional support.
2. Mistrust: Believing that others will humiliate, use you, abuse, or hurt you. One has the perception that every form of harm is intentional.
3. Dependence: Believing that one cannot handle their responsibilities without assistance from another, sometimes referred to as "learned helplessness."
4. Defectiveness Or Shame: Feelings of being unwanted, invalid, or inferior. As a result, one may feel hypersensitive to criticism or rejection.
5. Entitlement: Also known as grandiosity, entitlement may involve feeling superior to others. It may present with excessive competitiveness, controlling behavior, or a lack of empathy.
6. Undeveloped Self: Feeling intertwined with others, like a parent. It may appear as excessive emotional closeness with significant others or a lack of individualism.
7. Alienation Or Social Isolation: Alienation can involve believing that you are isolated from the world or must stay away from others. 
8. Abandonment: Abandonment may be a belief that others cannot be relied on to provide emotional support or that others will permanently abandon or leave you.
9. Vulnerability To Harm: Constant worries that catastrophes may occur.
10. Failure: Failure is a belief that one is a failure or will eventually fail in life achievements such as career, schooling, or goals.
11. Insufficient Self-Control: Refusing to exercise self-control. An individual might place an exaggerated emphasis on avoiding conflict, pain, and responsibilities.
12. Approval Seeking: Approval seeking might look like an excessive desire to gain recognition, attention, and approval from others. In such a case, self-esteem may depend on the reactions of others. For individuals who experience the schema of approval seeking recognition from others can lead to self-detrimental situations. 
13. Punitiveness: Believing that people should be punished for their mistakes. Punitiveness may involve difficulty forgiving others alongside angry, punitive, and intolerant behaviors. 
14. Unrelenting Standards: A belief that one must work hard toward meeting high performance standards to avoid criticism. It may show up as perfectionism.
15. Negativity Or Pessimism: A consistent focus on life's negatives, such as betrayal, harm, or fears, while reducing the significance of the positive aspects of life. People with such traits may present with chronic worry, constant complaints, or indecisiveness.
16. Self-Sacrifice: Self-sacrifice can mean meeting others' needs at the expense of personal needs to connect or reduce the chance of conflict.
17. Subjugation: Giving control to others to avoid being abandoned or angering the other party. Subjugation can be in terms of one's needs and emotions. Individuals might act obedient to the point that it harms them or leads to adverse mental health symptoms. 
18. Emotional Inhibition: Emotional inhibition schema is defined by excessive inhibition of spontaneous actions, feelings, and communication. This may include difficulty expressing emotions and disregarding emotions in favor of rationality when making decisions. 

The maladaptive coping modes in schema therapy

Child modes of coping with schemas lead some people to experience dysfunctional behavior and limiting beliefs as an adult. Experts in schema therapy say that the three main ways people adapt to schemas are: 

Surrender 

Avoidance

Overcompensation

People may overcompensate for schemas by doing the opposite of what the schema makes them feel. They may a perfectionist who is obsessed with orderliness and strictly adheres to a routine. On the other hand, overcompensation can also lead to rebellious behavior. Aggressiveness, status-seeking, and manipulative behavior are a few of the different ways that some people display overcompensation for schemas. 

Schema therapy and BPD

Borderline personality disorder (BPD) is defined by the DSM-5 as “a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts”. Schema focused cognitive therapy may be beneficial for patients experiencing symptoms of BPD because schemas like impaired autonomy, lack of self-control, and fear of abandonment are common for people with this diagnosis. 

Studies have shown that schema-focused therapy effectively treats BPD and other personality disorders. However, users of these schema therapy techniques don't necessarily have to be diagnosed with a personality disorder to benefit. The initial goals during the therapy session are identifying the client's relevant schema modes or coping styles and linking the schemas to the patient's past or current occurrences. Experiencing the same schema as individuals with BPD does not necessarily mean the patient has BPD, although the therapeutic approach may be the same.

Schema therapy may be effective in helping patients with borderline personality disorder change their coping styles related to damaging patterns. According to one study, participants who underwent the schema therapy treatment approach, and had been previously diagnosed with BPD, saw significant improvements in symptom severity. More specifically, patients experienced improved self-understanding and were more aware of strategies for managing symptoms. Learning about schemas and coping styles may be able to help individuals with borderline personality disorder develop healthy relationships.

The International Society of Schema Therapy is an organization dedicated to bringing together mental health professionals, researchers, and educators to further the advancement of schema-focused cognitive therapy in treating personality disorders and other mental health concerns. They seek to improve and expand upon current schema therapeutic approaches. 

Therapists and mental health professionals who want to expand on their knowledge of schema therapy can find a practitioner’s guide from Jeff Young and other resources through The International Society of Schema Therapy. The recommended book for learning about schema therapy is Schema Therapy: A Practitioner’s Guide (2003), by Jeff Young and colleagues. 

Schema therapy, which was clinically tested by Jeff Young in 1994 and 2003, was put to a systematic review in 2011. Researchers looked at all available details from a multicenter randomized controlled trial to determine the effectiveness and viability of schema therapy as a treatment option for people with personality disorders. Substantial results indicated that schema therapy had great potential for treating borderline personality disorder and other mental health conditions. 

In a follow-up to a 2014 study, researchers discovered that schema therapy patients had fewer depressive symptoms and better social functioning. Initial schema therapy research focused on patients with borderline personality disorder, but recent research has expanded on that to discover that treatment results were the same regardless of personality disorder. 

Schema therapy counseling options

Schema therapy is a practical, evidence-based approach that can effectively treat personality disorders, address early schema domains that a child may not have processed healthily, and improve coping styles for individuals of all ages living with early maladaptive patterns. The exact treatment approach may differ from person to person. You may also be asked to fill out a schema questionnaire to tailor the treatment to your coping styles when working with a therapist.

Online schema therapy

Schema therapy may change negative patterns or maladaptive schemas into positive behaviors and can be done online or in person. Online schema therapy can benefit those who struggle to leave home due to symptoms or face barriers to treatment like cost or availability. Online therapy can allow you to browse thousands of therapists and choose one that best fits your preferences. Additionally, studies have found that some forms of online schema therapy, like group versions of the treatment, were as effective as in-person modalities. In the study, there were low dropout rates among participants.