What Is… Schema Therapy

In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term is schema therapy.

Schema therapy was developed by Dr. Jeffrey Young in the 1990s. Kind of like dialectical behaviour therapy (DBT), it’s based on cognitive behavioural therapy (CBT), but developed to address the needs of people who weren’t getting better with CBT. It also draws on other concepts and approaches, like Gestalt therapy and attachment theory.

Schemas

Schemas, which are also a concept in CBT, are stable and enduring patterns of looking at the world and beliefs about ourselves, others, and the world around us. Schema therapy addresses early maladaptive schemas (EMSs), which develop in response to traumatic events in childhood and environments in which the child’s basic needs were unmet.

Dr. Young originally identified 16 schemas, and this later grew to 18. These are grouped into five domains, and each domain is associated with particular unmet needs. A given individual may have several EMSs.

Disconnection and rejection domain

• Abandonment/instability: the belief that as soon as an attachment is formed, the other person will leave
• Mistrust/abuse: the expectation that others will harm oneself
• Emotional deprivation: the belief that others will never meet one’s emotional needs
• Defectiveness/shame: the belief that one is fundamentally flawed, and anyone who gets close will realize this and leave
• Social isolation/alienation: the belief that one is isolated from and different from others

The key unmet needs are for safe attachment, acceptance, and care.

Impaired autonomy and achievement domain

• Dependence/incompetence: the belief that one is unable to handle basic tasks competently and independently
• Vulnerability to harm/illness: the expectation that a major catastrophe may happen at any time
• Enmeshment/undeveloped self: may involve enmeshed relationships with others or a sense of lack of identity and emptiness
• Failure to achieve: the expectation that one will fail and never be as good as others

The key unmet needs are for autonomy, competency, and sense of identity.

Impaired limits domain

• Entitlement/self-centredness: the belief that one should be able to do/have what one wants immediately, regardless of how it might affect others
• Insufficient self-control/self-discipline: inability to tolerate frustration re. achieving goals, lack of impulse control, and lack of control over emotional expression

The key unmet needs are for realistic limits and self-control.

Other-directedness domain

• Subjugation: the belief that one will be harmed unless one submits to the control of others
• Self-sacrifice: excessive focus on others’ needs while neglecting one’s own
• Approval-seeking: seeking approval from others at the expense of developing self-esteem and a secure sense of self

The key unmet needs are for free expression of needs and emotions.

Hypervigilance and inhibition domain

• Negativity/pessimism: focusing on the negative and minimizing the positive
• Emotional inhibition: the belief that expressing emotion would cause harm to others or negative effects for the self
• Unrelenting/unbalanced standards: the belief that whatever one does isn’t good enough, and there’s always a need to try harder to do better
• Punitiveness: the belief that others should be punished for mistakes

The key unmet needs are for spontaneity and playfulness.

Schema processes

There are several processes by which schemas influence people. Schema maintenance involves cognitive distortions as well as self-defeating behaviours that keep the whole shebang going.

Schema avoidance involves attempts to stay away from things that might activate a schema and lead to emotional distress. This avoidance may be cognitive, emotional, or behavioural.

Schema compensation also involves attempts to avoid activating schemas, but it’s done by going to the opposite extreme of the schema.

Schema modes

While schemas tend to be stable over time, schema modes involve emotions and ways of coping that may become activated at a particular point in time. People are able to switch between different modes, and these switches may happen quite rapidly.

The identified modes fall into four categories:

• Healthy adult
• Child modes:
  • Vulnerable: lonely child; abandoned and abused child; dependent child
  • Angry/unsocialized: angry child; enraged child; impulsive child; undisciplined child
  • Happy/contented
• Maladaptive coping modes:
  • Surrender: compliant surrender; surrender to damaged child modes
  • Avoidance: detached protector; spaced out protector; detached self-soother; avoidant protector; angry protector
  • Overcompensation: attention and approval seeker; self-aggrandiser; overcontroller; bully and attack; conning and manipulative; predator
• Maladaptive parent modes:
  • Punitive parent
  • Demanding parent

Weakening early maladaptive schemas

Different personality disorders have different typical combinations of modes that tend to be most prominent. In borderline personality disorder, there tends to be a strong punitive parent mode (associated with self-hate and low self-esteem), an abandoned/abused child mode (associated with feelings of abandonment and anxiety), an angry/impulsive child mode, and a detached protector coping mode (associated with attempts at numbing difficult emotional states, such as by using substances or self-injuring).

A schema triggering and mode analysis logbook is used to help the client recognize when and how their schemas are being activated.

Categories of interventions

There are four broad categories of interventions used to weaken maladaptive schemas: emotive (experiencing and expressing emotions), interpersonal, cognitive, and behavioural. These are some of the techniques used in schema therapy:

• One of the cognitive interventions used is gathering evidence against a schema and creating flashcards that the client can refer to as needed. PositivePsychology.com has a flashcard template here.
• Schema diary worksheets can be used to work through triggering situations.
• Chair work involves having chairs represent multiple aspects of the client, with the client moving between them. This is a way to engage with and express difficult feelings like anger.
• Guided imagery can be used for things like trauma rescripting and meeting unmet childhood needs.
• Empathic confrontation involves the therapist empathetically and nonjudmentally challenging the client on maladaptive cognitions and behaviours.
• Limited reparenting by the therapist to recognize, validate, and help to meet the client’s needs and allow the client to develop secure attachment. The client is able to develop a healthy adult mode based on what’s modelled by the therapist. Part of the limited reparenting process involves reaching the client’s vulnerable child mode and providing constructive outlets for angry child mode.
• Behavioural techniques can include rehearsing adaptive behaviour and behavioural homework.
• Letter-writing to parents or other significant figures in childhood (these aren’t usually sent).

Schema therapy in practice

Because schema therapy is less than 30 years old, there’s less research evidence behind it compared to some other therapeutic approaches, it’s not as commonly used, and it’s not as well-known as some other forms of therapy. Its use is most well-established in the treatment of borderline personality disorder, for which it’s considered an effective, evidence-based treatment. There have also been promising results for other conditions, including other personality disorders and depression.

Is schema therapy something that you’re familiar with or have tried?

Resources

These resources are recommended by Wandering Sprout:

• Reinventing Your Life, a book by Jeffery Young
• What the Schemata? podcast episode on integrating DBT and schema therapy

References

• Fassbinder, E., Schweiger, U., Martius, D., Brand-de Wilde, O., & Arntz, A. (2016). Emotion regulation in schema therapy and dialectical behavior therapy. Frontiers in Psychology, 7, 1373.
• Jacob, G. A., & Arntz, A. (2012). Emotion-focused techniques in schema therapy and the role of exposure techniques. In Exposure Therapy (pp. 167-181). Springer, New York, NY.
• PositivePsychology.com: Schema Therapy in Practice: 12 Worksheets & Techniques
• PsychologyTools: Schema Therapy
• Schema Therapy Institute of South Africa: Definitions of schema modes
• Schema Therapy Society: Limited reparenting
• Young, J. (1994). A client’s guide to schema-focused therapy. In Cognitive Therapy for Personality disorders, Revised edition.