SCHEMA THERAPY (ST) is an innovative development of cognitive behavioral therapy, highly effective in chronic disorders or psychological conditions considered “difficult to treat”. At the end of the 90s Jeffrey Young conceived this approach, starting from the observation that patients with pathological personality traits often do not respond to standard cognitive therapy. ST integrates elements of classical CBT with different psychotherapeutic approaches such as Gestalt, Transactional Analysis, imaginative techniques, attachment theory and psychodynamic schools, offering a coherent conceptualization, and a treatment easy to apply.
Initially developed to treat personality disorders, in recent years a flourishing body of research has shown its effectiveness in different types of disorders and clinical settings.
ST helps the clients to identify and break the dysfunctional patterns (i.e. Schemas) and modalities that were learned in childhood.
ST therapeutic rationale is grounded on the idea that psychological suffering arises from the interaction between Early Maladaptive Schemas and the dysfunctional strategies that people use to cope with difficult situations. The most basic concept in Schema Therapy is that of “Early Maladaptive Schema”. We define schemas as: “broad, pervasive themes regarding oneself and one’s relationship with others, developed during childhood and elaborated throughout one’s lifetime, and dysfunctional to a significant degree.” Schemas develop in childhood from the interplay between the child’s innate temperament, and the child’s ongoing aversive experiences with parents, siblings, or peers. According to this theoretical approach psychological suffering arises from these early aversive experiences in which one or more of the five core emotional needs (i.e. safe attachment; autonomy; competence & sense of identity; freedom to express needs, opinions and emotions; spontaneity and play and realistic limits & self-control) were not met.
Eighteen schemas have been formulated and grouped into five domains, which correspond to those needs (see Table below).
Overview of needs and the respective Early Maladaptive Schemas (EMSs)
|Safety & nurturance||Emotional deprivation|
|Autonomy, competence, & identity||Dependence/incompetence|
|Vulnerability to harm & illness|
|Freedom to express needs, opinions, & emotions||Subjugation|
|Spontaneity & play||Negativity/pessimism|
|Realistic limits & self-control||Entitlement/grandiosity|
To cope with the pain associated with schemas activation, three major coping styles are used:
- Surrendering by accommodating to the way we are treated and acting as if, and believing, it is the way things should be (behaving as if the Schema was true).
- Avoiding by disconnecting emotionally or physically from the people who mistreat us and/or by disconnecting from our own emotions (for instance using substances or compulsive behaviors) .
- Overcompensating by attempting to fight against the schema and prove it is not true by, for example, trying to do things perfectly so that we don’t feel defective or trying to get control over others so that we don’t get left “at the short end of the stick” or taken advantage of.
In a recent paper, Arntz et al. (2021) have reformulated the theory underlying ST identifying some additional needs, such as the need of Fairness and Self-coherence, leading to three new EMSs, namely Lack of a Coherent Identity, Lack of a Meaningful World, and Unfairness.
Also two of the three ways of maladaptive coping with schema activation have been relabeled in order to focus on their function; that is, dealing with intrapsychic processes related to schema activation, and not with external threat. These were labeled as resignation (formerly: surrender), and inversion (formerly: overcompensation).
While each of these three ways of coping help to reduce pain in the short run, they are maladaptive in the long run and end up perpetrating dysfunctional beliefs and negative affective states.
The simultaneous presence of numerous active Schemas and the observation of sudden changes in clients’ affective, mental and behavioral state, have led to the introduction of the Mode concept. In ST, a mode is a temporary mindset that includes both current emotional state and how the person is dealing with it. In other words, a mode is a combination of active schemas and coping styles. Modes can be helpful (adaptive) or unhelpful (maladaptive).Though most individuals inhabit various modes over time, the manner in which they transition from one mode to another— that is, the degree of separation or dissociation between the modes—differs and lies on a spectrum.
Schemas and Modes are the principal targets of ST intervention, which ultimately is aimed at satisfying patients’ emotional needs. To this aim, ST combines four different sets of techniques: cognitive, experiential, behavioral and relational.
Through cognitive strategies, the therapist questions the validity of schemas and modes, helping the patient to get rid of cognitive distortions. The purpose of cognitive strategies is also to overcome emotional avoidance mechanisms and prepare the patient for experiential work.
Experiential strategies are an extremely powerful tool, which brings about noticeable changes in a very short time. Through Imagery work or role-playing the therapist aims to reduce Schemas and Modes emotional power, preventing them from influencing individual choices.
Behavioral change represents a crucial stage in the therapeutic process and has the aim of replacing Schema-driven behaviors with more adaptive and effective ways of satisfying emotional needs. The therapist’s tools and techniques include behavioral homework, flashcards, rewarding adaptive behavior, and the rehearsal of adaptive behavior in imagery or role-play. This phase takes place normally in later stages of the therapy, while relational strategies are used across the entire therapeutic intervention.
Relational strategies are aimed to provide a corrective emotional experience. Through empathic confrontation the therapist gently but firmly challenges the client’s maladaptive behaviors or dysfunctional thinking styles showing understanding but at the same time clearly emphasizing the need for change. Through limited reparenting, on the other hand, the therapist tries to fulfill (within professional guidelines) the needs that the caregivers were unable to satisfy during childhood.