Cognitive-Behavioral Therapy (CBT) is widely practiced and immensely successful at treating a broad range of psychological issues.
However, while helping many in distress, it may have its limits.
What do we do when CBT is unsuccessful in helping our clients?
Schema Therapy may be the answer. It was designed to resolve deeply held, maladaptive, schematic beliefs that fail to respond to other treatments (Young, Klosko, & Weishaar, 2007).
And it’s becoming increasingly popular, attracting interest from both therapists and clients to deal with unresolved problems and achieve full recovery (Kopf-Beck et al., 2020).
This article explores what is meant by Schema Therapy by describing the model and its core concepts.
Before you continue, we thought you might like to download our three Positive Psychology Exercises for free. These science-based exercises explore fundamental aspects of positive psychology, including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.
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What Is Schema Therapy?
Jeffrey Young (1990) initially proposed Schema Therapy (ST) to help patients with psychological problems that hadn’t responded well to CBT.
Described as an “integrative therapeutic model,” it brings together elements or building blocks from other therapies, recognizing that there is no single approach to treat every client (Simpson, 2018).
While originally developed to treat complex problems such as personality disorders, ST has become increasingly valuable in the past 20 years across a range of client groups and clinical settings (Jacob & Arntz, 2013).
The treatment has proven valuable for clients deeply entrenched in how they perceive the world and the way they behave, and who are adopting “enduring attachment-based patterns that hinder the effectiveness of standard therapeutic approaches” (Simpson, 2018).
Research has confirmed Schema Therapy as an effective treatment for:
- Borderline personality disorder (Farrell, Shaw, & Webber, 2009)
- Chronic depression (Carter et al., 2013)
- Chronic and complex anxiety disorders (Hawke & Provencher, 2011)
- Eating disorders (McIntosh et al., 2016)
- Ruminative disorders (Thiel et al., 2016)
- Substance and alcohol abuse and dependency (Kersten, 2012)
ST successfully integrates CBT, attachment theory, humanistic therapies, and psychodynamic concepts. It targets maladaptive psychological patterns formed during childhood, through (Jacob & Arntz, 2013):
- An increased focus on unpleasant childhood experiences
- An expanded use of experiential techniques, such as imagery, and chair dialogues (conversations with an imagined person – sometimes oneself)
- Providing limited parenting, within ethical and professional boundaries, to approximate what was missing in childhood
- The schema mode model to direct the selection of therapy techniques.
While ST offers a general approach to treatment, it also uses varying approaches specific to each personality disorder (Jacob & Arntz, 2013).
The Schema Therapy Model
ST is process driven and uses experiential, interpersonal, cognitive, and behavioral techniques to drive corrective emotional experiences, emotional change, and growth (Simpson, 2018).
Expanding on traditional CBT treatments, therapist and client work together on (Arntz & Jacob, 2013):
- Problematic emotions
Helping the client, using experiential and emotion-focused interventions.
- Childhood issues
Encouraging the client to understand and validate the origins of unhelpful behavioral patterns.
- Therapeutic relationship
The therapist takes on a limited reparenting role (within clear professional limits) to provide care and warmth. Tailored to the specific needs of the client, it attempts to fulfill their unmet childhood needs.
Like CBT, ST is structured, systematic, and focused. It involves two clear phases (Young et al., 2007):
- Assessment phase, where schemas and coping styles are measured and understood
- Treatment phase, actively working toward cognitive, emotional, and behavioral change
During the treatment phase, cognitive techniques “challenge core beliefs at an intellectual level, through unpicking the evidence associated with long-held schemata” (Simpson, 2018).
Such unhelpful and maladaptive schemas arise from unmet core emotional needs in childhood and must be addressed for healing to occur (Young et al., 2007).
The therapist works with the client to help them develop a stronger focus on their needs through “validating, soothing and helping to process abuse and other negative experiences” (Arntz & Jacob, 2013).
Our Core Needs
Maladaptive schemas and schema modes are described as “dysfunctional knowledge representations acquired early in life” (Jacob & Arntz, 2013).
They result from unmet core emotional needs in childhood. And whether or not these needs are satisfied shapes who we are in later life.
According to Young and colleagues (2007), everyone has the following five universal core emotional needs:
- Secure attachments (includes feelings of safety, stability, acceptance, and nurture, etc.)
- A sense of autonomy, competence, and identity
- Feeling free to express needs and emotions
- Being able to play and act spontaneously
- Being set realistic limits and able to apply self-control
Being psychologically healthy depends on having all emotional needs met to some degree, and yet the strength of each will vary between individuals.
A child’s environment dictates whether their needs are met or frustrated and the creation of their most persistent schemas. The research from Young et al. (2007) suggests four types of experiences that lead to the acquisition of (positive and negative) schemas during early life:
- Toxic frustration of needs
The child receives too little of what they need, such as understanding, stability, and love. As a result, they acquire emotional deprivation or abandonment schemas.
- Traumatization or victimization
The child is mistreated or harmed and adopts defectiveness/shame or vulnerability to harm schemas.
- Too much of a good thing
The child is overly indulged or spoiled, leading to entitlement/grandiosity or dependence/incompetence schemas. The child may be excessively protected or given too much freedom and autonomy; either way, the absence of realistic limits is unhelpful.
- Selective internalization or identification with significant others
A child can internalize how they are treated, acquiring positive and negative coping mechanisms. A child may internalize aggression or nurturing depending on treatment from their parents and how they cope.
Unmet needs often, but not always, result in unhelpful schemas.
For a full list of needs see the Schemas, Needs, and Modes Reference Sheet.
Within the field of cognitive development, a schema is considered an “abstract representation of the distinctive characteristics of an event, a kind of blueprint of its most salient elements” (Young et al., 2007).
In psychotherapy, a schema typically refers to “any broad organizing principle for making sense of one’s life experiences” (Young et al., 2007). While formed early in our childhood, schemas can continue to develop in response to experiences throughout our lives.
Our need for cognitive consistency is so strong that we may continue to apply them even if incorrect and unhelpful.
Young et al. (2007) proposed that schemas arising from toxic childhood experiences cause many of our psychological issues and personality disorders.
These early maladaptive schemas are described as:
- Broad and pervasive patterns
- Comprising emotions, cognitions, memories, and even bodily sensations
- Relating to our self and our relationship with others
- Developing early in childhood and adolescence
- Continuing to develop throughout adulthood
- Significantly dysfunctional
The complete list of schemas and their domains are available in the Schemas, Needs, and Modes Reference Sheet.
Such schemas are unhelpful at best and damaging at worst; they drive our behavior and how we cope.
Young et al. (2007) describe them as “self-defeating emotional cognitive patterns that begin early in our development and repeat throughout life.”
There are many schemas that are typically grouped together. Four of the most damaging include:
- Emotional deprivation
They tend to follow consistent patterns.
For example, as young children, clients may have been (Young et al., 2007):
- Abandoned, neglected, rejected, or abused, resulting in the formation of negative schemas.
During adulthood, life events that appear similar to what happened in their childhood trigger the same schemas and produce powerful, negative emotions including shame, grief, fear, and rage.
- Overly sheltered and developed dependence/incompetence schemas.
While not originating from trauma, such schemas can still be damaging and lead to unhelpful behavior in later life.
Ultimately, experiences accumulate into full-blown schemas and compete for survival. While they may cause suffering, they meet our need for consistency. As a result, people are drawn to events that trigger their schemas.
Such schemas then perpetuate in later life in our interactions with other people, leading to significant issues such as anxiety, depression, failed relationships, and substance abuse (Young et al., 2007).
The more severe the schema is, the more likely it is to be activated.
For example, a robust defectiveness schema resulting from extreme parental criticism can be triggered easily and consistently in later life, resulting in feelings of being flawed, bad, and even worthless.
3 Coping Styles as a Consequence of Schemas
Individuals’ schemas become self-fulfilling prophecies, perpetuated through either what the client does or doesn’t do. Cognitive responses include (Young et al., 2007):
- Cognitive distortions
Incorrectly perceiving a situation to reinforce a schema, often denying contradictory information.
- Self-defeating life patterns
Unconsciously choosing and remaining in situations that keep the schema going and avoiding those that may help them break or move away from the schema.
- Schema coping styles
Coping styles driven by the client’s schema along with associated memories, bodily sensations, and unhelpful cognitions
Though not easy, schema healing involves behavioral change and the replacement of maladaptive coping styles with effective, less damaging ones.
Maladaptive coping styles form early in life in response to the schemas we develop.
They may help the patient avoid the situation and the related schemas, but they do not heal them.
Young describes three typical coping styles that correspond to most organisms’ primary responses: fight, flight, and freeze.
Coping styles develop in response to the problematic situations the child faces and are often used in adulthood, albeit unconsciously (Young et al., 2007):
- Overcompensation (fight)
The patient fights the schema by acting and thinking as though the opposite is true. “If they felt worthless as children, then as adults they try to be perfect,” or if brought up by controlling parents, as adults they may defy all authority (Young et al., 2007).
While it’s positive to fight back against a damaging schema, the tendency is to go too far.
- Avoidance (flight)
As a coping style, avoidance typically involves the patient finding ways to “arrange their lives so that it does not activate the schema.” The result is they live as though the schema is absent, avoiding thoughts and situations that could act as triggers.
Excessive behaviors, such as over-drinking, compulsive cleaning, overeating, and drug use, are avoidance mechanisms.
- Surrender (freeze)
When patients accept a maladaptive schema to be true, they may choose to surrender, sometimes even choosing partners that treat them as the offending parent did, thereby perpetuating the schema.
“Maladaptive coping styles ultimately keep patients imprisoned in their schemas.”
Young et al., 2007
The 10 Schema Modes
Schema modes are the “moment-to-moment emotional states and coping responses—adaptive and maladaptive—that we all experience” (Young et al., 2007). While some schemas may currently be inactive, those that are active we call our schema mode.
As therapists, we must recognize those modes presently active for the individual.
Such modes are triggered (often too easily) by our oversensitivity to specific situations, described by Young as pressing our emotional buttons.
Schema Therapy helps clients switch from maladaptive to adaptive modes as part of the schema healing process.
Young and colleagues (2007) recognize 10 schema modes that they group into the following four categories:
All children have the potential for these universal and innate modes:
- Vulnerable child – includes abandoned/abused/deprived or rejected child schema modes
- Angry child – enraged by unmet emotional needs
- Impulsive/undisciplined child – follow their desires and are often reckless
- Happy child – emotional needs are being met
Dysfunctional coping modes
These modes correspond to the three coping styles of surrender, avoidance, and overcompensation:
- Compliant surrenderer – submits to the schema
- Detached protector – withdraws through emotional detachment
- Overcompensator – behaves in extreme ways or mistreats others
Dysfunctional parent modes
The patient becomes like the parent in the following two modes:
- Punitive parent – the child is repeatedly and unnecessarily punished for being bad
- Demanding parent – has incredibly high expectations for the child and applies significant pressure to perform
Healthy adult mode
This is the goal of Schema Therapy. This mode, strengthened by ST, helps the patient “moderate, nurture, or heal the other modes” (Young et al., 2007).
4 Goals of Schema Therapy
While there are several ST goals, perhaps the most important is to increase the client’s psychological awareness. Such clarity is achievable by working with the client to “identify their schemas and become aware of the childhood memories, emotions, bodily sensations, cognitions, and coping styles associated with them” (Young et al., 2007).
Once understood, it is crucial to help the patient gain conscious control over their responses to the triggers present in their environment by learning to master their schemas (Jacob & Arntz, 2013).
A further, supportive goal requires the therapist to help “patients find adaptive ways to meet their core emotional needs” (Young et al., 2007).
Research has shown trauma and unmet needs in the early years of primates result in permanent physiological change. Only through healing the associated schemas can we restore both mental health and physical balance.
Overall, ST aims to heal maladaptive schemas and remove power from the associated memories, maladaptive cognitions, and bodily sensations.
A Brief Look Into Group Schema Therapy
Group ST can be more cost effective than individual sessions and include the additional benefits of peer support, learning from one another in a group environment and fostering a sense of belonging (Jacob & Arntz, 2013).
A 2018 study confirmed that group ST reduces anxiety and the use of negative emotional schemas (Morvaridi, Mashhadi, Shamloo, & Leahy, 2018).
For additional reading, consider our ultimate Group Therapy guide.
Further Reading: PositivePsychology.com’s Resources
We have many valuable and practical resources that can facilitate working with clients to understand their needs, recognize underlying bias, and improve coping styles.
- Compassionate Chair Work – Relate to your inner voice to help find and address lifelong maladaptive schemas.
- Personal Needs Meditation – Use this meditation to connect with your primary emotional reactions and uncover your psychological needs.
- Emotion Regulation Wheel – Use the wheel to explore how you deal with your emotions, including your personal regulation strategy.
- Adaptive and Non-Adaptive Coping Thoughts – Better understand how to manage the demands of a stressful event and recognize the coping styles in which you are engaged.
- Identifying False Beliefs About Emotions – We often hold implicit beliefs about our emotions that are incorrect. Use this tool to examine your basic assumptions.
- When Hot Buttons Are Pushed – Learn how to recognize your urges to act and how to manage them.
A Take-Home Message
Should the usual treatments prove unsuccessful for your client, consider Schema Therapy.
Schema Therapy can offer a practical and proven approach to addressing unresolved issues and meeting deep-seated needs.
By uncovering inappropriate thinking patterns and working with the client to understand their needs, it is possible to heal their schemas, putting in place effective cognitive plans for interpreting and solving problems and living a more complete life.
Increasing the client’s psychological awareness is central to success in ST. The therapist’s aim is to help them recognize their schemas and associated memories, cognitions, coping styles, and bodily sensations.
Avoidance, overcompensation, and surrender are unhelpful, if not damaging, coping mechanisms that lead to a less full and enjoyable life.
In turn, maladaptive coping styles keep patients imprisoned in their schemas and fixed in an unhelpful way of thinking and behaving. Such schemas, if left unchecked, will repeat themselves throughout adulthood.
By taking a limited parental role, the therapist facilitates schema healing and finds ways for clients to better care for their needs.
It is clear that ST is becoming increasingly popular with both clients and therapists because of positive research findings and successful therapy results (Arntz & Jacob, 2013), and it is now a recommended therapy for a more complete life.
We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free.
If you wish for more tools, our Positive Psychology Toolkit© contains over 350 science-based positive psychology exercises, interventions, questionnaires, and assessments for practitioners to use in their therapy, coaching, or workplace.
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