1. A schema is an extremely stable and enduring pattern that developed during childhood and is elaborated throughout adult life. Schemas hold important beliefs and feelings about oneself, which are associated with certain behaviors. These individuals accept without question their schemas, which are self-perpetuating and resistant to change.
There are numerous schemas identified empirically:
Mistrust/Abuse – others will intentionally always take advantage in some way. Abandonment/Instability – This states you will lose someone who you are emotionally attached to.
Emotional Deprivation – that one’s primary emotional needs will never be met by another person. This includes nurturance, guidance, empathy, and protection.
Other e.g. Subjugation, Failure, Defectiveness/Shame, Negativity, Entitlement.
There are approximately 18 schemas of importance.
Schema activation leads to associated feelings, behaviors, and thoughts which are entirely ego-syntonic, which means believed to be an acceptable part of their natural personality.
Patients may respond to their schemas instinctively in various ways. I will describe coping modes next as the patient’s natural responses to these schemas.
2. Schema Modes refer to attention-focused, schema-activated states triggered when an emotional unmet need occurs. They are triggered by relatively minor situations and are always disproportionate as reactions to the trigger. This creates symptoms that we observe, and the motivation for therapy.
My patients typically experience swings that are extreme between their modes called mode flipping. Fundamentally these are ego-syntonic: a patient will believe entirely that these modes are a normal acceptable part of their personality function.
Types of Schema modes:
Child Modes: Vulnerable Child, Angry Child Parent Modes: Demanding Parent, Critical Parent
Coping Modes: Overcompensate such as Self Aggrandizer, Avoidance – Detached Protector/self soother, Schema Surrender
Healthy Adult
E.g Stewart’s main schema is Failure to achieve. Whenever he is faced by a challenge, he believes he is incapable of dealing with it. Often he tries half-heartedly guaranteeing that he will fail and reinforcing his core schema of failure. {This is called Schema Surrender). At times he presents himself in an unrealistically positive light by overspending on clothes and cars (this is schema overcompensation which serves to avoid painful feelings of failure). Also, Stewart stays away from challenges altogether to avoid triggering the failure schema and convinces himself the challenge is not worth taking. (this is called Detached protection and schema avoidance
Aims of ST
Day-to-day life involves dynamic movement between our schemas and modes which a skilled schema therapist will be able to monitor and intervene to weaken the schema, to meet the unmet need of the patient during the session, to promote the Healthy Adult mode, and to tackle the presenting mode states appropriately. Eg Angry child mode will require empathic confrontation. Vulnerable CHild mode will require sympathy and empathy and to feel safe with the therapist. It is important over time for patients’ modes to shift towards a smooth transition in their personality functioning in daily life as opposed to abrupt sudden changes that are disruptive and distressing to themselves and others.
Who May Benefit From Schema Therapy?
Patients who have tried other therapies and never achieved any meaningful lasting change. Patients with chronic recurring symptoms and life problems since early life.
Personality Disorders, mainly Emotional subgroup Depressive disorders
Anxiety disorders
Alcohol and substance misuse disorders
How Does Schema Therapy Work?
Schema therapy will use four main techniques:
- Emotive
- Interpersonal
- Cognitive
- Behavioural
1. Emotive techniques are powerful – they use memory/images to help patients recreate the feelings of their schemas. We ask the patient to imagine they are expressing their feelings to the person to whom the emotion is directed. The therapist may intervene appropriately to provide for their emotional unmet need. E.g One woman whose core schema was ED had several sessions where she expressed her anger towards her parents for not being there for her emotionally. Each time she expressed her feelings, she was able to distance herself from the schema and not just experience it as a normal part of her personality (ego-syntonic). Gradually she was able to see that it was her parents’ failure to provide for her emotional needs that created her ED schema and her belief that she would never be loved( as a natural state of her personality experience). Over time, she was able to realize she had done nothing to deserve this schema state and that it was her parent’s inability and depriving behavior that had led to her believing she was unlovable.
There are variations on emotive techniques. Patients can take on the role of the other person in the dialogue, and express what they imagine their feelings to be.
2. Interpersonal techniques – we highlight the patient’s interactions with others to highlight their schema in action and so focus on the relationship with the therapist. E.g Patient with a Subjugation schema may always seek to please the therapist and suppress their own
Subjugation schema may always seek to please the therapist and suppress their own impulses and needs in order to go along with everything the therapist wants, even when the patient actually disagrees with the therapist. We can observe the patient’s overcompensatory mode and body language or indirect communications of resentment towards the therapist. This pattern of compliance and indirect expression of resentment likely is seen in all the patient’s relationships and can be explored in therapy
3. Cognitive techniques – Schema beliefs often reveal cognitive distortions and dysfunctional thoughts that need to be challenged by looking at the evidence for and against them.
4. Behavioral processes – typically these come later in therapy and include role-playing healthy adult responses to situations in daily life as opposed to schema-driven patterns. We then look at the outcome of the behavior change and compare it to previous experience.
What can clients expect from their first schema therapy session?
Assessment usually requires 2-3 sessions.
A full medical/psychiatric history will include looking at childhood factors that have led to adult schema patterns.
Relationships both personal and professional will be addressed.
The use of questionnaires. Schema Mode Inventory, Young Parenting Inventory, and Young Schema Questionnaire typically are filled during the first 3-4 weeks of assessment.
The goodness of fit between therapist and patient is assessed. Are the therapist’s schemas being triggered powerfully by the patient? Can trust be established over time?
Is Schema Therapy typically ongoing treatment?
Yes.
However, it is adaptive.
Treatment can be weekly, or two weekly. Less often is inadvisable in the early stages. Blocks of treatment can be offered. One to two months at a time.
Depending on the severity of schemas and modes, treatment can take from 6 months to two years.
