Schema Therapy is an integrative system of psychotherapy for people with personality problems and/or enduring Axis I disorders. Developed by Dr. Jeffrey Young (Young, Klosko, & Weishaar, 2003), it incorporates theories and techniques derived from cognitive-behavioral therapy, interpersonal psychotherapy, Gestalt therapy, psychodynamic therapy, and attachment theory (for a detailed description of relevant theory, practice, and research, see Van Genderen & Arntz, 2009; Van Vreeswijk, Broersen, & Nadort, 2012; Young et al., 2003).
Schema Therapy utilizes the concepts of schemas and modes. Schemas are considered to represent the way people perceive themselves, others, and the world around them. They are constructed out of sensory perceptions, emotions, and actions etched into memory during previous experiences, especially in childhood (Arntz, Van Genderen, & Wijts, 2006; Rijkeboer, Van Genderen, & Arntz, 2007; Young et al., 2003).
While schemas are seen as trait features of personality, modes refer to state features. Modes are a combination of the schemas and behaviors—adaptive or maladaptive—that are present at any particular moment (Lobbestael, Van Vreeswijk, & Arntz, 2007; Young et al., 2003). Modes can also be seen as the moods in which individuals may dwell for short or longer periods of time, and can alternate or change at the drop of a hat.
Nineteen schemas and twenty modes have been established so far (for an overview, see Table 2.1; for a description of schemas and modes, see the patient folder in Appendix II-B). Schemas can be evaluated using the Schema Questionnaire (YSQ-2; Schmidt, Joiner, Young, & Telch, 1995), and modes can be identified using the Schema-Mode Inventory (SMI-1; Young et al., 2007).
Table 2.1 Schemas and modes
| Nineteen schemas | Twenty modes |
| Emotional Deprivation | Vulnerable Child |
| Abandonment/Instability | Angry Child |
| Mistrust and/or Abuse | Enraged Child |
| Social Isolation/Alienation | Impulsive Child |
| Defectiveness/Shame | Undisciplined Child |
| Social Undesirability | Happy Child |
| Failure | Compliant Surrender |
| Dependence/Incompetence | Detached Protector |
| Vulnerability to Harm and Illness | Detached Self-soother |
| Enmeshment/Undeveloped Self | Self-Aggrandizer |
| Subjugation | Bully and Attack |
| Self-Sacrifice | Punitive Parent |
| Approval Seekinga | Demanding Parent |
| Emotional Inhibition | Healthy Adult |
| Unrelenting Standards/Hypocritical | Angry Protectorb |
| Negativity and Pessimisma | Obsessive Over-Controllerb |
| Punitivenessa | Paranoidb |
| Entitlement/Grandiosity | Conning and Manipulativeb |
| Insufficient Self-Control/Self-Discipline | Predatorb |
| Attention-seekerb |
aThese schemas are not yet identifiable using the Schema Questionnaire (YSQ).
bThese modes have not (yet) been added to the Schema Mode Inventory (SMI-1).
Schemas and modes are maintained through various schema coping behaviors, from which three distinct coping styles can be discerned: schema avoidance, schema compensation, and schema surrender. These are defined as follows.
The individual attempts to stay out of situations that might trigger the schema, or seeks distractions, in order to avoid thinking about the schema and experiencing related feelings. For instance, someone with the Abandonment/Instability schema will be slow to form attachments with others, because interpersonal bonds entail the possibility of being deserted at a later stage. Such an individual will also try to avoid situations that remind him of past abandonment, so that the feelings connected to those memories remain at bay.
The individual demonstrates the opposite behavior in order to resist the schema. Instead of striving for perfection, someone with the Unrelenting Standards/Hypocritical schema might get sloppy and impulsive, perhaps claiming to enjoy chaos.
The individual behaves in accordance with his schema. He thinks, acts, and feels consistently with the schema. For instance, when the Self-Sacrifice schema is triggered, a person engaging schema surrender as a coping strategy will feel compelled to put the needs and desires of others before his own. He thinks his opinion is unimportant and feels better when accommodating others.
A person can employ multiple coping styles. Schema Therapy involves working on improving the way in which schema and mode triggering is handled, and becoming less automatic in the way specific schema coping styles are engaged.
Schema Therapy1 is an integrative approach to treatment that encompasses a variety of techniques from several therapy modalities.
Central to Schema Therapy is the strategy of limited reparenting. The therapeutic alliance can have a corrective effect on schemas and modes resulting from early attachment relationships. The therapist is expected to remain active and transparent throughout. Key factors include judicious self-disclosure, discussion of the therapeutic alliance, and uncovering the schemas and modes that are active within this relationship.
Other important techniques in Schema Therapy involve formulating a schema and/or mode-focused case conceptualization, as well as keeping schema and mode journals that stimulate growing awareness of their activation and operation.
The adequacy of schemas and modes can also be examined through the application of cognitive interventions. Examples of cognitive techniques include advantage/disadvantage analysis, piecharts, multidimensional evaluation, data collection, and the use of a court-case style approach, in which schemas are accused and must be defended.
Other types of intervention may implement behavioral techniques. For instance, role-playing exercises can be used to help bring awareness to the here-and-now. The patient is asked to act out a situation in which a schema or mode typically becomes active. In the first round of the role-playing exercise, conditions are simulated in such a way as to trigger the schema and/or mode in question. Plenty of space is provided for the patient’s emotional experience, with particular attention to any schema behavior that may arise. The patient subsequently repeats the role-playing exercise, but this time attempts to react from the perspective of the Healthy Adult.
Experiential interventions are geared toward the experience and expression of emotions associated with (earlier) situations that have contributed to the development of schemas and modes. Examples of experiential techniques in Schema Therapy include historical role-play exercises, chair work techniques, imagery exercises, expressive therapy (e.g., psychomotor therapy, visual and drama techniques), and schema Mindfulness-Based Cognitive Therapy (sMBCT). In historical role-play, the patient’s exposure to a childhood situation is considered, alongside the experience of another individual, often a parent figure (through role reversal). Consequently, the patient learns more adequate ways to respond to the situation. The introduction of the Healthy Adult, who supports the patient and helps him express his needs and desires, is instrumental in the patient’s acquisition of more appropriate responses to a specific situation.
In the multiple-chair technique, the patient designates a different chair to each of his modes. This setup facilitates intrapsychic contact. The moment a patient enters a particular mode, the therapist directs the mode to a seat and addresses it from the perspective of the Healthy Adult. This spatial approach creates room for the patient’s vulnerable aspects and allows him to confront his basic needs within a controlled environment.
The imagination can thus be used to create a safe space for the patient. It is also employed in the process of rescripting. In this case, the patient is asked to recall a memory related to a certain schema. Once the memory has taken shape in his mind, the image of a Healthy Adult is introduced to the scene, such as a kind and caring grandmother. This imaginary adult then comes to the aid of the Vulnerable Child part of the patient, or provides whatever is needed for the Vulnerable Child to negotiate the situation that is being recalled in imagery.
Art therapy practices (see for example Haeyen, 2007) can similarly be applied to help transform schemas and modes using nonverbal techniques. Along with mindfulness techniques, art therapy approaches to Schema Therapy represent more recent developments in this field.
The effectiveness of Schema Therapy in treating borderline personality disorder patients has been demonstrated with a randomized controlled trial (Giesen-Bloo et al., 2006), in which Schema Therapy was compared with a form of psychodynamic therapy (Transference-Focused Therapy, TFP). Although both treatment conditions appeared to be effective in treating borderline personality disorder, Schema Therapy resulted in a greater number of full recoveries, a lower dropout rate, and greater cost efficiency (Giesen-Bloo et al., 2006; Van Asselt et al., 2008). A study by Nadort et al. (submitted) investigated the impact on (cost) effectiveness of Schema Therapy with borderline patients in outpatient clinics. Bamelis, Evers, Spinhoven, and Arntz (2014) examined the effects of Schema Therapy with other personality disorders. The use of Schema Therapy in group settings has been under study in several disorders (Farrel, Shaw, & Webber, 2009; Renner et al., 2013; Simpson, Morrow, Van Vreeswijk, & Reid, 2010; Van Vreeswijk, Spinhoven, Eurlings-Bontekoe, & Broersen, 2012). For a recent overview of the research literature on Schema Therapy see also Van Vreeswijk, Broersen, and Nadort (2012).
The continued development of Schema Therapy was stimulated by the publication of a randomized, multi-center research study on the effectiveness of Schema Therapy in patients with borderline personality disorder (Giesen-Bloo et al., 2006). Schema Therapy has been adapted for relationship therapy (see Atkinson, as cited in Van Vreeswijk et al., 2012), for adolescents (Geerdink, Jongman, & Scholing, 2012; Renner et al., 2013), and for patients in forensic settings (Bernstein, Arntz, & De Vos, 2007). It is increasingly being used by art therapists as well (Haeyen, 2006, 2007).