Crying woman faces empty chairSchema therapy can help individuals identify the thought and behavior patterns underlying and perpetuating mental health conditions. The treatment approach integrates elements from cognitive behavioral therapy, attachment theory, and a number of other approaches, expanding on CBT through exploration of emotions, maladaptive coping methods, and the origin of mental health concerns. 

Mental health professionals work with those seeking treatment to discover the origins of any unmet emotional needs. Through schema therapy, people frequently become better able to develop a greater sense of self-worth and adequacy, explore methods of constructing nurturing relationships, and develop and achieve goals to work toward a healthy and happy life experience. 

Development of Schema Therapy

Dr. Jeffrey Young began the development of schema therapy in the mid-1980s after he found cognitive behavioral therapy to be less helpful for some individuals than others, particularly those with chronic characterological concerns. He combined concepts from Gestalt, object relations, constructivist, and psychoanalytic approaches into a unified modality that focused on the particular strengths of each method. 

The first Schema Therapy Institute opened in Manhattan in the 1990s. A number of studies conducted with the approach found it to be a highly effective treatment for borderline personality, and research further developing schema therapy and demonstrating its efficacy continues today. More recently, schema therapy has also been combined with mindfulness meditation to form a more spiritual approach. 

How Does Schema Therapy Work?

When emotional needs—one’s basic needs for affection, guidance, love, shelter, and safety—go unmet in childhood, individuals may enter adulthood with deficits in their abilities to find ways for these needs to be met, independently and through healthy relationships with others. Schema therapy is based on the belief that early maladaptive schemas form based on these adverse childhood experiences. These maladaptive schemas, which can be described as ways individuals interpret life events and the behavior of others, can later disrupt life: Individuals may make unhealthy choices, form toxic relationships, lack fully developed social skills, engage in destructive behavior patterns, have a poor sense of judgment, and experience feelings of worthlessness or self-doubt. 

Identifying and modifying maladaptive schemas is central to schema therapy. Discovering the origins of one’s unmet emotional needs and learning to construct nurturing relationships through schema therapy can help people begin to build feelings of self-worth and adequacy. 

Therapeutic techniques used in this process may include:

  • Imagery: In this technique, people in therapy explore upsetting childhood memories in an attempt to understand the development of maladaptive schemas. Individuals are first asked to imagine the sights, sounds, and other sensations involved in these memories and then carry on imaginary dialogues with the caregivers involved in these memories and ask for their needs to be met. Following this process, individuals often become more able to identify the current situations eliciting similar emotions and may be more successful at getting needs met in healthy ways in future situations. 
  • Flash cards: In schema therapy, therapists work to help those in therapy create messages designed for the caregivers who failed to meet their childhood emotional needs. These messages can take the form of simple statements, notes, or even complex poems. The person in treatment will typically look over the flash cards between sessions. This regular review is intended to help individuals learn how to make healthy, effective statements about their emotional needs to important people in their adult lives.
  • Chair work: This aspect of therapy attempts to help those in therapy identify variations in emotions and personality. In chair work, the person in therapy moves between two chairs, expressing different emotions and aspects of personality in each chair. Chair work can also be used to help a person in treatment imagine dialogues with family, friends, or significant others. In this type of chair work, a person might make statements regarding emotional needs while sitting in one chair and then move to another chair to play the role of a person who might meet these emotional needs. Imagery work is often conducted in conjunction with chair work. Girl sitting on grass writes in diary
  • Diaries: People pursuing schema therapy are often asked to keep a diary or log of any experiences activating early maladaptive schemas. In treatment, individuals can learn to identify the thinking patterns associated with these schemas. When these thinking patterns occur between sessions, the diary allows individuals to write about the associated situations, feelings, and behaviors. These diaries are often reviewed in session and can be helpful in determining methods of practicing new ways of meeting emotional needs as well as situations in which these methods may be best applied. 

Issues Treated with Schema Therapy

Schema therapy was developed to more effectively treat mental health conditions affecting individuals across many periods and aspects of their lives after Dr. Young noticed not only were some concerns especially difficult to treat, but aspects of these conditions continued to cause problems for some individuals, even after generally effective treatment.

Studies conducted on schema therapy show this type of therapy is often effective in addressing: 

Schema therapy has been shown to be particularly effective in the treatment of borderline personality, and research shows individuals in treatment dropped out of schema therapy at lower rates than they dropped out of other types of treatment. 

In addition, schema therapy has shown potential as a treatment for narcissistic personality. Further research may be necessary to fully establish schema therapy as an effective treatment for narcissism, as individuals with narcissistic personality do not commonly seek treatment voluntarily. 

Training for Schema Therapy

The International Society of Schema Therapy (ISST) provides training and certification for therapists who wish to practice schema therapy and also maintains an online database of therapists trained in delivery of schema therapy. Schema therapists typically have a thorough background in the treatment of chronic mental health conditions and personality-related concerns.

To obtain standard certification in schema therapy, individuals must:

  • Hold a master’s degree in psychology or a medical degree with psychiatric residency and be licensed to practice. 
  • Complete 25 didactic hours, 15 hours of supervised role-playing, and 20 supervision sessions
  • Use a schema therapy approach in at least two cases of at least 25 therapy hours each
  • Provide a minimum of 80 sessions 

Self-therapy and peer supervision are strongly recommended as part of the certification process.

Advanced certification is also offered. Upon completion of an advanced certification program, practitioners are qualified to become certified as a supervisor or trainer and, after three years of practice, run training programs. 

Concerns and Limitations  

Schema therapy is a fairly new form of psychological intervention, and research on this approach to treatment is still emerging. A recent review of research on schema therapy found initial evidence of effectiveness but also noted the necessity of a more comprehensive research base regarding positive outcomes and cost-effectiveness. 

One major concern regarding schema therapy relates to the cost and length of time of the treatment. Given that schema therapy works to treat chronic problems, treatment often takes longer and costs more than other time-limited evidence-based interventions. But because chronic mental health conditions often become costly to health care organizations if left untreated, schema therapy may, in the end, be less expensive than the costs associated with chronic conditions when they are not successfully treated. 

References:

  1. Farrell, J. (2013, August 12). 2014-2015 ISST Certification Requirements as an Individual Schema Therapist. Retrieved from http://isstonline.com/sites/default/files/2014-15 ISST CERTIFICATION REQUIREMENTS_0.pdf 
  2. Lockwood, G. (2008, December 21). History. Retrieved from http://www.isstonline.com/history 
  3. Masley, S. A., Gillanders, D. T., Simpson, S. G, and Taylor, M. A. (2012). A systematic review of the evidence of Schema Therapy. Cognitive Behavior Therapy, 41, 185-202. 
  4. Schema Therapy. (n.d.). Retrieved from http://www.apa.org/pubs/videos/4310804.aspx?tab=2 
  5. Schema Therapy. (2004). Retrieved from http://www.schematherapy.com/ 
  6. Therapeutic techniques (n.d.). The International Society of Schema Therapy. Retrieved from http://www.isstonline.com/therapeutic-techniques
  7. Training, certification and supervision (n.d.). The International Society of Schema Therapy. Retrieved from http://www.isstonline.com/training-certification-supervision.
  8. Young, J. E., Klosko, J. S., and Weishaar, M. E. (2006). Schema Therapy: A Practitioner’s Guide. Retrieved from https://books.google.com/books?id=pS5uAAAAQBAJ&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false