SCHEMA THERAPY

PRESENTER: CHAIRPERSON:
SPURTHI S P SUDEEP P K
II YEAR M.PHIL CLINICAL PSYCHOLOGY ASST. PROFESSOR
DEPT. OF CLINICAL PSYCHOLOGY DEPT. OF CLINICAL PSYCHOLOGY
JSSMCH JSSMCH

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SCHEMA THERAPY
• Integrative therapy developed by Young and colleagues (Young, 1990, 1999)
• Blends elements from cognitive-behavioral, attachment, Gestalt, object relations,
constructivist, and psychoanalytic school

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EVOLUTION FROM COGNITIVE TO SCHEMA THERAPY
• CBT practitioners have progressed in developing effective psychological treatments for Axis I
disorders, including many mood, anxiety, sexual, eating, somatoform, and substance abuse
disorders.

• These treatments have traditionally been short term (roughly 20 sessions)

• Focused on reducing symptoms, building skills, and solving problems in the patient’s current life

• Often patients with underlying personality disorders and characterological issues fail to respond
fully to traditional cognitive-behavioral treatments (Beck, Freeman, & Associates, 1990)

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TREATMENT OUTCOMES FOR CBT
• In depression, the success rate is over 60% immediately after treatment, but the relapse rate is about
30% after 1 year (Young, Weinberger, & Beck, 2001)—leaving a significant number of patients
unsuccessfully treated

• Characterological problems can reduce the effectiveness of traditional CBT

• Some patients present for treatment of Axis I symptoms, such as anxiety or depression, and either
fail to progress in treatment or relapse once treatment is withdrawn

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TREATMENT OUTCOMES FOR CBT
• A female patient presents for cognitive-behavioral treatment of agoraphobia
• Breathing training
• Challenging catastrophic thoughts
• Graduated exposure to phobic situations
• Reduces her fear of panic symptoms
• Once treatment ends, however, the patient lapses back into her agoraphobia

• A lifetime of dependence, with feelings of vulnerability and incompetence—what we call

Dependence and Vulnerability schemas—prevent her from venturing out into the world on her own

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DEVELOPMENT OF SCHEMA THERAPY
• Young, developed schema therapy to treat patients with chronic characterological problems who
were not being adequately helped by traditional cognitive-behavioral therapy: the “treatment
failures.”

• Schema therapy can be brief, intermediate, or longer term, depending on the patient

• Expands on traditional CBT by placing greater emphasis on exploring the childhood and adolescent
origins of psychological problems, on emotive techniques, and maladaptive coping styles

• Schema therapy addresses the core psychological themes that are typical of patients with
characterological disorders.

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DEVELOPMENT OF SCHEMA THERAPY
• The model traces these schemas from early childhood to the present, with particular emphasis on
the patient’s interpersonal relationships

• The therapist allies with patients in fighting their schemas, utilizing cognitive, affective, behavioral,
and interpersonal strategies

• When patients repeat dysfunctional patterns based on their schemas, the therapist empathically
confronts them with the reasons for change

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HISTORY OF SCHEMA CONSTRUCT
• In general terms, a schema is a structure, framework, or outline

• Within cognitive development, a schema is a pattern imposed on reality or experience to help

individuals explain it, to mediate perception, and to guide their response

• A schema is an abstract representation of the distinctive characteristics of an event, a kind of

blueprint of its most salient elements

• Within cognitive psychology, a schema can also be thought of as an abstract cognitive plan that
serves as a guide for interpreting information and solving problems

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YOUNG’S DEFINITION OF A SCHEMA
• Young (1990, 1999) hypothesized that some of the schemas—especially schemas that develop as a
result of toxic childhood experiences— might be at the core of personality disorders, milder
characterological problems, and many chronic Axis I disorders

• Comprehensive definition of an Early Maladaptive Schema is:

• A broad, pervasive theme or pattern
• Comprised of memories, emotions, cognitions, and bodily sensations
• Regarding oneself and one’s relationships with others
• Developed during childhood or adolescence
• Elaborated throughout one’s lifetime and
• Dysfunctional to a significant degree

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CHARACTERISTICS OF EARLY MALADAPTIVE SCHEMAS
• Although not all schemas have trauma as their origin, all of them are destructive, and most are
caused by noxious experiences that are repeated on a regular basis throughout childhood and
adolescence
• Early Maladaptive Schemas fight for survival. Although it causes suffering, it is comfortable and
familiar. It feels “right”
• Patients regard schemas as a priori truths, and thus these schemas influence the processing of
later experiences
• Schemas begin in early childhood or adolescence as reality-based representations of the child’s
environment
• Schemas are dimensional, meaning they have different levels of severity and pervasiveness

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ORIGIN OF SCHEMAS

Schemas

Core Emotional Early Life Emotional

needs Experiences Temperament

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ORIGIN OF SCHEMAS
Core Emotional Needs

• Schemas result from unmet core emotional needs in childhood

• Young postulated five core emotional needs for human beings

1. Secure attachments to others (includes safety, stability, nurturance, and acceptance)

2. Autonomy, competence, and sense of identity
3. Freedom to express valid needs and emotions
4. Spontaneity and play
5. Realistic limits and self-control

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ORIGIN OF SCHEMAS
• Toxic childhood experiences are the primary origin of Early Maladaptive Schemas

• Four types of early life experiences that foster the acquisition of schemas
1. Toxic frustration of need
2. Traumatization or victimization
3. Too much of a good thing
4. Selective internalization or identification with significant others

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ORIGIN OF SCHEMAS
• The child’s emotional temperament is especially important. Each child has a unique and distinct
“personality” or temperament from birth

• Kagan and his colleagues (Kagan, Reznick, & Snidman, 1988) have generated a body of research
on temperamental traits present in infancy and have found them to be remarkably stable over
time
1. Labile ↔ Nonreactive
2. Dysthymic ↔ Optimistic
3. Anxious ↔ Calm
4. Obsessive ↔ Distractible
5. Passive ↔ Aggressive
6. Irritable ↔ Cheerful
7. Shy ↔ Sociable

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ORIGIN OF SCHEMAS
• Emotional temperament interacts with painful childhood events in the formation of schemas

• Different temperaments selectively expose children to different life circumstances

• For example, an aggressive child might be more likely to elicit physical abuse from a violent
parent than a passive, appeasing child

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SCHEMA DOMAINS AND EARLY MALADAPTIVE
SCHEMAS
• 18 schemas are grouped into five broad categories of unmet emotional needs called “schema
domains”

• Domain I: Disconnection and Rejection

• Domain II: Impaired Autonomy and Performance

• Domain III: Impaired Limits

• Domain IV: Other-Directedness

• Domain V: Overvigilance and Inhibition

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SCHEMA DOMAINS AND EARLY MALADAPTIVE SCHEMAS
Domain I: Disconnection and
Rejection
Abandonment/Instability
Mistrust/Abuse
Emotional Deprivation
Defectiveness/Shame
Social Isolation/Alienation
The patient expects that significant others will eventually abandon him. Others are
unreliable and unpredictable in their support and connection. When the patient
feels abandoned, he switches between feelings of anxiety, grief, and anger
The patient is convinced that others will intentionally abuse him in some way or
that they will cheat or humiliate him. These feelings vary greatly, and the patient is
continuously on edge
The patient expects that others will never or not adequately meet his primary
emotional needs (e.g., for support, nurturance, empathy, and protection). He feels
isolated and lonely
The patient believes that he is internally flawed and bad. If others get close, they
will realize this and withdraw from the relationship. The feeling of being worthless
often leads to a strong sense of shame
The patient feels isolated from the world and believes that he is not part of any
community
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SCHEMA DOMAINS AND EARLY MALADAPTIVE SCHEMAS
Domain II: Impaired Autonomy and
Performance
Dependence/Incompetence
Vulnerability to Harm or Illness
Enmeshment/Undeveloped Self
Failure
The patient feels extremely helpless and incapable of functioning independently.
He is incapable of making day - to day decisions and is often tense and anxious
The patient believes that imminent catastrophe will strike him and significant
others, and that he is unable to prevent this
The patient has an excessive emotional involvement and closeness with one or
more significant others (often his parents), as a result of which he cannot
develop his own identity
The patient believes that he is incapable of performing as well as his peer group.
He feels stupid and untalented.
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SCHEMA DOMAINS AND EARLY MALADAPTIVE SCHEMAS
Domain III: Impaired Limits
Entitlement/Grandiosity
Insufficient Self-Control/Self-
Discipline
The patient believes that he is superior to others and entitled to special rights.
He insists that he should be able to do or have what he wants, regardless of
what others think. The core theme is power and being in control of situations or
people
The patient has no tolerance of frustration and is unable to control his feelings
and impulses. He cannot bear dissatisfaction or discomfort (pain, conflicts, or
overexertion)
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SCHEMA DOMAINS AND EARLY MALADAPTIVE SCHEMAS
Domain IV: Other-Directedness

Subjugation The patient believes that he is superior to others and entitled to special rights.
He insists that he should be able to do or have what he wants, regardless of
what others think. The core theme is power and being in control of situations or
people
Self-Sacrifice The patient has no tolerance of frustration and is unable to control his feelings
and impulses. He cannot bear dissatisfaction or discomfort (pain, conflicts, or
overexertion)
Approval-Seeking/Recognition- The patient focuses excessively on gaining recognition, approval, and attention,
Seeking at the expense of his own development and needs.

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SCHEMA DOMAINS AND EARLY MALADAPTIVE SCHEMAS
Domain V: Overvigilance and
Inhibition
Negativity/Pessimism
Emotional Inhibition
Unrelenting
Standards/Hypercriticalness
Punitiveness
The patient is always focused on the negative aspects of life and ignores or plays
down the positive aspects. He is frequently anxious and hyper - alert
The patient inhibits emotions and impulses because he believes that any
expression of feelings will harm others or lead to embarrassment, retaliation, or
abandonment. He lacks spontaneity and stresses rationality.
The patient believes that whatever he does is not good enough and that he
must always strive harder. He is hypercritical of himself and others, and he is a
perfectionist, rigid, and extremely efficient. This is at the expense of pleasure,
relaxation, and social contacts.
The patient believes that people should be harshly punished for making
mistakes. He is aggressive, intolerant, impatient, and unforgiving.
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SCHEMA OPERATIONS
Every thought, feeling, behavior, and life experience relevant to a schema can be said to either
perpetuate the schema—elaborating and reinforcing it—or heal the schema—thus weakening it
• SCHEMA PERPETUATION • SCHEMA HEALING
• Schema perpetuation refers to everything • Schema healing is the ultimate goal of
the patient does (internally and schema therapy
behaviorally) that keeps the schema going
• Schema healing also involves behavior
• Schemas are perpetuated through three change, as patients learn to replace coping
primary mechanisms: cognitive distortions, styles with adaptive patterns of behavior
self-defeating life patterns, and schema
coping styles • Treatment thus includes cognitive,
affective, and behavioral interventions

• As a schema heals, it becomes increasingly

more difficult to activate

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MALADAPTIVE COPING STYLES AND RESPONSES

• Patients develop maladaptive coping styles and responses early in life in order to adapt to
schemas, so that they do not have to experience the intense, overwhelming emotions that
schemas usually engender

• However, although coping styles sometimes help the patient to avoid a schema, they do not heal
it

• Thus, all maladaptive coping styles still serve as elements in the schema perpetuation process

• Schema therapy differentiates between the schema itself and the strategies an individual utilizes
to cope with the schema

• Thus, the schema itself contains memories, emotions, bodily sensations, and cognitions, but not
the individual’s behavioral responses

• Behavior is not part of the schema; it is part of the coping response. The schema drives the
behavior

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 MALADAPTIVE COPING STYLES
• All organisms have three basic responses to threat: fight, flight, and freeze. These correspond to the three schema
coping styles

Schema Overcompensation
• Endeavour to be as different as possible from the children they were when the schema was acquired
• Fight the schema by thinking, feeling, behaving, and relating as though the opposite of the schema
were true

Schema Avoidance
• Arrange their lives so that the schema is never activated. They attempt to live without awareness, as
though the schema does not exist

Schema Surrender
• When patients surrender to a schema, they yield to it. They do not try to avoid it or fight it. They
accept that the schema is true
• They feel the emotional pain of the schema directly

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SCHEMA MODES AS STATES (STATE V/S TRAIT)
• A major development in the evolution of Schema Therapy was the introduction of the mode
concept

• Schema modes are the moment-to-moment emotional states and coping responses—adaptive
and maladaptive—that we all experience

• Often our schema modes are triggered by life situations to which we are oversensitive (our
“emotional buttons”)

• The predominant state that we are in at a given point in time is called our “schema mode”

• Modes are transient states. This contrasts with schemas which can be thought of as traits - stable
characteristics of the person

• 10 schema modes that can be grouped into four broad categories: Child modes, Dysfunctional
Coping modes, Dysfunctional Parent modes, and the Healthy Adult mode

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 SCHEMA MODES AS STATES (STATE V/S TRAIT)
Child modes Maladaptive coping Dysfunctional A healthy adult mode
modes internalized parent
modes
1. The Vulnerable Child 1. The Detached 1. Punitive Parent 1. Healthy Adult
Protector

2. the Angry Child 2. The Compliant 2. Demanding Parent

Surrenderer

3. The 3. The
Impulsive/Undisciplined Overcompensator
Child

4. The Happy Child

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SCHEMA ASSESSMENT AND EDUCATION
• Schema therapists begin their work with patients with a comprehensive assessment process

• The process usually involves several sessions (typically 2-4) devoted to gathering information in a
variety of assessment methods

• The Assessment and Education Phase of schema therapy has six major goals:
• Identification of dysfunctional life patterns
• Identification and triggering of Early Maladaptive Schemas
• Understanding the origins of schemas in childhood
• Identification of coping styles and responses
• Assessment of temperament
• Case conceptualization

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INITIAL EVALUATION AND FOCUSED LIFE HISTORY
• In the first session (or first several sessions), therapists interview patients to learn about their
presenting problems, their goals for therapy, and their unmet emotional needs

• When therapists interview patients about their history, they try to determine if the presenting
problems reflect long-standing patterns in the patient's life, or are constrained to a narrower
context

• When problems do seem to reflect schema activation, the therapist works to identify previous
periods of such activation

• This can help clarify which triggers exert the greatest influence on the patient, as well as which
thoughts, images, feelings, and behaviors occur when the schemas are activated

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SCHEMA INVENTORIES
• To augment the information gathered in the interview, therapists may ask patients to complete
one or more self-report inventories as homework

• Patients return these inventories in the next session and review their answers with the therapist

• Several inventories have been developed and are used for assessing schemas, coping responses,
predominant modes, and developmental history

• The most widely used questionnaires are

• Life History Assessment Forms
• Young Schema Questionnaire (YSQ)
• Young Parenting Inventory
• Young–Rygh Avoidance Inventory
• Young Compensation Inventory

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IMAGERY ASSESSMENT
• After taking a focused life history and reviewing completed questionnaires with the patient, the
therapist and patient build an intellectual understanding of the schemas and coping styles

• The next step is to trigger the patient’s schemas in the therapy session so that both the therapist
and the patient can feel them

• The therapist usually accomplishes this with imagery

• Goals of imagery assessment

• To identify and trigger the patient’s schemas
• To understand the childhood origins of the schemas
• To link schemas to presenting problems
• To help the patient experience emotions associated with the schemas

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IMAGERY ASSESSMENT
• After giving patients a brief rationale, therapist asks them to close their eyes and let an image
float to the top of their minds
Once patient gets an image
> asked to describe it loud
in present tense
Imagine the other person’s
response (loud) and carry
out a dialogue b/w
themselves and parental
figure
Instructed to speak the
Once they experience the
people expressing what
“safe place” image > asked
they are feeling and
to get an image of upsetting
thinking and what they wish
childhood situation with
to get from the other
parents
person
Carry out a dialogue with
the person from their adult
Switch to an image from the
life, saying aloud what they
current life that resembles
are thinking and feeling and
the childhood situation
what they wish they could
get from the other
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IMAGERY ASSESSMENT
• When doing imagery work, it is important for the therapist to begin early in the session so that
there is enough time to discuss what happens afterward

• In this discussion, the therapist helps patients explore the images in order to identify schemas,
understand their origins in childhood, and link them to the presenting problems

• In addition, the therapist helps the patient integrate the imagery work with information from
previous assessment modalities

• Sometimes patients are distraught after an imagery session

• After the exercise, the therapist may need to ground these patients in the present moment
before the session ends, using a mindfulness exercise

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EDUCATING ABOUT THE SCHEMA AND MODE MODELS, AND
USING THE SCHEMA CASE CONCEPTUALIZATION FORM
• The assessment phase culminates in a written and integrated conceptualization tying together
the information gleaned from the
• Interview, questionnaires
• Imagery for assessment
• Daily thought records
• Therapist's attention to the therapy relationship and to in-session behavior

• The culminating conceptualization is similar to, but broader than, ones used in other CBT case
formulation approaches (e.g., Persons, 2008)

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SCHEMA CASE CONCEPTUALIZATION FORM
1. Patient name, age, marital status, children (and ages), educational background, racial/ethnic/religious
background, occupation, and overall level of functioning
2. Axis I symptoms/diagnoses
3. Current (presenting) problems, connecting them to longer-standing life patterns
4. Developmental origin (with information about all caregivers and other relevant family members)
5. Core childhood images/memories
6. Core unmet needs
7. Relevant schemas
8. Current triggers for these schemas
9. Coping behaviors (including surrender, escape, and overcompensation behaviors, if present)
10. Relevant schema modes
11. Possible temperamental/biological factors
12. Core cognitions and distortions
13. Information about the therapy relationship
14. Goals and focus for change

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COGNITIVE STRATEGIES
• Cognitive strategies help the patient articulate a healthy voice to dispute the schema,
strengthening the patient’s Healthy Adult mode

• The most widely used cognitive tools/techniques are as follows:

• Testing the validity of a schema
• Reframing/reattribution
• Constructing schema flash card
• Filling out Schema Diary
• Schema dialogues between the “schema side” and the “healthy side”

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TESTING THE VALIDITY OF THE SCHEMAS
• Examining the objective evidence for and against the schema

• Similar to testing the validity of ATs in cognitive therapy

• Except that the therapist uses the patient’s whole life as empirical data and not just the present
circumstances

• T and P make a list of evidence from the past and present supporting the schema; then they
make by a list of evidence refuting the schema

• Patients find it easy to compose the first list, evidence supporting the schema, because they
already believe this evidence

• In contrast, they find it difficult to compose the second list, evidence refuting the schema, and
require a good deal of input from the therapist

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REFRAMING/REATTRIBUTION
• Reframing involves providing a different cognitive frame (or explanation) than the one
automatically generated for an event, problem, or situation

• Schema Therapy uses reattribution to help create a healthier view of schemas and their origins

• The goal is to discredit the evidence supporting the schema

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SCHEMA FLASHCARDS
• After completing the schema restructuring process, the therapist and patient begin to write
schema flash cards

• Schema flashcards provide very structured guidance for reattributing difficult (and recurring)
situations in daily life

• Flashcards are written summaries of the healthy response to a schema trigger, designed to be
carried around by the patient and used on-the-spot, in moments when schemas get triggered

• Flash cards contain the most powerful evidence and arguments against the schema

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SCHEMA THERAPY FLASH CARD
Acknowledgment of current feeling

Right now, I feel ___________ because__________________________________________________________________

Identification of schema(s)

However, I know that this is probably my ________ schema, which I learned through_____________________________

These schemas lead me to exaggerate the degree to which __________________________________________________

__________________________________________________________________________________________________

Reality-testing

Even though I believe _____________________________ the reality is that ______________________________________

The evidence in my life supporting the healthy view includes __________________________________________________

Behavioral instruction

Therefore, even though I feel like ________________________________________ I could instead ____________________

___________________________________________________

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SCHEMA DIARY
• The Schema Diary (Young, 1993) is a more advanced technique than the flash card

• With the flash card, the T and P construct a healthy response ahead of time for a specific schema
trigger, and the patient reads the flash card as needed before and during the event

• With the Schema Diary, patients construct their own healthy responses as their schemas are
triggered in the course of their daily lives

• The therapist therefore introduces the Schema Diary later in treatment, after the patient has
become proficient at using flash cards.

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SCHEMA DIARY
Trigger:

Emotions:

Thoughts:

Actual Behaviors:

Schemas:

Healthy view:

Realistic concerns:

Overreactions:

Healthy Behaviors:

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EXPERIENTIAL STRATEGIES
• Experiential techniques have two aims:
1. To trigger the emotions connected to Early Maladaptive Schemas
2. To reparent the patient in order to heal these emotions and partially meet the patient’s
unmet childhood needs

• Experiential techniques include:

• Imagery Dialogues
• “Reparenting” imagery work
• Letters to Parents

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IMAGERY DIALOGUES
• One of the primary experiential change techniques

• Patients conduct dialogues in imagery, both with the people who caused their schemas in
childhood and with the people who reinforce their schemas in their current lives

• Patients are instructed to close their eyes and to picture themselves with a parent in an upsetting
situation

• Often these images are the same as or similar to memories that arose in the imagery for
assessment

• Focus is on helping the patients to express strong affect toward the parent, particularly anger

• Goal: To empower the patient to fight back against the schema and to distance the patient from
the schema

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IMAGERY WORK FOR REPARENTING
• Imagery work for reparenting is helpful for patients with most of the schemas in the
Disconnection and Rejection domain (Abandonment, Mistrust/Abuse, Emotional Deprivation,
and Defectiveness)

• Through reparenting in imagery work, the therapist helps patients go back into that child mode
and to learn to get from the therapist, and later from themselves, some of what they missed. This
approach is a form of “limited reparenting”

• The three steps in this process are as follows:

1. The therapist asks permission to enter the image and speak directly to the Vulnerable Child
2. The therapist reparents the Vulnerable Child
3. Later, the patient’s Healthy Adult, modeled after the therapist, reparents the Vulnerable
Child

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LETTERS TO PARENTS
• Often give patients as a homework assignment

• Patients are asked to write letters to their parents or to other significant people who hurt them
when they were children or adolescents

• Patients bring the letters to subsequent sessions and read them aloud to the therapist

• The rationale for writing letters is to summarize what the patient has learned about the parent as
a result of doing the cognitive and experiential work

• Patients can use the letters as opportunities to state their feelings and assert their rights

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BEHAVIORAL PATTERN-BREAKING
• Patients attempt to replace their schema-driven patterns of behavior with healthier coping styles

• If the patient has not progressed adequately through the cognitive and experiential stages, the
patient is unlikely to achieve lasting changes in schema driven behavior

• Behavioral pattern-breaking targets coping styles

• The behaviors that are the focus of change are the ones patients use in surrendering to, avoiding,
and overcompensating for their Early Maladaptive Schemas

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SPECIFIC BEHAVIORS AS POSSIBLE TARGETS OF
CHANGE
• First step – therapist and patient develop an extensive list of specific behaviors to serve as
potential targets of change

• Sources of information – case conceptualization developed in the Assessment Phase, detailed

descriptions of problematic behaviors, imagery of problematic situations, relationships with
significant others, and schema questionnaires

• The therapist should start with the most problematic behavior. This is the behavior that causes
most distress and interferes with interpersonal and occupational functioning

• Once settled on a target behavior, the therapist works on helping the client build motivation

• In order to make patients feel empathic and supportive for themselves, the therapist links the
target behavior to its origin in the childhood

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SPECIFIC BEHAVIORS AS POSSIBLE TARGETS OF
CHANGE
• To strengthen the motivation, the patient and therapist review the advantages and disadvantages
of continuing the maladaptive behavior

• Develops a flashcard – patient can use the schema therapy flashcard as a guide, focusing more
specifically on the behavior

• The patient practices healthy behaviors in therapy sessions, using imagery and role play with the
therapist

• The therapist and patient agree on a homework assignment relevant to the new behavioral
pattern. Agrees to carry out the healthy behavior in a life situation, recording what happens

• The therapist and patient review the previous homework assignment at the start of the next
session

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REFERENCES

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