Have you been working as a therapist in shorter-term therapies such as cognitive behavioural therapy (CBT)? In Australia, the clients of psychologists, for example, have been able to access Medicare rebates for their therapy for a limited number of sessions. Their practitioners, in return, are strongly encouraged – if not mandated – to work in well-researched, “gold standard” therapies such as CBT; they are held accountable for certain outcomes. Yet not all clients respond equally well to therapies such as CBT, which usually include no more than 20 sessions and often less than that. What would you advocate as a therapist for the following clients?

Jon, a man in his 30s, underwent a short-term behavioural program of exposure combined with response prevention for his symptoms of obsessive-compulsive disorder (OCD). Obsessive thoughts and accompanying compulsive rituals (such as checking the locks on her doors and windows 12 times before going out because of the thought that someone would enter and steal all his possessions) had commandeered his waking life for as long as he could remember. Over the course of his therapy, Jon learned to eliminate these, allowing his symptoms to abate. But as the absence of time-consuming rituals freed up his schedule, Jon had to confront the nearly total absence of a social life which had resulted from his “loner” lifestyle with OCD. Feeling flawed as a human being, Jon had since childhood been hyper-sensitive to perceived offences and rejections and had thus avoided contact with most others. While he now had far reduced OCD symptoms, he also had no social life and needed to grapple with the pattern of avoidance that was still with him post-therapy.

Roberta presented for treatment of her agoraphobia and panic attacks. Her CBT-for-anxiety program consisted of breathing training, attempts to dispute catastrophic thoughts, and exposure to phobic situations (graduated to become more challenging). Through this, Roberta was able to reduce her fear of having panic attacks and overcome her avoidance of many of the situations that had been too hard to face before. But some months after Roberta’s treatment ended, she noticed that she lapsed back into agoraphobia. A lifetime of depending on others had left her feeling vulnerable and incompetent. Without a driver’s licence or ability to navigate even around her neighbourhood and few money management skills, Roberta continued to depend on others to make necessary life arrangements for her. Without the ability developed to organise even simple outings (such as to the local grocery store), Roberta could not maintain her treatment gains.

Therapists have long wondered how to help clients like Jon and Roberta, whose chronic psychological issues have been difficult to treat. While cognitive-behavioural programs can help them reduce, or even eliminate, the presenting symptoms, the underlying disorders continue to make such clients’ lives miserable, with ripples throughout their life spheres and wider communities. Schema focused therapy (also called “schema therapy” or sometimes “schema focused cognitive therapy”) is an integrative approach to treatment which combines the best aspects of cognitive-behavioural, attachment, Gestalt, object relations, interpersonal, and psychoanalytic therapies into one unified model. This article briefly examines the origin, definition and characteristics of this therapeutic approach.

How it began

Dr Jeffrey Young and his colleagues, while working at the Center for Cognitive Therapy at the University of Pennsylvania, identified a portion of clients who saw little benefit from the standard approach. Young realised that these people typically had long-standing patterns or themes in thinking, feeling, and behaving/coping that required a different means of intervention (Pearl, n.d.). For example, CBT was found to have a high success rate in treating depression: over 60 percent had their depression lifted right after treatment. Yet one year later, 30 percent of those had relapsed (Young, Weinberger, & Beck, 2001), meaning that – as this is a typical outcome – the total numbers ultimately helped with their depression by CBT is considerably lower than what initial success rates indicate.

Young realised that the unsuccessfully treated clients often had underlying personality disorders and characterological issues and that there was a need to develop effective treatment regimens for them. Young labelled these deeper patterns or themes “schemas” or “lifetraps” and noted that many of the more enduring, self-defeating patterns typically began early in life (Pearl, n.d.). The patterns that he targeted in the treatments were negative, dysfunctional thoughts and feelings which had been repeated and elaborated upon by the client, posing serious obstacles for accomplishing their goals and getting their needs met.

Examples of schema beliefs are statements such as, “I’m not good enough”, “People will leave me”, “I’m a failure”, and “Something bad will happen”. Schemas, said, Young, could also begin in adulthood (less commonly), and they are perpetuated behaviourally through the coping styles of schema surrender, schema avoidance, and schema compensation. Schema therapy is designed to help people break these stubborn, negative patterns of thinking, feeling, and behaving and replace them with healthier alternatives (Pearl, n .d.).

The definition

As early as 1990, Young hypothesised that some of the schemas, especially those developing chiefly as a result of toxic childhood experiences, were at the core of personality disorders, less serious characterological problems, and many clinical disorders that, in the DSM-IV-TR, were called “Axis I disorders” (i.e., acute symptoms needing treatment, such as a major depressive episode, schizophrenic episodes, and panic attacks). He called these “Early Maladaptive Schemas” or “EMS”. He defined these as:

• 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 (Young, n.d.)

Thus, the self-defeating cognitive and emotional patterns that begin early in a person’s development and repeat throughout life – the EMS – constitute the context for schema therapy. Note that an individual’s behaviour is not part of the schema itself; maladaptive behaviours are said to develop as responses to a schema, so behaviours are driven by schemas, but are not part of schemas.

The characteristics of early maladaptive schemas

Even though Young believed that most schemas developed early, he acknowledged that not all did. Moreover, he also noted that not all schemas were maladaptive; some were positive (Young, n.d.). Of the list of eighteen maladaptive schemas, Young considered that clients with one or more of the four most powerfully damaging schemas – that is, Abandonment/Instability, Mistrust/Abuse, Emotional Deprivation, and Defectiveness/Shame – were clients who as children had been abandoned, abused, neglected, or rejected. These clients’ schemas are triggered in adulthood by life events which they perceive, often unconsciously, as similar to the traumatic experiences of their childhood. The triggering of a schema produces a strong negative emotion, such as grief, shame, fear, or rage.

Clients could have never experienced trauma and yet develop a schema, however, in that not all schemas are based in childhood trauma or mistreatment. Young also postulated that a child that had been overprotected and sheltered throughout childhood could develop a schema: in this case a Dependence/Incompetence schema. All the schema constructs generated by Young are destructive, and most, said Young, are caused by toxic experiences repeated regularly throughout childhood leading, cumulatively, to a full-blown schema.

Young considered that schemas beginning early on were often reality-based. That is, a child might not know why his parents were cold and emotionally withholding, but he would be right about the emotional climate and the treatment that resulted from it. The maladaptive or dysfunctional aspect of a schema comes to be seen later, when clients perpetuate their schemas in their interactions with others even though their perceptions are no longer accurate. For the example given, the coldly treated child may, as an adult, enter his workplace and barely be greeted by an unsmiling receptionist, whom he then perceives “does not like me”. In reality, the receptionist may be hugely busy and preoccupied, but the adult may interpret the lack of warm attention as reflecting the same cold indifference his parents displayed toward him.

Also, we should note that schemas are said to be “dimensional”, having different levels of severity, pervasiveness, and permanence. The more severe the schema is, the greater the number of situations which activate it. Extreme schemas – such as when both parents wound a child in a particular way – let’s say, through abuse – can lead to an adult who believes that he or she can trust no one, as everyone is out to use him/her for their own selfish ends. Conversely, a parent who overemphasised status or appearance as a way of gaining approval from others – but only did this occasionally – may be at the core of that child sometimes but not always being anxious about making life decisions; the relevant schema will probably not be activated in the face of every decision (Young, n.d.).

This article was adapted from the upcoming Mental Health Academy course, “Schema Focused Therapy: The Basics”.

References

• Pearl, M. (n.d.). What is schema therapy? Schematherapy-nola.com. Retrieved on 8 June, 2016, from: hyperlink.
• Young, J.E. (n.d.). Schema therapy: Conceptual model. Retrieved on 8 June, 2016, from: hyperlink.
• Young, J.E., Weinberger, A.D., & Beck, T.A. (2001). Cognitive therapy for depression. In D.H.Barlow (Ed.), Clinical handbook of psychological disorders. A step-by-step treatment manual (3rd. edition) (pp.264-308). New York: Guilford Press.