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Schema Therapy For

Personality Disorders

 by Milton Spett

             In 1995 Jeffrey Young was NJ-ACT’s first Master Lecturer.  In Schema Therapy: A Practitioner’s Guide (2003, Guilford), Young and his associates present the latest version of their treatment for personality disorders.  According to Young, schemas are self-perpetuating patterns of memories, emotions, cognitions, sensations, and perceptions.  Schemas drive behaviors.  Young uses the term “schema” to refer to early maladaptive schemas -- dysfunctional schemas which are caused by innate emotional temperament and “toxic” childhood experiences.  Some examples of early maladaptive schemas are Defectiveness/Shame, Social Isolation/Alienation, Dependence/Incompetence, Entitlement/Grandiosity, Unrelenting Standards, Insufficient Self-Discipline, and Emotional Inhibition.

Young and his co-authors see all character pathology as representing one of three schema-driven coping styles:

1. Schema Surrender – Behaving, thinking, and feeling in accordance with a schema.  For example, feeling and acting inadequate.

2. Schema Avoidance – For example, suppressing feelings of inadequacy and avoiding situations which might evoke those feelings.

3. Schema Overcompensation – For example, overworking in an attempt to counteract feelings of inadequacy.

        Young developed Schema Therapy because he believes that many patients with personality disorders have schemas which make them unsuitable for traditional CBT.  Patients with schemas such as Self-Sacrifice and Approval-Seeking may be unable to establish clear treatment goals.  Patients with schemas such as Impaired Autonomy and Undeveloped Self may be unaware of their cognitions and emotions.  Patients with schemas such as Abandonment, Mistrust, and Shame, may be unable to develop a therapeutic relationship.  Therapy must modify these schemas before a positive therapeutic relationship can develop.

Schema Therapy

         The “assessment” phase of treatment educates patients about Schema Therapy, and helps patients to identify their early maladaptive schemas and the events that allegedly created those schemas.  The “change” phase of Schema Therapy begins by encouraging patients to collect and list evidence for and against the validity of their schemas.  The goal is to convince patients that their schemas are false.

Next Young employs experiential techniques such as imagery and role-playing to evoke negative emotions and change the associated cognitions.  For example, a patient may be asked to use imagery to stand up to a parent who criticized or controlled the patient as a child.  Or the patient might be encouraged to use role playing to talk back to a significant other who unfairly criticizes or attempts to control the patient in the present.  Young also uses imagery and flash cards to prepare patients for homework assignments that will counteract maladaptive schemas.

Flash Cards and the Schema Diary

        Schema Therapy asks patients to develop flash cards which have four sections:

1. Acknowledgment of a current maladaptive feeling, such as a single person's fear of talking to a member of the opposite sex.

      2. Identification of the schema – fear of rejection due to Defectiveness schema.

      3. Reality testing – “just because my mother criticized me doesn’t mean I am defective.”

4. Behavioral instruction – “I will talk to this person even though I feel nervous because that is the only way I have a chance of getting into a relationship.”

Young also uses the Schema Diary, where patients describe actual situations, cognitions, emotions, behaviors, schemas, and healthy cognitions and behaviors.

Finally, Schema Therapy utilizes the therapeutic relationship in three ways.  First of all, Young sees the therapist as a role model, enabling the patient to internalize the therapist’s (hopefully) healthy schemas.  Secondly, Young recommends that the therapist provide, within reason, what patients needed but did not receive from their parents in childhood (limited reparenting).  Thirdly, Young recommends empathic confrontation – showing empathy for the patient’s maladaptive schemas as they are experienced toward the therapist, but also pointing out that these schemas are distorted or dysfunctional (interpretation of transference).

Experiential Techniques

        Schema Therapy assumes that patients must experience their dysfunctional schemas in order to change them.  One experiential technique is “Letters to parents.”  Patients are asked to write a letter describing how the parent hurt them, summarizing the patient’s memories, emotions, and cognitions, and also what patients wanted from their parents in the past and what they want in the present.  Patients read these letters to the therapist, but usually do not actually send the letters to their parents. Another experiential technique is “Imagery Dialogues.”  Here patients picture themselves with their parents in an upsetting situation.  Patients are then encouraged to express strong affect, particularly anger about how their parents mistreated them and what they wanted from their parents.  This technique is intended to help patients weaken the maladaptive schemas which were created in their early interactions with their parents.

 How Schema Therapy Differs From Other Therapies

        Unlike Psychodynamic Therapy, Schema Therapy is highly structured and utilizes directive techniques.  A psychodynamic therapist will passively note that a patient’s thoughts, feelings, behaviors, and perceptions toward another person are similar to the patient’s reactions to a parent figure.  But a Schema Therapist will directly assert that these reactions are distorted and/or dysfunctional.  The Schema Therapist will also use imagery, role playing, flash cards, and homework assignments to actively counteract the patient’s dysfunctional schemas.

        Unlike traditional CBT, Schema Therapy uses childhood experiences and the therapeutic relationship as vehicles for change.  In traditional CBT, the therapeutic relationship is viewed as providing a supportive environment which enables cognitive and behavioral change to occur.  But in Schema Therapy, Young sees the therapeutic relationship as leading directly to therapeutic change by compensating for deficiencies in the original parenting. 

        The Schema concept of “limited reparenting” means that the therapist provides the support that the parents failed to provide, enabling patients to internalize the therapist and eventually provide their own support.  Young also recommends “empathic  confrontation,” which is similar to traditional CBT concepts, with possibly more emphasis on the “empathic.”

 Conclusion

My only negative comment is that the system tends to be somewhat obsessive.  Young goes into exquisite detail in enumerating and differentiating an ever-increasing number of schemas and categories of schemas.

        But overall, Schema Therapy is a very significant contribution to the cognitive-behavioral approach. Schema Therapy provides a wealth of useful techniques for treating patients with personality disorders.  Young’s intensive interventions can also be helpful with patients who have no Axis II disorder, but fail to respond to less emotionally intense cognitive and behavioral interventions.

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