Schema therapy is an
innovative psychotherapy developed by Dr. Jeffrey Young for
personality disorders, chronic depression, and other difficult
individual and couples problems.
Schema therapy integrates
elements of cognitive therapy, behavior therapy, object relations,
and gestalt therapy into one unified, systematic approach to
treatment. Schema therapy has recently been blended with
mindfulness meditation for clients who want to add a spiritual
dimension to their lives. © Copyright 2004 Schema Therapy
Schema Therapy For Borderline
Johnston, L.C.S.W, former About.com Guide,
Updated: May 3, 2007
What It Is:
Schema therapy, also
called schema-focused therapy, combines elements
of a variety of therapeutic interventions to
address ongoing problems like personality
disorders, eating disorders, and chronic
depression. It is designed to break life-long
Schema therapy is based
on the premise that maladaptive beliefs, or
schemas, are developed early in life and
played out over and over.
Jeffery Young, at
Columbia University, developed Schema Therapy
and opened the Schema Therapy Institute. Young
recognized that there were some individuals that
did not respond to the traditional cognitive
therapies, but instead seemed to operate through
a series of dysfunctional thought patterns, or
Main Concepts In Schema Therapy:
Maladaptive Schemas (EMS):
schemas are self-defeating patterns developed in
childhood that are repeated throughout life.
Schema therapy defines 18 potential schemas.
The 18 early maladaptive schema defined above
are further grouped into schema domains. These
domains relate to the basic emotional needs of
the child. If the child’s emotional needs are
not met an early maladaptive schema, or beliefs,
Coping styles refers to
the ways the child adapts to schemas and to
damaging childhood experiences. Not all children
cope the same way to stressful or even traumatic
events. The theory asserts that there are three
general ways that a person copes to the schemas:
surrender, avoidance, and overcompensation.
Schema modes are the
emotional states and coping responses everyone
experiences. Things that a person is
particularly sensitive to can trigger them.
Schema modes may cause a person to overreact or
act in ways that may be harmful to him or
Goals of Schema Therapy:
Stop using the
maladaptive coping styles (surrender,
avoidance, overcompensation) allowing a
person to access the “core feelings”
Heal the early
Learn to turn off
the self-defeating schema modes as quickly
Get emotional needs
in met in everyday life
Association, "Monitor on Psychology, 3/2007, by -C. Munsey)
Nearly half of the participants in a Netherlands-based
study testing schema-focused therapy's effectiveness for borderline personality
disorder (BPD) showed so few symptoms that they were evaluated as recovered
after completing three years of treatment, according to a recent study in the
Archives of General Psychiatry (Vol. 63, No. 6, pages 649–658).
And one year after the therapy ended, 70 percent of the
schema therapy patients had achieved "clinically significant and relevant
improvement" in symptom reduction-working, attending school, thinking less
frequently about suicide and more successfully regulating their emotions.
The study demonstrates for the first time that schema
therapy can help people with BPD live more stable lives and make deep
personality changes, says Jeffrey Young, PhD, a New York City-based psychologist
who developed the therapy in the mid-1980s.
Young says he developed schema therapy because other
therapies weren't serving his most difficult patients, particularly their need
to develop a deep bond of trust with a therapist.
Drawing from cognitive-behavioral therapy, attachment
theory and Gestalt techniques, the schema approach helps a therapist and client
confront severe emotional damage, usually stemming from abuse in childhood,
using an approach Young describes as "limited re-parenting."
Within firm limits, an attachment between therapist and
client is allowed to develop-an approach different from other therapies' more
neutral stances, Young says.
For the study, Dutch researchers divided 86 BPD patients
from four mental health treatment centers into two groups. The first received
schema therapy, and the second transference-focused psychotherapy, which seeks
to help a client change from seeing themselves, and other people, in split-off
extremes of "good" and "bad" to a more integrated mix of good qualities and bad
qualities. Both groups received 50-minute, twice-weekly sessions of therapy for
One year after completing treatment, 52 percent of the
schema therapy participants reached full recovery-evaluated as such if their
Borderline Personality Disorder Severity Index score fell below a cutoff point
for a BPD diagnosis, and if other quality-of-life measures, such as improved
social relationships and fewer incidents of self-mutilation, demonstrated a
fundamental shift in how they viewed themselves and other people, says project
leader Arnoud Arntz, PhD, a Maastricht University psychology professor.
By comparison, 29 percent of the transference-focused
psychotherapy participants reached full recovery.
The schema therapy dropout rate was 27 percent, while half
the transference group dropped out.
In fact, schema therapy limits societal costs as well as
bolsters quality of life, Arntz says. The researchers estimated that per BPD
participant who received schema therapy, Dutch society saved an average of
$5,700 per year in medical costs and more stable employment, Arntz says.
Arntz hopes follow-up studies replicate the results and
determine if group therapy based on schema therapy is possible.
Schema Therapy Builds on CBT by Mark Moran
Schema therapy, the newest of the psychotherapies for
BPD, appears to synthesize elements of several successful therapies. Paris has
described it as“ CBT with a psychodynamic component.”
Schema therapy founder Jeffrey Young,
Ph.D., who is on the faculty of the Department of Psychiatry at Columbia
University College of Physicians and Surgeons, was one of the first students of
Aaron Beck, M.D., the founder of cognitive therapy.
“I found that cognitive therapy was
extremely effective with many Axis I disorders, as research has since
substantiated, but was much less effective by itself with Axis II personality
disorders,” he told Psychiatric News. “I began to look for ways to expand
cognitive-behavior therapy to work with Axis II issues by integrating elements
drawn from other approaches as well as CBT, including psychodynamic therapies
such as object relations, emotion-focused/gestalt therapies, and attachment
Young described schema therapy as an
active, structured therapy for assessing and changing deep-rooted psychological
problems by looking at repetitive life patterns and core life themes, called
“schemas.” Schema therapists use an inventory to assess the schemas that cause
persistent problems in a patient's life.
“Once we have determined what schemas a
patient has, we use a range of techniques for changing these schemas,” Young
said. “These include cognitive restructuring, limited re-parenting, changing
schemas as they arise in the therapy relationship, intensive imagery work to
access and change the source of schemas, and creating dialogues between the
`schema,' or dysfunctional, side of patients and the healthy side.”
He added that systematic behavioral
techniques are also employed to change dysfunctional coping styles, especially
maladaptive behaviors in intimate relationships.
In a randomized trial of schema therapy
versus transference-focused therapy published in the Archives in June 2006,
statistically and clinically significant improvements were found for both
treatments on all measures after one, two, and three-year treatment periods.
Data on 44 schema therapy patients and 42 transference-focused therapy patients
Main outcome measures included scores on
the Borderline Personality Disorder Severity Index, quality of life, and general
psychopat hologic dysf unction. Patient assessments were made before
randomization and then every three months for three years.
Significantly more schema therapy patients
fully recovered (46 percent versus 26 percent) or showed reliable clinical
improvement (66 percent versus 33 percent) on the Borderline Personality
Disorder Severity Index than patients receiving transference-focused therapy.
They also improved more in general psychopathologic dysfunction and showed
greater increases in quality of life.
Statistical analysis also revealed a
higher dropout risk among transference-focused therapy (52 percent) patients
than among patients receiving schema therapy (29 percent), according to the
The authors also stated that, in a
separate analysis, schema therapy was found to be highly cost-effective for
society, despite the length and intensity of the treatment.
Young, who was not involved in the study,
said it is the first to demonstrate “deep personality change” in a high
percentage of patients long considered untreatable.
“Up until now, existing therapies for BPD
have proven to lead to only partial recovery or have only been able to reduce
self-harming behaviors,” he said. “This should be of great interest to
psychiatrists because patients with BPD are usually considered the most
difficult, frustrating, and risky patients within most therapists' practices.
“The second important implication for
psychiatrists is that the use of a neutral stance toward the BPD patient, which
is advocated in most psychodynamic approaches to BPD, is clearly much less
effective than the more engaged, warm, and nurturing stance of schema therapy,”
Young said.“ This was demonstrated by the dramatic differences in dropout rates
between the two treatments.”
Despite their proven effectiveness, all of
the psychotherapies for BPD are time and labor intensive.
“All suffer from the need for highly
trained therapists, specialized settings, human resources, and time,” Paris told
Psychiatric News. “There are many barriers to psychotherapy for BPD. Most
involve money, since only a small number of these patients can pay, and few have
adequate insurance. Another barrier is the failure of psychiatrists and other
professionals to recognize and diagnose BPD. Still another is the current
tendency to treat BPD with medication alone.”
Paris said in an address at APA's annual
meeting last year in Toronto that drugs were vastly overused in treatment of all
the personality disorders (Psychiatric News, July 7, 2006).
“The problem is that there is no science
to support poly-pharmacy, and it's probably bad for patients,” he said at the
meeting. “When you give patients with classical depression an antidepressant,
they may be cured in a few weeks. But you never see that in patients with
borderline personality. It might take the edge off, but patients never go into