About Schema Therapy All human beings have strivings towards connection, understanding and growth. Who Developed Schema Therapy? The goals of Schema Therapy Schema Therapy is designed to address unmet needs and to help clients break these patterns of thinking, feeling and behaving, which are often tenacious, and to develop healthier alternatives to replace them.
List of Schemas Emotional Deprivation: The belief and expectation that your primary needs will never be met. The sense that no one will nurture, care for, guide, protect or empathise with you. Abandonment: The belief and expectation that others will leave, that others are unreliable, that relationships are fragile, that loss is inevitable and that you will ultimately end up alone.
Defectiveness: The belief that you are flawed, damaged or unlovable and you will therefore be rejected. Social Isolation: The pervasive sense of aloneness, coupled with a feeling of alienation. Vulnerability: The sense that the world is a dangerous place, that disaster can happen at any time and that you will be overwhelmed by the challenges that lie ahead.
Failure: The expectation that you will fail or the belief that you cannot perform well enough. Subjugation: The belief that you must submit to the control of others or else punishment or rejection will be forthcoming. Self-Sacrifice: The belief that you should voluntarily give up your own needs for the sake of others, usually to a point which is excessive. Emotional Inhibition: The belief that you must control your self-expression or others will reject or criticise you.
Unrelenting Standards: The belief that you need to be the best, always striving for perfection or that you must avoid mistakes. You may need to undergo schema therapy for years. The International Society of Schema Therapy has a directory that lists formally trained schema therapists. Try to look for therapists who offer CBT. Schema therapy draws heavily from this approach, so some CBT therapists might have some experience with schema therapy or its core principles.
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Her new behavior plan is to self-validate herself, stop to blame and hurt herself, and on the contrary call her friend Sarah. The new skills are practiced intensively over and over again in individual therapy, group therapy and as homework.
After investigating Mona's current problems and her biography, the therapist develops an individual case conceptualization according to the mode model in interaction with Mona see Figure 2. These modes developed since basic childhood needs have been frustrated and Mona has two times experienced a loss of her most important attachment figure. In this mode she avoids getting close to others and distracts from intensive emotions or calms them down by self-injury, substance abuse, binge eating, social withdrawal, and sleeping.
Her frequent mood-shifts and identity disturbances can be explained with rapid mode shifts. The biographical context is brought into the case conceptualization with arrows see Figure 1. The therapist helps Mona to foster her mode awareness and educates her about the general and mode-specific goals of ST.
All of Mona's problems and symptoms are conceptualized and treated in terms of the modes involved. First the therapist works on Mona's detached protector mode, since it is very strong and rigid and blocks access to the child and parent modes. He starts by reviewing the pro and cons of this mode see Table 3. You're extremely important for Mona. I'd like to better understand you.
Can you tell me, why you are here today? Why did Mona need you? Nobody was there to help her. It was good, that you came to protect her. I really want to help her. But at the moment I can't see what it is, because you stand very strong in front of her and I cannot reach her.
And I think this is not, what little Mona needs right now. What do you think? She tells that she saw her ex-boyfriend with another woman and that she feels so sad, lonely and worthless. The therapist soothes and comforts her. You screwed it up. You are just not lovable. And then you cut yourself. In the next phase of treatment dysfunctional child and parent modes are addressed with a strong emphasis on experiential techniques and therapy relationship techniques.
An example is an imagery rescripting exercise on the physical abuse of the father. In the image Mona had accidently broken a bowl, the father shouts at her and loses his belt to beat her. The therapist enters the image, since he does not want Mona to relive the whole trauma.
You are not allowed to beat little Mona. Nobody is allowed to beat children. It is quite normal that a bowl breaks from time to time.
Mona has not done anything wrong! Mona sees how he is brought to jail. Asked for her feelings and needs, little Mona tells the therapist that it is good, that her father cannot harm her anymore, but that she still feels lonely and that she misses her mom, who died 3 months ago.
And that she does not know where to go. The therapist listens to little Mona and soothes her. Finally, he takes her and her sisters to their aunt Mary, who Mona likes very much. More imagery rescripting exercises of other adversive childhood memories are performed and with the course of therapy Mona herself in the healthy adult mode can comfort and soothe little Mona in the rescripting part.
Also Mona and the therapist perform several chair dialogs in which Mona understands her contradicting emotional processes. She understands why she can feel guilty punitive parent , angry angry child , and sad vulnerable child at the same time.
She learns to recognize and reduce her punitive parent mode including her feeling of guilt, self-hatred, and shame and to experience and validate the needs of her vulnerable child mode. First her therapist models these tasks for her, but with the course of therapy Mona can take over the role of her healthy adult mode herself each time a little better.
A systematic review and a Cochrane Review summarize the evidence for the efficacy of DBT in the treatment for patients with BPD, which has been shown in several randomized controlled trials Kliem et al.
The main effects are reduction of suicidality, self-injuring and impulsive behaviors, therapy dropouts and inpatient admissions. DBT has also shown effect in treating BPD with several comorbidities and other psychiatric conditions such as substance misuse Linehan et al. Research on mechanism of change has revealed that experiential avoidance impedes the reduction of depression in DBT-treatment of BPD and thus should be targeted Berking et al. Experiential avoidance was decreased better in DBT compared to Community Treatment by Experts in a randomized controlled trial Neacsiu et al.
Neacsiu et al. This study supports the skills deficit model for BPD. Also DBT as a transdiagnostic treatment of emotion dysregulation was superior to activities-based support group in decreasing emotion dysregulation, increasing skill use and decreasing anxiety, but not depression in patients with mood and anxiety disorders.
Skill use mediated the changes Neacsiu et al. Thus, behavioral skills are likely a potent mechanism of change for emotion dysregulation across disorders. However, evidence is preliminary and more research in other disorders than BPD is needed.
Moreover, there are more than 60 DBT-skills and we do not know whether some skills are more important and useful than others in general, whether this varies over psychiatric disorders e. Although, DBT has been evaluated intensively in efficacy and effectiveness studies, there is limited research on specific mechanisms of change in DBT.
Clarifying the mechanisms of change could lead to a more focused and effective treatment and improvement on emotion dysregulation. Promising results are also reported for depression Malogiannis et al. Low ratings at early treatment predicted dropout, whereas positive ratings of patients predicted clinical improvement.
Thus, the therapeutic alliance in ST may serve to facilitate change processes underlying clinical improvement in patients with BPD. Other hints on mechanism of change come from the non-BPD-trial Bamelis et al. The second wave of therapists had significantly less drop-out and stronger effects than the first wave of therapists. Therapists of the second wave reported to feel better equipped for the treatment and to have integrated all techniques. It is hypothesized that these therapist felt more secure in experiential techniques and thus experiential techniques were used to a greater extent and that this might have led to a better outcome.
Several studies showed that imagery rescripting as a stand-alone technique is successful in a broad range of psychiatric disorders, including post-traumatic stress disorder Arntz et al. Therapeutic techniques using imagery instead of verbalization probably have greater impact on emotions Holmes et al. It might be assumed, that imagery rescripting is an important technique to facilitate change in ST, however empirical evidence to support this hypothesis lacks.
Other techniques used in ST, such as chair dialogs or historical role play, call for further investigation. How all these techniques provided by ST and ST in general impact emotion dysregulation remains up to date unclear and needs further study. Also, it would be very interesting to compare the effects on emotion dysregulation of ST to DBT and other methods.
From this comparison of DBT and ST with respect to emotion regulation several questions arise calling for further research. Stated in a simplified manner, DBT argues that emotion dysregulation skills deficits are the key to psychopathology, while ST assumes that early maladaptive schemas and modes underlie psychopathology and emotion dysregulation is a secondary consequence.
If it is hypothesized that a treatment which addresses the key underlying factors of psychopathology has better treatment effects, the empirical question is to understand what underlies psychopathology. A question that is complicated to test, since assessment methods that specifically assess these underlying constructs with high validity need to be developed first. Other important questions address the mechanisms of change for each method, but also differences between the two methods.
Above for each method putative mechanism of change are discussed, e. However, the therapeutic alliance also plays an important role in DBT and ST is also targeting experiential avoidance, while skill use and use of experiential techniques are more specific to one of the methods. The question of specificity in these processes is very interesting, since basic processes that overlap in both methods and unique factors might be revealed and enable improvement of psychotherapy in general.
Both treatments offer a variety of techniques and features. Currently it is impossible to say which ones are the most relevant for change. Component-analysis-studies are needed to reveal the most important features. Treatment trials comparing DBT and ST are completely lacking, thus it remains an open question if one of the two methods is superior in efficacy and if the two methods have different efficacy for different groups of patients or different problems.
For further information on DBT we suggest the recent manual from Linehan a , b , and the chapter from Neasciu et al. EF wrote the first draft of the paper.
All the authors edited and revised the paper. The other author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Berking, M. The impact of experiential avoidance on the reduction of depression in treatment for borderline personality disorder. Bohus, M. Dialectical behaviour therapy for post-traumatic stress disorder after childhood sexual abuse in patients with and without borderline personality disorder: a randomised controlled trial.
Brewin, C. Imagery rescripting as a brief stand-alone treatment for depressed patients with intrusive memories. Cockram, D. Dickhaut, V. Combined group and individual schema therapy for borderline personality disorder: a pilot study. Psychiatry 45, — Dimeff, L. Dialectical behavior therapy for substance abusers. D'Zurilla, T. New York, NY: Springer. Ekman, P. Facial expression and emotion. The Nature of Emotions: Fundamental Questions. Oxford: Offord University Press.
Farrell, J. A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder: a randomized controlled trial. Psychiatry 40, — Frets, P. Imagery rescripting as a stand-alone treatment for patients with social phobia: a case series. Giesen-Bloo, J. Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy.
Psychiatry 63, — Gross, J. Emotion regulation: taking stock and moving forward. Emotion 13, — Grunert, B. Imagery rescripting and reprocessing therapy after failed prolonged exposure for post-traumatic stress disorder following industrial injury. Harned, M. Treating PTSD in suicidal and self-injuring women with borderline personality disorder: development and preliminary evaluation of a Dialectical Behavior Therapy Prolonged Exposure Protocol.
A pilot randomized controlled trial of Dialectical Behavior Therapy with and without the Dialectical Behavior Therapy Prolonged Exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Hayes, S. Acceptance and Commitment Therapy. Holmes, E. Behavioral techniques used with schema therapy include: rehearsal of adaptive behavior in imagery or role-play, behavioral homework, and rewarding adaptive behavior.
References Jacob, G. Schema therapy for personality disorders—A review. International Journal of Cognitive Therapy , 6 2 , — Rafaeli, E. Schema therapy. New York: Routledge. Young, J. Reinventing your life: The breakthrough program to end negative behavior and feel great again.
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