Schema therapy is a type of therapy that targets schemas, a term used clinically to describe maladaptive patterns of thinking that could cause someone to engage in unhealthy behavior, or to struggle to maintain adult relationships. Schemas are thought to develop during childhood, particularly in children whose emotional and physical needs weren’t met; they may also develop in children who were overindulged or whose parents did not maintain proper boundaries. In adulthood, these schemas are thought to influence an individual’s thoughts and actions in negative ways—leading to behaviors such as avoidance, overcompensation, or excessive self-sacrifice. These behaviors, in turn, can negatively affect relationships and emotional well-being.
The aim of schema therapy is to help the individual recognize their behavior, understand the underlying cause(s), and change their thoughts and behaviors so that they’re better able to cope with relationship challenges or emotions in healthy, productive ways. Schema therapy combines elements of cognitive behavioral therapy (CBT), psychoanalysis, Gestalt therapy, and related approaches. Though it is a relatively new therapeutic modality, small studies conducted so far suggest that schema therapy can be effective, especially for individuals with personality disorders. Because the literature is still fairly limited, however, some researchers caution that more research—especially that which uses randomized controlled trials—is needed to determine schema therapy’s efficacy and the conditions that make it more or less effective.
Schema therapy was originally developed to treat personality disorders, and is often used to treat borderline personality disorder (BPD) in particular. In one randomized controlled trial, for example, individuals with borderline personality disorder who underwent schema therapy were significantly more likely to enter recovery (i.e. to no longer meet the diagnostic criteria for BPD) than individuals who continued their usual treatment. Schema therapy has also been used to treat eating disorders, anxiety, depression, and other mental health concerns, especially those that appear unresponsive to other forms of treatment. Currently, schema therapy is primarily used to treat adults, though some researchers are exploring its potential for treating children and adolescents.
Schema therapy is typically a longer-term form of therapy (meaning it may continue for months or years, rather than a limited number of sessions). Over time, therapists aim to help clients identify their schemas, recognize how they react to them—reactions known as “coping styles”—and learn what they can do differently to get their needs met in healthy, adaptive ways.
Researchers who study schema therapy have identified many different schemas, but argue that most of them fall into one of five categories:
- Disconnection and rejection: Believing that others cannot be relied on for emotional support, for example, or believing that one is isolated from other people in society.
- Impaired autonomy and performance: Believing that one is doomed to failure, for instance, or believing that one cannot handle the responsibilities of daily life alone.
- Impaired limits: Believing that one is superior and entitled to special treatment.
- Other-directedness: Believing that the needs of others should always take precedence over one’s own needs or that one should always surrender control to others in most or all situations.
- Overvigilance and inhibition: Believing that expressing emotions will lead to negative consequences, for example, or believing that the negative aspects of life always trump the positive aspects.
Unhealthy coping styles thought to arise in response to these schemas include:
- Surrender: A person with this coping style will give into the schema or accept it as fact, and may behave in self-destructive ways as a result. Someone with a schema telling them they deserve to be mistreated, for example, may put up with abuse or not complain when treated unfairly.
- Avoidance: A person with this coping style goes to great lengths to avoid triggering the schema. To do this, they may engage in distracting behaviors such as substance use, or they may avoid entering relationships or situations that could set the schema off. They may, as a result, struggle to get close to others or experience personal growth.
- Overcompensation: A person with this coping style will try to “fight” the schema by deliberately behaving in ways that are counter to it. While deliberately questioning a schema can be healthy or even a part of the therapeutic process, the coping style of overcompensation often leads to negative outcomes. For example, a person trying to overcompensate for a schema that tells them that they’re worthless may try to instead be ultra-successful, which can lead to burnout, dissatisfaction, or strained relationships.
Coping styles may change over time, even as the underlying schema tends to remain the same. It’s also possible for someone to display more than one coping style in response to the same schema.
Once schemas and coping styles have been identified, the therapist will likely use a range of techniques to change the schemas themselves and/or replace unhealthy coping styles with adaptive behaviors. This is done through a range of cognitive, emotional, and behavioral techniques. Cognitive approaches, for example, may ask the client to look for evidence for and against the schema and directly challenge its veracity. Behavioral techniques might include role-playing common situations that trigger the schema, acting out an adaptive response instead of resorting to the maladaptive coping style.
Schema therapy clients may be asked to complete homework between sessions. This may include looking over flashcards that challenge the schemas or keeping a record of experiences that trigger them (often called a “schema diary”), which may be reviewed in session to help clients track their progress and identify situations that require different behavioral responses. In some cases, partners, family members, or close others may be asked to join a schema therapy session to help the client better understand how their schemas are impacting their relationships.
Schema therapy was first developed by psychologist Jeffrey Young from the 1980s to the 1990s, making it a relatively new therapeutic modality. Young theorized that maladaptive thinking patterns formed in childhood can interfere with healthy functioning in adulthood, particularly in people with personality disorders, serious depression or anxiety, or other mental health disorders. Young further argued that targeting these thinking patterns directly could help these individuals combat persistent negative feelings, learn more adaptive ways of navigating the world, and strengthen or rebuild the relationships that may have been harmed by their unhelpful schemas.
Schema therapy relies on a strong therapeutic relationship in which the client feels comfortable and emotionally safe. Schema therapy emphasizes empathic confrontation, in which the therapist responds to the client’s schemas and behaviors, no matter how maladaptive, with empathy and understanding, while encouraging the client to see the need for change and offering the tools to do so.
Schema therapists also engage in what’s called “limited reparenting,” in which they attempt to meet some of the client’s emotional needs that went unmet in childhood. A client who only rarely received emotional support from their caregivers, for example, may benefit from a therapist offering unconditional compassion and validation, while a client who experienced neglect or abandonment may benefit from a therapist who offers consistency and stability. Though the phrase “reparenting” suggests that a therapist will take on a parental role, a good schema therapist will make sure they are doing so in a “limited” way—that is, ethically and while adhering to specific boundaries.
Schema therapy strongly emphasizes the therapist-client relationship, so it’s important that clients seek a therapist with whom they feel comfortable and who is understanding and empathetic to their needs and behaviors. As with other types of therapy, feeling judged by a therapist is a red flag that the relationship is likely not a good fit. Clients may also wish to seek out clinicians who have pursued specific certifications in schema therapy, some of which are offered by the International Society of Schema Therapy (ISST) and partner organizations. In order to become ISST-certified in schema therapy, clinicians must hold at least a Master’s degree and complete a certain number of hours of training, including supervised sessions.