Schema Therapy: A Modern and Integrated Approach
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Schema therapy is a modern and integrated therapy that is mainly based on the expansion of concepts and methods of cognitive-behavioral therapy. This method of treatment provides a new system of psychotherapy that is especially suitable for patients with chronic and resistant psychological disorders who have so far been a complex issue in treatment.
What is a Schema?
The word schema has an old and prominent history in psychology and more broadly in the cognitive field. In the field of cognitive development, the schema is considered as a template that is formed based on reality or experience to help people explain their experiences.
Schemas, especially those that are mainly formed as a result of unpleasant childhood experiences, may be the core of many chronic personality disorders in adulthood.
Basic Needs of the Child in Schema Therapy
One of the most important factors in the creation of schemas (or life traps) is the failure to meet your basic emotional needs in childhood.
These needs include:
- Feeling safe and securely attached to others
- Feeling of individual identity and independence
- Freedom to express emotions and express your wishes to others
- Ability to play and spontaneous activity
- Existence of appropriate age restrictions
As our childhood passes, 4 types of negative experiences also play a role in the creation of schemas:
- Unmet needs: This experience is obtained when your caregiver is unemotional or your basic emotional needs are not met.
- Abuse or mistreatment: In these situations, the child experiences abuse, trauma, or similar stresses.
- Excessive freedom or lack of restriction: In such circumstances, parents over-support and favor the child. As a result, no restrictions are applied.
- Selective identification and internalization: Here, the child absorbs some of the attitudes or behaviors of the parents. Some of them show his personality. Some of these identifications and internalizations become schemas, while others become mentalities called coping techniques.
Characteristics of Inappropriate Treatment Schemas
After the initial definition of schemas that we presented, we come to the conclusion that the initial maladaptive schemas have the following characteristics:
- They are deep and pervasive patterns or themes.
- They are made up of memories, emotions, cognitions, and bodily sensations.
- They are formed in childhood and adolescence.
- They continue in the course of life.
- They are about the individual himself or his relationship with others.
- They are extremely inefficient and maladaptive.
In other words, the maladaptive and inappropriate behaviors of a person with a personality disorder are created in response to his initial maladaptive schemas. Initial maladaptive schemas and the inefficient ways that patients learn through them to get along with others and manage their social relationships, so to speak, often underlie chronic symptoms such as anxiety disorders, depression, substance abuse, and personality and psychosomatic disorders.
Schema Therapy for Complex Cases
Our clinical experience shows that patients with severe personality disorders respond very well to schema therapy. (Sometimes, of course, in combination with other treatment approaches).In other words, their problems are vague and ambiguous and look like a tangled skein. They feel deficient and think that something is always wrong with their work. But they are unable to understand the reasons for it. They are patients whose major issues are manifested in the form of communication problems and are seeking treatment because of the suffering caused by chronic problems that they endure in communication with important people in their lives or in their workplace. The use of other psychotherapy approaches is extremely difficult for such patients. Because they usually do not have specific symptoms or experience several symptoms simultaneously.
If you feel like traditional therapy hasn’t fully addressed your emotional patterns, schema therapy might offer the breakthrough you need.
Types of Inappropriate Treatment Schemas
Eighteen schemas are divided according to five unmet emotional needs, which we call schema domains. Here, we will only briefly mention the characteristics of the schemas in the first domain.
✓ Disconnection and Rejection
Patients whose schemas are in this domain cannot establish safe and satisfying attachments with others. Such individuals believe that their need for stability, security, love, and belonging will not be met. Their original families are usually unstable, abusive, cold and unemotional, rejecting, or isolated. Patients whose schemas are in the disconnection and rejection domains often suffer the most harm. Many of them have had traumatic childhoods and in adulthood tend to rashly and hastily take refuge from one harmful relationship to another, or avoid establishing interpersonal relationships. The therapeutic relationship is often the main focus of treatment for this group of patients.
✓ Abandonment/Instability
Instability and distrust in receiving affection and establishing communication with others. So that the person feels that the important people in his life cannot give him the necessary emotional support and encouragement. A person who has such a schema formed in his mind believes that at any moment it is possible for the important people in his life to die or leave him and become interested in another person.
✓ Mistrust/Abuse
The expectation that others will harm, mistreat, humiliate, and exploit a person. Such an expectation causes the person to perceive the events around him in a special way. The person may feel that someone is always stealing his property or violating his rights.
✓ Emotional Deprivation
The expectation that a person’s desires and needs for emotional support are not adequately met by others. There are three important types of deprivation, which are:
- Deprivation of affection
- Deprivation of empathy
- Deprivation of support
✓ Defectiveness/Shame
The feeling that a person in the most important aspects of his personality is an imperfect, undesirable, and worthless human being, or that in the eyes of the important people in his life, he is considered a hated and undesirable person. Also, in this schema, people are overly sensitive to criticism, rejection, blame, shyness, inappropriate comparisons, feeling insecure in the presence of others, and includes a feeling of shame in relation to inner defects and shortcomings.
✓ Social Isolation/Alienation
The feeling that a person has withdrawn from the world and is different from others, or that he does not belong to a particular society or group.
What is the experience of treatment in schema therapy like?
The pursuit of schema therapy leads the client to the conclusion that his central beliefs are not so correct and efficient, but his feelings and emotions act differently.
The following examples are for further familiarity with the types of inconsistencies that occur during the schema therapy experience.
- I know my thought is wrong, but my feeling does not accept this conclusion.
- I know that marrying this person will lead to misery, but I love him.
- I know my parents are not the main cause of the problems, but hatred for them does not leave me for a moment.
- I know that I have to get a divorce from my spouse, but longing for our children prevents this divorce.
- I know that I am not a worthless person, but I do not like myself.
- I know that I should not value my parents so much, but the feeling of guilt has cut me off.
- I know that I am not an incompetent person, but I am unable to do some things.
The difference between these two levels of beliefs may sometimes tie the therapist’s hand in the way of therapeutic challenges, and sometimes encounter technical problems in the treatment process. One of these problems is the difference between the patient’s rational beliefs and emotional beliefs, for which an appropriate therapeutic response will be provided during schema therapy for each of these existing challenges.
In all approaches, therapists deal to some extent with the emotional experience that patients bring with them into the treatment process. Therapists who use cognitive restructuring hope to change people’s attitudes towards events and how they feel about them.
Dialectical behavior therapy encourages patients to learn how to regulate emotions that often seem chaotic and terrible. Acceptance and commitment therapy calls for flexibility and tolerance in the face of emotion, while at the same time examining modern cognitive approaches and psychopathology beyond superficial cognitions and automatic thoughts, and examines deeper cognitive roots, namely cognitive schemas and fundamental beliefs. If a therapist wants to go beyond relieving the acute symptoms of mental illness, he should pay attention to the individual’s functioning before the onset of the disorder and after the subsidence of the acute phase. Research findings show that cognitive schemas play an important role in the creation and continuation of psychological disorders, as well as in the recurrence or return of subsequent episodes of the disorder.
Regardless of the theoretical orientation that any therapist chooses, emotions are a process that prompts people to seek help. But it has so far been less addressed how the patient thinks and how he manages about regulating these emotions. The term “emotional schemas” is used to describe the beliefs that individuals have about the causes, correctness, normality, persistence, and tolerance of the complexity of emotion. Immediately after the emergence of an emotion (for example, anxiety), the individual examines the nature of this emotion:
- Emotional Schemas: Understanding and Managing Your Emotions
- Will this emotion continue for an indefinite period?
- Do others feel the same way I do?
- Should I be ashamed of having these feelings?
- Is it wrong for a person to have different feelings?
- Can I express my feelings?
- Will others consider my feelings valid?
- Are my feelings logical?
When a particular emotion appears, what strategies does a person use to deal with this emotion?
Does the person take refuge in reassurance, withdrawal from others, rumination, blaming, avoidance, passive inaction, substance abuse, different interpretations of events, engaging in the problem-solving process, activating constructive behaviors, distraction, self-harm, dissociative states, overeating, accepting the emotion, or other reactions?
Furthermore, emotional schemas are related to how we think and react to the emotions of others.
For example, when one of our close friends is upset, do we think that
1. Emotional Schemas and Psychological Distress: Mediating Role of Resilience and Cognitive Flexibility – PMC
pmc.ncbi.nlm.nih.gov
His emotions are irrational?
- Do we consider these emotions a pathological trait and label them “abnormal”?
- Do we think these emotions will continue for an indefinite period?
- Do we prevent him from expressing his emotions?
- Do we believe that emotions interfere with the process of reasoning and problem-solving?
And finally, based on these interpretations, do we blame our friend, make fun of him, say that he is whining too much, withdraw from him and avoid him, or try to convince him that he should not have such feelings?
The emotional schema model, in addition to recognizing the importance of theories about how negative interpretations of reality can lead to feelings of sadness or anxiety? Or how avoidance and inaction can contribute to the intensification of depression? It seeks to expand our understanding of emotion further with the assumption that when an emotion arises, a person’s implicit theory about that emotion is activated, and this activation leads to constructive or useless coping strategies.
In simpler terms, when you feel sad, what do you think about this sadness and what you will do after that? If I believe that my sadness will continue for an indefinite period or will intensify further, I may desperately seek an “immediate remedy” by abusing substances or withdrawing from others.
In contrast, if I believe that sadness is a temporary experience and my emotions depend on the things I do and the people I interact with, I may adopt an adaptive behavior.
Interpretations lead to strategies, and strategies may make the situation worse or better.
We are fortunate to have multiple and very valuable methods of cognitive behavioral therapy at our disposal. By equipping the patient with insight and skill, these methods empower him and open a window of hope in the face of situations that often seem difficult and unsolvable.
How Schemas Work?
What happens to a person who is trapped in one or more of these traps? On good and happy days, maybe nothing.
But a small sign is enough to trigger early unpleasant experiences. The same experiences that initially led to the formation of the traps. This schema suddenly turns on like a time bomb and plunges its owner into a storm of pessimistic thoughts, painful feelings, and unpleasant physical sensations. Similar to the thoughts and feelings he has experienced in the past. When this happens, we say that there is a “schema mode”.
Some schema modes make you feel like an abused, angry, or spoiled child. In some modes, you are like the strict and unfair parents you once had. Some modes also make you a wise person and you can support yourself.
What are Schema Modes?
A mode in schema therapy is a temporary perspective that includes your current emotional state and how you deal with it. In other words, your way of thinking is a combination of active schemas and coping styles. The symptoms are either helpful (adaptive) or harmful (maladaptive). Schema modes allow therapists to categorize schemas so that they can interpret them as mental conditions rather than individual characteristics.
Schema modes can be divided into four categories:
- Child modes that are characterized by childlike feelings and behaviors.
- Maladaptive coping modes are useful in preventing emotional tension. But in the end, they reinforce the schema.
- Maladaptive parent modes that include the internalization of the critical, demanding, and abusive voice of the parents.
- Healthy adult mode expresses itself in a healthy and effective way. This mode regulates other modes by setting limits.
What Treatment Assumptions Does Schema Therapy Deal With?
- We all have a part in us that seeks happiness and satisfaction, but it has become exhausted under the burden of negligence, obedience, and many other factors.
- If people’s emotional needs are met sufficiently, their happiness will increase.
- Although change is a very difficult and exhausting task, it is not impossible.
- There are tendencies in all of us that resist change.
- Humans have a great tendency to avoid pain, avoid responsibility, and not accept.
- Excessive use of only one group of techniques does not solve the client’s problem.
- Reducing symptoms, changing schemas, and breaking behavioral patterns, although necessary, but for fundamental change, we must achieve an individual perspective (a new philosophy) of life.
What are the Treatment Services (Treatment Expectations) of Schema Therapy?
With the schema therapy approach, it can be concluded that the main goal of using various treatment techniques is to establish the rule of the healthy adult mode in the patient. People who are involved in maladaptive modes, their behavior, feelings, and decisions are تابع this unhealthy modes. For this reason, they experience interpersonal and intrapersonal problems.
What Techniques are Used in Schema Therapy?
Schema therapists can use several techniques during treatment. Some techniques work better for some people and schemas. If a particular technique does not work for you, discuss it with your therapist. Know that your relationship with the therapist is an important part of schema therapy. There are two important elements in many schema therapy techniques. Both of these are only effective if you feel comfortable and safe with your therapist.
These elements are as follows:
- Empathetic confrontation: Your therapist acknowledges the schemas obtained during the treatment and empathizes with you when you realize the importance of change.
- Limited reparenting: With the help of the therapist and creating a feeling of security, compassion, and respect from him, the emotional needs of childhood are met.
What is the Goal of Schema Therapy Techniques?
The goal of schema therapy techniques is for the healthy adult mode to be able to take control to some extent. The healthy adult mode can guide the individual towards satisfying the 5 main emotional needs:
- Secure attachment with others
- Autonomy, competence, identity
- Free in expressing healthy and important needs and emotions
- Fun and spontaneity
- Acceptance of realistic limitations
The footprint of the concept of a healthy adult mode can be followed in the concept of a wise self. The wise self has special characteristics. These characteristics are:
- Acceptance of self
- Acceptance of others
- Normal dependency need
- Enjoy the present
- Patience with problem
- Welcome work
The goal of schema therapy is to deactivate maladaptive modes and maximize the rule of the healthy adult mode. Perhaps in this way, the individual can reach acceptance, patience, enjoyment, and realism. An achievement that, if not obtained through effort, even stepping on that path is a valuable experience.
Who is a Schema Therapist?
When schemas are activated, the same feelings, evaluations, and tendencies similar to childhood are revived. So that a reaction like a distressed child is created. The schema therapist considers the interpersonal problems of adulthood to be the result of negative and maladaptive schemas established in childhood.
The greater the intensity of the schemas, the more therapeutic importance the therapeutic relationship established by the schema therapist gains. In fact, the therapeutic relationship can be considered the primary source of the patient’s improvement. During treatment, the schema therapist acts as a symbol of stable parents so that the patient can dare himself based on it and establish other stable relationships with others. The patient first learns to recognize and overcome his maladaptive schemas within the therapeutic relationship and using specialized schema therapy techniques. Then transfer this learning to the relationship with the important people in his life outside the realm of treatment. The therapist provides a stable relationship for the patient through the technique of limited reparenting.
One of the goals of the schema therapist is to help patients achieve a realistic attitude towards the stability of interpersonal relationships. Patients who successfully complete the treatment process can trust their loved ones and if the important people in their lives leave them for a few days for reasons, have reasonable and logical concerns and do not misinterpret the absence of their loved ones. As a result of the treatment, maladaptive schemas are less activated and they can feel more intimacy in their relationships and do not have to show controlling, mocking, or severely dependent behaviors. One of the signs of improvement in patients as a result of schema therapy is that they can endure a long time with their loneliness without being anxious and depressed. In other words, they do not have a morbid fear of being rejected.
Schema Therapy: Who is it for?
When schema therapists gradually moved from treating axis I disorders such as anxiety to working on deeper disorders such as axis II personality disorders, they encountered the limitations of Beck’s cognitive therapy model. Patients with personality disorders have a set of complex and resistant problems in the field of interpersonal relationships, which in many cases make the treatment process difficult. Therefore, Young, as the first schema therapist, influenced by structuralism, founded schema therapy, which targets personality disorders and other long-lasting disorders. Experience has shown that schema therapy has been effective in treating depression and anxiety resistant to treatment, eating and impulsive disorders, marital issues, and persistent problems in maintaining compatible intimate relationships. This method is also effective for criminals and in preventing relapse among drug addicts.
What are the Limitations of the Schema Therapy Method?
Schema therapy is a promising treatment for a variety of mental health problems, including mood disorders and depression. Most current research shows that schema therapy plays a significant role in the treatment of borderline personality disorder and other personality disorders. These studies have also found promising results. For example, according to the results of a controlled study in 2014, planned treatment has been effective in the treatment of personality disorders. Although the results of the present study are promising, most experts consider the need for further clinical efforts and research.
Schema therapy, like other treatments, requires a long-term commitment to treatment. You may need several years of treatment. This treatment is covered by insurance.