Science and practice in cognitive therapy. Foundations, mechanisms, and applications
Chapter 5
Schema therapy

Cognitive model

In schema therapy (ST), the basic idea is that maladaptive schemas can develop when basic emotional childhood needs are not adequately met.

The major emotional needs of children can be grouped as follows: safety and nurturance (including secure attachment), autonomy, competence and sense of identity, freedom to express needs, emotions and opinions, spontaneity and play and realistic limits and self-control.

In such needs are not adequately met, chances are great that the child develops fundamental representations of the self, of other people or the world in general, and of the meaning of emotions and needs, that are understandable in the given circumstances but are not necessarily adaptive in other circumstances.

Schemas can develop of very early experiences, before the age when verbal abilities are developed. This means that schemas need not to be verbal. The activation of the schema might become apparent primarily through bodily feelings and action tendencies.

People can differ in the way they deal with schema activation (coping style). Three groups of coping styles are distinguished: 1) Overcompensation, characterized by attempts to fight the underlying schema by pretending and behaving in the opposite manner 2) Avoidance, characterized by various kinds of situational, cognitive, and emotional avoidance manoeuvres so that full activation of the schema is avoided 3) Surrender, characterized by giving in to the schema.

Schema mode results form an activated schema through the model that coping style at the moment.

Clinical application

ST may be used between 20 and 200 sessions, depending on the severity of the disorder and the aims of treatment.

Limited reparenting is the idea that the therapist offers the patient a relationship during therapy that offers at least a partial antidote to what went wrong in important childhood relationships. The therapist tries to offer direct corrective experiences for emotional needs that were not adequately met during childhood-notably, safe attachment, guidance, stimulation of autonomy, and realistic limits. This should be offered within professional boundaries and should never lead to therapists transgressing personal limitations.

Limited reparenting also involves creating frustration by confronting patients with, for instance, lack of discipline, just as real parenting does. During therapy, the therapist gradually changes the therapeutic stance, increasingly stimulating the patient’s autonomy and responsibility in the later phase of treatment. ST therapist tend to be more open about their feelings about the patient and use personal disclosure more often if it is deemed to be helpful for the client.

Coping modes might block the access to vulnerably child modes that are associated with the childhood memories.
These barriers can be addressed in various ways. 1) The therapist explores with the patient what event during the last days or weeks triggered the coping mode, understanding and empathizing with its function, and invites the patient to address the vulnerable feelings that were initially triggered. 2) The therapist uses a  cognitive technique, reviewing the pros and cons of maintaining the coping mode in therapy and, if necessary, reminding clients of their initial reasons for requiring therapy. 3) Multiple-chair technique in which clients are invited to express views, emotions, and needs from different modes on different chairs. It is important that clients express these views, emotions, and needs for the coping mode, for the vulnerable child mode, and for the healthy adult mode. 4) Using the therapeutic relationship, especially the idea of limited reparenting, the therapist might explore the reasons for maintaining the coping mode and reassure the client that the therapist will guarantee that that what is feared won’t happen. Reassurance will be given in a personal way, showing genuine care for the client’s need for safety. 5) Emphatic confrontation in which the therapist expresses genuine empathy for the rigid use of coping mode. In addition to this empathy, the therapist confronts the client with the need for change, if the client wants to profit from therapy.

Another major barrier to accessing vulnerable feelings and their childhood origins might be the punitive and demanding (parent) modes. These modes might criticize and punish clients for accessing, showing and sharing vulnerable feelings. To prevent full activation of these modes, the patient might resist opening up. When trying to open up, clients might slip into a fully activated punitive mode, experiencing shame, guilt and worthlessness. Therapist must develop a sense of activation of these modes, inquire with the client whether the mode is activated and address the mode actively. The most important technique therapists can use to accomplish these goals is the empty chair technique, during which the punitive or demanding mode is symbolically place on an empty chair to help clients take a distance from these modes. After what the mode on the empty chair is stating is expressed, the therapist starts to combat the mode by talking in a firm voice to the empty chair, disagreeing with the position of the mode and standing up for the needs of the clients. Through this technique, the patient will feel protected against these modes and supported in the right to make mistakes, to have needs and emotions, and to express opinions.

When it is possible to access the vulnerable child mode, experiential techniques are recommended to emotionally process and correct dysfunctional meanings of childhood memories related to that mode. This is done by Imagery rescripting or drama therapy can also be used to rescript childhood memories

The core techniques of imagery rescripting and drama rescripting can be supplemented with other experiential techniques, such as the multiple-chair technique, writing letters to caregivers (without posting them), expressing needs to an empty chair where a caregiver is symbolically seated, and so on. Psycho-education is often used.

The client should feel safe to express anger in the session, after which the issue of how the client can express irritation earlier can be expressed, as a way of preventing too much anger buildup and, in more functional ways, preventing interpersonal difficulties. Anger often relates to a moment of experienced vulnerability, so it is always good when anger has been vented, to focus on the underlying vulnerable feelings and explore and process painful childhood experiences related to them.

For the impulsive child mode, empathic confrontation is the best technique. Empathy is expressed about the underlying intention to stand up for the right to have nice experiences and the like. At the same time, clients are confronted with the impulsive way they organize this.

The undisciplined child mode needs repeated psycho-education, empathic confrontation, and limit setting.

The most important ways to achieve development of the healthy adult mode are the following: the therapist should be a model for the healthy adult, psychoeducation and give more responsibility to clients and stimulate autonomous development  

Later in treatment, the focus will be more on the clients present and future life. For an ultimate change, it is necessary to start with ‘behavioural pattern breaking’, changing habitual ways of behaving and trying out new, more functional behaviours. Therapist and client discuss problems in present life, how modes, schemas, and childhood experiences are related, and what new behaviours are indicated, so that the client’s present needs are better met. New behaviours can be discussed and tried out using role plays and imagery techniques.

It is recommended that the therapy not be ended suddenly, but that a number of booster sessions, spread over several months, be planned, so that clients can practice with relying on their own and using newly acquired insights and strategies from treatment. Any problem encountered can be discussed during the booster sessions and related to the mode model, but clients are given more and more responsibility to choose how they want to address the problem.

Research

Qualitative research has given rise to some hypothesis regarding the effectiveness of ST. 1) the integrative character of ST that leads to use of multiple channels of change 2) the therapeutic relationship, which is more personal and caring than usual and in which the concept of limited reparenting plays an important role 3) the triple focus on childhood experiences 4) the schema mode model which offers a strong organizing metacognitive framework for clients that helps them understand their problems and choose functional alternative responses.