Lecture 2 schema therapy overview & early maladaptive schemas

LECTURE 2: SCHEMA
THERAPY OVERVIEW
ENHANCED CBT
KEVIN STANDISH

LEARNING OUTCOMES

• Describe the Historical development and Theoretical
underpinnings from Cognitive therapy
• Define the Origins of Schemas
• Describe in detail the Early maladaptive schemas
• Understand and describe types of Schema coping styles
• Give an overview of Schema Modes
• How Problems are conceptualised
• Practical Applications
• Read: Ohanian & Rashed: Chapter 8 Schema therapy in
Dryden, W. (2012) Cognitive Behaviour
Therapies, London Sage:

1. HISTORICAL DEVELOPMENT

• Schema therapy, which was developed by Jeffrey
Young (1990; Young et al., 2003), stems from cognitive
behavioral therapy (CBT) and has been attracting
increasing attention since it was first proposed.
• Young created schema therapy predominantly for
patients who did not respond well to ―classical‖ CBT
treatment.
• These patients often experience a variety of symptoms
and typically display complex interpersonal
patterns, which may
• be either fluctuating or persistent;
• they usually meet the criteria for one or more personality
disorders.

1. HISTORICAL DEVELOPMENT

• Although as a whole CBT is quite effective for the mood and
anxiety disorders, some patients continue to show symptoms or
experience relapses subsequent to treatment, particularly in
chronic cases (Durham, Chambers, MacDonald, Power, &
Major, 2003; Fournier et al., 2009).
• For these patients, a different approach would seem to be
required. (Young, 1990; Young, Klosko, & Weishaar, 2003).
• Young suggests that certain patients are a poor fit for cognitive
therapy and require a more extensive treatment approach, in
part because of their difficulty identifying, accessing, and
changing their cognitions and emotions.
• Young’s schema theory does not attempt to compete with
Beck’s theory, but rather expands on it for a treatment-resistant
clients
• Places greater emphasis on the developmental origins of severe
psychopathology.

. HISTORICAL DEVELOPMENT

• Compared to CBT, schema therapy has a more intensive
focus on the following three issues:
• 1. Problematic emotions, which are in the
foreground, alongside the cognitive and behavioral
aspects of the patient’s problems
• 2 Childhood issues, are of much greater importance
than in standard CBT, enabling schema therapy to
integrate approaches that have been mainly
considered psychodynamic or psychoanalytic
• 3 The therapeutic relationship, plays a very important
role is conceptualized as ―limited re-parenting,‖

2. THEORETICAL UNDERPINNINGS IN
COGNITIVE THERAPY
• Schema therapy is based on Becks cognitive therapy
model
• Adopts the systematic and empirical approach to
assessment and treatment
• Shares the following fundamental concepts:
• The collaborative nature of the therapeutic relationship in
directive role of the therapist.
• Psychoeducation.
• Emphasis on the cognitive and behavioural change; goal
setting and structured home-based tasks; and teaching of skills
as necessary.
• It builds on Beck's (1967)early definition of schemas and
modes in the revised model of cognitive therapy (1997)

2. THEORETICAL UNDERPINNINGS IN
COGNITIVE THERAPY
• Young draws on other theories to find ways of conceptualising
problems:
• psychodynamic models bring the issues of childhood origins, and
conscious processes, transference and counter transference and
the necessity to process trauma on an emotional level.
• Object relations therapy directs the focus of interpersonal
relationships to families of origin in the shaping of the child's view
of self and of the world.
• Attachment theory (Ainsworth & Bowlby 1991). Bowlby's concept
of the dysfunctional "internal working models" is similar to early
maladaptive schemas.
• Experiential therapies like Gestalt therapy bring the emotional
change skills into play.
• Schema theory is tightly woven with
cognitive, behavioural, emotional and experiential strategies to
form a unifying conceptual framework based on a solid
therapeutic relationship

3. SCHEMA THEORY

• Schema theory has four main concepts:
• 1. Early maladaptive schemas (EMS).
• 2. Schema domains.
• 3. Coping styles.
• 4. Schema modes.

4. ORIGINS OF SCHEMAS

• Young theorised that EMS developed when
children's core emotional needs of consistently not
met.
• Five core emotional needs considered universal:
• 1. Secure attachment to others that leads to safety
and stability.
• 2. Autonomy, competence and a sense of identity.
• 3. Freedom to express invalid needs and emotions.
• 4. Spontaneity and play.
• 5. Realistic limits and self-control


• 4 mechanisms develop early maladaptive
schemas:
• 1. Toxic frustration of needs: refers to an absence of
healthy experience.
• 2. Traumatisation or victimisation: consists of specific
traumatic an abuse of experiences.
• 3. Too much of a good thing: where parents do not
set realistic limits, overprotective or overinvolved.
• 4. Selective internalisation or identification with
significant other: internalisation of aspects of
parents thinking and behaviour


• The development of schemas is also influenced by
the child's emotional temperament interacting with
negative childhood experiences.
• Nature and nurture debate

5.EARLY MALADAPTIVE SCHEMAS

• Early maladaptive schemas (EMS) defined as:
• 1. A broad, pervasive theme or pattern
• 2. Comprised of memories, emotions, cognitions
and bodily sensations
• 3. Developed during childhood or adolescence
• 4. Elaborated throughout one's lifetime
• 5. Dysfunctional to a significant degree
• (Young et al 2003).


• EMS serve as templates for the processing of data experiences
and have certain core characteristics:
• They have unconditional rigid beliefs and feelings about
oneself, and the world that the individual never challenges.
• They form the core of the individual's sense of self.
• They are self perpetuating and resistant to change.
• They operate outside individual's conscious awareness.
• They are triggered by events relevant to the particular
schema, and associated with extreme negative emotions.
• Behaviours in do not form part of the schema; instead the
schema drives the behaviour.
• Schemas can be positive or negative, can develop early or
late in life, vary in degrees of severity.

• 18 EMS Identified and grouped under five domains reflecting the five
areas of core emotional needs identified above.
• Five domains:
• 1. Disconnection and rejection: the lack of secure attachment.
• 2. Impaired autonomy and performance: the lack of competence or a
sense of identity.
• 3. Impaired limits: the lack of freedom to express valid needs and
emotions.
• 4. Other – Directedness: the loss of spontaneity and play.
• 5. Over vigilance and inhibition: the loss of realistic limits and self control.
• EMS vary in severity and progressiveness; can be unconditional formed in
the early as part of life and conditional schemas which are set to
develop later.
• Schema perpetuation refers to all thoughts, feelings and behaviours
which reinforce and perpetuate the schema resulting in the maladaptive
behaviour patterns seen.

5.1. DISCONNECTION AND REJECTION

• This schema domain is characterized by attachment
difficulties. All schemas of this domain are in some way
associated with a lack of safety and reliability in interpersonal
relationships.
• The quality of the associated feelings and emotions differs
depending on the schema—for example, the schema
―abandonment/instability‖ is connected to a feeling of
abandonment by significant others, due to previous
abandonment in childhood.
• Individuals with the schema ―social isolation/alienation,‖ on
the other
• hand, lack a sense of belonging, as they have experienced
exclusion from peer groups in the past.
• Patients with the schema ―mistrust/abuse‖ mainly feel
threatened by others, having been harmed by people during
their childhood.

5.2. IMPAIRED AUTONOMY AND
PERFORMANCE
• People with these schemas perceive themselves as dependent, feel insecure, and suffer
from a lack of self-determination.
• They are afraid that autonomous decisions might damage important relationships and
they expect to fail in demanding situations.
• People with the schema ―vulnerability to harm and illness‖ may even be afraid that
challenging and changing their fate through autonomous decisions will lead to harm to
themselves and others.
• These schemas can be acquired by social learning through models, for example from
parent figures who constantly warned against danger or illnesses, or who suffered from
an obsessive–compulsive disorder (OCD)
• he schema ―dependency/incompetency‖ may develop when parents are not confident
that their child has age-appropriate skills to cope with normal developmental challenges.
• Schemas Can also develop when a child is confronted with demands which are too
high, when they have to become autonomous too early and do not receive enough
support to achieve it. Thus patients with childhood neglect, who felt extremely
overstressed as children, may develop dependent behavior patterns in order to ensure
that somebody will provide them the support they lacked earlier in life, and thus do not
learn a healthy autonomy.

5.3. IMPAIRED LIMITS
• People with impaired limits schemas have difficulty accepting normal
• limits.
• It is hard for them to remain calm and not cross the line,
• They often lack the self-discipline to manage their day-to-day lives, studies, or
• jobs appropriately.
• People with the schema “entitlement/grandiosity” mainly feel entitled and tend to
self-aggrandize.
• The schema “lack of self-control/self-discipline” is principally associated with
impaired discipline and delay of gratification.
• These schemas are learnt by direct modeling and social learning. Often patients
were spoiled as children, or their parents were themselves spoiled in their
childhoods and/or had problems accepting normal limits.
• These schemas can also develop when parents are too strict, when they inflict
too much discipline, and when limits are too narrow. In such situations, these
schemas develop as a kind of a rebellion against limits and discipline in general.

5.4. OTHER-DIRECTEDNESS

• People with other-directedness schemas typically put the needs, wishes, and
desires of others before their own. Most of their efforts are directed towards
meeting the needs of others.
• Individuals with a strong ―subjugation‖ schema always try to adapt their
behavior in a way which best accommodates the ideas and needs of others.
• In the schema ―self-sacrifice,‖ the focus is more on an extreme feeling of
responsibility for solving everyone else’s problems; typically feel that it is their
job to make everybody feel good.
• Schema ―approval-seeking‖ have as a sole purpose pleasing others; thus all
their actions and efforts reflect that desire, rather than their own wishes.
• With regard to the biographical background and development during
childhood, these schemas are often secondary.
• The primary schemas are often those from the domain ―disconnection and
rejection‖. I.e., schemas in the domain ―other-directedness‖ may have
developed to cope with schemas of disconnection and rejection..

5.5. OVERVIGILANCE AND INHIBITION

• People with Overvigilance and Inhibition schemas avoid the experience and expression
of spontaneous emotions and needs.
• People with the schema ―emotional inhibition‖ devalue inner experiences such as
emotions, spontaneous fun, and childlike needs as stupid, unnecessary, or immature.
• The schema ―negativity/pessimism‖ corresponds with a very negative view of the world;
people with this schema are always preoccupied with the negative side of things.
• Schema ―unrelenting standards‖ constantly feel high pressure to achieve; they do not
feel satisfied even when they achieve a lot, as their standards are extremely high.
• The ―punitiveness‖ schema incorporates moral codes and attitudes that are very punitive
whenever a mistake is made, regardless of reason.
• These schemas are acquired by reinforcement and social modeling, for example when
parent figures mocked the spontaneous expression of feelings, thus teaching their
children to be ashamed of being emotional.
• This can also take place indirectly, for example when parents reinforce only
achievement and success, and devalue or ignore other important aspects of life such as
fun and spontaneity.
• Some patients with these schemas report mainly negative experiences regarding intense
emotions in their childhood. They started to avoid intense emotional experiences in order
to protect themselves against these aversive stimuli.

SUMMARY: SCHEMA DOMAINS AND
BASIC NEEDS

6. SCHEMA COPING STYLES

• 3. Broad maladaptive schema coping styles of
identified.
• 1. Surrender
• 2. Avoidance
• 3. Overcompensation

6.1. SURRENDER

• With a surrendering coping style, a patient experiences
schema-associated feelings very intensely and
surrenders as it were to the ―messages‖ of the
schema, thus accepting them.
• In a surrendering coping mode, the client behaves as if
the schema was true and there was no other choice but
to tolerate bad treatment by others.
• the subjugating patterns of clients with a subjugation
schema frequently have had severe sexual childhood
abuse experiences
• they tend to accept abuse in intimate relationships later
in life as well
• Domestic violence repeats a pattern

6.2 AVOIDANCE

• Avoidant schema coping: when people avoid activation of the
schemas or the emotions associated with them in order to
protect themselves.
• Behavior patterns that are typical are social withdrawal and
avoidance or lack of emotional contact with others.
• In the therapeutic relationship, this coping style is activated when
the therapist feels a lack of connection and contact with the
client.
• Other behavior patterns can regarded as emotional avoidance
are substance abuse to avoid experience of and dealing with
• Emotions; keeping themselves continuously occupied in order to
maintain a constant level of stimulation, to avoid feelings. This
might take the form of computer games, workaholism, television
and the Internet, or overeating.
• When patients report the use of such activities to reduce feelings
of anxiety and so on, we speak about an avoidant schema
coping.

6.3. OVERCOMPENSATION
• With the Overcompensation schema people act as if the opposite of the schema
was true.
• People with a failure scheme, might show off and talk excessively about their
achievements.
• Mistrust/abuse schema might behave in an overly self-centered and aggressive
manner. Sometimes people with a mistrust/abuse schema who are
overcompensating even abuse others in order to avoid abuse or threat against
themselves.
• Subjugation schema insist that others subjugate themselves to them and accept
their ideas without discussion.
• In the therapy situation, overcompensation can be easily identified in the
therapeutic relationship when the therapist feels dominated, driven into a
corner, or even threatened by a patient.
• Patients with narcissistic overcompensation,typically devalue their
therapist, provoking them by questioning their experience and qualifications, and
so
• on.
• In contrast, people with an obsessive-controlling overcompensation
• mode might correct their therapist in a very detailed and rigid way. In both
• cases, the therapist feels controlled and devalued.

7. SCHEMA MODES

• A ―schema mode‖ is defined as a current
emotional state which is associated with a given
schema.
• Schema modes can either change frequently or be
very persistent.
• In patients with many different schemas and intense
schema modes, it is often much easier to address
these modes than to refer to the schemas behind
them.
• Schema modes are divided into modes associated
with mostly negative emotions and modes used to
cope with these emotions.

7.1. SCHEMA MODES

• There are 4 Modes overall:
• 1. Child Mode
• 2. Dysfunctional Coping Modes
• 3. Dysfunctional Parent Modes
• 4. Healthy Adult Modes

7.1. CHILD MODE

• Child modes are associated with intense negative
emotions such as rage, sadness, and abandonment.
• They resemble the concept of the ―inner child,‖ which
is used in many therapies
• A patient with a mistrust/abuse schema, for
example, may feel threatened and at the mercy of
others when they are in the abused child mode

7.2. DYSFUNCTIONAL COPING MODES

• Dysfunctional coping modes are related to
avoidant, surrendering, or overcompensating
schema coping.
• In avoidant coping modes, people avoid emotions
and other inner experiences, or avoid social
contact altogether.
• In overcompensating coping modes, people
stimulate or aggrandize themselves in order to
experience the opposite of the actual schema-
associated emotions.

7.3. DYSFUNCTIONAL PARENT MODES

• The other category of highly emotional modes is the
dysfunctional parent modes.
• they are viewed as internalizations of dysfunctional
parental responses to the child.
• In dysfunctional parent modes, people keep
putting pressure on themselves or hate themselves.
• Patients with a mistrust/abuse schema, de-value
and hate themselves when they are in the punitive
parent mode.

7.4. HEALTHY ADULT MODES

• Healthy modes are the modes of the healthy adult and
the happy child.
• In the healthy adult mode, patients are able to view
their life and their self in a realistic way.
• They are able to fulfill their obligations, but at the same
• time can care for their own needs and well-being.
• This mode has conceptual overlap with the
psychodynamic concept of ―healthy ego functioning.‖
• The mode of the happy child is particularly related to
fun, joy, and play.
• Don’t we all want to be like this!

8. HOW PROBLEMS ARE
CONCEPTUALISED
• Accurate identification of EMS; coping styles, and their links to negative
childhood experiences is essential for constructing a case conceptualisation.
• Therapist begins by assessing the clients presenting problems clearly and in
specific terms to enable both therapist and client to stay focused on them.
• A focused life history is taken to establish whether the clients current difficulties
represent dysfunctional life patterns in the client relationships and work.
• The therapist pays particular attention to schema eruption in the past, schema
triggers and coping styles used by the client.
• Various schema inventories can be used to assess the specific elements
required: Young schema questionnaire (YSQ-L3)
• Young Parenting Inventory (YPI)
• Young - Rygh Avoidance Inventory
• Young Compensation Inventory

• A detailed and technical analysis linking current situations to past EMS is the
difference to standard CBT

9. PRACTICAL APPLICATIONS

• Following assessment and education of the client
the most important phase is referred to as "changed
phase".
• The therapist employs cognitive, experiential and
behavioural strategies to challenge and modify
early maladaptive schemas, as well as coping styles
and modes.
• While utilising specific techniques the schema
therapist makes use of the therapeutic relationship
as a platform for assessment and treatment.

9.1. THE THERAPEUTIC RELATIONSHIP

• The therapeutic relationship is an important
component of schema therapy.
• In the assessment phase therapist notes schema
activation in the therapeutic relationship, becoming
aware on how to establish rapport, conceptualise
the client's difficulties and assess the clients
reparenting needs.
• There's a lot more emphasis placed on the nature of
the therapeutic relationship and the idea of limited
reparenting.
• This will be discussed in more detail later lectures

9.2. STRATEGIES OF TREATMENT:
COGNITIVE AND EXPERIENTIAL
• Schema therapy focuses on two broad areas: cognitive
strategies and experiential strategies.
• Cognitive strategies is used to introduce doubt about the
nature of schemas working collaboratively with the client to
encourage a more "healthy voice" to question and counter
the schemas. This is classical cognitive therapy.
• Experiential strategies are used in all phases of schema
therapy. They are used to elicit emotions and assess EMS. In
the treatment phase there are used to meet clients emotional
needs and help heal their EMS.
• Young et al (2003) "experiential strategies help clients in their
transition from knowing intellectually that schemas are false to
believing it emotionally".
• The most common experiential strategies are imagery, chair
work and letters to parents

10. RESEARCH STATUS

• There is a wealth of research on Young's schema theory
and the applications.
• Carine (1997) confirmed that emotion is integral to
schemas
• the psychometric properties of young schema
questionnaires to be subject to rigourous research and
have good psychometric properties
• schema mode inventory can be used reliably in the
assessment of modes in schema therapy( Lobbestael et
al 2010)
• the mode model is well researched with good outcome
studies on the model (Giesen-Bloo et al 2006)
• please research on Athens and the application of
schema therapy to depression, anxiety and phobias.

11. SUMMARY
• Young (1990) originally developed schema therapy to treat patients who had
failed to respond adequately to traditional cognitive-behavioral treatment,
• Schema therapy is a broad, integrative model; it has considerable overlap
with many other systems of psychotherapy, including psychodynamic models.
However, most of these approaches are narrower than schema
therapy, either in terms of the conceptual model or the range of treatment
strategies. There are also significant differences in the therapy relationship, the
general style and stance of the therapist, and the degree of therapist activity
and directiveness.
• Early Maladaptive Schemas are broad, pervasive themes or patterns
regarding oneself and one’s relationships with others that are dysfunctional to
a significant degree. They play a major role in how individuals
think, feel, act, and relate to others.
• Early Maladaptive Schemas are the result of unmet core emotional needs.
• We have defined 18 Early Maladaptive Schemas in five domains.
• A great deal of empirical support exists for these schemas and some of the
domains.
• We have developed four main categories of modes: Child
modes, Dysfunctional Coping modes, Dysfunctional Parent modes, and the
Healthy Adult mode.

12. READINGS

• Ohanian & Rashed: Chapter 8 Schema therapy in
Dryden, W. (2012) Cognitive Behaviour
Therapies, London Sage
• Rafaeli, et al (2010) Schema Therapy: chapter 1 & 2 & 3
• Advanced reading: Young, et al . (2003): chap 1
• Hawke & Provencher 2011 Schema Theory and Schema
Therapy in Mood and Anxiety Disorders A Review
• Riso et al (2006) The Long-Term Stability of Early
Maladaptive Schemas.
• Thimm (2010) Relationships between early maladaptive
schemas and psychosocial development

Lecture 2 schema therapy overview & early maladaptive schemas

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Lecture 2 schema therapy overview & early maladaptive schemas