Schema Therapy (Rafaeli, Bernstein, Young)

A Taxonomy of Maladaptive Schemas

Domain I: Disconnection and Rejection. These schemas involve violations of the basical universal need for security, safety, stability, nurturance, empathy, sharing of feelings, acceptance, and respect. These schemas often develop when the early family environment is detached, withholding, cold, rejecting, violent, unpredictable, or abusive.

1. Abandonment/Instability. The perception that others, especially those from whom we expect support and connection, are unstable and/or unreliable in providing these.  
2. Mistrust/Abuse. The expectation that others will hurt, abuse, humiliate, cheat, lie, manipulate, or take advantage of them. Often involves the perception that the harm is intention. 
3. Emotional Deprivation. The expectation that one's desire for a normal degree of emotional support will not be adequately met by others. 
4. Defectiveness/Shame. The feeling that one is fundamentally defective, bad, unwanted, inferior, or invalid in important ways, or that one would be unlovable to significant others if they could see the real self. 
5. Social Isolation/Alienation. The feeling that one is isolated from the rest of the world, esp. the world outside the family. These people feel different than others, not part of any group. 

Domain II: Impaired Autonomy and Performance. These schemas involve violations of the basic universal needs for autonomy and competence, which lead to expectations about oneself and the environment that interfere with one's perceived ability to separate, survive, function independently, and perform successfully. These schemas often develop when the family of origin is enmeshed, undermining the child's confidence, overprotective, or failing to reinforce the child for performing competently outside the family. 

1. Dependence/Incompetence. The belief that one is unable to handle one's everyday responsibilities in a competent manner. 
2. Vulnerability to Harm or Illness. The exaggerated fear that catastrophe is imminent, that it will strike at any time, and that one will be unable to prevent it. 
3. Enmeshment/Undeveloped Self. Excessive emotional involvement and closeness with one or more significant others at the expense of full individuality or normal social development. Often involves the belief that at least one of the enmeshed individuals cannot survive or be happy without the constant support of the other. 
4. Failure. The belief that one has failed, will inevitably fail, or is fundamentally inadequate relative to one's peers, in areas of achievement. 

Domain III: Impaired Limits. These schemas are related to deficiencies in internal limits, responsibility towards others, or long-term goal-orientation. These schemas often lead to difficulties respecting the rights or others, cooperating with them, making commitments. These schemas often emerge when family of origin is permissive, overindulgent, has a sense of superiority. 

1. Entitlement/Grandiosity. The belief that one is superior to other people, entitled to special rights, not bound by the rules of reciprocity. 
2. Insufficient Self-Control/Self-Discipline. Pervasive difficulty or refusal to exercise sufficient self-control and frustration tolerance to achieve one's personal goals, or to restrain the excessive expression of one's emotions and impulses. 

Domain IV: Other-Directedness. These schemas are related to deficits in the fulfillment of the basic universal need for self-directness. Such deficits lead to an excessive focus on the desires, feelings, and responses of others, at the expense of one's own needs. This focus is driven by the need to gain love and approval, maintain a sense of connection or belonging, or avoid retaliation. These schemas usually involve a suppression or lack of awareness regarding one's own emotions, needs, or wishes, and lead to difficulties in assertion or self-determination.

1. Subjugation. An excessive degree of relinquishing control to others because one feels coerced to do so to avoid anger, retaliation, or abandonment.
2. Self-Sacrifice. An excessive focus on voluntarily meeting the needs of others, at the expense of one's own gratification. 
3. Approval-Seeking/Recognition-Seeking. An excessive emphasis on gaining approval, recognition, or attention from other people, or on fitting in, at the expense of developing a secure and true sense of self. 

Domain V: Overvigilance and Inhibition. These schemas are related to violations of the basic universal need for spontaneity and playfulness. These violations may result in an excessive emphasis on suppressing one's spontaneous feelings, impulses, or choices. They also may result in a perpetual focus on meeting rigid, internalized rules and expectations about performance and ethical behavior, often at the expense of happiness, self-expression, relaxation, close relationships, or health. Family of origin is often grim, demanding, punitive. 

1. Negativity/Pessimism. A pervasive, lifelong focus on the negative aspects of life, exaggerated expectation that things will eventually go seriously wrong.
2. Emotional Inhibition. Excessive inhibition of spontaneous action, feeling, or communication, usually to avoid disapproval by others, feelings of shame, or losing control of one's impulses.
3. Unrelenting Standards/Hypercriticalness. Underlying belief that one must strive to meet very high internalized standards of behavior and performance, usually to avoid criticism.
4. Punitiveness. The belief that people (including oneself) should be harshly punished for making mistakes. Involves the tendency to be angry, intolerant, punitive, and impatient with any person who does not meet one's expectations or standards.

Coping Styles and Responses

We tend to focus on information that is consistent with our schemas and ignored that which is inconsistent. We also tend to act in ways that perpetuate our schemas. 

We tend to choose "high chemistry" partners who unconsciously activate and perpetuate these same schemas: a distant partner who reinforces an Emotional Deprivation schema, etc.

Surrender Responses. That is, giving in to one's schemas -- e.g., being drawn to those who mistreat you. This might temporarily make you feel safer. 

Avoidant Responses. That is, avoiding people or situations that trigger your schemas. 

Overcompensation Responses. That is, attempting to do the opposite of a schema. 

Schema modes

Mode = the predominant emotional state, schemas, and coping reactions that are active for an individual at a particular time. Modes are transient states, whereas schemas are stable characteristics or traits. 

Individuals with borderline personality or narcissistic personality experience quick, often intense fluctuation among various mood states, flipping among modes in response to external or internal triggers. 

Healthy people move between modes but retain a unified sense of self and can simultaneously experience blends of modes (or more than one mode at a time). When they shift between modes, the do so gradually and not abruptly. 

The Vulnerable Child Mode. When we're in this mode, we are like wounded children. We may appear sad, hopeless, anxious, overwhelmed, helpless. This is a remnant of the time when we were children needing the care of adults in order to survive but did not receive that care. This mode holds the most schemas. The therapist's goal is to help the patient to accept and experience the vulnerability rather than push it away. This is the healthiest mode to be in, as vulnerability is essential for the sake of ultimately healing the schemas and gaining the capacity for getting one's needs met. 

The Angry Child Mode. When we're in this mode, we feel and express anger in response to unmet core needs. This mode can be triggered by feelings of mistreatment, abandonment, or humiliation in patients whose early emotional needs were chronically frustrated or went unmet. 

The Impulsive Child Mode. When we're in this mode, we behave impulsively. Patients with this mode often grow up in families that lack firm and consistent limit setting. 

Maladaptive Coping Modes. The Detached Protector mode is a state of emotional avoidance; you might deny feelings and problems, be emotionally detached. The Compliant Surrender mode is a state of compliance. The Overcompensator mode refers to a number of specific emotional states, all of which involve overcompensatory forms of coping -- i.e., doing the opposite of schemas in an attempt to escape from the painful emotions associated with them. 

Internalized Parent Modes. These modes involve an internalized parental voice that criticizes or denigrates the patient (Punitive Parent) or places almost impossible demands on him/her (Demanding or Critical Parent). 

Healthy Modes: Healthy Adult and Contented Child. The Healthy Adult mode is the part of the self that is capable, strong, and well-functioning. Borderline patients have almost no Healthy Adult mode. When in the Contented Child mode, we might feel at peace because our core emotional needs are being met; we experience others as loving and appropriately protective. This latter mode represents the capacity to experience and express spontaneity, glee, and playful happiness. 

Two Fundamental Therapeutic Stances

The main goal of Schema Therapy is to help adults get their emotional needs met, even when these needs were not met in the past. To achieve this, the therapy relationship needs to be one in which the patient's needs are recognized, articulated, validated, and fulfilled. The most important fulfillment is of those needs that were not met by the patient's parents when they were children. This bounded fulfillment of needs is called limited reparenting. 

Limited Reparenting. If a patient has strong Abandonment and Mistrust/Abuse schemas, they will most benefit from a therapist's emphasis on constancy, reliability, honesty, and availability. A patient who has the schema of Unrelenting Standards or a strong Critical Parent mode will benefit the most from a therapist who is generalize with praise and acceptance. 

Through limited reparenting, the therapist supplies the patient with a partial antidote to needs that were not adequately met in childhood; this is similar to a corrective emotional experience. 

Schema therapists extend typical therapy boundaries by encouraging out-of-session contact, using judicious self-disclosure, and expressing genuine warmth and care. This is done to permit the relationship to become similar to a parental, caring relationship. With time, the warmth and caring the patient receives is internalized and becomes part of their Healthy Adult mode. The therapist must determine which needs can be met by the patient and which require reparenting. 

Empathic Confrontation. This is where the therapist confronts the patient on their maladaptive behaviors and cognitions in an empathic, non-judgmental way. One way to do this is to frame one's problems in terms of schemas and coping responses -- e.g., "When your boss criticizes you, there is a side of you, the Abused Child side, that feels he is being abused all over again, just like you were by your parents. It's no surprise that you become angry and turn the tables on your boss by going on the attack. When you were a child, fighting back was the only way that you could preserve your self-respect. However, when you get into a fight with your boss now, he doesn't see the side of you that feels abused or mistreated. He just sees the Angry Child side and feels attacked. As a result, you don't get what you need, which is empathy and understanding. That's what you want from your boss; it's what you really needed from your parents, too." 

Assessment

Schema therapist initially take 2-4 sessions to gather information through a variety of assessment methods. The goals are to learn about the dysfunctional life patterns, to identify early maladaptive schemas, to learn the developmental origins of the schemas. Examples: the focused life history interview, the employment of self-report inventories, and the use of self-monitoring. 

Guided imagery can be part of the assessment process. The patient closes their eyes and lets an image come to them. Patient then describes the image. The goal is to elicit core images, those connected with primary emotions like fear, rage, grief, that are linked to the patients' early maladaptive schemas and childhood memories. 

Another part of assessment includes attention to the therapy relationship.

The assessment phase concludes by educating the patient, giving them a written case conceptualization. The conceptualization describes the patient's symptoms, identifies schemas, etc. If the therapist concludes that the patient has Axis I symptoms, the therapist treats those first using conventional CBT techniques. 

Therapist Toolbox

Toolbox 1: Relational Techniques. The therapist establishes a caring, trusting relationship which allows the patient to undergo the corrective emotional experience of having their needs met in a sufficient, healthy, and adaptive way. The therapist also uses this relationship as a safe place for exploring interpersonal and behavioral cycles that are driven by the patient's schemas and modes. 

When a schema is triggered in a session (sometimes resulting in a "therapeutic rupture"), the therapist seizes the opportunity -- first, by acknowledging the rupture ("I notice you became very quiet in the last minute"). If the patient acknowledges their anger or disappointment, the therapist empathizes and takes responsibility for their contribution to the rupture. If the patient instead continues to withdraw, the therapist may say something like, "You say you're not angry at me, but it makes me wonder why not. Putting myself in your shoes, I can easily imagine getting pretty upset. What do you think will happen if you did get angry at me?" The therapist can also link that rupture to underlying schemas: e.g., "Do you remember having a similar feeling with other people in your life?" 

Toolbox 2: Cognitive Techniques. (1) Schema diaries -- the patient is asked to record one particular event each day and to note their automatic thoughts, feelings, and behaviors in response to the event. In time, the patient is taught to test the evidence for and against their schema-driven view. (2) Reframing/Reattribution. Reframing involves providing a different cognitive frame (or explanation) than the one automatically generated. Reattribution can be used to help create a healthier view of schemas and their origins -- e.g., the therapist helps the patient reattribute their current life problem to a schema, rather than seeing it as inherent to the patient. (3) Schema Flashcards. These provide guidance for reattributing difficult situations in daily life. These are written summaries of the healthy response to a schema trigger. (4) Schema Dialogues. At first, the patient plays the schema side, and the therapist plays the healthy side. Eventually, the patient takes on the healthy side and is asked to counter the schema's arguments to come up with healthy responses. 

Toolbox 3: Emotion-Focused Techniques. Even if cognitive interventions are successful, the intense emotions attached to the schemas usually remain. (1) Role-Playing. Borrowed from Gestalt Therapy. The therapist asks the patient to play various roles -- e.g., different sides of himself/herself -- and to switch back and forth between roles. One technique is the two-chair method in which the patient keeps switching chairs. (2) Imagery. This can be so effective because patients often use avoidance; When therapists ask the patient to close their eyes and allow a scene from childhood to emerge spontaneously, they bypass the patient's coping modes. The images that emerge are usually connected to painful events. Research shows that schemas are easiest to change when cognitions are "hot."

Toolbox 4: Behavioral Pattern-Breaking. (1) Use of schema flashcards focused on alternative healthy behaviors. (2) Rehearsing a behavior in imagery or role-play. (3) Assigning behavioral homework. (3) Self-rewards.

Mode Dialogues and Imagery

Therapists ask patients to play different sides of themselves (i.e., different modes), switching chairs as they assume the role of different modes. 

Imagery in mode work. The therapist begins by asking the patient to close their eyes and imagine a scene from the present that is bothering them. The therapist then asks the patient to let go off the feeling while maintaining the feeling associated with it and to travel back to childhood and allow another image to emerge that has the same or a similar feeling. This new image usually shares schemas with the one from the present, enabling the patient to understand the way in which these themes from the past play themselves out in present life. The therapist then asks permission to enter into the image to provide for some of what the child needed, thus allowing direct reparenting. 

Borderline Personalities

Individuals with BPD often alternate abruptly and with great intensity between extreme emotional and motivational states: of anger or self-loathing, of idealization or devaluation, of intense feeling and numb emptiness. Schema Therapy sees these fluctuations as shifts among a relatively fixed set of schema modes. Most prominent BPD schema modes: the Detached Protector mode, the Abandoned/Abused Child mode, the Angry/Impulsive Child mode, the Punitive Parent mode, the Healthy Adult mode (usually very weakened). The Abandoned/Abused Child mode contains the memories, feelings, etc. of the patient as a young child, when the abuse, invalidation, etc. were most pronounced. 

The therapuetic goal is to strengthen the Healthy Adult mode so that it can in turn nurture the Abandoned/Abused Child mode, empathize but place limits on the Angry/Impulsive Child mode, and fight the Punitive Parent voice. Before any of this happens, the patient must allow the Detached Protector mode to step aside. 

Narcissists 

As a child, the narcissist learned to overcompensate for his schemas by developing a Self-aggrandizer mode, a side that feels superior. However, there remains a Lonely Child who feels empty and lonely. The key to therapeutic success is making contact with the Lonely Child. 

The therapist must empathically confront the Impulsive or Spoiled Child, the side that wants immediate gratification and has trouble tolerating frustration. Schema dialogue: the therapist asks the patient to play the side that believes it is "good to always get what you want when you want it." The therapist plays the healthy side, challenging the patient's beliefs. In essence, the therapist is arguing that if you always get what you want, you remain a child, unable to handle disappointments or frustrations, to pursue goals or plans, to get the rewards and privileges that come with being an adult. "Where has it gotten you to let a Spoiled Child run your life?" Many of these patients were given everything they wanted as children. 

Schema Therapy is also being used to treat individuals with Antisocial Personality Disorder.