Young (2008) developed the schema-based therapy method as a treatment tool for patients who suffer from personality disorders. Usually, doctors use schema-based therapy for patients who have relapsed, or failed to respond to other treatment therapies (Reinecke, 2002, p. 291). Schema-based therapy relies on the assumption that complex personality disorders stem from experiences (usually negative) which make people vulnerable to personality disorders. Therapists know these negative experiences as maladaptive schemas. The maladaptive schemas normally manifest as a spectrum of “chronic, difficult, and characterological problems” (Samantha, 2012, p. 185). They may equally manifest as lifelong, self-defeating patterns of behavioral disorders.
Reinecke (2002) says these maladaptive schemas normally begin early in life and may create an endless pattern of negative and dysfunctional thoughts/feelings for the patients. These thoughts normally create a challenge for the patients to achieve their personal goals and objectives. Schema-based therapy understands the self-defeating patterns of these maladaptive behaviors and helps patients to break away from the resultant negative patterns of thinking and feelings. Schema-based therapy works through an integrative model that includes cognitive behavioral, experiential, interpersonal, and psychoanalytic therapies (Samantha, 2012). These therapies have demonstrated a high efficacy in treating maladaptive behavioral patterns, even in situations where other therapies have failed.
This paper seeks to conduct a proper review of schema-based therapy by exploring the theory, research, and practice of schema-based therapy. First, this paper understands the major tenets of the theory (by listing the core constructs of the theory), and describing the schema-focused cognitive behavior therapy approach to human development, personality, and psychopathology. Secondly, this paper explores schema’s mode of therapeutic action (the general goals of treatment) and finally, this paper outlines the strengths and limitations of schema-based therapy and its application in diverse and multicultural contexts. A review and critique of the scientific theories that underlie the application of this theory will outline the main constructs of schema-based therapy and its application in the treatment of post-traumatic stress disorder and depression.
Main Constructs of Schema-based Therapy
Young (2008) has subdivided schema-based therapy into four categories – child modes, maladaptive coping modes, maladaptive parent modes, and the healthy adult mode (Samantha, 2012). Child modes further subdivide into four main categories – vulnerable child, angry child, impulsive/undisciplined child, and the happy child. As their names suggest, the vulnerable child feels isolated, misunderstood and unsupported, while the angry child often exudes anger, frustration, impatience (and similar attributes). The impulsive child acts on non-core desires in a selfish and uncontrolled manner, while the happy child exudes feelings of love, contentment, and optimism.
Reinecke (2002) says the maladaptive coping mode includes three stages – compliant surrender, detached protector, and the over-compensator. The compliant surrender acts in a passive and “approval-seeking” manner to maintain the self-defeating schema-driven pattern that promotes the behavior in the first place. Detached protectors often detach their feelings from other people. They may exhibit this trait by refusing other people’s help (in a manner that promotes self-soothing desires). Lastly, the over-compensator behaves in an aggressive manner that is often exploitative and manipulative (Reinecke, 2002).
Unlike the child mode and the maladaptive coping modes, the maladaptive parent mode only comprises two stages. They include the punitive parent and the demanding parent. The punitive parent often thinks that they (or others) deserve punishment. Certainly, such parents exhibit signs of extreme blame and abuse towards others. The demanding parent often exhibits the need to do things in a perfect way so that they keep things in order, or keep a high status in behavioral conduct (Reinecke, 2002). These feelings may come from different internalized schemas, but the most common reason for this behavior is a set of internalized high standards and self-imposed strict rules.
Lastly, the healthy adult mode nurtures, validates, and affirms the vulnerable child (the healthy adult mode controls angry and uncontrolled child behaviors for a healthy and nurturing child mode). When compared to the other tenets of the schema-based therapy model, the healthy adult mode often replaces the maladaptive coping mode. When compared to the maladaptive parent mode, the healthy adult mode neutralizes the features of the maladaptive parent mode. Comprehensively, the healthy adult mode pursues self-fulfilling adult activities like cultural interest, healthy lifestyles, and sex (Samantha, 2012).
Goals of Treatment
The main goal of schema-based therapy is to help patients overcome their maladaptive schemas and adopt a healthy and normal life (Young, 2005). This happens by helping the patients to be in touch with their core feelings. Another goal of the schema-based therapy is to help patients heal their early schemas by helping them to overcome their self-defeating schemas, quickly. Comprehensively, these goals strive to help patients who have undergone schema-based therapy to experience emotional satisfaction.
Approach to Human Development, Psychopathology, and Personality
The application of schema-based therapy in psychopathology stems from the understanding of how the schemas refer to pervasive themes that define people’s behaviors. As explained in earlier sections of this paper, patients develop these pervasive themes early in their lives. Samantha (2012) mentions that these themes inhibit patients from viewing periodic events as unique occurrences and instead, as a function of what they believe to be true about themselves. For example, Hyland (2012) explains that a person who suffers from trauma may attribute his predicament to the fact that he is not strong enough to manage the trauma, as opposed to the impact that the event (causing the trauma) has on his psychological well-being.
Schema-based therapy works from the philosophy of people feeling secure, guided, and cared for. If these needs are unsatisfied during childhood, people develop coping mechanisms throughout their adult lives. These coping mechanisms usually result in the maladaptive schemas (as described above). Indeed, these maladaptive schemas lead to unstable relationships, poor social skills, and unhealthy lifestyle choices.
In adulthood, significant life events (like the loss of a job) trigger these maladaptive schemas. Young (2005) believes that these maladaptive schemas usually develop early in life, but subsequent studies showed that the same schemas might similarly develop later in life (adulthood). As mentioned in earlier sections of this paper, these maladaptive schemas perpetuate (behaviorally) when patients surrender to emotionally painful schemas, or when they avoid such emotional and psychological experiences.
Schema-based therapy has shown a high efficacy in treating maladaptive schemas, thereby leading to significant clinical outcomes when treating personality disorders. Seavey (2012) documents a case where a college age male student with significant personality disorders exhibited significant clinical outcomes through the schema-based therapy model. Initially, the patient suffered from serious personality disorders, which manifested through maladaptive symptoms like isolation, suicidal tendencies, sadness, and worthlessness. Moreover, the patient exhibited signs of narcissism. The schema-based treatment method focused on fostering therapeutic relationships by making the patient complete a Young’s schema questionnaire. The patient completed the questionnaire before and after the treatment process. The treatment process took about 68 weeks and it resulted in the endorsement of 18 schemas (by the patient) (Seavey, 2012). The patient endorsed these schemas at a “low” level. Subsequent studies tried to establish if the research demonstrated clinically significant change and the outcome showed that four out of seven of the schemas endorsed by the patients resulted in clinically significant improvements in the patient’s personality. These studies show the success of schema-based therapy in treating personality disorders.
Application of Schema Theory to Post-Traumatic Stress Disorder and Depression
Limited volumes of research explain the performance of schema-based therapy for a range of psychological disorders. However, numerous researchers have investigated the performance of schema therapy on post-traumatic stress disorder and depression. Most of these researchers have focused on the performance of schema-based therapy for soldiers returning from war. For example, Hartline (2011) has investigated the effectiveness of schema therapy on soldiers who returned from the Vietnam War. He established that schema therapy helped the soldiers evaluate the traumatic events that they went through during the war (Hartline, 2011). This treatment helped the soldiers to self-soothe whenever they were in hyperventilating situations. One notable outcome that surfaced in this study was the ability of schema therapy to help the soldiers overcome their helplessness and focus on their resilience to survive such wars. This way, therapists develop new schemas for war victims to rely on.
Schema-based therapy has also demonstrated a high efficacy in the treatment of depression. This success is very significant in psychology because depression is a common occurrence in psychology. Some researchers have even named it as the “common cold” in psychology (Hartline, 2011). In a study performed by Birjandi (2012) to investigate the efficiency of schema therapy to treat depressive disorder (based on irrational thinking), the researcher proved that schema therapy is effective in reducing irrational thoughts and beliefs among patients. The study also showed that schema therapy helped patients to control their irrational beliefs in a way that they do not feel the need to seek for peoples’ approvals and demand change desperately. The researchers later affirmed that, “teaching schema therapy techniques can be used as an effective method of decreasing irrational beliefs in depressed patients” (Birjandi, 2012, p. 8719). The study involved 120 patients who were suffering from depression.
In an unrelated finding, a research study that was done by Giesen-Bloo (cited in Birjandi, 2012) showed that schema-based therapy also demonstrated a high efficacy in treating patients with borderline personality disorder (better than the transference-focused therapy). Indeed, similar studies undertaken by other researchers showed that about 95% of patients who received treatment through the schema-based therapy no longer exhibited signs of borderline personality disorder (Farrell, Shaw, and Webber, 2009). Comprehensively, these studies show that schema based therapy is effective in treating post-traumatic stress disorders, borderline personality disorders, and depression.
Application of Schema therapy in diverse and Multicultural Contexts
Multiculturalism is an important concept in the application of schema therapy. Researchers consider several issues here, including race, gender, religion, and ethnicity (among others) (Birjandi, 2012). The importance of applying schema therapy in diverse and multicultural societies manifest because it may be difficult for therapists to refrain from stereotyping and discriminating patients, based on their diversity.
The application of schema therapy in a diverse cultural context requires both the therapist and the patient to be aware about the importance of cultural sensitivity in their relationship. It is vital to do so because cultural differences dictate that a person may view one psychological issue (say personality disorder) as irrelevant to a person’s growth, while in another culture, the same disorder may be very alarming (Samantha, 2012). The application of schema therapy requires therapists to be aware about these possible cultural differences. This is the main reason therapists undergo a training course on cultural diversity before they are certified as therapists (who specialize in schema therapy). However, Birjandi (2012) says there is a shortfall of certified therapists who specialize, or understand, how schema therapy works.
To counter some of the arguments leveled against schema therapy, Samantha, (2012) says the treatment method relies on empowering individuals as its main goal. To this extent, Samantha (2012) suggests that schema therapy appreciates the individual and unique cultural characteristics of different individuals because by acknowledging that the clients are in control of their treatment process, the model appreciates a collaborative approach that considers individual characteristics. The assertion of other researchers who say that schema therapy meets the needs of its patients support this view.
Another argument, which proponents of schema therapy support, centers on exploring the conscious processes and specific behaviors of patients, as opposed to the abstract understanding of patients’ behaviors through a therapist’s eye. Samantha (2012) proposes that this process is especially effective if the therapy sessions are conducted in the client’s native language (here, an interpreter may be sought). Since research studies say clients who communicate in a second language may fail to communicate well because of emotional distress, Reinecke (2002) says therapists should strive to communicate with patients in their languages so that they eliminate the potential for misunderstanding them. Lastly, Reinecke (2002) suggests that since schema therapies accommodate periodic assessments, it is easy to accommodate the client’s perspective in the treatment process. This feature easily complements the ease of addressing different concepts that are important to the client (such as family views) and any cultural or individualistic opinion. Comprehensively, these varied dynamics suggest that schema therapy can work well in a diverse and multicultural context.
Strengths and Limitations of Schema-Based therapy
In an interview with Jeffery Young (the founder of the schema theory), Young (2008) affirmed that schema theory was more comprehensive, integrative, and encompassing, than other therapeutic models. He said, “every therapy model has its strengths, but most other therapies mainly use only one or two modalities” (Young, 2008, p. 1). Conceptually, schema therapy is broader because it focuses on explaining people’s thoughts and feelings that they are unaware about. Moreover, schema theory uses diverse strategies for understanding and evaluating people’s feelings and thoughts. Young (2008) also adds that it does so in a very active way.
Schema theory also adopts a more structured way of treating patients, which leads the therapist to core themes in the treatment process. Ordinarily, a therapist would be more detached from the treatment process and rely on personal assessment criteria for treating the patients. Therefore, schema-based therapy responds better to a patient’s need.
When compared to other treatment methods (like cognitive therapy), schema therapy has a higher chance of treating long-term psychological disorders. For example, cognitive therapy works by encouraging a patient to avoid, or suppress, their negative emotions in a rational way (Young, 2008). However, schema therapy strives to evoke affection in the treatment process by trying to investigate why a patient experiences the negative emotions. This is one reason some researchers understand schema therapy to be deeper than other treatment methods. Therefore, cognitive therapies do not have a developmental model as schema therapies.
Lastly, schema-based therapies have proved to be more cost-effective than other treatment methods. In fact, Gaus (2011) affirms that even the most intensive version of schema-based therapy demonstrates a high level of cost-effectiveness. In fact, recent statistics (from a Dutch study) showed that the most intensive versions of schema-based treatment resulted in a net gain of about 4,505 Euros (about $5,750) for every patient treated (Young, 2008). These advantages show the main strengths of schema therapy.
A significant limitation in the application of schema-based therapy is its structural composition. Some observers consider the structured nature of the treatment method as a limitation to its application because it fails to consider varying individual diversities of different patients (Gaus, 2011). This limitation is especially profound when considering the cultural diversities of different patients. This view has however been countered by a different view from researchers like Gaus (2011) who propose that schema-based therapy does not involve the direct application of different structures (like a robot).
One other limitation of schema-based therapy is the excessive reliance of patients on their therapists. Certainly, past researches have said patients who have experienced schema-based therapy may develop a high dependency on their therapists (such that they are even unable to be independent) (Gaus, 2011). Ideally, therapists say patients should be individuals, but still maintain a strong connection with their therapists. Therefore, some therapists withdraw from the patients gradually so that they do not trigger a relapse.
Another limitation of schema-based therapy is the patient’s failure to withdraw from the treatment plan when it is most convenient to do so. For example, some therapists have discovered that if therapists push patients (too hard) to develop their personal connections (independent of the therapists); the patients see no need to continue the therapy sessions (Young, 2008). Ideally, therapists are supposed to encourage the patients to continue with the therapy sessions, even as they develop solid relationships with other people.
After weighing the findings of this paper, it is crucial to point out that schema-based therapy is a relatively new and unique approach for treating different personality disorders. Schema theory therefore seeks to capture all human developmental processes that influence personality behaviors. This way, the model aims to provide a structured understanding of the human development process. Few literatures outline the main weaknesses of the model, but the researchers who have investigated its weaknesses focus on the relationship between the patients and the therapists. Here, it is crucial to point out that most of these weaknesses also exist in other therapy models. Therefore, compared to other therapy models, schema-based therapy adopts a special and multifaceted understanding of behavioral therapy to provide emotional satisfaction for patients. These attributes position schema therapy as among the best therapies for treating most psychological disorders.
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