Schema Therapy

Distinctive Features

Eshkol Rafaeli, David P. Bernstein, Jeffrey Young

• Publisher: Routledge
• Year: 2010
• Print ISBN: 9780415462983
• eBook ISBN: 9781136900587
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Schema Therapy combines proven cognitive behavioral therapy techniques with elements of interpersonal, experiential, and psychodynamic therapies in order to help people with long-term mental health problems including personality disorders and chronic depression. Schema Therapy suggests that many negative cognitive conditions are based on past experiences, and therefore provides models for challenging and modifying negative thoughts and behaviors in order to provoke change.

In this book, Eshkol Rafaeli, David P. Bernstein and Jeffrey Young – pioneers of the Schema Therapy approach – indicate the 30 distinctive features of Schema Therapy, and how the method fits into the broader CBT spectrum.

Divided into two parts, Theoretical Points and Practical Points, this book provides a concise introduction for those new to the technique, as well as a discussion of how it differs from the other cognitive behavioral therapies for those experienced in the field.

Part 1

THEORETICAL
POINTS

1

Universal core emotional needs

Schema Therapy begins with recognizing a set of universal emotional needs. These include the needs for safety, stability, nurturance, and acceptance, for autonomy, competence, and a sense of identity, for the freedom to express one’s needs and emotions, for spontaneity and play, and for a world with realistic limits which fosters the emergence of self-control.

Everyone has emotional needs – in fact, we argue that everyone has these particular needs. Individuals may differ in the strength of particular needs – some people may have a stronger temperamental need for spontaneity and creative expression, some may be particularly wired to crave nurturance. But above and beyond these individual differences lies a universal similarity – we all, fundamentally, have some amount of all of these needs.

Emotional needs are present from childhood; indeed, most are at their strongest in childhood. For example, the need for safety or stability, though life-long, has its strongest implications the more vulnerable or helpless one is.

Psychological health is the ability to get one’s needs met in an adaptive manner. The central project of children’s development is to get their core needs met; the central project of effective parenting or childrearing is to help the child get these needs met; and the central project of Schema Therapy – its primary objective – is to help adults get their own needs met, even though these needs may not have been met in the past.

In addition to the core universal emotional needs, Schema Therapy recognizes the existence of needs that emerge in adulthood (for example, the need to work and the need to care for others). These needs are also important for psychological health, but they tend not to be the focus of therapy. One possibility is that when more fundamental (and earlier) emotional needs are met in an adequate manner, individuals have the capacity to handle later needs quite well.

Schema Therapy has its roots in cognitive behavioral therapy (CBT) (as we detailed in the Introduction and will return to in Point 28). But CBT does not typically address universal needs. If needs get invoked in cognitive therapy, it’s in an ad-hoc manner, when a patient or a therapist identifies them. Some cognitive behavioral approaches actually disdain needs – grouping them together with “shoulds” and “oughts” – rigid constructs that are best avoided. This is one example of how Schema Therapy departs from other CBT approaches, and of how it integrates useful ideas from other orientations (in this case, emotion-focused, attachment, and dynamic approaches).

Indeed, needs have been the focus of earlier clinical theories (e.g., control/choice theory: Glasser, 1969; the hierarchy of needs: Maslow, 1962) and are gaining some prominence in more recent research in personality, social, and developmental psychology (e.g., Baumeister and Leary’s (1995) need for belonging, or the broader work of self-determination theory on the universal needs for autonomy, competence, and relatedness (Deci & Ryan, 2000)).

Needs – especially those for nurturance, warmth, and security – are also central to attachment theory. Attachment theory has been a prominent approach to human development for the past half century, beginning with John Bowlby’s strikingly powerful observation that phenomena observed by evolutionary ethologists (like Lorenz and Harlow) have direct implications to child development, and to human social and emotional development more generally. As decades of both human and primate research show, secure attachment early in life serves as the basis for many adaptive processes later on: with a “secure base,” the child is able to develop curiosity and exploration, self-soothing and self-regulation, and ultimately the ability to form close emotional bonds.

Attachment theory and research have been major sources of influence on Schema Therapy. The ideas of Bowlby and Ainsworth (as well as of other writers from the British Object Relations School, particularly Margaret Mahler and Donald Winnicott) are one of the three legs on which Schema Therapy stands, and the one which most clearly spells out the notion of needs. (The other two legs, to which we turn in later points, are CBT and experiential/emotion-focused approaches.)

Some of the theories that speak strongly about needs (including, for example, Maslow’s hierarchy model as well as attachment theory) give certain needs “privileged” status – viewing them as more basic or fundamental. For example, attachment theory assumes that if attachment security needs are not attained, other (later) needs will be impeded. Schema Therapy avoids making assumptions such as these regarding a “hierarchy” or a gradient of importance. Instead, core needs are all seen as essential and universal, especially in the lives of adults.

A final point about needs as a feature of Schema Therapy: educating patients about needs in general, and about their own unmet (as well as met) needs, can be quite a powerful intervention in its own right. Being told (as many of our patients are) that they are needy, not greedy, and that the therapy is aimed at helping them get their needs met, helps provide a nonjudgmental view of the past and a focused, optimistic view of the future.

2

Early maladaptive schema development as a consequence of unmet needs

The concept that gives Schema Therapy its name is of course the schema, a word of Greek origin (σχημα) that refers to a pattern or an organizing framework which helps create order in a complex set of stimuli or experiences. Schemata (or as they’re more commonly referred to, schemas) have a rich history in a variety of fields, including philosophy, computer science, set theory, and education, to name a few. In psychology, schemas were first introduced in the cognitive/developmental literature, and from there, made their way into cognitive therapy (Beck, 1972).

In cognitive developmental research, the concept of schemas refers to patterns imposed on reality or experience to help individuals explain it, to mediate perception, and to guide their responses. A schema is an abstract representation of the distinctive characteristics of an event, a kind of blueprint of its most salient elements. Within cognitive psychology, a schema can also be thought of as an abstract cognitive plan that serves as a guide for interpreting information and solving problems. Thus we may have a linguistic schema for understanding a sentence or a cultural schema for interpreting a myth. The term “schema” in psychology is probably most commonly associated with Piaget (e.g., 1955), who wrote in detail about schemata in different stages of childhood cognitive development, and with Bartlett (1932), who originated the use of this term and demonstrated the roles of schemata in learning new information, as well as in recalling memories.

Moving from cognitive psychology to cognitive therapy, Beck referred in his early writing (e.g., 1972) to schemata. Yet the idea that schemas, or broad organizing principles, exist in every person’s life and guide the person in making sense of their own life is inherent in many approaches to therapy, cognitive or otherwise. Likewise, many theorists would agree that schemas are often formed early in life, but continue to be elaborated and developed over the lifespan. Also common to many approaches is the notion that schemas, which might have accurately captured earlier life experience, are often brought to bear in current life situations for which they are no longer applicable. In fact, that is exactly what cognitive and developmental psychologists would have predicted – that schemas would operate in a way that maintains our sense of cognitive consistency. That is how schemas function – they serve as shortcuts, bringing us quickly towards what we think is likely to be true and saving us the need to carefully process every detail we encounter. In some cases, schemas or shortcuts are quite efficient in helping us reach a fairly accurate grasp of the situation. But in others, they paint quick-and-dirty pictures for us that are inaccurate and distorted. In either case, they help us maintain a stable view of ourselves and our world – whether that stable view is accurate or inaccurate, adaptive or maladaptive.

Stability and predictability sound like good qualities to have, and they very well could be in some instances. For example, one kind of schema – mental scripts – helps us anticipate how one step (e.g., the main course) is going to follow another (e.g., the appetizer) so that we can handle being in an entirely new place (e.g., an unknown restaurant, even one in a foreign country where we do not speak the language) while still keeping our bearings. Even when a schema is not entirely accurate, it may, in some instances, still be harmless. For example, another kind of schema – group stereotypes – can lead us to respect a new acquaintance or to assume her to have some outstanding capacity, solely on the basis of her race, gender, country of origin, etc.

Yet some schemas – especially ones acquired as a result of toxic childhood experiences and related to the self and the interpersonal world – can be pernicious in their effects. Schemas such as these, which we label early maladaptive schemas are the focus of Schema Therapy, and are at the core of personality disorders, relational difficulties, and some Axis I disorders.

Young, Klosko, and Weishaar (2003) provided the following comprehensive definition of an early maladaptive schema:

• A broad, pervasive theme or pattern
• Comprised of memories, emotions, cognitions, and bodily sensations
• Regarding oneself and one’s relationships with others
• Developed during childhood or adolescence
• Elaborated throughout one’s lifetime, and
• Dysfunctional to a significant degree.

In other words, early maladaptive schemas are self-defeating emotional and cognitive patterns that begin early in our development and repeat throughout life. Note that according to this definition, an individual’s behavior is not part of the schema itself – instead, maladaptive behaviors are thought to develop as logical responses to a schema. Thus, behaviors are driven by schemas, but are not part of schemas. Many behaviors reflect the way we cope with schemas – and we discuss them in detail when we address coping styles in Points 4–7.

Early maladaptive schemas (which we will refer to simply as schemas from now on) emerge from toxic early experiences – ones in which a young person’s needs were profoundly not met. Most early needs (e.g., the need for safe and secure attachment, the need for nurturance) are present in their strongest form within a young child’s nuclear family. For this reason, problems within the close family unit are usually the primary origin of early maladaptive schemas. The schemas that develop earliest and are closest to a person’s core typically originate in the nuclear family. To a large extent, the dynamics of a child’s family are the dynamics of that child’s entire early world. When patients find themselves in adult situations that activate their early maladaptive schemas, what they usually are experiencing is a drama from their childhood, usually with a parent.

Other arenas that become increasingly important as the child matures include one’s peers, extended family, school, groups in the community, and the surrounding culture. Toxic experiences in these arenas – that is, experiences in which core emotional needs go unmet – may also lead to the development of schemas. However, schemas developed at later ages are generally not as pervasive or as powerful as ones developed early on, in the close family arena. This may be because of the nature of those needs directed towards the family; it could also be because of the longer duration of contact between a child and their family of origin (compared with most peer, school, or neighborhood contacts).

We have observed four types of early life experiences that foster the acquisition of schemas. The first is toxic frustration of needs. This occurs when the child experiences “too little of a good thing,” and acquires schemas that reflect deficits in the early environment. The child’s environment is missing something important, such as stability, understanding, or love – and that lack becomes a permanent presence in the child’s mind.

A second type of early life experience that engenders schemas is traumatization. Here, the child is harmed or victimized, and develops schemas that reflect the presence of danger, pain, or threat. The core emotional need for safety is unfulfilled; worse, it is directly challenged, often leading to schemas marked by mistrust, hypervigilance, anxiety, and hopelessness.

In a third type of experience, the child experiences “too much of a good thing”: the parents provide the child with too much of something that, in moderation, is healthy for a child. With schemas of this sort, the child is almost never mistreated, but instead, is coddled or indulged. The child’s core emotional needs for autonomy or realistic limits are not met. Thus, parents may be overly involved in the life of a child, may overprotect a child, or may give a child an excessive degree of freedom and autonomy, without any limits.

The fourth type of life experience that creates schemas is selective internalization or identification with significant others. The child selectively identifies with, and internalizes, the thoughts, feelings, experiences, and behaviors of an influential adult, usually a parent. One way to think of this process is as modeling – parents or other adults modeling for the young child how they are in the world. Some of these identifications and internalizations can become schemas, when the learning that occurs fails to meet core emotional needs in the observing child. For example, a young girl raised by a hypervigilant, overly anxious mother may not experience any direct deficit, trauma, or over-indulgence, but is being taught that the world is dangerous or unmanageable. In an indirect manner, she is deprived of a secure base – not because of a weak parent–child bond, but because the parent herself feels insecure.

Other factors, beyond early environment, can play an important role in the development of schemas. These can include the child’s emotional temperament, as well as the cultural context within which the child and the family live. Schemas ultimately emerge from the interaction of a child’s temperament with his formative environment. Among the various temperamental vulnerabilities are biased/deficient information processing, emotion dysregulation, or disrupted interpersonal behavior. Schemas may emerge even in individuals without temperamental vulnerability, if faced with particularly toxic family environments or harsh life circumstances; however, the greater the temperamental vulnerability, the less environmental contribution needed.

Schemas create a sense of cognitive consistency – of a world that is predictable (if not controllable). And because people strive for this sort of predictability, schemas prove to be very durable; in a sense, schemas fight for their own survival. Our schemas are what we know – even if they torment us, they do so in ways that are somewhat familiar and comforting. They feel “right.” Cognitively, schemas draw our attention to information that is consistent with the schema itself, and make us remember things in ways that “fit” with the schema. Behaviorally, they lead us to be drawn to certain familiar events. These cognitive and behavioral processes are responsible for schema maintenance – the self-perpetuating way in which long-established schemas keep a stronghold on our sensibility, influence how we think, feel, act, and relate to others, and paradoxically lead us to inadvertently recreate in our adult lives the conditions in childhood that were most harmful to us.

Schemas have their root in actual childhood or adolescent experience, and to a large degree, accurately reflect the tone of a person’s early environment. For example, if a patient tells us that his family was cold and unaffectionate when he was young, he is usually correct, even though he may not understand why his parents had difficulty showing affection or expressing feelings. His attributions for their behavior may be wrong, but his basic sense of the emotional climate and how he was treated is almost always valid. Importantly, these early environments are ones over which the young child or adolescent has little influence – they are not the ones who create the particular emotional climate; instead, they are the ones whose needs are not met.

Later in life, schemas become dysfunctional because (a) cognitively and emotionally, they render all new situations, even ones that are profoundly different from the toxic early experiences, similarly toxic (even when in reality they are not), and (b) behaviorally and interpersonally, they lead the person to maintain particular types of environments or relationships, even when they can exert influence or choice and create other kinds of experiences.

Early maladaptive schemas, and the maladaptive ways patients learn to cope with them, often underlie chronic Axis I symptoms such as anxiety, depression, substance abuse, and psychosomatic disorders. They also underlie chronic Axis II symptoms such as dependence, avoidance, attention seeking, or perfectionism. Schemas are cognitive-affective traits, and as such, are dimensional: each exists on a...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Introduction
• Part 1: Theoretical Points
• Part 2: Practical Points
• References