Schema Therapy: How It Works & What to Expect

What Is Schema Therapy & How Does It Work?

Schema therapy is a form of psychotherapy that helps people who may not experience benefit from other forms of therapy. For those with longstanding, negative patterns of thinking and acting, schema therapy encourages them to recognize and dispute these themes (called schemas or lifetraps) to feel better and function well in society.²

The basis of schema therapy involves the power of the early maladaptive schema, sometimes called EMS or simply schema, to create a harmful influence on the person’s life.² With more powerful or significant schemas, people will struggle to see themselves, others, and the world around them in objective and fair ways.³ Due to the flawed ways of thinking and perceiving, a person will be prone to numerous unwanted effects of mental health conditions, poor relationships, and overall instability in life.

Schema Therapy Phases

No matter the condition, schema therapy is separated into two phases:³

1. Assessment & education phase: The therapist helps the person identify their schemas, where they come from, and the schema mode. Next, the therapist works to help the client notice their unhelpful coping styles, how these continue to maintain their schemas, and when they flip from one mode to another.
2. Change phase: By implementing a combination of cognitive, experiential, behavioral, and interpersonal techniques, the therapist aims to challenge and dispute schemas in place. When a schema is challenged and found to be false, it will have a less impactful influence.

What Are Schemas?

Schemas are the themes and patterns at the core of people that create self-defeating thoughts, feelings, and behaviors, repeating and growing during someone’s life.⁴ The schemas fit into five domains that represent a core component of the person’s needs.

The five schema domains are:⁴

1. Disconnection and Rejection

The disconnection and rejection domain is based on the idea that the client’s desire for love, safety, stability, acceptance, and respect will not be met by family members and caretakers. People with issues in this schema domain may have family members who are detached, cold, unpredictable, and abusive.

The schemas within this domain are:⁴

• Abandonment and instability
• Mistrust and abuse
• Emotional deprivation
• Defectiveness and shame
• Social isolation and alienation

People with these issues feel that they do not fit in their family or society. They cannot rely on others for support or assistance.

2. Impaired Autonomy and Performance

In the impaired autonomy and performance domain, people believe they cannot function well and succeed independently. Family members and caretakers will typically point out flaws, undermine their successes, or act in overprotective ways, which stifles the child’s confidence and self-assurance.

The schemas within the impaired autonomy and performance domain are:⁴

• Dependence and incompetence
• Vulnerability to harm and illness
• Enmeshment and underdeveloped self
• Failure

Without feeling capable in their acts and abilities, the person will be too afraid to embark on new challenges or will fail to perform well in their current undertakings. The people around them will discourage them or mock them for trying in the first place.

3. Impaired Limits

The domain of impaired limits relates to the person’s ability to establish healthy limitations and boundaries with other people. This issue leads to problems respecting others, cooperating with different people, following through with commitments, and meeting long-term goals.

The family influence will come from a place of permissiveness, overindulgence, lack of direction, and a feeling of superiority. This impact will result in the child being unable to tolerate normal stress or recognize their shortcomings.

The schemas specific to the impaired limits domain include:⁴

• Entitlement and grandiosity
• Insufficient self-control and self-discipline

People struggling with this schema domain will have overly inflated self-esteem with feelings of grandiosity. They could also lack a sense of responsibility for their actions, and engage in overtly selfish behaviors.

4. Other-Directedness

On the other side of the spectrum is the domain of other-directedness, where a person is more focused on selflessness rather than selfishness. As with other extremes, too much selflessness can result in problems in the short and long-term.

The family of origin offers only conditional love and acceptance, so the person learns to suppress and replace their wants and needs for the wants and needs of others. In these families, the parents’ are the focus, instead of the children.

The schemas linked to the other-directedness domain are:⁴

• Subjugation – surrendering control of needs and emotions to others
• Self-sacrifice
• Approval-seeking and recognition-seeking

The person will appear generous and giving but to a fault. They will expend all of their physical and emotional resources doing for others before meeting any of their own needs, leaving nothing left for themselves.

5. Over Vigilance and Inhibition

The over vigilance and inhibition domain is based on the tendency of the person to suppress and restrict their impulses to meet their expectations of performance and behavior. They will sacrifice their happiness and health along the way.

Family will create hypervigilance and inhibition by being demanding and pessimistic. Here, issues of duty, performance, and avoiding mistakes is key.

The specific schemas related to this domain include:⁴

• Negativity and pessimism
• Emotional inhibition
• Unrelenting standards and hypercriticalness
• Punitiveness

The person in this situation will seem tense, anxious, and frequently worried. They will judge themselves harshly and believe that others who make mistakes should be judged harshly as well.

Maladaptive Coping Skills Outlined in Schema Therapy

Schema therapy pays particular attention to coping skills a person used as a child and uses in the present. People who react positively can avoid unwanted schema, and people with negative coping skills will only produce problems.³ As a reaction to stress and danger, a person’s reaction is to fight, take flight, or freeze. Schema therapy views overcompensation as the fight, avoidance as the flight, and surrendering as the freeze.³

Three maladaptive coping styles outlined in schema therapy include:³

1. Overcompensation

In overcompensation, the person attempts to fight back against the schema by thinking, acting, and feeling like the schema is not true. The person may take it further to say the opposite of the schema is more accurate. On the outside, they may seem confident and capable, but under the surface, they are struggling to feel good about themselves. This person is still controlled by their schema because they go too far in trying to deny it.

2. Avoidance

Through avoidance behaviors, the person will try to organize and shift their life so they never have to activate their schema. As the schemas push closer to the surface, people will go to great lengths to avoid their feelings. They may engage in substance use, risky sex, overeating, compulsive behaviors like cleaning or gambling, or overworking.

3. Surrender

When people surrender as a maladaptive coping skill, they fully understand the connection and feel the associated pain. Their reaction when triggered by the schema is intense and disproportionate to the stimuli. Additionally, they will place themselves in situations at school, work, or home that act as a continuation of the established schemas, so the same patterns play out into adulthood.

What Are Schema Modes?

The way a person is feeling and coping at any given moment is their schema mode. Schema modes are constantly shifting and changing.³ Each person’s schemas are different, with some being dormant while others are quite active and controlling. People will “flip” between schema modes at various times during the day and experience both functional and dysfunctional schema modes.

Dysfunctional schema modes present when an unhelpful schema is paired with a maladaptive coping skill. It’s important to note, though, that all schema modes fall on a continuum, so some will be more dysfunctional than others.³

There are 10 schema modes that are separated into four broad categories:³

1. Child modes:
   • The vulnerable child
   • The angry child
   • The impulsive/ undisciplined child
   • The happy child
2. Dysfunctional coping modes:
   • The compliant surrenderer
   • The detached protector
   • The overcompensator
3. Dysfunctional parent modes:
   • The punitive parent
   • The demanding parent
4. Healthy adult mode, which is the goal mode.

The goal of schema therapy will be to have the client and therapist work to identify the current or recent modes to shift towards healthier, more functional modes.

What Can Schema Therapy Help With?

Schema therapy’s goal is to help people recognize and treat their emotional needs.

Schema therapy can help treat emotional needs by helping the client:⁴

• Stop using maladaptive coping skills
• Stop using schema modes that block contact with true feelings
• Repair schemas and modes by working to meet needs in and out of the therapy relationship
• Establish reasonable limits for anger, impulsivity, and overcompensating
• Resist and combat punitive, critical, and demanding schemas and modes
• Create and nurture healthy schemas and modes

The types of mental health disorders and diagnoses that may be successfully treated with schema therapy are broad.

Researchers have found the schema therapy to be effective for:

Schema Therapy for Personality Disorders

Personality disorders like borderline personality disorder and avoidant personality disorder are more persisting and long lasting conditions, so schema therapy is a great option to address the long-term impacts of the condition. Studies show that schema therapy is effective for treating all personality disorders by reducing the effect of schemas at the end of sessions and at future follow ups.²

Schema Therapy for Eating Disorders

Bulimia, anorexia, and other eating disorders can result in serious physical and mental health consequences to the individual. According to several studies, schema therapy is helpful in improving body mass index and reducing the severity of schemas related to disordered eating.²

Schema Therapy for Agoraphobia

People with symptoms of panic and agoraphobia may struggle for long periods before finding helpful treatments that allow them to routinely leave their home. With the use of schema therapy, these people can expect a reduction of overall symptoms and schema ratings. Studies show best results with a combination of schema and cognitive behavioral therapies.²

Schema Therapy for Depression

Chronic depression may make people feel hopeless and that not treatments will create benefit. One study found that schema therapy can make a significant improvement in depressive symptoms, but interestingly, the effects were not immediate. At the end of treatment, the improvements were minor, but when the researchers completed follow up assessments, larger benefits were found.²

Schema Therapy for Post-Traumatic Stress Disorder (PTSD)

Schema therapy appears to provide substantial benefit to people with PTSD with notable improvements from intake to follow up contact months after treatment ends.²

Schema Therapy Techniques

Schema therapy involves several techniques that are unique to this therapeutic intervention.

Some of the techniques you might encounter during schema therapy include:⁵

Emotive Techniques

Experiential activities are often used to draw out emotions during sessions and provide an opportunity to work through them utilizing imagery, role-play and chair work. In chair work, for example, the client will physically move between two chairs as they create a dialogue by taking on the roles of two different parts of self, perhaps the schema side and the healthy side. This technique is also often used as a chance for the client to find closure or practice assertiveness by utilizing the empty chair to talk to imagined significant others in the person’s life.

Interpersonal Techniques

Interpersonal work is emphasized in schema therapy. This important work is done in the context of the therapist-client relationship. Limited reparenting is one technique utilized in schema therapy in which the therapist reparents the client, offering the warmth, nurturing, firmness, playfulness or healthy limit setting that the client did not receive during childhood.

Cognitive Techniques

There are many cognitive techniques employed in schema therapy. The schema diary is one cognitive technique that is often utilized. This involves recording moments throughout the week when schemas or modes are activated, and working through a written reflection that examines the related thoughts, feelings, behaviors and reactions. Therapists often provide a schema diary form for the client to complete in between sessions as a way of furthering their self-awareness.

Behavioral Techniques

Behavioral techniques that may be used in schema therapy widely vary depending upon the client’s schemas and modes. For example, a client might engage in assertiveness training to overcome the compliant surrenderer, empathy training for entitlement schemas and modes, or exposure tasks to overcome avoidance modes. The goal is to change the behavior patterns resulting from your coping style.

Benefits of Schema Therapy

Some of the benefits of schema therapy include:^6,7

• Addresses unmet emotional needs
• Helps clients adjust negative patterns of behavior
• Instills healthier coping skills
• Increases emotional awareness

Is Schema Therapy Effective?

Schema therapy may not be as widely-known or well-researched as CBT, but the treatment is proven effective for a variety of long-term mental health issues and complications.

Schema can improve schemas and coping skills for people with:²

• Borderline personality disorder
• Other personality disorders like avoidant personality disorder
• Eating disorders
• Anxiety disorders
• Depression
• PTSD

In the coming years, professionals and clients should expect to be able to learn more about the efficacy of schema therapy as the treatment receives more attention and testing. Currently, the full capabilities of schema therapy are not well understood.

Criticisms & Limitations of Schema Therapy

Perhaps the most significant criticism or drawback of schema therapy is how new the treatment is. In the field of psychology, the most well-known and respected treatments have been around for between 60 and 160 years, so schema therapy is somewhat unproven after only 30 years.³

For people only interested in a large body of evidence-based research to support a therapy style, schema therapy does not yet have the backing to put it on the same level as others like CBT.

Schema Therapy Examples

All schema therapies will focus on assessing and changing schemas. By completing this process, the client can find new happiness and freedom from the influence of unwanted childhood experiences.

Schema Therapy With Borderline Personality Disorder

Borderline personality disorder is a serious mental health disorder marked by chaotic, intense, and inconsistent relationships where the individual commonly fears a threat of abandonment.⁸ Treatment will start in the assessment and education phase by ensuring the person understands their diagnosis and works to learn about schemas in play.

If the person fears rejection and instability in relationships, the therapist will likely focus on the disconnection and rejection schema domain. By searching for examples of love, acceptance, and nurturance, the therapist and client can work to combat the negative pattern of thinking.

Schema Therapy for Post-Traumatic Stress Disorder

Schema therapy with PTSD symptoms will begin with a period of assessment and education. By investigating the nature of the trauma, the timing of the trauma, and the schemas that interact with the trauma, the therapist will build a conceptualization of the client’s symptoms.

During this period, the schema therapist will inform the client about schema therapy, the effects of schema, and common effects of trauma. They will also emphasize connections between the trauma and the client’s childhood.

Since a person with symptoms of PTSD may experience issues within the domains of disconnection and rejection as well as over vigilance and inhibition, the therapist will examine present schemas and coping skills. The client may prefer to isolate and avoid as their primary coping skill, so the therapist will push them towards changing their behaviors through a slow and steady progression.²

Schema Therapy for Depression

Chronic, low-grade depression, like that found in persistent depressive disorder, can make life feel like a never-ending cycle of pain, doubt, and unhappiness.⁸ People with this condition will be great candidates for schema therapy.

After the assessment and education phases, the schema therapist will work to illustrate to the client the connections between their childhood, their parents, their schema, and their depression. As people with depression seek out maladaptive coping skills to manage their symptoms, the client may have issues within the other-directedness domain. They may give and give to others as a way to create bursts of happiness, but these feelings will be fleeting.

The therapist will point out how being more selfish as times can improve the client’s mental health and well-being. The therapist will also prepare the client for the possible negative reactions from people who normally take advantage of the client’s kindness. With communication, behavioral, and cognitive skills learned from the therapist, the client will control and shift their schemas.

How to Find a Schema Therapist

People interested in therapists offering schema therapy directly may find it challenging to locate providers through common means like asking the family doctor or local mental health agency for a referral. Schema therapists will not be as common as CBT practitioners.

The International Society of Schema Therapy offers a directory. If that does not yield any success, consider typing “schema therapist near me” into an online therapist directory, or ask your primary care provider for a referral.

Who Is Able to Offer Schema Therapy?

Any therapist can claim to use schema therapy as their primary approach, but their credentials and experience may be lacking. Schema therapists will have at least a masters degree in counseling, social work, psychology, or a related field, specific training, and frequent supervision in the practice of schema therapy.

Key Questions to Ask a Therapist Before Beginning Schema Therapy

With any therapist, it is helpful to prepare a list of questions before treatment begins or during the first session. Good questions to ask a schema therapist include:

• What are your experiences and credentials as a schema therapist?
• Is schema therapy a good fit for my symptoms?
• I don’t want to talk about the past. Can schema therapy help me?
• How long will I need to attend schema therapy?
• What, if any, other psychotherapy orientations do you utilize in sessions?

Cost of Schema Therapy

Schema therapy is a widely-recognized form of psychotherapy that integrates other styles and orientations into sessions, which means insurance will typically cover its use. People with high deductibles or no insurance may have to pay an average therapy cost of $50 to $150 for one session.⁹

Professionals with higher levels of education may charge higher rates, with psychiatrists and psychologists being more expensive than social workers and counselors. Some providers who are especially renowned may charge higher for their services and might not accept insurance coverage.

What to Expect at Your First Appointment

The first session (or several sessions) of schema therapy will likely involve a lot of assessment and psychoeducation. Depending on the therapist and their particular style, they could accomplish this by completing an informal interview of your presenting problems and symptoms, or the therapist could use a formal assessment tool like the Young Schema Questionnaire (YSQ), the Young-Atkinson Mode Inventory, or the Schema Mode Inventory.²

From the earliest sessions, the therapist will employ empathic confrontation and limited reparenting to improve symptoms.³

• Empathic confrontation: Offering support and encouragement for the client while showing that their schemas are distorting client perceptions
• Limited reparenting: Supplying the client with what the client never received from their parents, within the appropriate limits of the therapeutic relationship

The History of Schema Therapy

Jeffrey Young began as a therapist using a cognitive therapy or cognitive behavioral therapy (CBT) model for treatment, but around 1990, he noted limitations to the treatment style. Although treatments worked really well for some people, others, like those with personality disorders, never seemed to make the progress he wanted.

Over years of theorizing and research, he began to develop the framework of schema therapy that took many aspects of CBT and blended it with the idea of “going deeper” that is fundamental to approaches like psychoanalysis. By taking helpful aspects of various established treatments, Young created something unique in schema therapy.

With schema therapy being a contemporary therapy style, it continues to grow and evolve under the mentorship of its creator. As awareness and acceptance builds, Young hopes that schema therapy can be applied to more psychological concerns.