Schema Therapy

An introduction by David Edwards

The cognitive aspect of CBT is about changing problematic personal meanings.

Often, when we work with cognitive restructuring, the client tells us, “I can see it rationally but I just don’t feel it.” This is usually because of the way the brain is structured: there’s one system that is language-based, and rational and linear (the explicit or propositional system), and another system that  is holistic and based on sensory and emotional experiences (the implicit or episodic system). 

When we do rational analysis and reality testing, we mostly only impact the propositional system.  However, problematic emotions and behaviours usually have their origin in the episodic system, which is already running at birth and, among other things, encodes patterns based on attachment experiences.  

When there is insecure or disorganised attachment, these patterns are disturbed, and we call them early maladaptive schemas (EMSs). 

They arise when the normal needs of a human infant and small child are not properly met either because of neglectful or abusive parenting or adverse events such as maternal depression or the death of a parent.

Schema therapists recognise 18 EMSs and their themes are common in clients’ problematic automatic thoughts: 

• “I’m alone and no-one cares” (Emotional Deprivation)
• “As soon as you get close, they leave” (Abandonment)
• “People just want to get the better of you” (Mistrust/Abuse)
• “There’s something wrong with me, I’m never good enough” (Defectiveness/Shame)
• “I have to do my very best at all times” (Unrelenting Standards).

If those don’t shift with rational analysis, we probably need to find a way to effect change in the underlying episodic memory system where they are encoded. 

How do we do this?

Schema therapists use emotion-focused techniques to activate the underlying schemas and then employ imagery re-scripting to provide corrective experiences.

The memories in which these beliefs are embedded are usually interpersonal – they are memories of a child whose needs are not being met. This means providing corrective experiences in which the child’s needs are met – whether the need for nurturing care, for empathic understanding, for protection from mistreatment or for guidance and support for the development of autonomy. 

The child in the memory needs to be re-parented to counteract the failure of the parents to meet the child’s needs in the first place.

Finding new roles

In the re-script, the role of parent is taken by the therapist, or the client’s adult self or by other caring people in the client’s life. The therapist also offers a warm re-parenting relationship to the client throughout the therapy process – in contrast to the more functional and business-like relationship we find in some CBT approaches.

Schema therapists use all the evidence-based CBT interventions, but when these don’t work, we move to working at the early schema level.

In due course, clients are ready to work with cognitive and behaviour change again – a phase we call behavioural pattern breaking.  

Schema therapy is a system that integrates relational work and emotion-focused work – often using imagery and chairwork – with cognitive and behavioural methods.

By accessing the implicit meaning system and understanding the problematic patterns embedded there, it provides an approach to conceptualising cases that can guide treatment decisions in working with complex cases where there are, for example, personality disorders and a history of childhood neglect and/or trauma.