Schema Therapy: Working with Complex Clinical Presentations and Personality-Based Problems

What is Schema Therapy? Schema Therapy (ST) is an integrative therapeutic model, with a strong relational emphasis, designed to address deeper level maladaptive schematic beliefs and interpersonal patterns that are not responsive to first-line therapeutic approaches.ST was initially developed as a treatment for ‘Personality Disorders’ and complex clinical problems. However, over the past 20 years, it has been further applied to an increasing range of clinical problems, and client groups.

More recently, the ST model has been adapted to working with couples, children and adolescents.ST draws on a range of therapeutic modalities, including psychodynamic, object relations, gestalt, person-centred and cognitive-behavioural (CBT), and is steeped in attachment and developmental theory and research.

The practice of ST is process-oriented, and utilises techniques from 4 main domains: experiential, interpersonal, cognitive and behavioural, as well as powerful experiential techniques (such as imagery rescripting, chair-work, and historical roleplay) designed to provide corrective emotional experiences that facilitate deeper level ‘core’ emotional growth and change.

A range of interpersonal strategies are also implemented through the ‘Limited Reparenting’ framework, aimed at providing an antidote to clients’ unmet needs from childhood within the boundaries of the therapeutic relationship, and cognitive techniques are used to challenge core beliefs at an intellectual level, through unpicking the evidence associated with long-held schemata.

The use of behavioural change work aims to reduce maladaptive coping behaviours that reduce opportunities for interpersonal connection, whilst promoting healthy behaviours directed at getting emotional needs met, and all of these techniques are chosen and applied in accordance with an overarching systematised theoretical model, based on the premise that a state of emotional homeostasis can only be reached once core emotional needs are consistently met in healthy ways.

When to consider Schema Therapy

ST is particularly helpful for those whose difficulties have become entrenched or chronic, and who experience enduring attachment-based patterns that hinder the effectiveness of standard therapeutic approaches.

Those with problems linked to characterological or lifelong difficulties tend to describe more rigid cognitions and coping behaviours, whilst deriving minimal benefit from conventional therapeutic techniques (e.g., identifying thoughts and emotions, completing thought records and homework assignments).Furthermore, those with more entrenched difficulties tend to experience a more significant gap between intellectual & emotional change.

Whilst cognitive challenging can lead to intellectual change, at an emotional level their problems may remain entrenched and ego-syntonic (e.g. I understand intellectually that I am not unlovable, but I still feel unlovable). 

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