Is Schema Therapy effective?
There is growing evidence not only in our practice but also in large-scale international research studies, that Schema Therapy is effective in helping people with a range of difficulties. Schema Therapy is an integrative therapy, holding together in a coherent structure, theories and methods from a range of long-established, research-based therapies. However, Schema Therapy itself is a relatively young therapy, and so its research-base is still limited. Nonetheless, the evidence so far is encouraging; and the rapidly growing interest in Schema Therapy is being accompanied by an huge increase in studies into this approach.
Here’s what the research so far indicates.
Basic assumptions of the model
Nordahl et al.’s (2005) study supports the notion that schemas underpin psychological problems. They found that the strength of their 82 participants’ schemas was associated with personality level pathology and that modification of these schemas strongly predicted symptom relief at the end of treatment. Similarly, Wang et al. (2010) assessed 115 participants’ schemas and found that these significantly predicted concurrent depression severity and depressive episodes and severity 9 years later. Wang et al.’s study also suggests that schemas warrant our attention in treating depression.
Mood and anxiety disorders
Several authors have described how Schema Therapy can be effective in treating anxiety and mood disorders, especially if utilising schema mode work (e.g. Young & Mattila, 2002). Empirical evidence for this includes Wang et al.’s (2010) study above and a single case undertaken by (Morrison, 2000), which demonstrates positive outcomes for a woman who had complex, longstanding problems, that include a reduction in symptoms of depression and anxiety to normal levels.
In Cockram et al.’s (2010) study of 220 Vietnam war veterans, those diagnosed with Post Traumatic Stress Disorder (PTSD) had higher schema scores than veterans not diagnosed with PTSD, again suggesting the important role of schemas in the development or maintenance of PTSD. Their second study compared traumatised war veterans who received treatment that included Schema Therapy with those who completed a Cognitive-Behavioural programme that did not include Schema Therapy. Both groups had similar levels of schemas, and of symptoms of depression, anxiety, PTSD at the start of treatment. The scores for those receiving the former, on measures of symptoms of PTSD, anxiety, depression and 17 schemas, decreased significantly after treatment. PTSD and anxiety symptoms reduced more significantly for patients in this group compared to the group that did not receive Schema Therapy as part of their treatment.
The effectiveness of Schema Therapy has mainly been investigated for Borderline Personality Disorder (BPD). A large Dutch study (Giesen-Bloo et al., 2006) with 86 participants demonstrated significant reductions in BPD symptoms and psychological dysfunction, and an improvement in overall quality of life. These gains were greater than for matched patients who received Transference Focussed Therapy instead of Schema Therapy. Also, fewer patients dropped out of Schema Therapy than Transference Focussed Therapy, and both patients’ and therapists’ ratings of the quality of the patient–therapist relationship were higher in Schema Therapy than in Transference Focussed Therapy.
Studies have subsequently confirmed these positive effects. These include the study conducted by Nadort et al. (2009 b) of sixty-two patients who initially met the criteria for BPD. After 18 months of Schema Therapy, 42% of these participants no longer met the criteria for this diagnosis. Studies of Schema Therapy for other personality disorders also demonstrate encouraging results (e.g. Weertman & Arntz, 2007; Hahusseau & Pélissolo, 2006; and Zorn et al., 2007).
Some initial studies have been conducted on eating disorders and Schema Therapy. These include single case studies (e.g. Ohanian, 2002 and Simpson & Slowey, 2011) and larger scale studies (e.g. George et al., 2004). These demonstrate that Schema Therapy techniques are relevant to the treatment of eating disorders, supporting the theory that schemas are underlying psychological themes that give rise to eating disorders. In particular, Waller et al. (2000) identified four schemas that distinguished those with the eating disorders by comparing 50 women with an eating disorder with 50 women without. The schemas that were associated with eating disorders are: Defectiveness/Shame, Emotional Inhibition, Failure and Insufficient self-control. This study informs us with a deeper understanding of the psychological mechanisms of eating disorders and thus equips us to work more effectively with these.
Forensic & Psychopathic Populations
To date many have held a view that forensic populations are difficult to help. Notably, psychopaths have been labelled as untreatable. Their lack of empathy, emotional attachment to others and callousness were thought to preclude therapeutic exploration or change. This traditional view is now being challenged. David Bernstein and his team have been collecting data from 120 participants in a study evaluating the efficacy of Schema Therapy with psychopathic male populations. Their initial data suggests that psychopaths can benefit from Schema Therapy, however, the data are yet to be analysed formally. They are currently writing up a case study of one patient who initially met the criteria for psychopathic personality disorder. He received 4 years of Schema Therapy, in which his psychopathology reduced to a clinically significant degree. He was interviewed two years after treatment ended; in this, his emotional attachment to his therapist and capacity to express vulnerable emotions are clearly evident. This is an outcome that flies in the face of standard predictions for psychopathic patients.
Schemas and Adult Attachment Styles
Tünde recently completed her PhD research on schemas and adult attachment styles. Her findings point to the key schemas characteristic of Borderline Personality Disorder (BPD), anxiety disorders and mood disorders, enabling a better understanding of how to treat these presentations.
Her study evidenced:
- An association between schema severity and symptom severity in her patient groups
- That in participants with BPD, Abandonment, Mistrust/Abuse, Defectiveness, Social Isolation and Enmeshment/Underdeveloped self are the strongest schemas
- An insecure attachment style in all cases in her BPD group; i.e. these patients usually had a history of childhood trauma where the early needs for nurturing, protection and bonding were not adequately met
- In depressed participants: compared to healthy controls, significantly higher Negativity/Pessimism schema scores; and compared to healthy controls and anxious patients, significantly higher Emotional deprivation schema scores
- In anxious participants compared to healthy controls, higher Vulnerability to Harm schema scores
- That maladaptive schemas function as mediators in the relationship between insecure attachment styles and the development of psychopathology
If you are interested in exploring further the research supporting Schema Therapy, then visit www.isst-online.com/publications.
Brewin, C.R., Wheatley, J., Patel, T., Fearon, P., Hackmann, A., Wells, A., Fisher, P., & Myers, S. (2009). Imagery rescripting as a brief stand-alone treatment for depressed patients with intrusive memories. Behaviour Research and Therapy, 47, 569-576.
Cockram, D.M., Drummond, P.D., & Lee, C.W. (2010). Role and treatment of early maladaptive schemas in Vietnam veterans with PTSD. Clinical Psychology and Psychotherapy, 17, 165-182.
George, L., Thornton, C., Touyz, S.W., Waller, G. & Beaumont, P.J. (2004). Motivational enhancement and schema-focussed cognitive behaviour therapy in the treatment of chronic eating disorders. Clinical Psychologist, 8(2), 81-85.
Giesen-Bloo, J., Dyck, R. van, Spinhoven, P., Tilburg, W. van, Dirksen, C., Asselt, T. van, Kremers, I., Nadort, M., & Arntz, A. (2006). Outpatient psychotherapy for borderline personality disorder, randomized trial of schema-focused therapy vs transference-focused psychotherapy. Archives of General Psychiatry, 63, 649-658
Hahusseau, S., & Pélissolo, A. (2006). Young’s schema-focused therapies in personality disorders: a pilot study [Thérapies comportementales et cognitives centres sur les schemas de young dans les troubles de la personnalité : étude pilote sur 14 cas]. Encephale, 32, 298-304.
Morrison, N. (2000). Schema-focused cognitive therapy for complex long-standing problems: a single-case study. Behavioural and Cognitive Psychotherapy, 28, 269-283.
Nadort, M., Arntz, A., Smit, J.H., Giesen-Bloo, J., Eikelenboom, M., Spinhoven, P., van Asselt, T., Wending, M., & van Dyck, R. (2009 b). Implementation of outpatient schema therapy for borderline personality disorder with versus without crisis support by the therapist outside office hours: A randomized trial. Behaviour Research and Therapy, 47, 961-973.
Nordahl, H.M., Holthe, H., & Haugum, J.A. (2005). Early maladaptive schemas in patients with or without personality disorders: does schema modification predict symptomatic relief? Clinical Psychology and Psychotherapy, 12, 142-149.
Ohanian, V. (2002). Imagery rescripting within cognitive behaviour therapy for bulimia nervosa: an illustrative case report. International Journal of Eating Disorders, 31, 352-357.
Simpson, S.G., & Slowey, L. (2011). Video therapy for atypical eating disorder and obesity: A case study. Clinical Practice and Epidemiology in Mental Health, 7, 38-43.
Vanko, T. (2012). Attachment and early maladaptive schemas in specific psychological disorders. Unpublished Doctoral Dissertation. University of Pécs.
Waller, G., Ohanian, V., Meyer, C., & Osman, S. (2000). Cognitive content among bulimic women: The role of core beliefs. International Journal of Eating Disorders, 28, 235-241.
Wang, C.E., Halvorsen, M., Eisemann, M., & Waterloo, K. (2010). Stability of dysfunctional attitudes and early maladaptive schemas: A 9-year follow-up study of clinically depressed subjects. Journal of Behavior Therapy and Experimental Psychiatry, 41, 389-396.
Weertman, A., & Arntz, A. (2007). Effectiveness of treatment of childhood memories in cognitive therapy for personality disorders: A controlled study contrasting methods focusing on the present and methods focusing on childhood memories. Behaviour Research and Therapy, 45, 2133-2143.
Young, J.E. & Mattila, D.E. (2002). Schema-focussed therapy for depression, in Comparative Treatments of Depression (eds M.A. Reinecke and M.R.Davison). New York: Springer, pp. 291-316.