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

Susan Simpson, a Consultant Clinical Psychologist working for the Regional Eating Disorders Unit at St. John's Hospital in Lothian, provides an introduction to Schema Therapy.

19 January 2018

By Guest

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). 

Schema Therapy: What’s the evidence? 

Schema Therapy has demonstrated effectiveness within randomized controlled trials as a treatment for Borderline Personality Disorder (e.g. Farrell, Shaw and Webber, 2009Giesen-Bloo et al., 2006Nadort et al., 2009) as well as Cluster C and Narcissistic PDs (Bamelis et al., 2014).

Preliminary evidence also supports the use of Schema Therapy with chronic depression (Carter et al., 2013Renner et al., 2016), chronic and complex anxiety disorders (Hawke & Provencher, 2011); eating disorders (Simpson, Morrow, van Vreeswijk & Reid, 2010(link is external)McIntosh et al., 2016), ruminative disorders (Thiel et al., 2016), substance misuse, alcohol dependence (Kersten, 2012Straver, 2017), and forensic populations (Bernstein et al., 2012).

A list of reviews that synthesise the recent growth in evidence across a range of psychological disorders can be found at

Schema Therapy training options

Training is available from six ST training programs across the UK, all of which have been accredited by the International Society for Schema Therapy (ISST).

Details can be found at:

Workshops can be attended as stand-alone training, or as part of a standard or advanced accreditation program. Accreditation also incorporates 20-40 sessions of specialist supervision, feedback and ratings on treatment fidelity.

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