Schema-focused therapy for borderline personality disorder (BPD) is a type of psychotherapy that focuses on identifying and changing specific unhealthy ways of thinking. The therapy includes some elements that are traditional parts of cognitive-behavioral therapy (CBT) but also includes some elements of other types of psychotherapy.
Childhood Needs and Maladaptive Schemas
The theory underlying schema-focused therapy presumes that when our basic childhood needs (such as needs for safety, acceptance, and love) are met inadequately, we develop unhealthy ways of interpreting and interacting with the world, which is called maladaptive early schemas.
Schemas are broad and pervasive patterns of thinking and behavior. These are more than just beliefs; schemas are deeply held patterns that are closely related to our sense of self and view of the world.
Schema theory proposes that schemas are triggered when events happening in our current life resemble those from our past that were related to the formation of the schema. If we have developed unhealthy schemas because of difficult experiences in our childhood, we will resort to unhealthy ways of thinking and behave in response to this new situation.
Schema theory proposes that many of the symptoms of BPD are caused by difficult childhood experiences (such as maltreatment or early separation from caregivers), which lead to the formation of maladaptive early schemas.
Examples
In order to understand how schema therapy works, it is helpful to look at some of the unhealthy early schemas people may have and the issues they may later cause.
A few examples of maladaptive schemas include:
- Defectiveness / Shame: People who believe that they are fundamentally unloveable may sabotage their relationships because they are afraid of being abandoned.
- Emotional Deprivation: People who believe that other people will not meet their needs may end up in relationships with people who are emotionally neglectful.
- Social Isolation: People who hold a schema that they are separate or unaccepted in the world may isolate themselves from others.
- Enmeshment: People who hold a schema that they cannot be happy or successful without the support of other people, often family members, may become overly dependent on their loved ones. They may lack a sense of direction, autonomy, and individuality.
Not everyone responds to early schemas in the same ways. Schema therapy suggests that there are three primary coping styles that people use to deal with these beliefs.
- Surrender causes people to engage in behaviors that reinforce their existing beliefs.
- Avoidance leads people to try to avoid any situation that triggers feelings of fear or vulnerability.
- Overcompensation involves engaging in behaviors that act in opposition to the belief, often to an extreme degree.
Goals
The initial goals of schema-focused therapy for borderline personality disorder are to identify the patient’s relevant schemas and to link these schemas to past events and current symptoms.
Following this initial work, the therapist and patient then work on ways of processing emotions related to the schemas and altering unhealthy coping styles that are the result of maladaptive schemas (unhealthy schemas that could be causing symptoms in BPD). For example, the therapist and client may conduct exercises focused on venting anger, breaking unhealthy patterns of behavior, and changing unhelpful ways of thinking.
Research Support
While there has not yet been extensive research on schema-focused therapy, one study has been published to date which suggests that patients randomly assigned to receive schema-focused therapy had significantly larger reductions in borderline personality disorder symptoms than those assigned to receive psychodynamic therapy. While this is preliminary evidence of the effectiveness of schema-focused therapy, it suggests that this therapy shows promise in treating BPD.
In addition, an analysis of multiple research studies on psychological therapy for borderline personality disorder also concluded that schema-focused therapy appears effective, but the authors also said more research is needed.
How to Find a Schema Therapist
Finding a qualified professional who has experience with schema therapy can be a challenge, but there are resources that can help. You might start by looking for therapists in your area who specialize in cognitive-behavioral therapy (CBT). Because schema therapy uses many of the same techniques as CBT, these therapists may also have experience with both approaches.
The International Society of Schema Therapy also provides a directory of therapists, or you can utilize the American Psychological Association’s therapist finder to look for providers in your area.
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Schema therapy is a newer type of therapy that combines elements of cognitive behavioral therapy (CBT), psychoanalysis, attachment theory, and emotion-focused therapy, among others.
It’s an integrative approach that aims to treat personality disorders and other mental health concerns that don’t always respond to other treatment options. It can be particularly useful for treating borderline personality disorder.
In schema therapy, you’ll work with a therapist to uncover and understand your schemas, sometimes called early maladaptive schemas.
Schemas are unhelpful patterns that some people develop if their emotional needs aren’t met as a child.
These schemas can affect you throughout life and contribute to problematic coping methods and behaviors if they aren’t addressed.
Schema therapy aims to teach you how to ensure your emotional needs are met in a healthy way that doesn’t cause distress.
What are the core needs of a child?
One of the biggest factors in the development of schemas is not having your core emotional needs met as a child.
These core needs include:
- a sense of safety and being securely attached to others
- a sense of self-identity and autonomy
- the freedom to express how you feel and ask for what you need from others
- the ability to play and be spontaneous
- safe, age-appropriate limits and boundaries
In addition, four types of negative experiences can also contribute to the development of schemas. These include:
- Unfulfilled needs. This can happen when you don’t receive affection from caregivers or fail to have other core emotional needs met.
- Traumatization or victimization. This describes a situation when you experienced abuse, trauma, or similar distress.
- Overindulgence or lack of limits. In this situation, your parents may have been overprotective or overinvolved. They may not have set proper boundaries for you.
- Selective identification and internalization. This refers to the way you absorb some of your parents’ attitudes or behaviors. You might identify with some of these and internalize others. Some may develop into schemas, while others develop into modes, also called coping methods.
What are the different schemas?
Schemas tend to develop in childhood and are usually resistant to change. But left unmanaged, schemas can cause negative patterns that are often reinforced through unhealthy interactions.
Once you develop a schema, it can unconsciously influence your thoughts and actions in an effort to prevent emotional distress. While this sounds like it could be useful, the coping methods that schemas create are often unhealthy or harmful.
Most people tend to develop more than one schema.
Experts have identified 18 distinct schemas, but they all fall into one of five categories or domains:
- Domain I, disconnection and rejection, includes schemas that make it difficult to develop healthy relationships.
- Domain II, impaired autonomy and performance, includes schemas that make it difficult to develop a strong sense of self and function in the world as an adult.
- Domain III, impaired limits, includes schemas that affect self-control and the ability to respect boundaries and limits.
- Domain IV, other-directedness, includes schemas that lead you to prioritize the needs of others above your own.
- Domain V, overvigilance and inhibition, includes schemas that prioritize avoiding failure or mistakes through alertness, rules, and disregarding desires or emotions.
What kind of coping styles do schemas create?
In schema therapy, your reactions to schemas are known as coping styles. These can involve thoughts, feelings, or behaviors. They develop as a way of avoiding the painful and overwhelming emotions experienced as a result of a certain schema.
Coping styles can be helpful in childhood, as they provide a means of survival. But in adulthood, they can reinforce schemas.
There aren’t any firm rules about which schemas lead to certain coping styles. Your coping style might be based on your overall temperament or even coping styles you learned from your parents.
They also vary from person to person. Two people could respond to the same schema with the same style in very different ways. Similarly, two people with the same schema might also respond with two separate styles.
Your own coping style can also change over time, although you’re still dealing with the same schema.
The three main coping styles loosely correlate with the fight-or-flight or freeze response:
Surrender
This involves accepting a schema and giving into it. It usually results in behavior that reinforces or continues the schema pattern.
For example, if you surrender to a schema that formed as a result of emotional neglect as a child, you may later find yourself in a relationship involving emotional neglect.
Avoidance
This involves attempting to live without triggering the schema. You might avoid activities or situations that could possibly trigger it or make you feel vulnerable.
Avoiding your schema may leave you more prone to substance use, risky or compulsive behavior, and other behaviors that provide a distraction.
Overcompensation
This involves attempting to fight a schema by acting in complete opposition to it. This may seem like a healthy response to a schema, but overcompensation generally goes too far.
It often leads to actions or behaviors that seem aggressive, demanding, insensitive, or excessive in some way. This can take a toll on your relationships with others.
What are schema modes?
In schema therapy, a mode is a temporary mindset that includes both your present emotional state and how you’re dealing with it.
In other words, your mode is a combination of active schemas and coping styles. Modes can be helpful (adaptive) or unhelpful (maladaptive).
Schema modes help therapists group schemas together so they can address them as a single state of mind, rather than individual traits.
Schema modes are divided into four categories:
- Child modes are characterized by childlike feelings and behaviors.
- Dysfunctional coping modes are used to prevent emotional distress but end up reinforcing the schema.
- Dysfunctional parent modes are internalizations of critical, demanding, or harsh parental voices.
- Healthy adult mode represents your healthy, functional self. This mode can help regulate the other modes by setting limits and countering the effects of other modes.
What are the goals of schema therapy?
In schema therapy, you’ll work with your therapist to:
- identify and begin healing schemas
- identify and address coping styles that get in the way of emotional needs
- change patterns of feelings and behaviors that result from schemas
- learn how to get your core emotional needs met in healthy, adaptive ways
- learn how to cope (in a healthy way) with frustration and distress when certain needs can’t be met
Ultimately, all of this will help you develop a a strong, healthy adult mode. A well-developed healthy adult mode can help heal and regulate other modes and help keep you from being overwhelmed by their effects.
What techniques are used?
Schema therapists might use several techniques over the course of therapy. Certain techniques may work better for some people and schemas than others. If a certain technique doesn’t work for you, be sure to let your therapist know.
On that note, keep in mind that your relationship with your therapist is an important part of schema therapy. There are two important concepts that pop up in many of the techniques used in schema therapy. Both work best when you feel safe and comfortable with your therapist.
These concepts are:
- Empathic confrontation. Your therapist validates the schemas coming up in therapy, offering understanding and empathy while helping you realize the importance of change.
- Limited reparenting. Your therapist helps fulfill emotional needs that weren’t met in childhood by offering security, compassion, and respect. “Limited” simply means your therapist makes certain this reparenting aligns with ethical standards for mental health professionals.
Generally, these concepts are carried out with techniques that fall into four categories:
Emotive
Emotive techniques involve using emotions to counter schemas. They help you fully experience emotions and express them in the safety of therapy. Common emotive techniques include guided imagery and role-playing.
Interpersonal
Interpersonal techniques help you examine your relationships to identify ways schemas affect them.
Seeing how schemas and responses play out in therapy can help you uncover similar patterns in your life. This might involve bringing in a partner or close friend to a therapy session.
Cognitive
Cognitive techniques involve identifying and challenging harmful thought patterns that result from schemas. You’ll work with your therapist to review life experiences for evidence that supports or contradicts the schema.
This might be done through the use of flashcards or structured conversations in which you’ll speak both in favor of and against a schema.
Behavioral
Behavioral techniques help you learn to make positive, healthy choices by changing the behavior patterns that result from your coping style.
To change behavioral patterns, you might work on communication skills through role-play or talk through a problem and solution with your therapist. They might also give you some exercise to do between sessions.
What are the limitations of schema therapy?
Schema therapy shows promise as a treatment for many mental health concerns, including eating disorders and depression.
Most of the existing research has looked at the role of schema therapy in treating borderline personality disorder and other personality disorders.
So far, the results are promising. For example, a 2014 controlled trial concluded that schema therapy may be more effective for treating personality disorders.
But schema therapy has only been around since the 1980s. This is a fairly short amount of time in the world of psychology. As a result, there aren’t many quality, long-term studies about its effects.
While the existing research is promising, most experts agree that there’s a need for further trials and research.
Compared to other types of therapy, schema therapy can also be a long-term commitment. You may need to undergo schema therapy for years. If you don’t have insurance, this can also become quite expensive.
How can I try schema therapy?
It’s a bit harder to find a schema therapist than other types of therapists, especially in the United States, but resources are out there.
The International Society of Schema Therapy has a directory that lists formally trained schema therapists.
You can also try searching general therapist databases, including the American Psychological Association’s therapist finder.
Try to look for therapists who offer CBT. Schema therapy draws heavily from this approach, so some CBT therapists might have some experience with schema therapy or its core principles.
Since schema therapy may cost more than other types of mental health treatment, it’s a good idea to ask therapists about cost, whether they accept insurance, and other financial concerns you might have. Our guide to affordable therapy can also help.
