Schema Therapy

This chapter introduces schema therapy (ST), an integrative theory- and evidence-based clinical approach for the treatment of personality disorders (PDs) and other enduring psychological difficulties. ST deliberately employs few technical terms, and instead relies on concepts that allow clinicians from diverse orientations to find common ground. Moreover, ST’s straightforward language helps therapists share their case conceptualization and treatment goals with their patients. To illustrate this, we introduce ST’s basic concepts and link them to the ICD-11 model of PDs. We define three early ST concepts (needs, schemas, and coping styles) and link these to ICD-11’s (dimensional) trait domains. We then expand on the ST concept of modes, which we link to ICD-11’s PD severity dimension, and note how it takes a further step toward attending to fluctuating states and within-person changes. The focus on modes also guides schema therapists’ differential use of therapeutic stances, on which we elaborate. These include limited reparenting, which helps address patients’ unmet primary needs, soothe their distressed or hyper-aroused child modes, help them return into a window of tolerance (Ogden & Minton, 2000), and (ultimately) serve as a model for their self-care (i.e., their Healthy Adult mode). They also include the dialectic stance of empathic confrontation, which helps address the ill effects of well-intentioned but often maladaptive coping modes (e.g., detachment, avoidance, hostility, dependence, perfectionism, etc.). We use two case examples to explore ST conceptualizations and interventions.