Schema therapy – working on unmet needs

Schema therapy is an innovative treatment method that combines several proven psychotherapy approaches. It brings together cognitive-exercise measures of behavioral therapy, experience-activating techniques of Gestalt therapy, and the understanding-oriented perspective of psychodynamic methods. Especially patients with personality disorders and chronic depression, for whom conventional therapy attempts have failed, may place great hope in this method.

What are schemas and how do they arise?

A schema is understood to be a typical pattern of feelings, thoughts, and sensations that governs behavior. This pattern is learned in childhood and serves to satisfy basic emotional needs such as secure attachment, autonomy, control, or spontaneity. If there is a deficiency in needs satisfaction, unfavorable schemas can emerge and have negative consequences on the rest of life and relationship formations. Despite the disadvantages, schemas and their associated coping strategies continue to be maintained. Examples of schemas are:

• Abandonment/Instability: Belief that important relationships will not last and fear of being abandoned by others.
• Mistrust/abuse: fear of being intentionally hurt or abused by others.
• Inadequacy/shame: belief of not being worthy of love, attention, or respect.
• Social isolation/alienation: feeling different and unable to connect with others.
• Dependence/Dependency: feeling helpless and unable to make decisions without help from others.
• Failure: conviction of never being able to succeed due to lack of talent.
• Striving for approval and recognition: need to make a good impression in order to be worth something.

Schema Modes

The aforementioned schemas are always associated with so-called modes, states of experience to which a certain behavior is reacted. A mode can be activated in certain situations and change rapidly. Modes are classified as follows:

Child modes
These modes have their origin in childhood and help to get in contact with the needs for attachment, autonomy, recognition as well as pleasure satisfaction:

Hurt child: feelings of loneliness, lack of understanding, and abandonment
Angry child: feelings of anger at unmet basic needs
Impulsive child: Impulsive and undisciplined behavior for self-fulfillment of non-basic needs (e.g., consumption)
Happy child: fulfilled basic needs make the child feel loved and connected to others

Coping modes
Endurance: In situations where the schema is activated, nothing is done to change the situation. For example, poor treatment is allowed to happen, which is followed by withdrawal and loneliness
Compensate: Behavior is opposite to the schema. For example, after emotional neglect of parents, others are exploited or clinging to others through the helper syndrome.
Avoidance: Behavior is engaged in such a way that the schema cannot be activated. For example, after social isolation through exclusion in the school class, only close relationships with family and peers are established and no effort is made for further integration.

Harmful parenting modes
The dysfunctional parenting modes arise from the fact that the affected person has internalized the unfavorable behavior of his parents or other caregivers and now behaves in this way himself.

Punitive parenting: Punishes the child mode, devalues him and mistreats him emotionally or physically.
Demanding parent: Overstrains and criticizes the child constantly and immoderately.

Healthy adult mode
The healthy adult mode involves being aware of one’s feelings and needs and taking care to satisfy them in a favorable manner. Meaningful limits are set and responsibility for one’s own actions is taken without overtaxing or devaluing.

Inner tensions often arise between the different modes. An example of this would be the conflict between the inner voice of the parent mode (“The task must be done perfectly immediately”) and the reaction of the vulnerable child (being overwhelmed and putting off the task). If those affected then fail to reduce the inner tension, this is precisely what leads to mental illness in the long term.

What happens between therapist and patient?

The goal of schema therapy is to identify unfavorable patterns of experience and behavior and to change them from a secure therapeutic relationship so that feelings and behavior can be better regulated and needs can be met in a favorable way. In this process, the therapist assumes the role of a parent in a limited way: He shows appreciation and support to the patient and thereby lets him feel that his basic needs are recognized. At the same time, he points out limits and confronts him with his harmful behaviors. In this way, relationship experiences can be made that were absent in childhood and adolescence.

It is important for the patient to accept that the tension will rise again for the time being and that they will be confronted with the unpleasant feelings of childhood. Only in this way can the earlier experiences be corrected by new emotional experiences and it can be learned that difficult situations can turn out better today than in the past. The goal is also to build up distance to one’s own experience or to build up the negative thoughts and feelings.

In the course of this, the mode of the “healthy adult” is to be strengthened more and more and the affected person learns to meet his needs in an adult way. Towards the end of the therapy, what has been learned is transferred more and more into everyday life. At the same time, the patient should now slowly detach from the therapy relationship and take away strategies that avoid relapses into old behavior patterns.

Insight into schema therapy: change through role-playing.

Mr. S. is 36 years old, married and has three children. He works in a high management position and a few months ago took over the leadership role for another team. Mr. S. has always been very worried about not being able to fulfill his tasks and suffers from insomnia, lack of energy and appetite.

A few weeks after taking over, he is diagnosed with severe depression and his therapist recognizes that the schema “failure” plays a major role. Mr. S. continually has the feeling that he is not good enough and can never be successful due to insufficient skills. Through an imagination exercise it becomes clear that he knows these feelings from his childhood. Every time he had a conflict with classmates and received a bad grade, his parents told him that his lack of skills was the reason.

In order to break up and change a schema like this, therapy often resorts to role-playing games in which the patients symbolically take on the role of the various inner parts. First, Mr. S. has to put himself in the role of the “inner child” in a certain situation and describe what he feels. The therapist thereby assumes the role of a parent and offers Mr. S. the parental qualities he has lacked so far in the sense of recognition and appreciation for his efforts.

Emotional attention and care can provide security, satisfy his needs for attachment, and strengthen Mr. S.’s independence and self-confidence. In this way, he can reduce his beliefs about failing and his own pressure to perform. Likewise, his feeling of not being good enough will gradually reduce and the symptoms of depression will decrease. Another approach is that Mr. S. himself takes on the role of the “healthy adult” in therapy and tries to give his “hurt child” what it would have needed in the situation.

In this way, he can also reflect from the adult perspective on how his caregivers could have dealt with him better. In addition, the therapist could also have Mr. S. take on the role of the “happy child.” In this way, he should get to know the playful ease with which challenges at work can be tackled and develop the ability to better deal with stress and distance himself from problems.

And who benefits?

As already mentioned, schema therapy was developed for patients who could not achieve any improvement with conventional therapy methods. In particular, it is used for long-lasting mental disorders such as chronic depression or personality disorders. Studies show that especially patients suffering from borderline and narcissistic personality disorder experience success. Furthermore, it is often used for longstanding anxiety disorders, eating disorders, substance abuse as well as relationship disorders.

Categories: Therapy