CBT vs. Schema Therapy: Is There a Difference?
The simple answer to this question is yes. Schema therapy tends to be initiated once CBT has not been successful for patients and includes some elements of CBT. Let’s get into what each therapy entails and exactly what the difference is.
CBT (Cognitive Behavioral Therapy)
CBT is a popular form of psychotherapy that examines the relationships between thoughts, feelings, and behaviors. Its purpose is to help people overcome emotional problems, make patients aware of automatic thoughts, and how those automatic thoughts affect how patients feel and behave.
The psychiatrist and patient work together to expose patterns of thinking and determine the best ways to positively change those patterns. Because CBT is an active intervention, the patient should expect homework and practice outside of therapy. CBT emphasizes changing the ways people think in order to improve their moods.
Schema Therapy (ST)
Schema therapy combines CBT, gestalt, imagery and other techniques to help weaken the maladaptive schemas and coping styles and re-build the patient’s healthy side. In a sense, schema therapy works with the patient’s inner child to help correct the emotional difficulties experienced during childhood in a strong effort to change them.
Schema therapy doesn’t simply target feelings of depression or anxiety; it works to rectify past emotional disturbances and change long-term patterns.
The Difference
While schema therapy combines elements of CBT, these elements are often practiced later. The purpose of schema therapy is to bring to light schemas suffered by a patient during childhood that have entrenched themselves in their adult life.
In CBT, recognizing automatic thoughts and how they make patients feel and behave is sufficient. However, in schema therapy, the focus is to do all of the above while changing the schemas so that they are no longer a hindrance to the patient’s adult life.
To learn more about CBT and schema therapy, contact Dr. Scott Shapiro at 212-631-8010 or [email protected] for a fifteen minute phone consultation at no charge.
Dr. Shapiro is a NYC psychiatrist who is also certified in CBT and schema therapy.
What is a scheme-therapy?
Schema therapy is a psychological approach that was developed by Jeffry Young as a modification of cognitive behavioral therapy (CBT) for patients for whom a standard CBT was not effective. Mostly such patients suffered from personality disorders, the consequences of complex psychological trauma and neglect of emotional needs in childhood. Perhaps this is why the schema therapy along with a number of other approaches refer to the so-called “third wave” in the CBT.
The most important concept in the scheme-therapy are Early Maladaptive Schemas.
Schemas are defined as: “broad, pervasive themes regarding oneself and one’s relationship with others, developed during childhood and elaborated throughout one’s lifetime, and dysfunctional to a significant degree.”
Healthy schemas develop when the basic emotional needsof a child are met. This enables children to develop positive images about other individuals, themselves and the world as a whole.
Schema therapy usually distinguishes five categories of basic emotional needs of the person, some of them are especially important in childhood (Young, Klosko, & Weishaar, 2006):
1. Attachment and security.
2. Independence, competence and identity.
3. Freedom to express your important needs and feelings.
4. Spontaneity, fun and game.
5. Realistic boundaries, self-discipline and self-control.
More details about what these basic emotional needs are, see the link below.
Schemas develop in childhood from an interplay between the child’s innate temperament, and the child’s ongoing experiences with parents, siblings, or peers.
Because they begin early in life, schemas become familiar and thus comfortable. We distort our view of the events in our lives in order to maintain the validity of our schemas. Schemas may remain dormant until they are activated by situations relevant to that particular schema.
So what happens if in a child our basic emotional needs are not satisfied?
We develop maladaptive schemas or “life-traps”.
These life themes, patterns, or “traps” are formed when basic emotional needs are not met during childhood (but also may result from deprivation in adolescence). From then on, the schema prevents similar basic emotional needs from being fulfilled in adulthood. For instance a child whose need for secure attachments is not fulfilled by his parents may go for many years in later life without secure relationships as a response to not having valid, early needs met and repeat throughout life.
This may at first seem counter-intuitive, but psychotherapy and psychology as far back as Freud recognises this “repetition compulsion”. We recreate in our adult lives early childhood deficiencies, because we somehow feel more “comfortable” with these schema even whilst realising that they aren’t serving us as adults. Herein lies the conflict.
Schemas are extremely stable and enduring patterns, comprising of memories, bodily sensations, emotions, and cognitions. Once activated, intense emotions are often felt and they can usually underlie long-term issues we feel we’re struggling with.
One of the reasons that schemas are hard to change is because they are not stored through logic, but in an emotional part of the brain called the amygdala, as opposed to a part of the brain that’s readily amenable to logical analysis or discourse (where for example “classic” CBT might target).
Although schema therapy uses many of the procedures of a cognitive/mindful approach, it also probes more deeply into early life experiences, utilising behavioural and interpersonal techniques, which promotes higher levels of affect in sessions and is somewhat longer-term.
Allocate 18 early maladaptive schemaswhich are grouped into 5 categories according to dissatisfied basic emotional needs:
1. Disconnection/Rejection:
- Emotional Deprivation
- Abandonment/Instability
- Mistrust/Abuse
- Defectiveness/Shameу
- Social Isolation/Alienation
2. Impaired Autonomy and/or Performance:
- Dependence/Incompetence
- Vulnerability to Harm or Illness
- Enmeshment/Undeveloped Self
- Failure
3. Impaired Limits:
- Entitlement/Grandiosity
- Insufficient Self-Control and/or Self-Discipline
4. Other-Directedness:
- Subjugation
- Self-Sacrifice
- Approval-Seeking/Recognition-Seeking
5. Overvigilance/Inhibition:
- Emotional Inhibition
- Unrelenting Standards/Hypercriticalness
- Negativity/Pessimism
- Punitiveness
For more information about early maladaptive schemas, see the link below.
Often, if we are in a particularly severe crisis, or experiencing abrupt changes in thoughts, feelings and behaviours the therapist will choose to present and work with the client’s schema through a “mode model”. Modes are clusters of early maladpative schema and coping responses which may feel like distinct and quite different parts of ourselves (often in conflict).
More information about a “mode model” can be found at the link.
Together with the client, these different modes will be given names and treated almost like “characters” in the internal world of the client’s psyche, examining how these different parts interact and how they function in perpetuating whatever distressful patterns/life-traps the client keeps on returning to as well as ways in which in seeking to sometimes cope with our own unmet basic emotional needs, we create further problems for ourselves in the form of partially helpful, but usually, in the long term unhelpful modes..
How schemas work?
There are two primary schema operations: Schema healing and schema perpetuation. All thoughts, behaviours and feelings may be seen as being part of one of these operations. Either they perpetuate the schema or they heal the schema. In a later section on the therapy process we will explain more about schema healing.
Schema perpetuation refers to the routine processes by which schemas function and perpetuate themselves. This is accomplished by cognitive distortions, self-defeating behaviour patterns and schema coping styles.
Cognitive distortions are a central part of cognitive therapy. These distortions consist of negative interpretations and predictions of life events. The schema will highlight or exaggerate information that confirms the schema and will minimize or deny information that contradicts it. Likewise, unhealthy behaviour patterns will perpetuate the schema’s existence. Someone who was abused in childhood and developed a Mistrust/Abuse schema may seek out abusive relationships in adulthood and remain in them, providing a constant stream of evidence for the schema.
In order to understand how schemas are thus perpetuated, there are three coping styles that must be defined. These styles are schema surrender, schema avoidance, and schema overcompensation. It is through these three styles that schemas exert their influence on our behaviour and work to insure their own survival.
Schema surrender refers to ways in which we sometimes passively give in to our schema. We accept the schema as truth and then act in ways that confirm the schema. For instance, a young man with an Abandonment/Instability schema might choose partners who are unable to commit to long-term relationships. He might then react to even minor signs indications of abandonment, such as spending short times without his partner, in an exaggerated way and feel excessive negative emotion. Despite the emotional pain of the situation, he might also passively remain in the relationship because he sees no other possible way to connect with women.
Schema avoidance refers to the ways in which we do anything we can to avoid activating schemas. As mentioned earlier, when schemas are activated, this causes extreme negative emotion. So we might find ways to avoid triggering schemas in order not to feel this pain. There are three types of schema avoidance: cognitive, emotional and behavioral.
Cognitive avoidance refers to efforts that people make not to think about upsetting events. These efforts may be either voluntary or automatic. People may voluntarily choose not to focus on an aspect of their personality or an event, which they find disturbing. There are also unconscious processes which help people to shut out information which would be too upsetting to confront. People often forget particularly painful events. For instance, children who have been abused sexually often forget the memory completely.
Emotional or affective avoidance refers to automatic or voluntary attempts to block painful emotion. Often when people have painful emotional experiences, they numb themselves to the feelings in order to minimize the pain. For instance, a man might talk about how his wife has been acting in an abusive manner toward him and say that he feels no anger towards her, only a little annoyance. Some people drink or abuse drugs to numb feelings generated by schemas.
The third type of avoidance is behavioural avoidance. People often act in such a way as to avoid situations that trigger schemas, and thus avoid psychological pain. For instance, a woman with a Failure schema might avoid taking a difficult new job which would be very good for her. By avoiding the challenging situation, she avoids any pain, such as intense anxiety, which could be generated by the schema.
The third schema process is Schema overcompensation. The individual behaves in a manner which appears to be the opposite of what the schema suggests in order to avoid triggering the schema. On the surface, it may appear that the overcompensators are behaving in a healthy manner, by standing up for themselves. But when they overshoot the mark they cause more problem patterns, which then perpetuate the schema. For instance, a young man with a Defectiveness schema might overcompensate by presenting himself as perfect and being critical of others. This would likely lead others to criticize him in turn, thereby confirming his belief that he is defective.
Therapeutic process – changing schemas.
In schema therapy the goal of the treatment is to engage in schema healing processes. These processes are intended to weaken the early maladaptive schemas and coping styles as much as possible, and build up the your healthy side. An alliance is formed between the therapist and the healthy part of the client against the schemas. Any of the therapy activities described below may be seen as examples of schema healing.
The first step in therapy is to do a comprehensive assessment of the client. The main goal of this assessment is to identify the schemas and coping styles that are most important in the client’s psychological makeup. There are several steps to this process. The therapist generally will first want to know about recent events or circumstances in the clients’ lives which have led them to come for help. The therapist will then discuss the client’s life history and look for patterns which may be related to schemas.
There are several other steps the therapist will take in assessing schemas. We use the Young Schema Questionnaire, which the client fills out, listing many of the thoughts, feeling and behaviours related to the different schemas; items on this questionnaire can be rated as to how relevant to the client’s life they are.
There are also various imagery techniques which the therapist can use to assess schemas. One specific technique involves asking clients to close their eyes and create an image of themselves as children with their parents. Often the images that appear will lead to the core schemas. Also, just describing key, painful, memories will help us do this.
There are many techniques that the therapist can use to help clients weaken their schemas. These techniques can be broken down into four categories: emotive, interpersonal, cognitive and behavioral.
Emotive techniques encourage clients to experience and express the emotional aspects of their problem. One way this is done is by having clients close their eyes and imagine they are having a conversation with the person to whom the emotion is directed. They are then encouraged to express the emotions as completely as possible in the imaginary dialogue. One woman whose core schema was Emotional Deprivation had several such sessions in which she had an opportunity to express her anger at her parents for not being there enough for her emotionally. Each time she expressed these feelings, she was able to distance herself further from the schema. She was able to see that her parents had their own problems which kept them from providing her with adequate nurturance, and that she was not always destined to be deprived.
There are many variations on the above technique. Clients may take on the role of the other person in these dialogues, and express what they imagine their feelings to be. Or they may write a letter to the other person, which they have no intention of mailing, so that they can express their feelings without inhibition.
Interpersonal techniques highlight the client’s interactions with other people so that the role of the schemas can be exposed. One way is by focusing on the relationship with the therapist. Frequently, clients with a Subjugation schema go along with everything the therapist wants, even when they do not consider the assignment or activity relevant. They then feel resentment towards the therapist which they display indirectly. This pattern of compliance and indirect expression of resentment can then be explored to the client’s benefit. This may lead to a useful exploration of other instances in which the client complies with others and later resents it, and how they might better cope at those times.
Another type of interpersonal technique involves including a client’s spouse in therapy. A man with a Self-Sacrifice schema might choose a wife who tends to ignore his wishes. The therapist may wish to involve the wife in the treatment in order to help the two of them to explore the patterns in their relationship and change the ways in which they interact.
Cognitive techniques are those in which the schema-driven cognitive distortions are challenged. As in short-term cognitive therapy, the dysfunctional thoughts are identified and the evidence for and against them is considered. Then new thoughts and beliefs are substituted. These techniques help the client see alternative ways to view situations.
The first step in dealing with schemas cognitively is to examine the evidence for and against the specific schema which is being examined. This involves looking at the client’s life and experiences and considering all the evidence which appears to support or refute the schema. The evidence is then examined critically to see if it does, in fact, provide support for the schema. Usually the evidence produced will be shown to be in error, and not really supportive of the schema.
For instance, let’s consider a young man with an Emotional Deprivation schema. When asked for evidence that his emotional needs will never be met, he brings up instances in which past girlfriends have not met his needs. However, when these past relationships are looked at carefully, he finds that, as part of the schema surrender process, he has chosen women who are not capable of giving emotionally. This understanding gives him a sense of optimism; if he starts selecting his partners differently, his needs can probably be met.
Another cognitive technique is to have a structured dialogue between the client and therapist. First, the client takes the side of the schema, and the therapist presents a more constructive view. Then the two switch sides, giving the client a chance to verbalize the alternative point of view.
After having several of these dialogues the client and therapist can then construct a flashcard for the client, which contains a concise statement of the evidence against the schema.
A typical flashcard for a client with a Defectiveness/Shame schema reads: “I know that I feel that there is something wrong with me but the healthy side of me knows that I’m OK. There have been several people who have known me very well and stayed with me for a long time. I know that I can pursue friendships with many people in whom I have an interest.”
The client is instructed to keep the flashcard available at all times and to read it whenever the relevant problem starts to occur. By persistent practice at this, and other cognitive techniques, the client’s belief in the schema will gradually weaken.
Behavioural techniques are those in which the therapist assists the client in changing long-term behavior patterns, so that schema surrender behaviours are reduced and healthy coping responses are strengthened.
One behavioural strategy is to help clients choose partners who are appropriate for them and capable of engaging in healthy relationships. Clients with the Emotional Deprivation schema tend to choose partners who are not emotionally giving. A therapist working with such clients would help them through the process of evaluating and selecting new partners.
Another behavioral technique consists of teaching clients better communication skills. For instance, a woman with a Subjugation schema believes that she deserves a raise at work but does not know how to ask for it. One technique her therapist uses to teach her how to speak to her supervisor is role-playing. First, the therapist takes the role of the client and the client takes the role of the supervisor. This allows the therapist to demonstrate how to make the request appropriately. Then the client gets an opportunity to practice the new behaviors, and to get feedback from the therapist before changing the behavior in real life situations.
In summary: schema therapy can help people understand and change long-term life patterns. The therapy consists of identifying early maladaptive schemas, coping styles and modes, and systematically confronting, challenging and healing them.
Based on schematherapylondon.org
