Schema Therapy (ST) arises from the need for a therapeutic approach for clients not responding to standard first-line treatments (e.g. cognitive-behavioral therapy) and who, therefore, continue to suffer from chronic pathologies, frequent relapses or various clinical comorbidities, i.e. coexisting multiple pathologies.
Over the years, ST has proven effective in the treatment of personality disorders, depression, chronic anxiety and eating disorders; moreover, clinical trials regarding this approach are increasing.

The theoretical model (which draws from cognitive-behavioral, psychodynamic, gestalt, constructivist and attachment theory models) integrates both evolutionary factors and personality factors at a deeper level, allowing us to look at psychopathology under a more complex frame, reconstructing the psychological functioning of the person and the elements underneath the symptom or pathological behavior and responsible for the "resistance" to change. These elements are called Early Maladaptive Schemas (EMS).

Origins and role of schemas

EMS can be seen as a sort of pattern of thoughts, memories, emotions, physical sensations and impulses which, in a rigid and pervasive way, act as a "subtext" to the moments of our life (inner and relational) affecting situations and events’ interpretation, causing high suffering and creating self-destructive patterns.
An EMS generates and consolidates following the repeated frustration of primary emotional needs throughout a person's developmental history (childhood/adolescence).

Examples of primary emotional needs are:

• secure attachment to others
• freedom to express one's emotions and needs
• spontaneity, play, creativity
• sense of limits and self-control
• sense of identity, autonomy and competence

These needs are frustrated when the developmental environment is harmful or when there is a mismatch between environment and individual's temperament. Depending on which needs have been most frustrated in their personal history, each individual develops EMS to find a sort of generic "explanation" for such frustration experiences, unfortunately in dysfunctional and out of context terms.

For example, when a child experiences trauma or is victim of violence, schemas such as Mistrust/Abuse ("sooner or later people will hurt/exploit/abuse me") or Defectiveness/Shame (I'm worthless/not good enough") may arise. If childhood history is lacking in nurturance, attunement, understanding, love and stability, a child could develop schemas such as Emotional Deprivation ("no one cares how I feel/no one can understand me") or Abandonment ("sooner or later everyone will leave me or will not be there when I will need them most"). On the other hand, if a child is spoiled or overprotected, experiencing too much of what would be healthy in moderate amounts, schemas such as Entitlement/Grandiosity ("I am superior to others/I get anything I want") o Dependence/Incompetence (“I’m incapable of doing things on my own”) may develop.

One individual, many parts

ST doesn’t only talk about schemas, but also refers the concept of "mode" to identify all those individuals’ modalities/parts that get triggered in different situations, such as the inner critic mode (demanding/punitive/depreciative), the most vulnerable and needy part - inner child mode, and all those dysfunctional coping modes used to manage, unconsciously, the activation of EMS (e.g. attacking others or pleasing others fearing of being criticized/ abandoned; rationalize or minimize one's experience to avoid being judged and feeling ashamed; numbing oneself with substances or by binging, to avoid feeling defective). The activation of EMS causes distress: these coping modes are part of automatic reactions, they take over in order to avoid painful emotions and have essentially a survival – short term protection - role . In therapy, individuals get to learn about these coping modes, to understand not only their protective function, but also their long term costs, for example how they negatively affect relationships or physical/mental health. Therapy also trains and strengthen clients’ resources (i.e. the healthy adult mode) in order to let them find alternative and more adaptive responses, less impacting on their quality of life, so as to weaken the EMS and take directly care of their vulnerable parts, needs and painful emotions, in a healthy and long-term way. In other words, in ST people learn to become more and more good parents of themselves, reducing their own suffering and its maintaining mechanisms, opening up to change through more conscious, integrated and courageous choices.

Techniques and tools

This therapy uses cognitive/behavioral techniques as well as emotional and experiential techniques (imagination exercises, working with chairs). The latter can be extremely powerful, because they allow to re-activate sensations, images and emotions linked to the psychological experience in clients’ evolutionary history, at the heart of their suffering. By processing what emerges in the session, these techniques lead to a re-scripting of some dysfunctional learning linked to negative past experiences, encouraging clients’ greater awareness of their own emotional needs.
Finally, in ST, the therapeutic relationship is a fundamental tool for change: communicating with therapist, clients are given the opportunity to access their own automatisms, compare, modulate or interrupt them and choose more functional alternative ways of cope with their own suffering and their relationships. Clients are taught how to dialogue with themselves during their emotionally activating situations, to take care of their "inner child" and their needs.