PREFACE

 

It is difficult to believe that it has been 9 years since we wrote our last major book on schema therapy. During this decade of burgeoning interest in this therapy approach, we continually have been asked, “When are you going to write an up-to-date, comprehensive treatment manual?” With some embarrassment, we had to admit that we had not found the time to take on such a major project.

After 3 years of intensive work, however, we have finally written what we hope will become “the bible” for the practice of schema therapy. We have attempted to include in this volume all the additions and refinements from the past decade, including our revised conceptual model, detailed treatment protocols, case vignettes, and patient transcripts. In particular, we have written extended chapters that describe a major expansion of schema therapy for borderline and narcissistic personality disorders.

During the past 10 years, many changes in the mental health field have had an impact on schema therapy. As practitioners from many orientations have become dissatisfied with the limitations of orthodox therapies, there has been a corresponding interest in psychotherapy integration. As one of the first comprehensive, integrative approaches, schema therapy has attracted many new clinicians and researchers who have been searching for both “permission” and guidance to go beyond the confines of existing models.

One clear sign of this heightened interest in schema therapy has been the widespread use of the Young Schema Questionnaire (YSQ) by clinicians and researchers around the world. The YSQ has already been translated into Spanish, Greek, Dutch, French, Japanese, Norwegian, German, and Finnish, to indicate just a few of the countries that have adopted elements of this model. The extensive research on the YSQ offers substantial support for the schema model.

Another indication of the appeal of schema therapy has been the success of our two earlier books on schema therapy, even 10 years after their publication: Cognitive Therapy for Personality Disorders: A Schema-Focused Approach is now in its third edition, and Reinventing Your Life, which has sold more than 125,000 copies, is still available at most major bookstores and has been translated into several languages.

The past decade has also seen the extension of schema therapy beyond personality disorders. The approach has been applied to a wide variety of clinical problems, populations, and disorders, including, among others, chronic depression, childhood trauma, criminal offenders, eating disorders, couple work, and relapse prevention for substance abuse. Often schema therapy is being used to treat predisposing characterological issues in patients with Axis I disorders, once the acute symptoms have abated.

Another important development has been the combining of schema therapy with spirituality. Three books (Emotional Alchemy by Tara Bennett-Goleman; Praying Through Our Lifetraps: A Psycho-Spiritual Path to Freedom by John Cecero; and The Myth of More by Joseph Novello) that blend the schema approach with mindfulness meditation or with traditional religious practices have already been published.

One disappointing development, that we hope will change in the decade to come, is the impact of managed care and cost containment on the treatment of personality disorders in the United States. It has become increasingly difficult for practitioners to get insurance reimbursement and for researchers to obtain federal grants for personality disorders because Axis II treatment generally takes longer and thus does not fit a short-term, managed care model. As a result, the United States has fallen behind many other countries in supporting work on personality disorders.

The result of this reduced support has been a paucity of well-designed outcome studies with personality disorders. (The notable exception is Marsha Linehan’s dialectical behavior therapy approach to borderline personality disorder.) This has made it extremely difficult for us to obtain funding for studies that might demonstrate empirical support for schema therapy.

Thus we are turning now to other countries to fund this important research area. We are particularly excited about a major outcome study, directed by Arnoud Arntz, nearing completion in the Netherlands. This large-scale, multisite study compares schema therapy with Otto Kernberg’s approach in treating borderline personality disorder. We are eagerly awaiting the results.

For readers who are unfamiliar with schema therapy, we will review what we consider the major advantages of schema therapy over other commonly practiced therapies. Compared to most other therapy approaches, schema therapy is more integrative, combining aspects of cognitive, behavioral, psychodynamic (especially object relations), attachment, and Gestalt models. Schema therapy regards cognitive and behavioral components as vital to treatment, yet gives equal weight to emotional change, experiential techniques, and the therapy relationship.

Another key benefit of the schema model is its parsimony and seeming simplicity, on the one hand, combined with depth and complexity, on the other. It is easy for both therapists and patients to understand. The schema model incorporates complex ideas, many of which seem convoluted and confusing to patients receiving other forms of therapy, and presents them in simple and straightforward ways. Thus schema therapy has the commonsense appeal of cognitive-behavioral therapy (CBT), combined with the depth of psychodynamic and related approaches.

Schema therapy retains two vital characteristics of CBT: It is both structured and systematic. The therapist follows a sequence of assessment and treatment procedures. The assessment phase includes the administration of a number of inventories that measure schemas and coping styles. Treatment is active and directive, going beyond insight to cognitive, emotive, interpersonal, and behavioral change. Schema therapy is also valuable in the treatment of couples, helping both partners to understand and heal their schemas.

Another advantage of the schema model is its specificity. The model delineates specific schemas, coping styles, and modes. In addition, schema therapy is notable for the specificity of the treatment strategies, including guidelines about providing the appropriate form of limited reparenting for each patient. Schema therapy provides a similarly accessible method for understanding and working with the therapy relationship. Therapists monitor their own schemas, coping styles, and modes as they work with patients.

Finally, and perhaps most important, we believe that the schema approach is unusually compassionate and humane, in comparison with “treatment as usual.” Schema therapy normalizes rather than pathologizes psychological disorders. Everyone has schemas, coping styles, and modes—they are just more extreme and rigid in the patients we treat. The approach is also sympathetic and respectful, especially toward the most severe patients, such as those with borderline personality disorder, who are often treated with minimal compassion and much blame in other therapies. The concepts of “empathic confrontation” and “limited reparenting” ground therapists in a caring attitude toward patients. The use of modes eases the process of confrontation, allowing the therapist to aggressively confront rigid, maladaptive behaviors, while still retaining an alliance with the patient.

In closing, we highlight some of the new developments in schema therapy during the past decade: First, there is a revised and much more comprehensive list of schemas, containing 18 schemas in five domains. Second, we have developed new, detailed protocols for the treatment of borderline and narcissistic patients. These protocols have expanded the scope of schema therapy, primarily with the addition of the schema mode concept. Third, there is a much greater emphasis on coping styles, especially avoidance and overcompensation, and on altering coping styles through pattern-breaking. Our goal is to replace maladaptive coping styles with healthier ones that enable patients to meet their core emotional needs.

As schema therapy has developed and matured, we have placed much more emphasis on limited reparenting with all patients, but especially those with more severe disorders. Within the appropriate bounds of the therapeutic relationship, the therapist attempts to fulfill the patient’s unmet childhood needs. Finally, there is more focus on the therapist’s own schemas and coping styles, especially in regard to the therapy relationship.

We hope that this volume will provide therapists with a new way of approaching patients with chronic, longer-term themes and patterns, and that schema therapy will provide significant benefits for those extremely difficult and needy patients whom our approach is designed to treat.