In the development of a conceptual and treatment approach, schema therapists adopt a philosophy of openness and inclusion. They cast a wide net, searching for solutions with little concern about whether their work will be classified as cognitive-behavioral, psychodynamic, or Gestalt. The primary focus is on whether patients are changing in significant ways. This attitude has contributed to a sense of freedom for both patients and therapists concerning what they discuss in sessions, which interventions they use, and how they implement these interventions. Moreover, the model readily incorporates the therapist’s personal style.
Schema therapy is not, however, an eclectic therapy in the sense of proceeding by trial and error. It is based on a unifying theory. The theory and strategies are tightly woven into a structured, systematic model.
As a result of this inclusive philosophy, the schema model overlaps with many other models of psychopathology and psychotherapy, including cognitive-behavioral, constructivist, psychodynamic, object relations, and Gestalt approaches. Although aspects of schema therapy overlap with these other models, the schema model also differs in important respects. Although schema theory contains concepts similar to those in many psychological schools, no one school overlaps with schema therapy completely.
In this section, we highlight some key similarities and differences between schema therapy and Beck’s recent formulations of cognitive therapy. We also touch briefly on some other therapy approaches that overlap in important ways with schema therapy.
Beck and his associates (Beck et al., 1990; Alford & Beck, 1997) have revised cognitive therapy to treat personality disorders. Personality is defined as “specific patterns of social, motivational and cognitive-affective processes” (Alford & Beck, 1997, p. 25). Personality includes behaviors, thought processes, emotional responses, and motivational needs.
Personality is determined by the “idiosyncratic structures,” or schemas, that constitute the basic elements of personality. Alford and Beck (1997) propose that the schema concept may “provide a common language to facilitate the integration of certain psychotherapeutic approaches” (p. 25). According to Beck’s model, a “core belief” represents the meaning, or cognitive content, of a schema.
Beck has also elaborated his own concept of a mode (Beck, 1996). A mode is an integrated network of cognitive, affective, motivational, and behavioral components. A mode may comprise many cognitive schemas. These modes mobilize individuals in intense psychological reactions, and are oriented toward achieving particular aims. Like schemas, modes are primarily automatic and also require activation. Individuals with a cognitive vulnerability who are exposed to relevant stressors may develop symptoms related to the mode.
According to Beck’s view (Alford & Beck, 1997), modes consist of schemas, which contain memories, problem-solving strategies, images, and language. Modes activate “programmed strategies for carrying out basic categories of survival skills, such as defense from predators” (p. 27). The activation of a specific mode is derived from an individual’s genetic makeup and cultural and social beliefs.
Beck (1996, p. 9) further explains that a corresponding mode is not necessarily activated when a schema is triggered. Even though the cognitive component of a schema has been triggered, we may not see any corresponding affective, motivational, or behavioral components.
In treatment, a patient learns to utilize the conscious control system to deactivate modes by reinterpreting trigger events in a manner inconsistent with the mode. Furthermore, modes can be modified.
After an extensive review of the cognitive therapy literature, we conclude that Beck has not elaborated—except in very general terms—on how the techniques for changing schemas and modes are different from those prescribed in standard cognitive therapy. Alford and Beck (1997) acknowledge that the therapeutic relationship is a valid mechanism for change and even that structured imagery work can alter cognitive structures by communicating “directly with the experiential (automatic system) [in its own medium, mainly fantasy]” (p. 70). But we cannot find detailed and distinctive change strategies for schemas or modes.
Finally, Beck et al. (1990) discuss patients’ cognitive and behavioral strategies. These strategies seem equivalent to the schema therapy notion of coping styles. Psychologically healthy individuals cope with life situations with adaptive cognitive and behavioral strategies, whereas psychologically impaired people utilize inflexible, maladaptive responses within their vulnerable areas.
Conceptually, Beck’s revised cognitive model and Young’s latest statement of his schema model presented in this chapter have many points of similarity. Both emphasize two broad central structures—schemas and modes—in understanding personality. Both theories include cognition, motivation, emotion, genetic makeup, coping mechanisms, and cultural influences as important aspects of personality. Both models acknowledge the need to focus on both conscious and unconscious aspects of personality.
The differences between the two theoretical models are subtle and often reflect differences in emphasis, not fundamental areas of disagreements. Young’s concept of an Early Maladaptive Schema incorporates elements of both schemas and modes, as defined by Beck (1996). Young defines schema activation as incorporating affective, motivational, and behavioral components. Both the structure and content of schemas that Beck discusses are incorporated into Young’s definition of schemas.
Mode activation is very similar to Young’s concept of schema activation. It is unclear why Beck (1996) needs to differentiate schemas from modes, based on his definitions of these terms. In our opinion, his mode concept could easily be broadened to encompass the elements of a schema (or vice versa). Perhaps Beck wants to differentiate schemas from modes to emphasize that modes are evolutionary mechanisms for survival. The concept of a schema, in Beck’s revised model, remains closer to his original cognitive model (Beck, 1976) and as such is more closely related to other cognitive constructs such as automatic thoughts and core beliefs.
Young’s concept of a schema mode is only marginally related to Beck’s use of the term “mode.” Beck (1996) developed his mode construct to account for intense psychological reactions that are survival related and goal oriented. Young developed his mode concept to differentiate between schemas and coping styles as traits (enduring, consistent patterns) and schemas and coping styles as states (shifting patterns of activation and de-activation). In this sense, Young’s concept of a schema mode is more related to concepts of dissociation and “ego states” than to Beck’s mode concept.
Another important conceptual difference is the relative emphasis placed on coping styles. Although Beck et al. (1990) refer to maladaptive coping strategies, Beck did not include them as major constructs in his reformulation (Beck, 1996; Alford & Beck, 1997). Young’s model, in contrast, assigns a central role to coping styles in perpetuating schemas. This emphasis and elaboration on schema surrender, avoidance, and overcompensation is in sharp contrast with Beck’s limited discussion.
Another major difference is the greater importance placed on core needs and developmental processes in schema therapy than in cognitive therapy. Although Beck and his associates agree in general that motivational needs and childhood influences play an important role in personality, they do not expand on what the core needs are or on how specific childhood experiences lead to the development of schemas and modes.
Not surprisingly, as Young’s primary influence prior to developing schema therapy was Beck’s cognitive approach, there are many areas of overlap in the treatments. Both encourage a high degree of collaboration between patient and therapist and advocate that the therapist play an active role in directing sessions and the course of treatment. Young and Beck agree that empiricism plays an important role in cognitive change; therefore, both treatments encourage patients to modify their cognitions—including schemas—to be more in line with “reality,” or empirical evidence from the patient’s life. The two approaches similarly share many cognitive and behavioral-change techniques, such as keeping track of cognitions and behavioral rehearsal. In both approaches, patients are taught strategies for altering automatic thoughts, underlying assumptions, cognitive distortions, and core beliefs.
Cognitive and schema therapies both emphasize the importance of educating the patient about the respective therapy models. Thus the patient is brought into the therapeutic process as an equal participant. The therapist shares the case conceptualization with the patient and encourages the patient to read self-help material elaborating on each approach. Homework and self-help assignments play a central role in both therapies as a mechanism for assisting patients in generalizing what they learn in the session into their lives outside. Also, to facilitate this transfer of learning, schema and cognitive therapists both teach practical strategies for handling concrete life events outside the session in an adaptive manner, rather than relying on patients to figure out for themselves how to apply general cognitive-behavioral principles.
Despite these similarities, there are also major differences in treatment approach between schema and cognitive therapies. Many of these differences flow from the fact that the treatment techniques of cognitive therapy were originally developed to reduce symptoms of Axis I disorders, whereas schema therapy strategies focused, from the beginning, on personality disorders and lifelong chronic problems. It has been our experience that there are fundamental differences in effective change techniques for symptom reduction compared with personality change.
First, schema therapy begins from the “bottom up” rather than “top down.” In other words, schema therapists begin at the core level—schemas—and gradually link these schemas to more accessible cognitions, such as automatic thoughts and cognitive distortions. In contrast, cognitive therapists begin with surface-level cognitions such as automatic thoughts and address core beliefs later, if the patient remains in treatment once the symptoms have been alleviated.
In schema therapy, this bottom-up approach leads to a dramatic shift in focus early in treatment from present issues to lifelong patterns. Furthermore, in schema therapy, the majority of time is devoted to schemas, coping styles, and modes, whereas these are usually secondary in cognitive therapy. This shift in focus also leads schema therapists to impose less structure and a less formal agenda on sessions. The schema therapist needs the freedom to move fluidly between past and present, from one schema to another, within a session and between sessions. In cognitive therapy, by contrast, clearly identified current problems or sets of symptoms are pursued consistently by the therapist until they have remitted.
Furthermore, because schemas and coping styles are most central to the model, Young has elaborated 18 specific early schemas and three broad coping styles that form the basis for much of the treatment. These schemas and coping mechanisms are assessed and are further refined later in therapy to better fit each individual patient. Thus the schema therapist has valuable tools to help identify schemas and coping behaviors that might otherwise be missed through normal cognitive assessment techniques. An excellent example is the Emotional Deprivation schema, which is relatively easy to uncover using schema-focused imagery, but very difficult to recognize by asking for automatic thoughts or exploring underlying assumptions.
Another important difference is in the emphasis placed on childhood origins and parenting styles in schema therapy. Cognitive therapy lacks specificity about the origins of cognitions, including core beliefs. In contrast, schema therapists have identified the most common origins for each of the 18 schemas, and an instrument has been developed to assess them. The therapist explains these origins to patients to educate them about the normal needs of a child and to explain what happens when these needs are not met and links childhood origins with whichever schemas from the list of 18 are relevant for the patient. In addition to assessing and educating patients about the origins of their schemas, schema therapists guide patients through a variety of experiential exercises related to upsetting childhood experiences. These exercises help patients overcome maladaptive emotions, cognitions, and coping behaviors. In contrast, cognitive therapists generally deal with childhood experiences in a peripheral manner.
A crucial difference between the two approaches is in the importance of experiential work, such as imagery and dialogues. Although a small minority of cognitive therapists have begun to incorporate experiential work (Smucker & Dancu, 1999), the majority do not see this as central to treatment and use imagery primarily for behavioral rehearsal. In contrast, schema therapists view experiential techniques as one of four equal components of treatment and devote considerable time in therapy to these strategies. It is difficult to understand the reluctance of most cognitive therapists to incorporate these strategies more widely, as it is generally accepted in the cognitive literature that “hot cognitions” (when the patient is experiencing strong affect) can be changed more readily than “cold cognitions” (when the patient’s affect is flat). Experiential techniques can sometimes be the only way to stimulate hot cognitions in the session.
Another primary difference is in the role of the therapy relationship. Both therapies acknowledge the importance of the relationship for effective therapy, yet they utilize it in very different ways. Cognitive therapists view the therapy relationship primarily as a vehicle to motivate the patient to comply with the treatment (e.g., completing homework assignments). They recommend that the therapist focus on cognitions related to the therapy relationship when the relationship appears to be impeding progress. However, the relationship is not generally considered to be a primary vehicle of change but rather a medium that allows change to take place. To use a medical analogy, cognitive techniques are viewed as the “active ingredients” for change, and the therapy relationship is considered the “base” or “vehicle” through which the change agent is delivered.
In schema therapy, the therapy relationship is one of the four primary components of change. As mentioned earlier in the chapter, schema therapists utilize the relationship in two ways. The first involves observing schemas as they are activated in the session and then using a variety of procedures to assess and modify these schemas within the therapy relationship. The second function involves limited reparenting. This process involves utilizing the therapy relationship as a “corrective emotional experience” (Alexander & French, 1946). Within the appropriate limits of therapy, the therapist acts toward the patient in ways that serve as an antidote to early deficits in the patient’s parenting.
In terms of style, the schema therapist utilizes empathic confrontation more than collaborative empiricism. Cognitive therapists use guided discovery to help patients see how their cognitions are distorted. It has been our experience that characterological patients cannot typically see a realistic, healthy alternative to their schemas without direct instruction from the therapist. Schemas are so deeply ingrained and implicit that questioning and empirical investigation alone are not enough to allow these patients to see their own cognitive distortions. Thus the schema therapist teaches the healthy perspective by empathizing with the schema view while confronting the patient with the reality that the schema view is not working and is not in line with reality as others see it. The schema therapist must constantly confront the patient in this way or the patient slips back into the unhealthy schema perspective. As we tell patients, “the schema fights for survival.” This concept of doing battle with the schema is not central to cognitive therapy.
Because schemas are far more resistant to change than are other levels of cognition, the course of treatment utilizing schema therapy for Axis II disorders is significantly longer than brief treatment that uses cognitive therapy for Axis I disorders. It is unclear, however, whether cognitive therapy and schema therapy differ in duration for Axis II problems.
Both in conceptualizing a case and in implementing change strategies, schema therapists are more concerned with changing long-term dysfunctional life patterns than with altering discrete dysfunctional behaviors in the current life situation (although both are necessary). Cognitive therapists, because they are focused on rapid symptom reduction, are much less likely to inquire about such long-term problems as dysfunctional partner choices, subtle problems with intimacy, avoidance of important life changes, or core unmet needs, such as nurturance and validation. Along the same lines, cognitive therapists generally do not place central importance on identifying and changing lifelong coping styles, such as schema avoidance, surrender, and overcompensation. Yet, in our experience, it is exactly these coping mechanisms—not simply the rigid core beliefs or schemas—that often make patients with personality disorders so difficult to treat.
We alluded earlier in this section to the concept of modes. Although cognitive and schema therapies both incorporate the concept of a mode, cognitive therapists have not yet elaborated techniques for altering them. Schema therapists have already identified 10 common schema mode states (based on Young’s definition noted earlier in the chapter) and have developed a full range of treatment strategies, such as mode dialogues, to treat each individual mode. Mode work forms the basis of schema therapy for patients with borderline and narcissistic personality disorders.
Schema therapy has many parallels to psychodynamic models of therapy. Two major elements shared by both approaches are the exploration of the childhood origins of current problems and the focus on the therapy relationship. In terms of the therapy relationship, the modern psychodynamic shift toward expressing empathy and establishing a genuine relationship (cf., Kohut, 1984; Shane, Shane, & Gales, 1997) is compatible with our notions of limited reparenting and empathic confrontation. Both psychodynamic and schema approaches value intellectual insight. Both stress the need for the emotional processing of traumatic material. Both alert therapists to transference and countertransference issues. Both affirm the importance of personality structure, asserting that the kind of personality structure the patient presents holds the key to effective therapy.
There are also essential differences between schema therapy and psychodynamic models. One key difference is that psychoanalysts have traditionally attempted to remain relatively neutral, whereas schema therapists endeavor to be active and directive. In contrast to most psychodynamic approaches, schema therapists provide limited reparenting, partially meeting the patient’s unmet emotional needs in order to heal schemas.
Another major difference is that, unlike classical analytic theories, the schema model is not a drive theory. Instead of focusing on instinctual sexual and aggressive impulses, schema theory emphasizes core emotional needs. Schema theory rests on the principle of cognitive consistency. People are motivated to maintain a consistent view of themselves and the world and tend to interpret situations as confirming their schemas. In this sense, the schema approach is more a cognitive than a psychodynamic model. Where psychoanalysts see defense mechanisms against instinctual wishes, schema therapists see styles of coping with schemas and unmet needs. The schema model views the emotional needs the patient is trying to fulfill as inherently normal and healthy.
Finally, psychodynamic therapists tend to be less integrative than schema therapists. Psychodynamically oriented therapists rarely assign homework, nor are they likely to utilize imagery or role-playing techniques.
Attachment theory, based on the work of Bowlby and Ainsworth (Ainsworth & Bowlby, 1991), had a significant impact on schema therapy, especially on the development of the Abandonment schema and on our conception of borderline personality disorder. Bowlby formulated attachment theory by drawing on ethology, systems, and psychoanalytic models. The main tenet is that human beings (and other animals) have an attachment instinct that aims at establishing a stable relationship with the mother (or other attachment figure). Bowlby (1969) conducted empirical studies of children separated from their mothers and noted universal responses. Ainsworth (1968) elaborated the idea of the mother as a secure base from which the infant explores the world and demonstrated the importance of maternal sensitivity to infant signals.
We have incorporated the idea of the mother as a secure base into our notion of limited reparenting. For patients with BPD (and with other, more severe disorders), limited reparenting provides a partial antidote to the patient’s Abandonment schema: The therapist becomes the secure emotional base the patient never had, within the appropriate limits of a therapy relationship. To some extent, almost all patients with schemas in the Disconnection and Rejection domain (with the exception of the Social Isolation schema) require the therapist to become a secure base.
In the schema model, echoing Bowlby, childhood emotional development proceeds from attachment to autonomy and individuation. Bowlby (1969, 1973, 1980) argues that a stable attachment to mother (or other main attachment figure) is a basic emotional need that precedes and promotes independence. According to Bowlby, a well-loved child is likely to protest separation from parents but later develops more self-reliance. Excessive separation anxiety is a consequence of aversive family experiences, such as loss of a parent or repeated threats of abandonment by a parent. Bowlby also pointed out that, in some cases, separation anxiety can be too low, creating a false impression of maturity. An inability to form deep relationships with others may ensue when the replacement of attachment figures is too frequent.
Bowlby (1973) proposed that human beings are motivated to maintain a dynamic balance between preserving familiarity and seeking novelty. In Piagetian (Piaget, 1962) terms, the individual is motivated to maintain a balance between assimilation (integrating new input into existing cognitive structures) and accommodation (changing existing cognitive structures to fit new input). Early Maladaptive Schemas interfere with this balance. Individuals in the grip of their schemas misinterpret new information that would correct the distortions that stem from these schemas. Instead, they assimilate new information that could disprove their schemas, distorting and discounting new evidence so that their schemas remain intact. Assimilation, therefore, overlaps with our concept of schema perpetuation. The function of therapy is to help patients accommodate new experiences that disprove their schemas, thereby promoting schema healing.
Bowlby’s (1973) notion of internal working models overlaps with our notion of Early Maladaptive Schemas. Like schemas, an individual’s internal working model is largely based on patterns of interaction between the infant and the mother (or other main attachment figure). If the mother acknowledges the infant’s need for protection, while simultaneously respecting the infant’s need for independence, the child is likely to develop an internal working model of the self as worthy and competent. If the mother frequently spurns the infant’s attempts to elicit protection or independence, then the child will construct an internal working model of the self as unworthy or incompetent
Utilizing their working models, children predict the behaviors of attachment figures and prepare their own responses. The kinds of working models they construct are thus very significant. In this light, Early Maladaptive Schemas are dysfunctional internal working models, and children’s characteristic responses to attachment figures are their coping styles. Like schemas, working models direct attention and information processing. Defensive distortions of working models occur when the individual blocks information from awareness, impeding modification in response to change. In a process similar to schema perpetuation, internal working models tend to become more rigid over time. Patterns of interacting become habitual and automatic. In time, working models become less available to consciousness and more resistant to change as a result of reciprocal expectancies.
Bowlby (1988) addressed the application of attachment theory to psychotherapy. He noted that a large number of psychotherapy patients display patterns of insecure or disorganized attachment. One primary goal of psychotherapy is the reappraisal of inadequate, obsolete internal working models of relationships with attachment figures. Patients are likely to impose rigid working models of attachment relationships onto interactions with the therapist. The therapist and patient focus first on understanding the origin of the patient’s dysfunctional internal working models; then the therapist serves as a secure base from which the patient explores the world and reworks internal working models. Schema therapists incorporate this same principle into their work with many patients.
Anthony Ryle (1991) has developed “cognitive-analytic therapy,” a brief, intensive therapy that integrates the active, educational aspects of cognitive-behavioral therapy with psychoanalytic approaches, especially object relations. Ryle proposes a conceptual framework that systematically combines the theories and techniques derived from these approaches. As such, cognitive-analytic therapy overlaps considerably with schema therapy.
Ryle’s (1991) formulation is called the “procedural sequence model.” He uses “aim-directed activity” rather than schemas as his core conceptual construct. Ryle considers neurosis to be the persistent use of and failure to modify procedures that are ineffective or harmful. Three categories of procedures account for most neurotic repetition: traps, dilemmas, and snags. A number of the patterns Ryle describes overlap with schemas and coping styles.
In terms of treatment strategies, Ryle encourages an active and collaborative therapeutic relationship that includes a comprehensive and depth-oriented conceptualization of the patient’s problems, just as schema therapy does. The therapist shares the conceptualization with the patient, including an understanding of how the patient’s past led to current problems and a listing of the various maladaptive procedures the patient uses to cope with these problems. In cognitive-analytic therapy, the main treatment strategies are transference work to clarify themes and diary-keeping about maladaptive procedures. Schema therapy includes both of these components but adds many other treatment strategies.
Cognitive-analytic therapy utilizes a threefold change method: new understanding, new experience, and new acts. However, new understanding is Ryle’s main focus, what he considers the most powerful agent of change. In cognitive-analytic therapy, the Change Phase primarily involves helping patients become aware of negative patterns in their lives. Ryle’s emphasis is on insight: “In CAT the therapeutic emphasis is put most strongly on strengthening the higher levels (of cognition), in particular through reformulation, which modifies appraisal processes and promotes active self-observation” (Ryle, 1991, p. 200).
In schema therapy, insight is a necessary, but not sufficient, component of change. As we move toward treatment of more severe pathology, such as occurs in patients with borderline and narcissistic disorders, we find that insight becomes less important relative to the new experience provided by experiential and behavioral approaches. Ryle (1991) views new understanding as the main vehicle for change with patients with BPD. His focus is on what he calls “sequential diagrammatic reformulations.” These are written diagrams summarizing the case conceptualization. The therapist places the diagrams on the floor in front of the patient and refers to them frequently. Sequential diagrammatic reformulations are intended to help patients with BPD develop an “observing eye.”
Schema therapy diverges from cognitive-analytic therapy in several ways. Schema therapy places more emphasis on the elicitation of affect and on limited reparenting, especially with patients who have severe characterological disorders. Schema therapy thus does more to facilitate change on an emotional level. Ryle (1991) acknowledges that procedures for activating affect, such as Gestalt techniques or psychodrama, may be appropriate in some cases to help patients move beyond intellectual insight. In contrast, Young views experiential techniques, such as imagery and dialogues, as useful for nearly all patients.
In Ryle’s (1991) approach, the therapist interacts primarily with the adult side of the patient, the Healthy Adult mode, and only indirectly with the child side of the patient, the Vulnerable Child mode. According to the schema approach, patients with BPD are like very young children and need to attach securely to the therapist before separating and individuating.
Horowitz has developed a framework that integrates psychodynamic, cognitive-behavioral, interpersonal, and family systems approaches. His model emphasizes roles and beliefs based on “person schemas theory” (Horowitz, 1991; Horowitz, Stinson, & Milbrath, 1996) A person schema is a template, usually unconscious, comprising one’s views of self and others, and it is formed from memory residues of childhood experiences (Horowitz, 1997). This definition is virtually identical to our notion of an Early Maladaptive Schema. Horowitz focuses on the general structure of all schemas, whereas Young delineates specific schemas underlying most negative life patterns.
Horowitz (1997) elaborates on what he terms “role relationship models.” Horowitz associates each role relationship with (1) an underlying wish or need (the “desired role relationship model”); (2) a core fear (the “dreaded role relationship model”); and (3) role relationship models that defend against the dreaded role relationship model. In terms of schema theory, these correspond loosely to core emotional needs, Early Maladaptive Schemas, and coping styles. Horowitz (1997) explains that a role relationship includes scripts for transactions, intentions, emotional expressions, actions, and critical evaluations of actions and intentions. As such, a role relationship contains aspects of both schemas and coping styles. The schema model conceptualizes schemas and coping responses separately, as schemas are not directly linked to specific actions. Different individuals handle the same schema with distinctive coping styles, depending on innate temperament and other factors.
Horowitz (1997) also defines “states of mind,” which are similar to our concept of modes. A state of mind is “a pattern of conscious experiences and interpersonal expressions. The elements that combine to form the pattern that is recognized as a state include verbal and nonverbal expression of ideas and emotions” (Horowitz, 1997, p. 31). Horowitz does not present these states of mind as lying along a continuum of dissociation. In the schema model, more severely disturbed patients, such as those with narcissistic and borderline personality disorders, flip into states of mind that fully subsume the patient’s sense of self. More than experiencing a state of mind, the patient experiences a different “self” or “mode.” This distinction is important in that the degree of dissociation associated with a mode dictates major modifications in technique.
What Horowitz (1997) calls “defensive control processes” also resemble Young’s coping styles. Horowitz identifies three major categories:
Defensive control processes that involve avoidance of painful topics through the content of what is expressed (e.g., shifting attention away or minimizing importance)
Those that involve avoidance through the manner of expression (e.g., verbal intellectualization)
Those that involve coping by shifting roles (e.g., abruptly shifting to a passive role or a grandiose role).
Within this typology Horowitz (1997) covers many of the phenomena encompassed by schema avoidance, surrender, and overcompensation.
During the treatment, the therapist supports the patient, counteracts avoidance by redirecting the patient’s attention, interprets dysfunctional attitudes and resistance, and helps the patient plan trials of new behavior. As in Ryle’s (1991) work, insight is the most vital part of treatment. The therapist clarifies and interprets, focusing the patient’s thoughts and discourse on role-relationship models and defensive control processes. The goal is for new “supraordinate” schemas to gain priority over immature and maladaptive ones.
In comparison with schema therapy, Horowitz (1997) does not provide detailed or systematic treatment strategies and does not utilize experiential techniques or limited reparenting. Schema therapy places more emphasis on activating affect than does Horowitz’s approach. The schema therapist accesses what Horowitz (1997) terms “regressive states”—and what we term the patient’s Vulnerable Child mode.
Emotionally focused therapy, developed by Leslie Greenberg and his colleagues (Greenberg, Rice, & Elliott, 1993; Greenberg & Paivio, 1997) draws on experiential, constructivist, and cognitive models. Like schema therapy, emotionally focused therapy is strongly informed by attachment theory and therapy process research.
Emotionally focused therapy places emphasis on the integration of emotion with cognition, motivation, and behavior. The therapist activates emotion in order to repair it. Much weight is placed on identifying and repairing emotion schemes, which Greenberg (Greenberg & Paivio, 1997) defines as sets of organizing principles, idiosyncratic in content, that tie together emotions, goals, memories, thoughts, and behavioral tendencies. Emotion schemes emerge through an interplay of the individual’s early learning history and innate temperament. When activated, they serve as powerful organizing forces in the interpretation of and response to events in one’s life. Similar to the schema model, the ultimate aim of emotionally focused therapy is to change these emotion schemes. Therapy brings into the patient’s awareness “inaccessible internal experience … in order to construct new schemes” (Greenberg & Paivio, 1997, p. 83).
Like schema therapy, emotionally focused therapy relies heavily on the therapeutic working alliance. Emotionally focused therapy utilizes this alliance to develop an emotionally focused “empathic dialogue” that stimulates, focuses, and attends to the patient’s emotional concerns. To be able to engage in this dialogue, therapists must first create a sense of safety and trust. Once this sense is securely established, therapists engage in a delicate dialectic balance of “following” and “leading,” accepting and facilitating change. This process is similar to the schema model ideal of empathic confrontation.
Like schema therapy, emotionally focused therapy recognizes that the mere activation of emotion is not sufficient to engender change. In emotionally focused therapy, change requires a gradual process of emotional activation through the use of experiential techniques, overcoming avoidance, interrupting negative behaviors, and facilitating emotional repair. The therapist helps patients recognize and express their primary feelings, verbalize them, and then access internal resources (e.g., adaptive coping responses). In addition, emotionally focused therapy prescribes different interventions for different emotions.
Despite considerable similarities, several theoretical and practical differences distinguish emotionally focused therapy from the schema model. One difference is the primacy emotionally focused therapy gives to affect within emotion schemes compared with the schema model’s more egalitarian view of the roles played by affect, cognition, and behavior. Additionally, Greenberg maintains that there are an “infinite amount of unique emotional schemes” (Greenberg & Paivio, 1997, p. 3), whereas the schema model defines a finite set of schemas and coping styles and provides appropriate interventions for each one.
The emotionally focused therapy model organizes schemes in a complex, hierarchical organization, distinguishing between primary, secondary, and instrumental emotions, and breaking these further into adaptive, maladaptive, complex, and socially constructed emotions. The type of emotion scheme suggests specific intervention goals, taking into account whether the emotion is internally or externally focused (e.g., sadness vs. anger) and whether it is currently overcontrolled or undercontrolled. Compared with the more parsimonious schema model, emotionally focused therapy places a considerable burden on the therapist to analyze emotions accurately and to intervene with them in very specific ways.
The assessment process in emotionally focused therapy relies primarily on moment-by-moment experiences in the therapy room. Greenberg and Paivio (1997) contrast these techniques with approaches that rely on initial case formulations or those that rely on behavioral assessments. Although the schema model utilizes in-session information, it is more multi-faceted, including structured imagery sessions, schema inventories, and attunement to the therapy relationship.