Oct 2, 2018
How do we develop patterns of thinking and behaving from our earlier experiences?
What is Schema Focussed Therapy and how does it fit in the wider family of CBTs?
Dr Gill Heath and Mary speak to Dr Lucy Maddox.
Show Notes and Transcript:
If you’re interested in finding out more...
BABCP has a Schema Therapy Special Interest Group which you can find out about here: https://www.babcp.com/Membership/SIG/Schema-Therapy.aspx
The Schema Therapy Society has more information about the therapy and therapists, and some more resources: https://schematherapysociety.org
The book we talk about in the episode is the first one:
Young, J. E., & Klosko, J. S. (1994). Reinventing Your Life: The Breakthough Program to End Negative Behavior... and Feel Great Again. Penguin.
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner's guide. Guilford Press.
Rafaeli, E., Bernstein, D. P., & Young, J. (2010). Schema therapy: Distinctive features. Routledge.
Lucy: This is Let's Talk About CBT, and I'm Dr Lucy Maddox. This series of podcasts, brought to you by the BABCP, explores cognitive behavioural therapy, or CBT, what it is, what it's not, and how it can be useful.
We've been thinking about the wider family of CBTs, and today we're going to be thinking about schema-focused therapy.
For this episode, like the others in the series, I spoke to somebody who has experienced schema therapy for themselves, as well as someone who is used to delivering schema therapy. I went to London to speak with Mary and Dr Gill Heath.
Mary has been having schema therapy for a while, and she took the time to explain to me what it has been like for her and how she sees it.
Mary: My understanding of schema therapy is it's like separating out the different ways that you think about things and so like looking at the different parts of yourself and the different ways of approaching things. So, like the part that is just furiously angry at things, or the part that’s just really, really, really sad and doesn't really understand why.
It's separating those out and going, “Okay, when I'm feeling that, what is that?” so like, “What do I want when I'm feeling that? What are those? What's underneath those feelings? What am I trying to get to?”
Lucy: I also spoke to Mary's therapist, Gill Heath, clinical psychologist and co-director of Schema Therapy Associates. She told me some of the things that she likes about using this approach.
Gill: It's really flexible. In my experience, it seems to work with quite a broad range of issues because you can really understand the person's individual patterns. The techniques, the things like the imagery, and the chair work, and being real with a person, they work with all sorts of different patterns.
I feel like, pretty much whatever someone brings in, I can understand it in schema terms, and that's helpful. I've found that clients really like it, too. They seem to make changes a bit more quickly and at a deeper level for me than when I was practising using other approaches.
Lucy: Now, if you've ever studied child psychology, you might recognise the word ‘schema’ from the work of a researcher called Jean Piaget. Piaget thought we all develop schemas, or frameworks, about how the world works, and that we either assimilate new ideas into these frameworks or we change the framework to make sense of new information.
In schema therapy, the therapist is working with you to identify what your schemas are and to spot ones that might not be helpful. One of the things that I find interesting about schema therapy is that it brings together approaches which are often seen as quite different.
Gill explained some of the different influences on the therapy, and the theory behind it.
Gill: Schema therapy is what we call an ‘integrative therapy’. That means it has taken the strongest elements of more well-established psychotherapy, such as CBT and psychodynamic therapy. It has, kind of, pulled them together into a coherent whole, so it has pulled out some of the strengths that CBT has in really focusing in on thinking patterns. That’s very much testimony to its CBT roots.
It's borrowed from other sides, such as I don't know if any of your listeners will have come across an approach called ‘gestalt therapy’. That therapy talks about different parts of yourself. Psychodynamic theory has some very useful ideas about how relationships work and how attachments work.
So, schema therapy has brought together those different principles and different techniques from different areas, but within a unified… It does have its own unified theory for how problems develop and how to change them.
It’s really designed for longer-standing problems, and its primary goal is to help you get your needs met by healing your schemas rather than just reducing your symptoms.
Lucy: What's a schema?
Gill: A schema is like a lens that colours how we see the world and how we relate to ourselves and other people. Schemas develop in childhood and adolescence when certain core needs go unmet. For example, if you were criticised excessively as a child, you might learn to think of yourself as inadequate.
You might try and cope with that feeling, either by avoiding challenge, for example, or you might try and overcompensate to try and prove your worth. When these patterns become strong enough, they’re sort of like coping mechanisms, in a way. They can become almost like different sides of yourself, like a state of mind or a mode that you get into when your schemas are triggered.
Lucy: Do we all have schemas?
Gill: Yes, all of us have schemas. Sometimes they're stronger, sometimes they're weaker. Sometimes we have a really good awareness of them, just without therapy even, and we know how to deal with them. Sometimes they come out under particularly difficult situations – situations that we hadn't previously experienced. For example, you might lose a job, and then something that wasn't an issue before, like a failure schema, might come up for you much more strongly.
Lucy: Are they always unhelpful, or can you have helpful schemas as well?
Gill: Yes, you can have helpful schemas. Fortunately, we do, all of us – all of us, even if you're really struggling with a lot of things – everyone has a healthy side, something called your ‘healthy adult’. That healthy side is the part of you that watches everything, watches over everything inside yourself and in your life, and it’s trying to pull you in a good direction. Schema therapy really works to try and strengthen that healthy side.
Lucy: So, just what is it like in the room? What can you expect if you're thinking of going for schema therapy?
Mary: It's just you and the therapist. I know she does things with bits of paper, but mostly it's just talking.
What I found with the schema therapy stuff is it gives you a lot of scope for just feeling how you're feeling, or saying how you feel, and not trying to necessarily relate it to your childhood or not. So, it's not backwards-looking, but then it's also not just trying to fix broken bits. It's really looking at how what you’re feeling works and when it comes to you.
One thing that we do quite a lot is thinking about, like, when I start to get overwhelmed by particular thoughts or feelings, what has happened around me? So, like, “Where am I? What have I just done? What have I just heard? What have I just said, or what has just been said to me?” so that you can work out ways to protect yourself in future so that you can work out: “All right, what are the kinds of things that make me feel like this? How can I either avoid them in quite a straightforward way, (Laughs) or how can I think about ways that, if they come up in future, I won't then spiral downwards if I hear people saying those things or if I'm in those places? What can I do to make this not happen to me again?”
It's really about, like, looking forward to looking after yourself in the long-term, and I find that's really helpful.
Sometimes I've come with no clear idea of, like, any of the thoughts that I have. I'm just like I've just come in, and I've just been full of sadness and full of, like, the knowledge that I'm really, really struggling to do all of the normal day-to-day things. There’s no clear reason for that. I don't understand why and so I've just come in and just spewed a lot of that out.
Then my therapist has been able to separate that out and go, “All right, let's put that on a piece of paper, and take each of those things and work out what part each of them is. Like there's part of that that's really vulnerable, that's really hurt, and there’s part of that that's really angry. There's part of that that's watching yourself constantly, waiting for you to make a mistake.”
So, some of what it is – and particularly, I think, with the writing it down on paper – is turning those really difficult-to-grasp feelings into words so that you can then think about them in a way that enables you to say, “Is that really true?” Like, “How can I counter that? How can I work with that?” It turns it from something that is just this intense blackness around you, into a series of different thoughts that have words attached to them. That's much easier to understand.
When I first turned up to see to see Dr Heath, pretty much the first few sessions, either I sat without saying very much or I just cried. Or I just said lots and lots of things, but they weren't very clear. So it didn't require me to have very much understanding about what was going on inside me. She just let me be and feel those things that I hadn't, really, that I'd been feeling for a really long time but hadn't really been giving space to, yeah.
Gill: In the first few sessions, what your therapist will be doing is asking lots of questions and really being a psychological detective, in a way, to try and figure out which of your schemas are most linked to your current problems.
So, the focus is on the things that you want to change, you want to make a difference with. The therapist is thinking, “Okay, so what schemas are going on here? Yes, what are the particular patterns? What lenses are going on that are influencing how you're reacting in your life?”
They also try and figure out with you how your schemas developed, how you learned to think and feel in the way that you are, and also what's keeping your problems going now. Why hasn't it resolved itself, in a way? What is the block? Your therapist will map this out with you, generally on paper. This can help you spot your schemas coming up in your day-to-day life.
Lucy: What sort of names would you give the different schemas? Just to give people a flavour of if they came along and they might be describing a particular kind of thinking problem. Have you got any examples of something like that?
Gill: Yes, sure. Some common examples of schemas are, there's a schema called ‘emotional deprivation’. That’s a schema where you have a sense that you don't really matter to other people and that they might not be there to meet your emotional needs consistently.
Another example might be a failure schema, where you just feel, even if you're outwardly quite successful, you feel like you're on the brink of failure. You're expecting that to come up for you. Or some people have mistrust schema, where often, if they weren't treated very well when they were young, they’re wary and on the lookout for that pattern to repeat itself. They might be a bit guarded or that kind of thing.
Lucy: Great, so sometimes, I guess, are they schemas that we all might have a little bit of, but sometimes they might end up running the show for someone?
Gill: Exactly, yes. Most of the patterns that are seen within these different schemas, they're very human. They're trying to predict, and control and understand the world, but they've become too dominant and too inflexible to learning that they might not be relevant in this particular situation. They're unbalanced, in a sense.
Lucy: What happens after you map out somebody’s schemas with them?
Gill: Then you try and work to develop the person's healthy adult side, this overarching part that we all have that can watch what's going on, and help them react differently, more adaptively, to get their needs met.
As the therapist, you're also aware of what their needs are. You do your best to meet those needs or to feed back to the person if they're reacting in ways in their relationships that are off-putting or stopping other people meeting their needs, if that makes sense.
Lucy: So, you might use the relationship that you have with the client to highlight some schemas that are in action.
Gill: Exactly. Like, you try and be as open as possible about how the schemas impact on you, as a human being; to be as real as possible, really. In my experience, clients really appreciate that. It makes it feel more authentic.
Lucy: There are some specific techniques that schema therapy uses. These techniques are ones that some other types of therapy use as well, and one of these is imagery.
Gill: Imagery is a technique that’s very simple, really, where the therapist asks the client to close their eyes and picture a situation. That can be for things that have happened in the past, or in the present, or even imagining things that might happen in the future.
Imagery is a very powerful technique. There's a lot of research showing that, when you imagine something, it puts you more in touch with your emotions. I think many of us have had the experience where you might remember something from childhood in an image, and tear up instantly, in a way that you might not just through talking about it.
There's also really a lot of research here that fits with my clinical experience, too, my experience with clients that, when you practise changes or you intervene in an image – you change an image so that someone’s needs are better met – it has a really powerful effect.
Lucy: Another technique is chair work.
Gill: Chair work is a great technique for helping people understand and separate out these different sides that we've been talking about.
Lucy: So, it's bit like you've got them on different chairs in the room with you?
Gill: Yes, exactly. Yes, or you can draw it out, or you can be quite creative with it.
Mary: One thing that I found really helpful, actually, that she does is when I'm talking about separating out the bits, so like saying, “Okay, there's part of me that is feeling really upset, and there another part of me that's going, ‘Why are you feeling upset? What's the point? How does that help?’” So, separating that out and going, “What's that part saying? Let's put that part on a different chair, and look at it and go, ‘Okay, yes, that's a different part, and that part is shouting at me. That is not fair.’” (Laughs)
I’ve found that particularly helpful for when there's a part of you that's really attacking yourself, that's really going, like, “You're making these terrible decisions. You're doing things wrong,” that's attacking you, to take that out and go, “All right, let's say that's another person who’s saying those things. Those are really, really awful things to say to someone. Those are really nasty things to say to someone.”
So, it can be really useful to separate that out and go, “What would you say back if someone was saying that to you? What would you say if someone was saying that – those things – to someone that you love?” and like, “How would you experience it from that perspective?” Then go, “Actually, that part is so attacking.” So, it's quite helpful to have it physically separated out like it's another person who's shouting at you, and you are going, “I don't deserve that. I don't.” I’ve found it really helpful.
Lucy: I asked Gill about what the evidence base is like for schema therapy.
Gill: I think schema therapy is most effective where there's a strong schema or belief system that resists change. So, really, despite your best efforts to reason your way out of the problem, it still seems to take over, no matter what.
For example, you might have struggled with problems such as low self-confidence, perfectionism, mistrust, anger, feeling very anxious or depressed. Nothing you do seems to shift it. You keep coming back to the same place.
There's good evidence for the effectiveness of schema therapy for more severe and entrenched problems, such as personality disorders. In these studies, therapists were helping people with a wide range of issues, such as emotional regulation, very low self-esteem, interpersonal clashes, severe avoidance, dependency, and problems functioning in their day-to-day life generally.
I think the research teams thought that, if schema therapy could help with these harder-to-treat problems, it might be more effective with other more specific problems, too.
More recent research supports this idea, with smaller-scale studies coming out with good preliminary results for working with specific disorders, like agoraphobia, substance misuse, depression, eating disorders. So, that's quite promising.
In those problems, there's a wide range of mechanisms that are at play in those difficulties. I think they all share strong belief systems at play, strong mechanisms at play that keep these symptoms going.
For example, say you suffered from, say, borderline personality disorder. At the centre of that is a fear of abandonment, and it’s a strong belief system that people will abandon you. Schema therapy has a way of working with that and healing that schema so that you feel safer in relationships. That would underpin its effectiveness for that particular kind of problem, and it will work in different ways with different disorders, according to what the key belief systems, what the key schemas are.
But I do think more research is needed. I think every therapy should prove its worth. Schema therapy is on its way to doing that, but there’s still some way to go.
Lucy: Borderline personality disorder in itself is quite a contentious diagnosis in some ways, so just to acknowledge that, really.
Lucy: I don't know if you want to add anything on that?
Gill: Yes. Personality disorders, they can be used with very pejorative connotations. In my view, we all have patterns in how we relate to ourselves, how we relate to other people. When someone might be diagnosed with a personality disorder, it's more that those patterns have got stronger and more entrenched.
They often just haven't had the conditions or the help they need to start to change those patterns. So, I don't see someone who has been diagnosed with that kind of problem as fundamentally different from anyone else. It's just that the issues have become more entrenched and more severe, but we all have these patterns.
Lucy: In their book about schema therapy, called ‘Reinventing Your Life’, Jeff Young and Janet Klosko refer to schemas as ‘life traps’. They say, “A life trap is a pattern which starts in childhood and reverberates throughout life.” They recognise that these early beliefs provide us with a sense of predictability and certainty. They write that “They are comfortable and familiar. In an odd sense, they make us feel at home.”
This is partly why schemas are so hard to change. In the same book, Jeff Young and Janet Klosko write about how schema therapy involves continually confronting yourself.
Mary: I wouldn't want to suggest it's easy, like if you're feeling really anxious, if you're feeling really unhappy, it's not easy to get out of that.
One of the things I found really frustrating when I was looking at doing – when I was doing – different kinds of therapy, was people's expectation that you get better really fast. Definitely, definitely, I feel much better than I did years ago. Definitely, I'm much more in control of myself than I was years ago, but it takes different time for different people.
Gill: One of the things I like about the therapy is that it has enough structure that you keep a focus on what you're hoping to change, but there isn't a rulebook on, “You must only have five sessions, or you must only have 10 sessions.”
Obviously, if you're working with someone in the NHS, there may be external constraints around that, but you can talk with your therapist about your needs. It's very led by what your needs are.
I'd say most commonly you might be seeing a client for 20 sessions or longer, particularly if you've been struggling with something for a long time or if your problems are a bit more severe.
Lucy: What advice would you give anyone who's listening to this podcast and thinking they might be interested in having some schema therapy?
Gill: I often recommend reading ‘Reinventing Your Life’ by Jeffrey Young and Janet Klosko. It's widely available on internet bookstores. It's very reasonable. It's a really easy read, but I think it gives a very clear impression of the therapy. I think if it resonates with you, then you're likely to get on well with schema therapy.
I suppose the other thing is also no therapy is the right therapy for everyone and so, particularly at the start, in the first few sessions, I'm listening out for when it's not hitting the spot for someone.
For example, sometimes people, they don't want an approach that's more emotional. They don't want their therapist getting that involved. They want something, perhaps, more concrete, more cognitive. In that case, I'll try and help them find a good match for what they're looking for.
Lucy: For Mary, it has been a helpful experience. She had some advice for anyone thinking about it.
Mary: These days I notice, when I start feeling those, like when I start sliding downwards, when I start falling back into depressions or falling back into self-hating things, I notice that. I notice that in time to step back and say, “Okay, this is happening. I know this is happening,” like, “I don't need to panic about it happening, because there are things I can do.” I notice it. Yeah, I notice it in time to then give myself space to do things that can either stop it from happening or can mitigate it.
Can I look around and go, “Am I recognising these triggers? Am I recognising that this person I'm talking to is making me feel really unhappy? Therefore, can I stop talking to them?” Or, “Can I recognise that this situation at work is really awful and that’s actually not my fault? If I stop being in this situation, then maybe it'll be better.” Or, “Can I recognise that I just feel miserable and I just need to spend the day drinking tea and reading a book?” That’s fine. (Laughs) That doesn't mean everything is terrible. It just means I need to do that for a day.
Really, it is hard to remember that, in order to not be overwhelmed by that, you have to do something actively. (Laughs) It doesn't just happen. You have to go, “Okay, I worked on this. I did this. What were the things I did that made it help?”
Lucy: It's quite hard work, isn’t it, when you're in that state of mind, as well? That’s so difficult.
Lucy: It’s like the opposite of what you feel like, so, yeah.
Mary: Yeah, absolutely. Absolutely, but that's actually why… That's why the physical components of schema therapy have helped, I think. That's why the, like, putting the part of you that goes, “You're terrible at everything you do” onto a chair, or putting it into a circle on a page.
Because when you're feeling – when you start to feel – awful, you don't necessarily remember the specific things that you talked about. You don't necessarily remember those kinds of things, but it's much easier to remember: “Okay, last time I said that was over there, and I looked at it over there. Then it wasn't in me. It was something that was outside of me and was shouting at me.” The physicality of that helps you – helps you that, when you're in another situation where you're not in the therapist’s office and you can't put it on another chair, you can go, “Okay, but say this was outside of me, how would I react to that?”
Lucy: Then anything else that you would want people to know or that you want to add about what the experience has been like?
Mary: What I would say is, if you start a kind of therapy or you start with a therapist and you feel like it's not working, stop. Go somewhere else. Don't hang around because you feel like you should try it longer, or you feel like you shouldn't let your therapist down, or you feel like it ought to be working, even though it isn't. Just stop.
Just don't be discouraged by therapy as a whole, but go somewhere else. That therapist doesn't work for you. I really wish I'd known that much earlier. So, I would say, “Try different things,” absolutely. I would encourage you to try schema therapy, but also try other things.
I guess it's worth adding that it covers quite a range of different things. I talked about being quite unhappy when I first started doing therapy. Then more recently I'm actually really okay, in a way that I really, really wasn't when I started this, but I still find it helpful.
I still find it helpful to come along and talk about the things that are going on in my life, and the ways in which I'm approaching making decisions and thinking about, when I'm making those decisions, what's coming in. Am I making those decisions based on what I want, or am I making those decisions based on what I think other people want from me?
Or whether you feel that you're being totally overwhelmed and a lot of things are really terrible, or whether you feel like you just need a bit of help getting a handle on things, I think it can be helpful at both ends of the spectrum, really.
Lucy: That's all from me. I hope that has been helpful in understanding more about what schema therapy is. For more information, have a look at the show notes on the podcast website. It has got lots of links to other resources, like websites and books that you can read if you're interested.
This podcast is brought to you by the British Association for Behavioural and Cognitive Psychotherapies, or BABCP. For more information about BABCP and about cognitive behavioural therapies in general, including a list of BABCP-accredited therapists, check out BABCP.com.
Thanks to Gabe Stebbing for the title music, Doctor Turtle for the incidental music, Dr Gill Heath and Mary for speaking to me, and Eliza Lomas for editing consultation.
Any feedback or ideas for future podcast topics, please, do let us know, and please rate us on iTunes if you've enjoyed the show. It helps other people to find us.
END OF AUDIO