Schema Therapy

Core Components

Schema therapy is used to address long standing emotional difficulties and maladaptive coping strategies associated with eating disorder behaviours and personality disorder behaviours, that have developed as a result of unmet developmental needs and/or adverse life circumstances over the course of childhood and adolescence. Maladaptive patterns, which consist of negative/dysfunctional thoughts, memories, and feelings, have been identified as essential maintaining factors for variety of mental health disorders, including eating disorders. Schema therapy therefore aims to address the core emotional needs and facilitate a change in the mental health disorder by strengthening adaptive schema modes and weakening maladaptive schema modes. The intervention specifically targets the contribution of childhood experiences to the development of key schema-level beliefs and identifies helpful coping mechanisms to address these. Further, schema therapy incorporates processing of trauma memories where required.

Therapy sessions include the identification of core schema and their link to life history and present difficulties; identification of maladaptive coping strategies and discontinuation of their use; and application of healthy strategies for coping and interpersonal relationships. Schema Therapy has a strong emphasis on the therapeutic relationship, with limited re-parenting used as an antidote to unmet childhood needs. Core techniques applied in schema therapy include attachment-focused limited reparenting techniques, imagery rescripting and other experiential methods, and cognitive and behavioural techniques to achieve cognitive, emotional, interpersonal and behavioural changes. Schema therapy adopts a transdiagnostic approach which allows treatment of complex difficulties, as opposed to focusing on specific symptoms. It can be delivered over 6 to 18 months or longer, with the number of sessions delivered dependent on challenges experienced by the patient and the goals that have been set. Shorter term protocols are becoming commonly used in NHS settings.

Fidelity

Practitioner training and supervision will enhance treatment fidelity. Therapy sessions can be recorded for review. Adherence can be measured by the Schema therapy competence scale, available through training routes, but without published psychometric properties (1).

Modifiable Components

Schema therapy is widely available across the UK and internationally. It can be delivered in individual and group formats, either online/ remotely or in-person. It can also be delivered with couples and families. It has been delivered to individuals with a range of mental health disorders including borderline and other personality disorders, and eating disorders. Schema therapy can also be delivered to address current challenges associated with self-defeating life patterns and longstanding emotional difficulties.  Schema therapy materials have been translated into many languages.

Implementation Support

Implementation support and training in Scotland can be provided by Schema therapy Scotland. They provide schema therapy training workshops either as stand-alone courses, or as part of the schema therapy accreditation programme. Training workshops are available both online and in-person. Schema therapy Scotland also provide bespoke workshops for services looking to adapt a workshop to their specific needs, and to that of the clinical populations they serve.

Start-up Costs

Start-up costs can include cost of certification programmes offered by Schema therapy Scotland. The fees for these certification programmes are to be confirmed. Costs of stand-alone workshops include £500 for both of the 3-day foundation training workshops, £110 for 4-hour online webinar, £340 for 2-day brief schema therapy workshop, and €194 for the 7-module online training course on schema therapy for eating disorders with complex comorbidity. Other workshops are also available and can be accessed via the Schema therapy Scotland website.

Building Staff Competency

Qualifications Required

Schema therapy can be delivered by qualified mental health practitioners including psychologists, counsellors, mental health social workers, mental health occupational therapists, mental health nurses, nurse therapists, community psychiatric nurses and psychiatrists. Practitioners will have existing training and experience in delivering psychotherapy, typically training in Cognitive Behavioural Therapy.

Training Requirements

Practitioners attend training workshops prior to delivering schema therapy. Workshops include a) Foundation Workshop 1, Schema Therapy: The Model, Methods & Techniques; and b) Foundation Workshop 2, Schema Therapy: Beyond the Basics. Each workshop is delivered online, in interactive Zoom sessions, over three days. Other online and face-to-face training workshops can be accessed via the Schema therapy Scotland website. Certification programmes in schema therapy are also available, and consist of two workshops, weekly or bi-weekly consultation sessions (remote or in-person), readings, and periodic ratings of client sessions. Certification programmes can be completed in 1 or 2 years.

Supervision Requirements

As part of the standard certification programme, practitioners receive 20 hours of supervision, each lasting about 1-hour. Sessions are delivered weekly or fortnightly, over a period of one-year. Practitioners will be granted advanced certification status if additional training and supervision requirements are fulfilled. Supervisory sessions can be conducted face-to-face or remotely.

It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/).

Theory of Change

Schema therapy is founded on an integration of concepts from cognitive behaviour therapy (CBT), and integrates concepts from attachment theory, object relations theory, gestalt psychology, psychodynamic and other experiential and interpersonal therapeutic models. This integrated model supports the application of a flexible, formulation driven approach to achieve interpersonal, experiential, cognitive and behavioural changes that address the mental health disorder. 

Values

Schema therapy approach is used to address long standing emotional difficulties in people who have adopted maladaptive coping strategies to manage their difficulties, e.g. eating disorder behaviours. Schema therapy is founded on an integrated model that includes CBT, and that supports the application of a flexible, formulation driven approach to achieve changes that address the mental health disorder.  This approach addresses not only the eating behaviours themselves, but also the emotional difficulties and unmet emotional needs that drive these behaviours.

• Does the integrated approach of schema therapy align with the requirements of your organisation?

Priorities

Schema therapy addresses unmet core emotional needs and aims to facilitate changes in the mental health disorder by strengthening adaptive schema modes and weakening maladaptive schema modes.

• Is your organisation looking to deliver an intervention that addresses unmet emotional needs by focusing on their beliefs about themselves and their relationships with others? Is your organisation looking to address personality disorders or eating diff

Existing Initiatives

• Does your service currently deliver interventions to treat personality or eating disorders?
• Are existing initiatives practicable and effective? (2)
• Do existing initiatives fit current and anticipated requirements?

Workforce

Schema therapy can be delivered by qualified practitioners with a core training in mental health. Practitioners must have existing training in psychotherapy and attend training workshops prior to delivering schema therapy. Certification programme in schema therapy is available and can be completed over 1 or 2 years. Practitioner supervision is required in this period. Schema therapy is generally over 20 to 65 sessions, depending on severity.

• Does your service have qualified practitioners who are available and interested in learning and delivering schema therapy?
• Can your service support the time commitment required for practitioner training, supervision, and intervention delivery?

Technology Support

Schema therapy can be delivered without access to technology, but access to video platforms for remote training, remote supervision, and remote delivery can be useful, as is access to methods of recording sessions for review.

• Will schema therapy be delivered in-person or remotely?
• Does your service have the technology to support remote training, remote supervision, and remote delivery of schema therapy?
• Can your practitioners access technology to record sessions for review?

Administrative Support

Schema therapy can be delivered in individual or group formats across several settings. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.

• In what setting will schema therapy be delivered?
• Does your service have a venue to deliver schema therapy sessions?
• Can administrative supports be provided to deliver schema therapy in the chosen format?

Financial Support

Start-up costs can include cost of certification programmes offered by Schema therapy Scotland. The fees for workshops can be found on the Schema Therapy Scotland website.

Comparable Population

Schema Therapy is used to address long standing emotional difficulties associated with maladaptive coping strategies that have developed in response to difficult circumstances and stressful life events during childhood and adolescence. The evidence to support the use of Schema Therapy with people with eating disorders includes one RCT that included females, age 16–65 years, with binge eating diagnoses (BN, BED) and the evidence for personality disorders included 4 RCTs of schema focused therapy and associated treatments.

• Is this comparable to the population your organisation would like to serve?

Desired Outcome

The delivery of schema therapy is associated with significant improvements across several outcomes including frequency of binge eating, severity of eating disorder psychopathology, and overall functioning.