The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 4
4 - Usable
The intervention has operationalised principles and values, core components that are measurable and observable, tools and resources to measure fidelity, and identified modifiable components
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.
Supports - Rating: 4
4 - Supported
Some resources are available to support implementation, including at least limited resources to support staff competency and organisational changes as a standard part of the intervention
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/).
Evidence - Rating: 4
4 - Evidence
The intervention has demonstrated effectiveness with one rigorous, external research study with the focus population and a control group.
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.
Bulimia Nervosa - Adults - Rating: 4
Research Design & Number of Studies
Adults with Eating disorders
Research evaluating the effectiveness of schema therapy with eating disorders is limited. One of the best available pieces of evidence for schema therapy in eating disorders includes one RCT that compared schema therapy to cognitive-behavioural therapy, and appetite-focused cognitive-behavioural therapy for transdiagnostic binge eating (2). The study included 112 females, age 16–65 years, with binge eating diagnosis. Schema therapy was delivered in weekly sessions over six months, followed by monthly sessions for six months. Recent systematic and narrative reviews summarise the evidence base across eating disorders (3)(4).
Outcomes Achieved
Compared to the other psychological interventions, the following outcomes were observed;
- Comparable decrease in frequency of binge eating at 12-months follow-up
- Comparable decrease in severity of eating disorder psychopathology at 12-months follow-up
Comparable increase in overall functioning at 12-months follow-up
Binge Eating Disorder - Adult - Rating: 4
Research Design & Number of Studies
Adults with Eating disorders
Research evaluating the effectiveness of schema therapy with eating disorders is limited. One of the best available pieces of evidence for schema therapy in eating disorders includes one RCT that compared schema therapy to cognitive-behavioural therapy, and appetite-focused cognitive-behavioural therapy for transdiagnostic binge eating (2). The study included 112 females, age 16–65 years, with binge eating diagnosis. Schema therapy was delivered in weekly sessions over six months, followed by monthly sessions for six months. Recent systematic and narrative reviews summarise the evidence base across eating disorders (3)(4).
Outcomes Achieved
Compared to the other psychological interventions, the following outcomes were observed;
- Comparable decrease in frequency of binge eating at 12-months follow-up
- Comparable decrease in severity of eating disorder psychopathology at 12-months follow-up
Comparable increase in overall functioning at 12-months follow-up
Personality Disorder - Adult - Rating: 4
Adults with Personality Disorder
Psychological therapies for Borderline Personality Disorder have been reviewed in a Cochrane Meta Analysis and included 4 RCTs of Schema‐focused therapy (SFT) and SFT‐related treatments (5)(6)(7)(8)(9)
Outcomes Achieved
One trial reported continuous data on BPD symptom severity. SFT reduced BPD severity and improved social functioning at end of treatment compared with treatment as usual, no data was available for follow-up (6).
Need
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.
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.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
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.
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.
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
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.
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.
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.
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.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
