Schema therapy is a model designed for adverse childhood experiences and is well suited as a treatment framework for complex post-traumatic stress disorder cases. Schema therapy can provide a middle path between trauma-focused and phase-based approaches. Rather than focusing on stability before moving to trauma processing (primarily via imagery rescripting), the focus is on the client’s emotional needs. Schema therapy does not primarily focus on stability as a core treatment process. Instead, trauma-processing imagery and other experiential exercises are encouraged to commence early in treatment, focusing on creating corrective emotional experiences for the client involving experiences of getting their needs met (e.g., for safety, validation etc.). There are two main ways to conceptualise schema therapy for complex PTSD: 1) as a ready-made approach that incorporates imagery rescripting as the primary trauma-focused approach; and 2) a broader integrative approach, where a range of trauma-focused interventions (e.g., EMDR) can be embedded within a schema therapy conceptualisation.

Behavioural pattern breaking is arguably the most important phase of schema therapy. Although some degree of behavioural pattern breaking occurs throughout the therapeutic process, the most significant changes mostly occur in the middle and final phases of therapy. Empathic confrontation is used to gently push for changes to take place in the early phases of therapy, in order to address therapy-interfering behaviours and to set limits on behaviours which may lead to danger for clients and/or others. Behavioural change work should be carried out incrementally, and explicitly linked to the client’s needs. Chairwork is used to uncover the unmet needs that have been masked by coping modes, and to challenge modes that block recovery. Useful techniques for bringing about behavioural change include empathic confrontation, limit setting, flashcards, pattern-breaking forms, and future pattern-breaking imagery. While coping modes continue to dominate, schemas will be perpetuated and lasting progress will not be possible. It is therefore crucial that the therapist works to address their own schemas and the client’s schemas that block change, to enable them to overcome presenting issues and to facilitate authentic emotional vulnerability and interpersonal connection.

Cognitive techniques in schema therapy make use of an array of methods traditionally drawn from cognitive-behavioral therapy (CBT) but which focus on the ‘schema’ or ‘mode’ level. However, in clients with more chronic presentations (e.g. those with a personality disorder), the healthy part as addressed in traditional CBT is often not sufficiently developed. Cognitive methods and techniques in schema therapy therefore need to be adjusted to the particular mode being targeted and must take into account the limited capacity for rational, reflective processing often seen during the initial phases of therapy. Socratic dialogue, for example, might not prove effective when addressing a Parent mode in the start phase of therapy. Frequently used cognitive techniques in the early phase of schema therapy focus on developing awareness of activated schemas or modes through the use of psychoeducation, using the white board or flip-over to reformulate emotional experiences into modes, and the use of cognitive ‘schema’ or ‘mode’ diaries. In the later stages of therapy cognitive techniques are used to change the beliefs in activated schemas or modes. This can include simple (e.g. listing pros and cons of a coping mode) or more complex techniques (e.g. Socratic dialogue).

Schema therapy is often characterised by its focus on maladaptive processes, healing and managing the painful and maladaptive aspects of a client’s presentation (e.g. Vulnerable Child, Detached Protector). While this may be accurate to a large extent, Jeff Young, in his seminal book, also outlined the importance of two positive modes that often require development during schema-based treatment: The Healthy Adult mode and the Happy Child mode. This chapter provides updated definitions of the Healthy Adult and Happy Child modes, before describing a therapeutic approach to building and inducing these modes for client well-being and self-regulation.

Schema therapy is built on the assumption that we all have schemas. Just as our clients are caught in self-perpetuating lifetraps that prevent them from getting their emotional needs met, so are we as schema therapists. Within the context of our therapeutic work, our schemas can function as blindspots, potentially leading to reduced empathy and misattunement in our therapy sessions, as well as putting ourselves at risk for suffering from emotional difficulties, including burnout. Over the past twenty years, as the ST model has expanded so have opportunities for us to explore and work on our own schemas and access both professional and emotional nourishment. In this chapter, opportunities for building therapist well-being are explored through four main areas: (1) professional nourishment through participation in continuing professional development and schema therapy committees and special interest groups; (2) self-therapy, including personal therapy and self-practice/self-reflection; (3) individual and peer supervision with a focus on therapists’ own schemas and modes; (4) self-care based on core needs, including mindfulness, self-compassion practices, connection with nature, breathwork and movement, as well as connection with peers and colleagues.

Schema therapy (ST) supervision is an essential ingredient in the journey towards confidently and competently working with the schema therapy model. The primary aims of ST supervision include providing good treatment adherence, as with all treatment models, but in practice can offer so much more to the schema therapist. ST supervision supports the clinician in understanding nuances in the model and its practical application that are difficult to convey in the training context. Supervision also assists clinicians in understanding and formulating a wide range of presentations. The ST supervisor holds three specific roles within the supervisory relationship depending on the supervision needs at any given point: (1) supervisor as educator/coach; (2) supervisor as mentor/role model; and (3) supervisor as (limited) therapist and agent of limited reparenting.

The formulation and communication of a clear and accurate case conceptualisation is a central task for the schema therapist and should occur before treatment begins. The main purpose of case conceptualisation is for the schema therapist to develop and work from an accurate understanding of the schema-based maintenance factors assessed to underpin a client’s presenting issues. The application of treatment strategies is always informed by the therapist’s understanding of the client based on this case conceptualisation. Thus, schema therapy has been likened to a form of ‘psycho-surgery’; interventions are tailored to meet the client’s needs at that very moment. A second important function of case conceptualisation is to help engage the client in therapy. The clear communication and understanding that comes from the collaborative formulation process aids the therapy relationship by making the client feel heard and understood, while also helping the client understand themselves better and building mode awareness. By the end of the assessment phase, the schema therapist will document a full schema therapy case conceptualisation and communicate a summary of the most important parts of the case conceptualisation using a schema therapy mode map.

Schema therapy could have very easily been named as ‘needs therapy’, so central is the concept of core emotional needs to the practice of modern schema therapy. Borrowing from the basic needs concept and theories of attachment that had been well developed in the developmental psychology literature, Young described the following core domains as pivotal to understanding problems that emerge in the developmental period: (1) Secure attachments to others (includes safety, stability, nurturance, and acceptance); (2) Autonomy, competence, and sense of identity; (3) Freedom to express valid needs and emotions; (4) Spontaneity and play; (5) Realistic limits and self-control. Need satisfaction during childhood leads to the development of healthy schemas and related functional affective and behavioural patterns, while early need frustration leads directly to the development of early maladaptive schemas (EMS) and related negative patterns of behaviour and maladaptive coping styles. This chapter describes the central theories and concepts which underpin schema therapy practice including the original set of eighteen schemas, as well as schema modes and the schema mode model.

Although coping modes were needed as survival mechanisms earlier in the client’s life, in the present they block the capacity to emotionally connect with others and to achieve fulfilment of their needs. In schema therapy, experiential techniques are emphasised because information processing is enhanced in the presence of affect. All the methods and techniques described herein rely on the schema therapist empathically bypassing any coping modes that block the client from experiencing their Vulnerable Child mode. A range of techniques are described, including labelling, interviewing coping modes, chairwork to bypass coping modes, implicit assumption technique, and empathic confrontation. Variations in chairwork include Contamination of the Chair to access Vulnerable Child, and Therapist Plays the Vulnerable Child. Schema therapy relies on the client inhabiting Vulnerable Child mode to receive limited reparenting and corrective emotional experiences and messages that counteract outdated schema-driven messages. As this process unfolds, there is potential for the client to open up to new and unexpected ways of developing a revitalised capacity to connect with others in their own lives.

This chapter illustrates the complex functions that eating disorder behaviour can take, including self-punishment, emotional avoidance, empowerment, mastery, self-regulation, and appeasement of others. The schema therapy approach encourages disaggregating these functions, personifying them, understanding them, and directing dialogues between them. A case study illustrates the way in which the schema mode model can be applied to work with eating disorder symptoms alongside complex trauma. A sufficient level of medical and nutritional stability (as indicated by blood tests and weight) must be reached in order to provide sufficient safety for therapy to proceed. A key component of schema therapy is to understand the unmet needs and schemas that have led to the development of an eating disorder. In schema therapy, the client gradually learns to reconnect with her/his inner child states and needs through extensive therapeutic work – which includes imagery rescripting, chairwork mode dialogues, and somatic, cognitive, and behavioural techniques. Coping modes are not just bypassed, but through imagery and chairwork are actively acknowledged and integrated to form a Healthy Adult ‘team’ that works to prioritise the inner child modes and ultimately meet the client’s nutritional, physiological, and emotional needs.

Limited reparenting is a cornerstone of schema therapy. It is a style of interacting with clients in which the therapist aims to give the client experiences of having their emotional needs met directly within the therapeutic relationship. The therapist here serves as a ‘healthy model’ or template of caring, self-control, and guidance that, over time, is internalised by the client into their own ‘Healthy Adult’ mode. The core ingredients of limited reparenting include offering care, guidance, empathic confrontation, and limit setting. The aim of this therapeutic relationship is to provide corrective experiences that ‘kick start’ the emotional development of the client. Based on a thorough assessment and conceptualisation, limited reparenting offers a specific roadmap to harnessing the power of the therapeutic alliance to promote schema change.

Experiential techniques are central to schema therapy. Moreover, they can be synergetic to changes within cognitive or behavioural domains, or within the therapy relationship. Nonetheless, they are often challenging and are omitted from the schema therapy treatment. Typically, experiential work comes in the form of chairwork or imagery-based interventions or ‘dialogues’. Imagery Rescripting is a powerful experiential method and a central change mechanism in schema therapy; it aims to change the legacy of childhood experiences, images, and memories linked to schema and mode development; rescripting results in the formation of new adaptive meanings and access to feelings and insights. In contrast, a chairwork technique is highly suitable within a schema therapy context, enhancing schema mode work. First, chairwork can result in a more distinct and clear illustration to the client of mode interplay. Second, it allows the client to take the ‘perspective’ of the mode and make dysfunctional modes and schemas as ego-dystonic and defused. Often emotional techniques are avoided by therapists learning the schema therapy model, typically related to confidence in interventions and making things ‘worse’ for the client. It is essential for the schema therapist to learn to utilise emotion-focused work to be helpful for the client.

Cognitive-behavioural therapy (CBT) is rightly considered a first-line psychological treatment for a plethora of psychological disorders due to its extensive research base. Evidence for schema therapy (ST) as a first-line treatment is strongest where personality disorders are concerned. With other high-occurrence disorders, once known as ‘axis 1 disorders’ (e.g. depression, anxiety disorders), evidence is now emerging for ST as a second-line treatment in its own right. From a schema therapy point of view, in focusing treatment on presenting ‘axis 1’ problems, patterns of avoidance and rigidity characteristic of underlying personality disorder pathology often remain unaddressed and can drive treatment non-response. In this chapter, we outline a ST approach to mood and anxiety disorders where ST may be considered as a second-line treatment option in those cases where there is (a) an inadequate response to first-line treatment (e.g. CBT) and/or (b) where significant symptoms of personality disorder, or traits thereof, are assessed to be maintaining the severity and/or chronicity of illness, including the engagement with and response to any treatment.

This chapter outlines a range of methods for developing a comprehensive schema therapy assessment, including clinical interview, identification of key problem areas and related therapy goals, functional assessment of key problem areas, self-monitoring forms, mode assessment, questionnaires and psychometric data, diagnostic imagery, and process assessment. The assessment process largely continues throughout the entire therapeutic process, as more information is understood and revealed, allowing for reformulation and fine tuning. Throughout the assessment process the schema therapist suggests possible links between current presenting issues and interpersonal patterns, early attachment processes and schema development. This process is aimed at building rapport through deep attunement and transparency, whilst providing education about schema development, thereby gradually strengthening the client’s capacity to self-reflect. A shared formulation (even if tentative) provides the groundwork for the therapeutic process. It is therefore essential to spend sufficient time exploring childhood and adolescent issues and the way in which these link to presenting issues.

Schema therapy research has increased significantly over the last twenty years. This chapter reviews empirical support for the schema therapy model, including evidence for the existence of core emotional needs, that early maladaptive schemas result from unmet needs, and that early maladaptive schemas and schema modes are associated with various forms of psychopathology. Next, it reviews the randomized controlled trials of schema therapy for personality disorders and the uncontrolled trials of schema therapy for a range of other problems including anxiety and related disorders and eating disorders. Finally, empirical support for two key interventions within schema therapy – imagery rescripting and chair dialogues – is discussed. There is strong support for the efficacy of long-term individual schema therapy for females with borderline personality disorder. Support for other applications of schema therapy is promising but requires replication with more rigorous study designs. There is evidence that belongingness/secure attachment, competence, and autonomy are basic psychological needs. Both maladaptive and adaptive schemas cluster according to themes of whether or not early experiences provided connection, autonomy, and reasonable limits.