Schema-Focused Therapy (SFT)

Schema-Focused Therapy (SFT), also known simply as schema therapy, is commonly referred to as a modified cognitive-behavioural treatment. However, schema therapy has been described by its developer as “a truly integrative psychotherapy”. Initially conceived of as a cognitive therapy for patients with chronic depression and personality disorders, the theoretical underpinning of schema therapy has evolved to incorporate substantial developments in psychodynamic theory. As in psychodynamic object relations and attachment theories, schema therapy emphasizes the internalization of early relationships into cognitive-affective representations. Borderline Personality Disorder (BPD) is characterized by a predominance of certain maladaptive representations, known as early maladaptive schemas. SFT seeks to modify these schemas through the explicit use of interventions from various therapy models, including CBT, Gestalt, and Emotion-Focused Therapies.

Conceptual Model

SFT regards the essence of BPD as a constellation of maladaptive schemas. These schemas develop in the context of early family environments, in combination with genetic influences, which are experienced primarily as unstable, unsafe, depriving, punitive, or subjugating. When reinforced over time, these experiences develop into schemas which subsequently form core aspects of the individual’s personality structure. Individuals with BPD will function in accordance with these schemas, often rapidly flipping between different modes of identity. The major modes that comprise BPD are labelled as: (1) the abandoned and abused child, (2) the angry and impulsive child, (3) the detached protector, (4) the punitive parent, and (5) the healthy adult. For example, a patient may occupy an abandoned child mode in the face of an interpersonal rejection, and then switch to an impulsive child mode in acting out against the rejection, or a punitive parent mode in criticizing the self for being bad and causing the rejection.

The Treatment

SFT regards internal changes in schema modes to be necessary for recovery from BPD. As such, long-term treatment – typically two sessions per week over an average of three years – is recommended. Several types of interventions, drawing from various other therapy models, are implemented in SFT in order to address schema modes and their associated emotional, cognitive, and behavioural difficulties. These consist of “limited re-parenting,” emotion-focused and Gestalt techniques, cognitive restructuring, and breaking behavioural patterns. “Limited re-parenting” refers to the therapist taking on an “as if” – rather than actual – parenting type of role toward the patient. This involves creating an atmosphere of safety and acceptance within the therapeutic relationship. An empathic therapeutic relationship is considered to be the most important element of SFT. Emotion-focused and experiential / Gestalt techniques consist of imagery work regarding early dysfunctional relationships as well as enacted dialogues between different schema modes. Cognitive-behavioural interventions include the use of Socratic dialogue, homework exercises, and recommendations for modifying maladaptive behaviours.

Research on SFT

A multi-centre randomized clinical trial (RCT; N = 86) examined schema-focused therapy for BPD, comparing this with Transference-Focused Psychotherapy (TFP). In this trial, patients were seen in individual therapy twice per week over a three year period, with therapists receiving regular supervision. Patients in both treatment conditions achieved significant gains across all symptom domains, personality features, and quality of life. SFT was found to outperform TFP on measures of personality dysfunction and in positive personality changes. SFT also demonstrated better cost-effectiveness than TFP at one year follow-up. Patients in the TFP condition, however, had significantly higher levels of suicidality than those receiving SFT, and the adherence of TFP therapists to the treatment protocol was questioned by the TFP consultant to the trial. Nonetheless, this study indicates that the integrative treatment offered in schema therapy can contribute to positive changes in several domains for patients with BPD.

Schema therapy provided in a group format has also been tested empirically in a small RCT (N = 32) of female outpatients with BPD. In this trial, patients received either treatment as usual – largely individual psychotherapy offered once per week – or treatment as usual plus group SFT. The SFT consisted of 30 weekly sessions over 8 months. The treatment involved emotional awareness training, psychoeducation, distress management, and schema change work. Patients in the SFT group improved significantly on a range of measures of borderline pathology, and achieved increases in overall global function, with 94% of SFT patients no longer meeting criteria for BPD. Patients in the SFT group also had a 100% retention rate: they did not drop out.

The above-mentioned studies provide empirical support for SFT as a treatment for BPD. One of the strengths of SFT may be its integrative approach, embracing techniques from different therapy schools. This may make SFT more accessible and welcoming for clinicians who have trained in other models. From an empirical perspective, however, this integrative perspective makes SFT somewhat difficult to examine with regards to which elements of SFT are most central in promoting change and recovery.