Schema Therapy:
Helping Clients Break the Links
of Complex Trauma
Liz Lacy, LCSW
Advanced Schema Therapist, Certified Trainer/Supervisor
The International Society of Schema Therapy, ISST
Complex Trauma:
• Definition: repetitive, prolonged and/or
cumulative
• Most often interpersonal – direct harm,
exploitation and maltreatment (including
abandonment, neglect)
• Usually occur at developmentally vulnerable
time – but can occur later if repetitive,
prolonged
Common Reactions
Affection
Dysregulation
(anger, selfdestructivene
ss, methods
of self
soothing)
Somatization
Difficulties in
Relationships
with others
(trust)
Changes in
attention and
consciousness
(dissociative,
numbing,
detachment)
Negative SelfPerception
(esp shame)
Schema Therapy Defined

An integrative, trans-diagnostic, unifying
theory & treatment
 Designed
to treat a variety of long-standing
emotional difficulties, in individuals &
couples

With significant origins in childhood &
adolescent development
Combines elements of cognitive-behavioral,
emotion-focused, attachment & object
relations models
ST vs other Evidence-Based
Treatments for Trauma
• Prolonged Exposure
• Cognitive Processing Therapy (with or
without narrative)
• EMDR – negative cognitions and images
• DBT – Best for Stage 1 BPD Treatment
• Schema Therapy
Outcome Research
Arntz, A. (2008). Schema-focused therapy for
borderline personality disorder and complex trauma: effectiveness and
cost-effectiveness, evidence from a multicenter
trial. European Psychiatry, 23, Suppl. 2, S65-S66.
Arntz, A., Tiesema, M., & Kindt, M. (2007).
Treatment of PTSD: a comparison of imaginal
exposure with and without imagery rescripting.
Journal of Behaviour Therapy and Experimental
Psychiatry, 38, 345-370.
Cockram, D. M., Drummond, P. D., & Lee, C. W.
(2010). Role and Treatment of Early Maladaptive
Schemas in Vietnam Veterans with PTSD. Retrieved
May 2, 2012, from www.interscience.wiley.com
Morrison, N. (2000). Schema-focused cognitive
therapy for complex long-standing problems: a
single-case study. Behavioural and Cognitive Psychotherapy
ST Core Components
• Limited Re-parenting
• Empathic Confrontation
• Experiential Strategies
• Cognitive Strategies
• Case Conceptualization
Stages of Treatment
• Comprehensive Assessment: written, history,
imagery, YSI, SMI
• Case Conceptualization
• Change Stage: Breaking Links, Meeting Core
Needs, Cognitive Change, Decrease in
Emotion Dysregulation, Strenthening Healthy
Adult Mode, Behavior Change
Schema Therapy for Complex Trauma or
PDOs vs
other CBT Models for Axis I Disorders

Greater emphasis on the therapeutic relationship

More emphasis on affect (e.g., imagery, roleplaying) and mood states

More discussion of childhood origins and
developmental processes

More emphasis on lifelong coping styles (e.g.,
avoidance, overcompensation, and modes)

More emphasis on entrenched core themes (i.e.,
schemas)
Broad Goal of Schema Therapy
 To
help patients get their core
needs met

Through breaking the links to
maladaptive schemas, coping
styles & modes
Core Emotional Needs

Safety

“Stable Base,” Predictability

Love, Nurturing & Attention

Acceptance & Praise

Empathy

Autonomy

Realistic Limits

Validation of Feelings & Needs
Schemas &
Developmental Needs
Early Maladaptive Schemas develop
when specific, core childhood needs
are not met
Young Schema Inventory (YSI)
Definition Of an
Early Maladaptive Schema

A broad, pervasive theme or pattern

Comprised of memories, emotions &
cognitions (not behaviors )

Regarding oneself and one's relationships
with others

Developed during childhood or adolescence,
and elaborated throughout one's lifetime

Dysfunctional to a significant degree
Eighteen Early
Maladaptive Schemas
 Abandonment
 Mistrust
-X
& Abuse-X
 Emotional
Deprivation-X

Failure

Subjugation-X

Self-Sacrifice

Unrelenting
Standards

Negativity

Entitlement

Insufficient SelfControl (addicts)

Emotional Inhibition

Punitiveness-X
 Dependence
 Vulnerability-X
 Enmeshment
 Defectiveness-X
 Social
Isolation
 Approval-Seeking
Origins of Schemas



Negative childhood &
adolescent experiences
Innate temperament
Cultural influences
(ethnicity, SES, religion, etc.)
Maladaptive Coping Styles
The ways in which we
adapt to distressing environments – and
schemas

Surrender responses (giving in)

Avoidance responses (running away)

Overcompensating responses (fighting
back in dysfunctional ways)
Common Coping Responses
Overcompensation
Surrender
 Compliance

Aggression,
Hostility

Excessive SelfReliance
 Social

Manipulation
 Stimulation,

Demandingness

Perfectionism

Overcontrol
Avoidance
 Substance
abuse
 Detachment
isolation,
Avoidance
Workaholism
Schema Therapy:
The Mode Approach
Trait vs State
Rationale & Advantages
to the Mode Approach

History of schema mode concept

Developed for more severe or complex
clients (BPD, NPD, APD, Complex Trauma)

Places more focus on here-and-now mood
states – linking to past and core needs

Provides more effective strategies to
overcome avoidance and overcompensation
The Schema Mode Concept
“The specific emotions, cognitions &
behaviors that are currently
activated”
A mode is the predominant state that
we’re in at a given point in time
(including our neurobiological state)


Modes include whatever schemas,
coping responses & healthy reactions are
activated
More About Modes

Modes are parts of the self that have not
been fully integrated (spectrum of
dissociation)

Maladaptive schema modes develop
when core needs are not met in
childhood & adolescence – as a response

We flip into maladaptive modes when
core needs are not met and our schemas
are triggered
Four Types of Schema Modes

Innate Child Modes

Maladaptive Coping Modes

Internalized Parent Modes

Healthy Adult Mode
Assessing Modes
 Observe
each mode in the session &
through discussion of events outside the
session
 Administer
& interpret the SMI (if approp)

Explain modes to client, with examples.
Get feedback and tailor names of modes
(e.g, Little John, The Wall, The Bully, The
Soldier, The Guard, Scorched Earth…).

Teach client to monitor modes by
recognizing the signs for each mode