Schema Therapy for Personality Disorders: Evidence-Based Treatment Strategies That Work

Schema Therapy for Personality Disorders: Evidence-Based Treatment Strategies That Work

Personality disorders are among the most intricate and least treated mental health conditions. They are defined by predominant, rigid modes of thinking, feeling, and relating that lead to severe distress and disability, and which most other therapies were not made to treat.

The gap was created specifically to be addressed with the use of schema therapy for personality disorders. It addresses the cognitive and emotional wounds at the root of personality pathology, and lasting change can be achieved even with individuals who have undergone a series of preceding treatments without seeing a lasting positive result. This blog will discuss the mechanism of schema therapy and what the evidence claims about the outcomes of schema therapy.

How Schema Therapy Addresses Personality Disorder Symptoms

Schema therapy combines concepts of cognitive behavioral therapy, attachment theory, gestalt therapy, and object relations theory into one approach specifically tailored to personality disorder symptoms and chronic characterological problems. The Society of Clinical Psychology (APA Division 12) reports that schema therapy has excellent research support on borderline personality disorder and encouraging evidence of other presentations of personality disorders, such as narcissistic, avoidant personality disorders, and dependent personality disorders.

The Role of Early Maladaptive Schemas in Personality Pathology

Early maladaptive schemas are fixed, deeply self-referential beliefs about the self, others, and the world that develop in reaction to the unmet emotional needs in early life. They cannot be merely negative thoughts that can be detected and reorganized within a couple of sessions. They are passive patterns of perception, feeling, and action that seem to be so true as to not be like beliefs that might be tested and modified. The most important clinically significant personality disorder presentation schemas are:

• Abandonment and instability. The perception that the relationships will be destroyed by a rejection or loss.
• Defectiveness and shame. The notion that the self is essentially defective, unlovable, or inferior.
• Subjugation. The assumption that their needs and feelings must be suppressed to avoid retaliation from others.
• Entitlement and grandiosity. The feeling that you are special and are not subject to the same rules or restrictions as others.
• Emotional deprivation. The belief that their need for nurturing and emotional support will never be adequately met.

Borderline Personality Disorder and Emotional Dysregulation

Borderline personality disorder is the most widely studied personality disorder in terms of treatment, and schema therapy is one of the two interventions with the strongest evidence base, alongside dialectical behavior therapy. The National Institute of Mental Health (NIMH) has identified the following traits of borderline personality disorder: emotional volatility, fears of desertion, sense of identity disorder, impulsivity, and unstable relationships.

Building Distress Tolerance and Emotional Regulation Skills

Emotional regulation capacity in schema therapy for personality disorders is built across multiple parallel tracks. The competencies of distress tolerance and emotion regulation developed in skills-based work allow someone to have the capacity to face some of the most intense schemas without impulsively reacting to them.

Narcissistic Personality Disorder Treatment Approaches

The defensive mechanisms that define narcissistic personality disorder make it much more difficult to treat than BPD, since the grandiosity, the entitlement, and the devaluation of others serve to shield the person behind the underlying vulnerability that motivates them. The majority of individuals with NPD do not seek treatment for their personality disorder but rather depression, relationship failure, or other secondary effects. The personality disorders schema therapy uses NPD as a way of going beneath the grandiose to the defectiveness, emotional deprivation, and abandonment schemas that the narcissistic presentation is in defense of.

Dialectical Behavior Therapy Versus Schema Therapy for Personality Disorders

The two evidence-based treatments that have the most support in borderline personality disorder are DBT and schema therapy, and they operate in different ways. The table below will compare the two approaches:

Maladaptive Coping Mechanisms and How to Replace Them

Personality disorders schema therapy recognizes three types of maladaptive coping responses to managing the arousal of early maladaptive schemas that individuals cope with. The three coping styles include schema surrender, where the individual acts in a manner that substantiates the schema; schema avoidance, where the individual avoids circumstances that would trigger the schema; and schema overcompensation, where the individual acts in a way that would invalidate the schema. All three coping styles maintain the schema while providing only short-term distress relief.

Evidence-Based Outcomes in Personality Disorder Treatment

Schema therapy for personality disorders has produced some of the most compelling outcome data in the personality disorder treatment literature. The benefit of long-term follow-up studies is that the benefits are sustained for a number of years following the end of treatment, and this fact aligns with the objective of schema therapy to bring about structural change in the schemas and modes and not just symptomatic change.

Transforming Lives Through Specialized Care at California Mental Health

California Mental Health offers schema therapy for personality disorders in addition to DBT, CBT, and other evidence-based therapies, depending on the presentation of the personality disorder and the clinical requirements of an individual. Our clinicians are educated in schema therapy and understand the long-term, relational character of the work that personality disorder treatment involves.

Contact California Mental Health today to speak with a care specialist about schema therapy for personality disorders and other evidence-based treatment options.

FAQs

1. How do early maladaptive schemas develop and contribute to personality disorder symptoms?

Early maladaptive schemas are formed in cases where primary emotional needs with respect to safety, connection, autonomy, and self-expression have been repeatedly unmet in childhood. These unmet needs generate enduring beliefs about the self and others, encoded not as explicit thoughts but as emotional memories that later shape perception, emotion, and behavior in all significant relationships.

2. Can schema therapy reduce emotional dysregulation in borderline personality disorder patients?

Yes. The schema therapy BPD randomized controlled trial demonstrates substantial changes in emotional dysregulation, self-harm, and suicidal behavior, and positive changes in global functioning and quality of life that remain long-term. The process of change is the reinforcement of positive adult modes, which affords internal regulatory abilities that BPD depletes, and the processing of the childhood memories that imbue the abandonment and defectiveness schemas with the emotional charge that precipitates the dysregulation.

3. What specific coping mechanisms do people with narcissistic personality disorder use most often?

The coping style that predominates in narcissistic personality disorder is schema overcompensation, whereby the grandiosity, entitlement, and devaluation of others are overcompensation of underlying schemas of defectiveness, emotional deprivation, and abandonment. Schema avoidance, emotional detachment, and steering clear of situations that might trigger the underlying vulnerability are also common. The less evident in NPD but frequently the basis of self-sabotage in situations where the grandiose compensatory structure comes into question is schema surrender, whereby the person acts in manners that reinforce the underlying schema.

4. How does emotional regulation training differ between DBT and schema therapy approaches?

DBT is an explicit method of emotional regulation, taught through psychoeducation about emotions, identification of emotional vulnerabilities, and behavioral strategies to decrease the intensity of emotions, with the ultimate aim of reducing crisis-level behavior in the short term. Schema therapy treats emotional regulation by experientially processing past experiences that gave rise to emotional vulnerabilities, with the goal of reducing the intensity of schema-generated emotional responses at their source rather than largely developing skills to control the intensity of unchanged underlying emotional reactions.

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   Which personality disorder treatment method produces the fastest measurable behavioral changes?

DBT results in the quickest quantifiable decrease in the riskiest actions related to BPD, especially self-harm and suicidal conduct, and this is usually seen in three to six months of treatment; this is one of the main reasons why it is suggested as the initial line of treatment in cases of a high level of safety. Schema therapy results in slower behavioral change but more extensive and lasting change in the underlying personality structure, most of the gains of which are often seen after one to two years of treatment and which persists after termination of treatment.