Schema therapy is an integrative form of psychotherapy drawing from multiple psychological approaches, which is informed by formulation and involves adapting therapeutic strategies in response to the individual’s problems (Bernstein, Arntz, & Vos, 2007; Keulen-de Vos, 2013). 

It places emphasis on the early-life origins and developmental pathways of current psychological problems, and how these have led to maladaptive coping strategies. These are then targeted through emotive therapy techniques and using the therapeutic relationship (Fassbinder, Brand-de Wilde, & Arntz, 2019; Keulen-de Vos, Bernstein, & Arntz, 2014; Young, Klosko, & Weishaar, 2003).

It uses the concepts of early maladaptive schemas, schema modes, and disorder-specific schema modes related to personality disorder(s) (Fassbinder et al., 2019; Masley, Gillanders, Simpson, & Taylor, 2012; Young et al., 2003).

The schema mode model (i.e. combining multiple schemas into one unit) is used for more severe and complex presentations as these often involve multiple schemas and coping strategies being active simultaneously (Van Genderen, Rijkeboer, & Arntz, 2012).

Motivation toward therapy is viewed as dynamic and fluctuating instead of static (Bernstein et al., 2012).

It can be delivered as group therapy in forensic populations but it is mostly implemented via individual therapy (Farrell, Shaw, & Webber, 2009; Vreeswijk & Broersen, 2012).

Schema therapy was developed by Jeffrey Young in the 1980s with the aim of improving interventions for individuals with personality disorders and more complex and chronic difficulties. It came about as a follow on from CBT for individuals who had tried other therapies and still had unresolved issues (Young, 1990). It was developed as a systematic approach that brought together several therapies and approaches into one unified model of intervention (Young et al., 2003). 

The original Schema Therapy Model (Young et al., 2003) focused on individual schemas that would be triggered individually. Schema modes were added to the approach to assist practitioners in working with personality disorder, where it was felt that schemas were too simple to capture the quickly shifting emotions and behaviours (Keulen-de Vos et al., 2014’ Young et al., 2003). This also led to disorder-specific schema modes being developed for other personality disorders and forensic individuals.

It differs from traditional cognitive and behavioural therapies in the conceptual framework underpinning it (i.e. Young’s Early Maladaptive Schema, Schema modes, and Schema coping styles), the use of experimental techniques aimed at reworking schemas, and the importance placed on the therapeutic relationship (Bernstein et al., 2007).

Schema therapy was not originally created for forensic populations but has been adapted based on evidence that it worked well with personality disorders (Farrell et al., 2009; Giesen-Bloo et al., 2006; Nadort et al., 2009) of which there are higher rates of within forensic populations. Applying it to forensic populations involves considering a number of elements; the risk of violence and deception, the function of motivation for treatment and the impact on the therapeutic relationship, and the dissonance between a restrictive environment and the need for safety and security (Keulen-de Vos et al., 2014).

It builds in more elements than CBT (e.g. character, life, behaviour and environment). It also places significant emphasis on the therapeutic relationship (Young et al., 2003).

It is an integrative psychotherapy that draws from various theories (i.e. cognitive-behavioural, attachment, Gestalt, psychodynamic, object relations, existential/humanistic) and approaches (i.e. constructivist and psychoanalytic) to produce one unified treatment model (Bernstein et al., 2007; Young et al., 2014). It relies on a techniques such as the Empty Chair exercise which draws from Gestalt and Drama therapies (Keulen-de Vos et al., 2014).

Within forensic populations it applies Risk Need Responsivity (RNR) as it is aimed at high risk, prevalent personality disorder, and projects a 2-3 year treatment period (i.e. intensive) (Keulen-de Vos et al., 2014).

Schema therapy has the following core concepts; early maladaptive schemas, schema coping styles, and schema modes (Rafaeli , Bernstein, & Young, 2011; Young et al., 2003) –

1. The term ‘schema’ came from data processing theory and the idea of mental frameworks being developed to organise information. They also build upon Aaron Beck’s (Beck & Freeman, 1990) work around early maladaptive cognitions. Schemas are considered to be stable (trait), enduring and one-dimensional thinking frameworks that guide perceptions and behaviours over the course of our life (Keulen-de Vos, 2013). Early maladaptive schemas are self-defeating dysfunctional themes or patterns about the self or others that are formed from unfulfilled or unmet childhood emotional needs (i.e. attachment, autonomy, expression, etc.) (Bernstein, Clercx, & Keulen-de Vos, 2019).

1. Schema coping styles are the response to the emotional reaction of early maladaptive schemas. They can be to; surrender, avoid or overcompensate. In forensic populations, the focus is often on overcompensation playing a role in violent behaviour (Keulen-de Vos, 2013).

1. Schema modes reflect a constellation of schemas and coping styles active at a particular moment. Schema modes are instantaneous, continuously changing short-term situations that represent an individual’s dominant state of mind (Van Genderen et al., 2012). In forensic populations, violent behaviour is conceptualised in the form of particular schema modes thought to stem from genetic vulnerability and adverse childhood experiences (Keulen-de Vos et al., 2014; Caspi et al., 2002). 

The intention behind the theoretical model underpinning Schema Therapy is to provide a framework for both the individual and therapist to understand the meaning and reasons behind triggering events (Bernstein et al., 2007).

Understanding offending from a Schema Therapy perspective involves thinking of events leading up to and resulting in offending as a sequence of schema modes. This involves emotional triggers, modes being activated, and maladaptive coping styles being employed in response to modes (Keulen-de Vos et al., 2017; Keulen-de Vos, Herzog-Evans, & Benbouriche, 2022). Maladaptive schema modes are considered the internal, or psychological, risk factors that increase the likelihood of antisocial behaviour, whereas healthy modes are considered internal protective actors decreasing its likelihood. Likelihood of offending behaviour is therefore determined by the relative activation of maladaptive and healthy modes.

Schema Therapy tries to change maladaptive schemas, coping styles and modes into more healthy and productive ones (Young et al., 2003; Masley et al., 2012). It aims to teach an individual how to regulate, moderate and eliminate their various maladaptive schema modes and to develop a ‘healthy adult mode’ where the person is able to meet their own emotional needs in a successful and adaptive way (Bernstein et al., 2007; de Klerk, Keulen-de Vos, & Lobbestael, 2021). The therapist aims to ‘re-parent’ the individual through ‘corrective emotional experiences’ with the aim of the individual learning how to better understand and react to triggering situations.

It is a more intensive treatment for individuals with personality disorder(s) (particularly antisocial, narcissistic, borderline and paranoid, in forensic populations) and other difficult to treat problems who have often showed poor outcomes in other forms of therapy (Bernstein et al., 2007; Young et al., 2003). The aim is for long-term positive change in the person’s life, such as reducing personality disorder symptoms, dealing with issues related to an individual’s likelihood of recidivism, and teaching constructive ways of dealing with emotions such as anger (Bernstein et al., 2012; Keulen-de Vos et al., 2014; Spinhoven, Giesen-Bloo, Dyck, Kooiman, & Arntz, 2007).