Schema Therapy

Schema Therapy, created by Dr Jeffrey E. Young, is an integrative psychotherapy combining original theoretical concepts and techniques with those from pre-existing models. Schema Therapy was designed to treat people diagnosed primarily with Borderline Personality Disorder (BPD), but has been extended to Trauma / PTSD, Substance Use Disorder and any other condition that is considered ‘hard to treat‘.

Schema Therapy’s cited inspirations:

  1. Cognitive Behavioural Therapy (CBT),
  2. Attachment Theory,
  3. Gestalt Therapy,
  4. Constructivism, and
  5. Psychodynamic Psychotherapy.

Schema Therapy’s main concepts:

  1. Early maladaptive schemas (aka schemas),
  2. Coping styles,
  3. Modes, and
  4. Core emotional needs.

Part of the Pseudoscience Therapies Series

  • Pseudoscience: a system of beliefs, theories, or practices that are presented as scientific but do not use the real scientific method. (‘pseudo‘ = ‘false‘).

Red Flags

Schema Therapy’s pseudoscience Ref Flags:

  • Poor Purple Hat Therapy
  • Buzzwords / psycho babble
  • Mechanism:
    • Schema Therapy’s explanation for why ill health exists is now considered false, but they continue to teach it.
    • Schema Therapy is a synthesis of 5 ideas: CBT (which is good) and 4 other dubious or discredited ideas.
  • Quality Research shows “a weak positive effect”
    • … but this is a very weak signal considering how much of the research is not acceptable.
    • and far more expensive than a treatment like CBT that has much better evidence of success.

Origin Story

Schema Therapy was developed by Dr Jeffrey E. Young. According to the AIPC Schema Therapy: Origin, Definition and Characteristics, Dr Young was working at the Centre for Cognitive Therapy at the University of Pennsylvania, when he identified a portion of clients who saw minimal benefit from “the standard approach” of talking therapy (model not specified). He noted that these clients had long standing patterns or themes in thinking, feeling and behaving / coping that required a different means of intervention. In his research paper “Cognitive therapy for depression”, 2001, the optimistic view for treating Major Depressive Disorder (MDD) with antidepressant medication or CBT is at most 60% during the acute phase, and when followed up 1 year later, 30% of those treated with CBT only had relapsed into major depression and 60% of those treated with antidepressant medication only had relapsed.

Young developed the Schema Therapy paradigm primarily for the treatment of personality disorders and other chronic conditions such as long-term depression, anxiety, and eating disorders. Many therapists consider these disorders to be too complex or resistant to treatment to address, so Young’s therapies that specifically focus these seemed welcome.

Schema therapy is often utilized when patients relapse or fail to respond after having been through other therapies (for example, traditional CBT, medication etc).

Schema has 5 base therapies that inspired it:

  • CBT (Cognitive Behavioural Therapy) is the gold standard therapy and works for pretty much everything if done properly for that condition (where talking therapy can work) and gets best results when used in conjunction with medication
  • Attachment Theory is very useful when working with children before they have good language and cognitive function, and mostly useless for adults
  • Gestalt therapy is lovely in theory, looking at the whole person and their networks, but unfortunately, almost none of that is used by therapists
  • Constructivism is a lovely theory about learning and being active in learning, which is already inherent in CBT.
  • Psychodynamic Psychotherapy is mostly psychobabble. It had an interesting aspect of recognising that not all of our brain’s functions are directly available to our conscious reasoning, but after that is became almost magical thinking with no evidence of fact.

Does it work? (No)

Options: No / Mostly no / Purple hat (usual practice, but pretending to be more), Yes.

TLDR:

  • The mechanism is effectively psychoanalysis, which we know doesn’t do what it claims.
  • The research doesn’t support the claims, beyond the ‘therapeutic effect’ (positive white coat effect).

Mechanism

How Schema Says it Works

In a nutshell, Schema Therapy proposes this basic model:

  • If your childhood current core emotional needs aren’t met, you will develop maladapted schemas (lit bad habits and views), which lead to poor coping styles (lit bad default actions to perceived adversity), which leads to poor modes (lit ways of being you).

Schema promises that by changing the cognitive patterns connect to the schema, you will diminish the intensity of your emotional memories that compromise you,

Schema Therapy attempts to address this by helping you meet your basic emotional need, by helping you while intensifying bodily sensations. Schema Therapy states this will then replace maladaptive coping styles and responses with adaptive patterns of behaviour. To do this, Schema Therapy uses elements of CBT, Attachment Theory and Experiential Approaches, which enable therapists to address deeply rooted maladaptive schemas, leading to improved regulation and interpersonal functioning.

Young proposed that what DSM IV TR called Axis 1 Disorders, were “caused by toxic early childhood experiences“, aka childhood trauma.

He called these “Early Maladaptive Schemas” (EMS).

EMS Definitions

  • A broad, pervasive theme or pattern
  • Comprised of memories, emotions, cognitions and bodily sensations
  • Regarding oneself and one’s relationships with others
  • Developed during childhood or adolescence
  • “Elaborated” throughout one’s lifetime
  • Dysfunctional to a significant degree
  • [Source: AIPC Schema Therapy: Origin, Definition and Characteristics]

Schema Therapy seeks to address the EMS to fix the root problem.

  • That is: Toxic early childhood experience (childhood trauma) -> early maladaptive schemas (early poor conceptions of the world) -> maladaptive behaviours (the actions you regret doing in situations) -> reinforced throughout your life.

On the surface, this matches what many psychologists think.

The traditional epistemology (origin story) of many mental health disorders is thought to be early childhood trauma, and if that is true, fixing the erroneous world view you have that developed from this experience makes sense.

It is a pity that we know that this is mostly false, even though psychologist epistemology for most conditions still looks like this.

The Actual Science

Regarding the epistemology of the Axis 1 conditions that Schema Therapy was created are generally congenital neurological conditions (you are born with that neurodivergent neurology), thus the idea that they are caused by early childhood trauma is clearly erroneous.

“The reason why I disagree with the default trauma based epistemology (explanation) for congenital neurological conditions (such as Autism, ADHD, BPD etc, is because, early childhood trauma doesn’t back date to your time in the womb.“

Joshua Davidson, BSW

“Many psychiatric conditions, such as anxiety, depression, substance use disorder, rejection sensitivity disorder and higher traumatic responses are secondary to undiagnosed and untreated Autism and ADHD. Many neurodivergent people are misdiagnosed with these and other conditions, while their fundamental neurology is missed. To try to treat them with just some model of trauma therapy and wonder why they are hard to treat is first gaslighting the person and then victim blaming them for the medical expert’s incompetence.“

Joshua Davidson, BSW

We are now aware that many of these disorders are biological in nature (Therapies, Understanding Mental Health, Neurodivergence).

“Biological Problems need Biological Solutions.”

Joshua Davidson, BSW

Non Neurological Causal Factors

  • While Trauma/ PTSD can be a primary root cause of some discomfort and troubling behaviours, but this is quite rare despite the ongoing dogma otherwise.
  • Conflict and Toxic People can be an exacerbator of existing issues, a temporary problem on its own or in extremes, the source of trauma.

That is, Schema therapy attempts to explain why people have different neurology or behaviours through bad experience(s) to hypothesises addressing the schemas (world views) generated from trauma with schema focused therapy – but we now know that different neurology is generally congenital (you are born with it), many symptoms are best explained by biology (cardiopulmonary, adrenaline, hormonal), and thus fixing schemas from early childhood trauma is erroneous since most of these conditions aren’t caused by early childhood trauma.

What is needed for most people is correctly working out the biological cause and addressing that [biological problems require biological solutions], in parallel to standard or specialised CBT to address the maladapted cognition and behaviour you may have created to survive the biology.

Mechanistically speaking, the hypothesis that these complex conditions are caused, at their root, “toxic early childhood experiences” is wrong and misleading.

Let us allow for a moment that the outdated model is correct, that these complex mental ill health conditions are caused by “toxic early childhood experiences“.

Reviewing EMDR Inspiration Therapies

This all assumes that EMDR’s aetiology (toxic early childhood experiences) is correct:

  • Cognitive Behaviour Therapy (CBT): The proposed method to address this hypothetical aetiologically with elements of CBT has, on that erroneous assumption, a level of soundness.
  • Attachment Theory: Attachment Theory is used when trying to work out if a child / parent interaction is going well. The outcome approximately is:
    • Good attachment: All is likely fine,
    • Poor attachment:
      • Check for:
        • Problems with the parents,
        • Child – Autism / ADHD,
        • Child abuse from not-parents.
      • Types of Poor Attachment:
        • There are a small number of ‘types of poor attachment’ that are thought to give clues about what might be wrong, or where to look for what might be wrong, but they amount to the simple part of “parent” or “child”.
  • Gestalt Therapy:
    • What is it? A lovely therapy in theory, where the entire person and their surrounding networks are meant to be considered.
    • Does it work? No. In practice, I have not seen this done well. Research shows little objective empirical evidence that it is effective.
  • Constructivism:
    • What is it? An education model based on the theory / philosophy stating that people actively construct knowledge and meaning from their personal experiences and interactions with the world, rather than passively absorbing information.
    • Does it work? No. Decades of education research indicates this is an error in education.
  • Psychodynamic Psychotherapy:
    • What is it? A talking therapy that explores how unconscious thoughts, repressed emotions, and past experiences shape current behavior.
    • Does it work? No. After decades of Psychodynamic Psychotherapy, almost not evidence shows a consistent positive result.

The fact that the hypothesis (EMS cause) is generally wrong for the people seeking Schema Therapy, means the proposed solution is likely not a good fit.

The “toxic early childhood experiences” may exacerbate existing conditions, and should be addressed, but not at the expense of checking to see if there is an undiagnosed, untreated, underlying neurological conditions that is being exacerbated. To not do that is harmful.

Psycho Babble: Schema Therapists use a great deal of jargon in there therapies. Some of the words seem to be intuitive in their meaning (as in self-descriptive), but a great deal of it is a mystery. Many patients have no idea what the jargon means. For example:

  • People complain of patronising and infantalising terms.
  • 20 Schema Modes (some site 18):
    • Is quite overwhelming, non-specific and runs the risk of psycho-babble astrology.
    • eg Punitive Critic, Defiant Protector, Compliant Surrenderer etc.
  • Proprietary / hyper-specific terms:
    • Empathic Confrontation,
    • Imagery rescripting,
    • Limited Reparenting.

However, just because the hypothesis is flawed doesn’t mean that Young didn’t accidentally make an effective therapy.

Quality Research

I’m going to be quite frank here – It isn’t good.

Remember that Schema Therapy has existed for 25 years. Locally, here in WA, as of 2025, a course of Schema Therapy treatment costs around $5,000. We need to compare the cost and efficacy (consistency and confidence that the treatment will work) versus the gold standard for therapy CBT (Cognitive Behavioural Therapy) & TF-CBT (Trauma Focused CBT). CBT, and for people working through Trauma , TF-CBT, has strong evidence of efficacy. TF-CBT costs between free (bulk bill) and $1,650 (assuming 10 sessions and government rebate) – Schema Therapy costs 3 times more than TF-CBT.

You would want Schema Therapy to work at least 3 times better than TF-CBT to make it worth doing.

A meta analysis (2015) examined 3,200 abstracts published between 2011 to 2015, for described examining Schema Therapy for Personality Disorders. The authors were trying to establish the effectiveness of Schema Therapy for Personality Disorders (remember, that is what Schema Therapy was initially created to help). The meta analysis discarded most of them (not a good sign) for failing to meet basic criteria (see below).

A total of 31 studies of 3200 abstracts met all of the basic inclusion criteria without tripping the basic exclusion criteria (see the Inclusions and Exclusion Criteria below).

  • Of those 31 studies, 9 addressed the treatment effectiveness of Schema Therapy.
    • 1 of these compared Schema Therapy to CBT for Depression (not a ‘Personality Disorder‘),
    • 1 investigated Schema Therapies effectiveness in treating Chronic Depression (not a ‘Personality Disorder‘),
    • “The remaining seven articles evaluated ST in different samples of personality disorders” (not the same ones).

[Systematic review of the clinical effectiveness of schema therapy, 2015.]

That is, from 3200 possible candidates (based on the abstracts) to a final 9 (7+2) is quite a culling of studies – usually a Red Flag for the treatment. The odds of most of the studies being discarded due to not being in 1 of the 3 languages is very low.

The inclusion and exclusion criteria were not very demanding (look to the right).

For only 9 to meet this simple criteria to treat Personality Disorder and be of a high enough standard (low bar of high in this case) is damning. Considering that Personality Disorder was one of the primary disorders that inspired Young to develop Schema Therapy.

The Conclusion section of the meta analysis briefly discussed how bad the excluded studies were and gave recommendations for how to improve Schema Therapy studies moving forwards so that they can be included in a meta analyses.

In the Analysis section, the authors say “empirical support for ST [schema therapy] is growing, RCTs [Randomized Controlled Trial] are still rare, preventing broader generalizations“. Double blind Random Control Trials (RCT) is the gold standard for comparing an intervention, and according to the authors, so far Schema Therapy is not even doing just the Random Control Trials.

Frankly, it is damning that the authors of the meta analysis spent precious words schooling the researchers of Schema Therapy on how to do basic psychology science, and that these 3200 studies were published in Peer Reviewed Journals (granted, some were excluded because of the wrong language, but surely not 3,100 or more of them).

Inclusions and Exclusion Criteria

Inclusion required all of the following criteria:

  1. Studies included evidence of schema therapy,
  2. Published in 1 of 3 languages,
    • English, Portuguese, Spanish
  3. Participants had a diagnosis,
  4. Included either individual and or group treatment

Exclusion criteria were any one of the following:

  1. Participants younger than 18 years of age,
  2. Few than 10 sessions of intervention,
  3. Few than 4 participants.

In the paper’s discussion section, there was a semi positive statement “Although their findings are preliminary, favorable results were reported for the application of ST in a difficult-to-manage population including patients with antisocial personality and high psychopathy scores.” However, consider that this was 9 out of 3,200 papers examined, and where I suspect the other 2 were included, so that it wasn’t just 7 papers.

This is kind of like saying

“After the claims of excellent apples from an apple distributor, we asked for a sample pallet of their excellent apples. Of the 3,200 items provided on the pallet (the studies by proponents of Schema Therapy), we discarded some of the fruit because they weren’t apples (some oranges and strawberries) that is, wrong language. After we discarded the rotten ones (poor studies that mean nothing because they didn’t meet the basic criteria for a useful study – Schema Therapy vs Personality Disorder with the basic rigor of science), we had 9 left. One of the sample fruits was a pear and one was a nashi (sort of related, but not really apples). We sent them some ideas for how they can improve the quality of their apples. These 9 bits of fruit seemed to taste okay, so we think there is some hope that fruit from this provider might be good quality apples.”

If I had asked for proof of a providers apples being really good, and of 3,200 samples provided, I could only find 9 that kind of fit the criteria of ‘quality apple’, and some of those showed some promising taste, I think that I would steer clear of apples from that provider.

If meta studies are finding it this difficult to find quality studies, and the ones that pass the criteria only have an indication that there may be some good aspects to the therapy, then it is fair to say that this therapy does not consistently work. That is, the research is very poor, and the results of the few studies that weren’t horrible were weak.

If Schema Therapy was as effective as claimed by those selling their services ($5,000 for a basic course of treatment, 3 times the standard TF-CBT), then surely it should be easy to show in good quality research. Yet, somehow, after 25 years of this very expensive therapy intervention, we have next to no good quality studies showing that it works.

RED FLAG ALERT: If you have good evidence that your product works, then share the results.

If you are trying to make an argument that your product works, but you can’t show the evidence that unambiguously demonstrates that, then you are probably lying or have been deceived.

If I were looking to spend $5,000 on therapy, I wouldn’t be spending it on this.

Where is the Harm?

Schema Therapy is exploitation of the vulnerable:

  • It victim blames (the vulnerable person) when it doesn’t work.
  • It is often very expensive, especially in comparison to treatments that have good evidence for working.
  • It leaves vulnerable people even more vulnerable.
    • High risk of misery.
    • High risk of mortality.
  • Therapists are often fooled into mistake this as an effective method.

People who have complex mental health, such as Major Depressive Episode, Schizophrenic episodes, Panic Attacks, and ‘Personality Disorders’ do not need a therapy that promises to help them better than the gold standard, costs 3 times more than the gold standard, but then fails to deliver any effective treatment, fails to provide a valid mechanism of why these people struggle, and uses known flawed psychological remedies to try to address it.

Therapists have often been fooled into thinking that this is a valid therapy method by educators who are making bank on selling this so called ‘Evidence Based Therapy‘. These therapists are guilty of failing to look at the actual research into how effective Schema Therapy is, and are thus complicit participants with the con artists who sold them the therapy.

Erroneously leaning into the trauma narrative myths makes it very hard for patients to address the actual biological problems that underlie the obvious psychiatric experiences, to receive effective treatment, both medication and talking therapy, to learn better coping and thriving strategies for what remains. Poorly executed trauma therapy can lead to very bad results.

The suicide rate for these conditions is high (20%) and the quality of life for those who do not kill themselves is low. These vulnerable people do not need yet another exploitation or false promise of help.

Warning: This is anecdotal (my experience as a therapist). The plural for anecdote is not data, but it is a place to start from.

I have had quite a few clients that have come to see me spouting all kinds of strange buzzwords about their modes of operations, their coping styles and their schema types. I have asked what those words actually mean, or at the least, what they mean to them. My clients had no idea, so I would assume these phrases and concepts didn’t help. It took much longer to get to the core problems, causes and useful solutions so that my clients could experience gains that were not dependent on luck. It was much harder to help these clients out of the self blame victim mode that schema left them in.

To be fair, those who Schema Therapy may have helped didn’t need to come and see me.

Joshua Davidson,. BSW

Summary

When Young proposed his ideas for addressing what he thought was the root cause of some complex mental ill health, his logic was sound for the time, and the therapies he meshed together were also considered somewhat sound at the time.

Unfortunately, we now know that his proposed reason for complex mental ill health is wrong, and all of the therapies that he meshed together bar CBT, are flawed. Research into Schema Therapy effectiveness shows grossly incompetent studies are the norm, and the tiny percentage that were passable showed only a small, limited, positive result.

If Schema Therapy worked like they claim it does, it shouldn’t he hard to find and provide clinical evidence that it works. Yet, after 25 years, the papers are awful and the few papers that pass basic quality checks show faint positives.

If you were investing in product with that kind of record, you would wisely not invest in it.

References

Schema Therapy: Origin, Definition and Characteristics. (2016, July 12). AIPC Article Library. https://www.aipc.net.au/articles/schema-therapy-origin-definition-and-characteristics/

Mor, N. (2009). Cognitive-behavioral therapy for depression. The Israel Journal of Psychiatry and Related Sciences. https://www.academia.edu/download/83251890/2009_4_6.pdf

Bakos. D.S., Gallo, A.E. Wainer, R. Systematic Review of the Clinical Effectiveness of Schema Therapy. Oat, Contemporary Behavioural Health Care., https://www.researchgate.net/profile/Alex-Gallo/publication/291829462_Systematic_review_of_the_clinical_effectiveness_of_schema_therapy/links/56af4bd308ae43a3980fb2eb/Systematic-review-of-the-clinical-effectiveness-of-schema-therapy.pdf