Schema therapy

Schema therapy is a longer-term talking therapy that works on deep, long-standing patterns rather than current problems. It draws on several traditions: the structure of thought-and-behaviour-focused therapies, plus attachment theory, emotion-focused work, and psychodynamic ideas about how early experience shapes the present.

It was developed in the 1980s by Jeffrey Young, a researcher in cognitive behavioural therapy (Cognitive behavioural therapy (CBT) A structured, practical form of talking therapy. It's built on a simple idea: what you think affects how you feel, and both affect what you do. More in the jargon decoder ) — the structured, present-focused Approach (modality) The kind of therapy someone uses, such as CBT or psychodynamic therapy. You'll also see it called a modality. More in the jargon decoder that works on the links between thoughts, feelings and behaviour, and the most common therapy in Australia.

Young was interested in a particular group: people who finished that kind of therapy properly and didn’t get better. Understanding their current circumstances and adjusting their thoughts and behaviour didn’t help them as much as it helped other people.

So he built something that kept the structure of CBT but added what it was missing — early history, emotion, and the therapy relationship as an active part of the treatment.

The central idea

A schema is a deep belief about yourself and other people, formed early, that goes on to shape how you read situations for the rest of your life.

Unhelpful schemas tend to form where a normal childhood need went unmet often enough to become a rule. Not a thought you notice having. More like a lens you look through without realising it’s there.

The model describes eighteen of them, grouped into five broad areas. Some common examples:

Abandonment — people I depend on will leave
Defectiveness — if someone really knew me they’d pull away
Emotional deprivation — no one is going to meet my needs
Unrelenting standards — nothing I do is quite good enough
Subjugation — my needs matter less than everyone else’s

Schema therapy also talks about modes: the states you flip into when a schema fires. A vulnerable child mode, a harsh inner critic, an angry mode, or a detached mode that shuts everything down. Much of the work is learning to notice which one you’re in.

It also describes three ways people cope, all of which keep the schema in place. You can give in to it, avoid anything that sets it off, or push hard in the opposite direction.

What happens in a session

Assessment comes first, and it’s more thorough than in shorter therapies. Life history, questionnaires, working out which schemas are active and where they came from. This can take several sessions.

Then it shifts from talking things through to working with feelings directly, which is where it differs most from shorter, thought-focused approaches.

Imagery work. You bring to mind a recent moment when a feeling hit, then follow it back to an early memory with the same emotional flavour. Sometimes you’re asked to go back into that memory and change what happens — bringing in an adult who steps in, or saying what needed saying at the time. It sounds odd described in writing, but many people find it the most useful part of the therapy.

Chair work. Speaking from different modes, sometimes moving between chairs to do it. For example, the critic in one chair, the part it’s aimed at in another. You practise responding to your own inner critic.

Limited reparenting. Within clear professional boundaries, the therapist deliberately provides some of what was missing — warmth, consistency, honest feedback. The relationship isn’t the backdrop to the technique here - it’s part of the method.

Expect sessions to be more emotional than in a structured therapy. That’s by design: the model holds that these patterns were formed emotionally and don’t shift through understanding alone.

Who it tends to suit

Schema therapy is aimed at difficulties that are long-running rather than recent. If something has been there as long as you can remember, that’s the sort of thing it was built for.

It suits people who notice the same relationship pattern repeating, and people who can explain exactly why their self-criticism is unreasonable while still feeling it completely. Closing that gap between knowing and feeling is a central aim of this approach.

It’s also used for difficulties where shorter therapies often fall short, including personality disorders, long-term depression and complex trauma.

It asks for time and a tolerance for emotional work, so it fits better when you have some stability to work from.

What the evidence says

The strongest evidence is in borderline personality disorder, where trials have found large improvements that last, including against other active treatments. Support is growing for other personality disorders and long-term depression, and there’s early evidence for eating disorders and complex trauma.

The evidence base is real and much smaller than the one behind the most-researched therapies. Fewer trials, smaller numbers of people, and a good deal of the research comes from groups connected to the model’s development. That’s common in newer therapies, and worth knowing.

It’s best described as well-supported for particular long-standing difficulties rather than broadly proven.

Getting it in Australia

Trained practitioners are relatively few. Schema therapy takes substantial extra training and certification, and most certified therapists are in capital cities. Many practitioners describe themselves as schema-informed, which can mean anything from years of supervised practice to familiarity with the model. Asking what training someone has done is a fair question.

It runs longer than the rebated sessions last. A Mental Health Treatment Plan gives a Medicare Australia's public health insurance scheme. For mental health, it gives rebates on sessions with psychologists and some other professionals, usually through a Mental Health Treatment Plan. More in the jargon decoder Rebate The amount Medicare pays back towards a session. It comes back to you after you've paid, so what you pay yourself is the fee minus the rebate. More in the jargon decoder on up to ten sessions a calendar year — six on your first Referral A letter from a GP, psychiatrist or paediatrician that you need for the Medicare rebate. You can see a psychologist without one if you pay the full fee. More in the jargon decoder , then four more after a review with your GP (general practitioner) For most people, where getting help starts. A GP can write a Mental Health Treatment Plan, prescribe medication and refer you on, and some are trained to deliver a small number of structured therapy sessions themselves. More in the jargon decoder . Schema therapy typically runs one to two years, so the numbers don’t line up on their own.

People manage this in several ways: using the rebated sessions and paying full fee for the rest, meeting fortnightly, finding a practice with a sliding scale, or working in blocks with breaks between them. Group schema therapy is available in some services and costs considerably less.

Both cost and expected length are reasonable things to ask about in the first conversation, and you should get a straight answer.

Choosing a schema therapist

Because the work is long and emotionally exposing, fit with the individual therapist matters more here than in a short, structured therapy.

Use the first session or two to work out whether this is someone you could do difficult, emotional work with over a long period. Ask what training they’ve done, how they work, and what they think the therapy would involve for you. Therapists expect these questions and good ones are glad to answer them — you’re choosing someone to meet with for a year or more.