Highlights of Ian James' Critique of Schema Therapy

Ian James’ article “Schema Therapy: The Next Generation, but Should It Carry a Health Warning?” (Behavioural and Cognitive Psychotherapy, 2001, pp. 401-407) raises some excellent points. Over the past decade there has been an increasing shift to more schema-focused forms of therapy (Young’s Schema Therapy or the schema-focused interventions discussed by Chris Padesky, Judy Beck, me, and others in various places). Ian recognizes the value of schema-focused approaches but suggests that they are being used too pervasively, are often being used by people without adequate training in dealing with the complexities that can arise in doing schema-focused work, and are too often being used by people who lack a foundation in the empirically validated “traditional” CBT approaches.

First, schema-focused approaches were developed as methods for treating individuals with personality disorders but in some circles they seem to be becoming the preferred approaches with Axis I problems as well. With many Axis I problems, “traditional” CBT has been well studied and has been found to be effective. Schema-focused approaches have not been demonstrated to be equally effective as treatments for Axis I problems, let alone more effective. One could argue that we have an ethical obligation to first use “traditional” CBT with problems where it has been shown to be effective and schema-focused approaches have not. If “traditional” CBT is effective, there is no need to use schema-focused approaches. If “traditional” CBT is not adequately effective, then one could argue that a trial of a schema-focused therapy is justified.

Second, schema-focused interventions can increase the client’s distress if they are used without the therapist’s being adequately prepared to deal with the schemas once they are elicited. Ian writes “Recently one of my trainees said to me: ‘It was relatively easy to get his schema out, but I didn’t know what to do next.’ ... I was particularly concerned to hear that the patient had been allowed to leave the session, now convinced that he had always seen himself as ‘worthless’. During the session the trainee had not made any attempt to re-evaluate the belief: apparently, the client walked from the room visibly shaking.” He emphasizes the responsibility of the supervisor in situations such as this. However, when a therapist learns about schema-focused techniques by reading a book or attending a workshop, there is no supervisor to handle these situations.

Third, schema-focused techniques appeal to therapists because they are exciting, they give the therapist a feeling of “power” and, they seem familiar to therapists from psychodynamic backgrounds. Many therapists from traditional backgrounds are attracted to schema-focused techniques but do not take the time to master the basics of “traditional” CBT. When this is the case, interventions which are known to be effective are being pre-empted by interventions. Also, schema-focused approaches are based on the presumption that the therapist is skilled in “traditional” CBT as well. I don’t believe that any of the proponents of schema focused therapy has been advocating that schema-focused techniques be used in isolation.

As a final caution, Ian mentions a video of a therapy session which he reviewed as part of a research study in which an Axis I patient who had been administered schema focused therapy said “Before coming into therapy, I didn’t realize that I had so many problems ... and that I was such a sh*t.” Is this what we are hoping to accomplish?

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