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Response to Critiques of Schema Therapy (Long)
Jeffrey Young · 01/06/02 at 4:58 ET
I find myself increasingly frustrated by the uninformed criticisms of cognitive therapists like Jim and Paul. I also am sick of snide comments like Paul's implying that I am one of the "charismatic therapists and teachers who "dine out" on teaching techniques which are highly plausible and entirely unvalidated." The fact is that schema therapy was developed for patients who were not responding to cognitive therapy. Most of these patients turned out to have personality disorders. I have devoted most of my professional career to developing a theory and treatment that draws on what I consider excellent strategies from other models, as well as my own experience and formulations, in order to help difficult, severe patients, such as Linda describes. I do not teach or write about my model in order to make money; it is a "cause" that I strongly I believe in. (I could have made substantially more income just treating private Manhattan patients than I have developing, writing about, and training therapists in the schema approach.) It is worth noting that a large number of cognitive therapists have integrated many of my schema concepts and techniques into their own work since I began to develop this model in the 1980's. Some of the more recent outcome studies using CT actually incorporate some schema-based techniques, although they have been relabeled as "changing core beliefs." Cognitive science and neuroscience have both independently moved increasingly in the direction of unconscious processes, including what I call schemas and schema processes. And many research studies utilizing my schema inventories offer support for the conceptual model. As for hypocrisy, some cognitive therapists make claims about the usefulness of cognitive therapy for personality disorders. Yet there is little or no data supporting its usefulness for PD's (other than DBT). Yet the Beck, Freeman, et al. book on CT for PD's was published in 1990, the same year as my own first book. Shouldn't criticism regarding the lack of empirical evidence for treating PD's be applied equally to CT and to Schema Therapy? Or are we to assume naively that CT works well with PD's because it is effective with depression and anxiety? So what are therapists to do who have patients like Linda's with severe personality disorders but who do not find CT alone adequate? We try out many of the other therapies that are available, even when they so far lack empirical evidence of efficacy, and combine them with cognitive-behavioral approaches. Do Jim and Paul refuse to treat patients with PD's because there is not yet a validated treatment for most of them? Or do they use CT anyway, much as I advocate using ST, even though there is little empirical support as yet with PD's? I don't want to beg the question of why there are so few studies on the efficacy of Schema Therapy with personality disorders. The implication is that I do not care about evidence of efficacy. This is a complete fallacy. I have been trying to collaborate on, and encourage, outcome research regarding ST for many years. But the task has been frustrating. It is crucial to recognize that there are almost no studies on the efficacy of ANY treatment modality for PD's. There are several reasons for the paucity of research in this area. (1) The diagnostic system for assessing PD's is terribly inadequate. The Axis II categories were originally developed from Freudian theory, and have never been significantly expanded beyond this. The categories in Axis II are relatively unreliable, overlap enormously, and do not include categories that fit many patients with lifelong, characterological disorders. So how does one do a study when there is no acceptable system of personality diagnosis, and when most PD patients fit into more than one category? (2) Even if the categories were more reliable and non-overlapping, how does a researcher find enough subjects with just one Axis II disorder to do a decent outcome study? One must have access to an extremely large population in order to get enough subjects who are relatively "pure" examples of one Axis II category. (3) The treatment of PD's, in our experience, requires a year or more of weekly psychotherapy. Unfortunately, longer term treatments for Axis II disorders are not on the list of research funding priorities in the US, as several researchers have discovered who have submitted grants in this area. What researcher can afford to do a long-term study like this, with more than one treatment condition, without outside funding? On a more encouraging front, both Jim and Paul appear to be unaware that an extremely large-scale outcome study is underway in Holland, comparable in scale to the NIMH Collaborative Study of Depresion. This multi-site study, led by Arnoud Arntz, compares schema therapy with a major psychodynamically-based model for BPD. Because the treatment is long-term, it will still be at least another year before data are published, even though preparation for the study (including pilot patients and therapist training) has already been in progress for more than three years. Then we will finally have some empirical data about schema therapy. Until then, therapists will have to muddle around with PD's, trying existing approaches that seem promising, because patients cannot wait for empirical data to receive treatment. Linda's excellent work extending ST to criminal offenders is a great example of creative work in an area that is vital, yet extremely difficult to research. I could make a case that there would not be so many practitioners utilizing ST if it lacked any significant value in treating PD's, when briefer treatments are available. But this will certainly not be a convincing argument to most researchers. Before attacking me, or others working with personality disorders, critics should become more informed about the difficulties of researching PD's. Furthermore, impugning the character of researchers like myself, or ascribing mercenary motives, has no empirical basis whatsoever and probably reflects the schemas of the critics themselves. I could as easily accuse them of "unconscious motives" like professional jealousy or competitiveness, because they have not yet developed a new therapy model of their own, or because they erroneously believe I am becoming wealthy teaching this approach. But I would have no basis for making such hypotheses about them, since I do not truly know their motives, so I refrain from doing so. I can only respond accurately to the content of their criticisms, not to what their motives are in making them. More constructively, perhaps Jim or Paul would like to develop their own outcome studies on PD's and try to receive funding. I would support them in any way possible, as I have with many other researchers who approach me for help in writing grants for outcome research with PD's. Finally, let me address Ian James' critique of ST in the British journal. Unlike the comments of the current writers, I find Ian's article to be generally fair and balanced (despite its title). While acknowledging the apparent usefulness of the approach, he also points out the dangers of utilizing ST in place of proven treatments for Axis I disorders. While this is not in any way a criticism of ST iself, it is a legitimate problem. Some therapists appear to be utilizing ST with acute Axis I disorders, even though I specifically teach, and emphasize, that ST is supposed to be initiated once acute Axis I symptoms have already been reduced (see my chapter on "Depression" in Dave Barlow's book, co-authored with Tim Beck and Arthur Weinberger). ST is designed specifically for the characterological components of psychological disorders, not for acute Axis I symptom reduction. Fianlly, I want to thank Linda Nauth, Tim Beck, and Judy Beck (among others)for their ongoing support. I also hope Jim, Paul, and others will reply to the substance of my response. Otherwise, the same uninformed criticisms will continue to "recirculate" within the CT community, without any true give and take with me or other schema therapists.
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