The evidence is moderate. The Young Schema Questionnaire measures most of the 18 schemas reliably, and every schema is linked with depression. Randomized trials support schema therapy for borderline and other personality disorders. The five domains don't come out cleanly when the schemas are analyzed, and the three coping styles come mostly from clinical work and have been measured less often.
All 18 schemas were linked with depression, and social isolation and defectiveness had the strongest links
In 2022, Amy Bishop, Rita Younan, Jennifer Low and Pamela Pilkington pooled 51 studies of adults, 17,830 people in all. Every one of Young's 18 schemas was linked with depression.
A correlation shows how closely two things rise together, where 0 means no link and 1 a perfect one. The links ran from small, at .23 for entitlement, to large, at .53 for social isolation, the sense of not belonging anywhere. Defectiveness, the sense of being flawed or unlovable, was close behind at .50.
What it doesn’t show: Most of the studies measured schemas and depression at the same time. They can't tell us whether a schema leads to depression, or whether depression colors how people rate themselves. The schemas also overlap, so part of a link with one may belong to others.
Amy Bishop, Rita Younan, Jennifer Low and Pamela Pilkington, Early maladaptive schemas and depression in adulthood: a systematic review and meta-analysis, Clinical Psychology and Psychotherapy, 2022.
When the schemas were pooled across 13,958 people, Young's five domains didn't come out cleanly
In 2022, Jens Thimm combined 27 studies that used the Young Schema Questionnaire, with 33 groups and 13,958 people. The groups' average ages ran from 16 to 72. He looked at how the 18 schemas cluster, to see whether they fall into Young's five domains.
None of the domain models proposed so far fit well, Young's five included. The standard statistical tests pointed to two broad groups. Thimm kept four, because they were easier to read and close to the four domains schema therapy now uses: disconnection and rejection, impaired autonomy and performance, excessive responsibility and standards, and impaired limits. In a five-group solution, the fifth group held only self-sacrifice. Three groups gave the simplest structure of all.
What it doesn’t show: It shows how the schemas cluster on average, and it doesn't test whether any single schema is real or useful. Only studies using the Young Schema Questionnaire were included, and its versions may not measure quite the same thing. One researcher coded all the studies, which raises the risk of error.
Jens Thimm, The higher-order structure of early maladaptive schemas: a meta-analytical approach, Frontiers in Psychiatry, 2022.
In a three-year trial for borderline personality disorder, about twice as many recovered with schema therapy
In 2006, Josephine Giesen-Bloo, Arnoud Arntz and seven colleagues reported a trial in four community mental health centers in the Netherlands. It included 88 people with borderline personality disorder. Chance decided who got schema therapy and who got transference-focused psychotherapy, a psychodynamic therapy built for the same disorder. Both ran for three years, with two sessions a week.
Both groups improved on every measure. After three years, 45.5 percent of the schema therapy group had recovered, against 23.8 percent of the other group. People were also more likely to drop out of transference-focused psychotherapy.
Schema therapy45.5%
Transference-focused psychotherapy23.8%
Percent who had recovered from borderline personality disorder after three years.
What it doesn’t show: There was no group given usual care or no treatment. The research assistants gradually learned who had which therapy, and the study psychiatrists knew all along. Each therapy was supervised by its own developers, Jeffrey Young among them, and Arnoud Arntz is a leading researcher of schema therapy. It is one trial, and it tested the therapy as a whole.
Josephine Giesen-Bloo, Richard van Dyck, Philip Spinhoven, Willem van Tilburg, Carmen Dirksen, Thea van Asselt, Ismay Kremers, Marjon Nadort and Arnoud Arntz, Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy, Archives of General Psychiatry, 2006.
In a trial for six other personality disorders, more people recovered with schema therapy than with usual treatment
In 2014, Lotte Bamelis, Silvia Evers, Philip Spinhoven and Arnoud Arntz reported a trial run in 12 Dutch mental health centers from 2006 to 2011. It included 323 people with avoidant, dependent, obsessive-compulsive, paranoid, histrionic or narcissistic personality disorder. Chance decided who got 50 sessions of schema therapy, the center's usual treatment, or another talking therapy called clarification-oriented psychotherapy. The groups had 147, 135 and 41 people.
Three years after treatment began, interviewers who didn't know who had which treatment judged who had recovered. More people recovered with schema therapy than with either of the others, and fewer dropped out of it than out of usual treatment. A second group of schema therapists, trained mainly through practice exercises, got better results than the first group, trained mainly through lectures.
Schema therapy81.4%
Clarification-oriented psychotherapy60%
Usual treatment51.8%
Estimated percent who had recovered from the personality disorder three years after treatment began.
What it doesn’t show: On questionnaires people filled in about themselves, the treatments didn't differ. Only 41 people had the other talking therapy. The trial tested schema therapy as a whole, so it can't show which part helped or whether schemas themselves changed. Arnoud Arntz, the senior author, is one of the main researchers behind schema therapy.
Lotte Bamelis, Silvia Evers, Philip Spinhoven and Arnoud Arntz, Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders, American Journal of Psychiatry, 2014.