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Integrating mental health professionals into medical settings acknowledges the interplay between mental health and physical health conditions

Schema Therapy in Medical Settings

Cesar A. Gonzalez, PhD, ABPP Primary 

Care Psychologist 

Assistant Professor of Psychology and Family Medicine, Mayo Clinic,

Rochester, Minnesota, USA


Early Life Experiences and Health in Adulthood

Schema theory posits that life experiences promote the development of adaptive and maladaptive schemas through conscious and non-conscious cognitive, affective, and somatic experiences and inform the perception of ourselves, the world, and our future. When our developmental needs are not met, the theory implies that we turn to conscious and non-conscious behaviors (whether adaptive or maladaptive) to promote survival in an attempt to meet our cognitive, affective, and somatic need for autonomy, relatedness, and competency.      

While the direct influence of maladaptive schemas on health conditions has not been examined, there is evidence that correlates adverse early life experiences to maladaptive behaviors and to health conditions in adulthood that go above and beyond the influence of gender, age, race/ethnicity, income, and educational level. Maladaptive behaviors include smoking, substance use, risky sexual behaviors, suicide attempts, poor diet, and health conditions that include chronic pain, diabetes, myocardial infarction, coronary heart disease, stroke, asthma, difficulty with maintaining weight loss after bariatric surgery, and spontaneous preterm birth. Moreover, adverse childhood experiences have been associated with multimorbidity among patients with health conditions. 

Schema Therapy Fills a Gap in Medical Settings

Integrating mental health professionals into medical settings acknowledges the interplay between mental health and physical health conditions and promotes access to mental health care by reducing stigma associated with mental health diagnoses.  For example, a recent review of 40 studies found that nearly 45% of individuals who completed suicide had contact with a primary care provider within a one-month period of time before the individual completed suicide. 

Currently, the majority of medical-behavioral interventions are guided by traditional cognitive-behavioral models that do not directly target and acknowledge the integration of cognitive, affective, and somatic experiences and their impact on health behaviors. While integrated medical-behavioral models are proving to be associated with positive outcomes for population health, in both mental and physical health conditions, much of the reported outcomes are clouded by selection bias and are focused on patients who are already engaged in treatment. In addition, the effectiveness of traditional cognitive-behavioral treatments in integrated medical-behavioral models are most effective for patients with mild-to-moderate chronicity and complexity, suggesting that treatments may not be identifying and targeting key mechanisms to promote change. 

In my practice, schema therapy is filling a gap by expanding the current models in integrated behavioral-medical care from a strictly cognitive-behavioral model, to one that is cognitive-affective-somatic and helps me understand and facilitate behavioral changes. Further, there is also evidence to suggest that schema theory-developed conceptualizations may be more acceptable to patients compared to a diagnosis-based conceptualization and reduce stigma related to mental health.  

Case Example # 1 – Diabetes Management

Jane, a 33 year old woman, whose type 2 diabetes was not well managed, was referred to me by her diabetes care coordinator.  Jane participated in collaborative care focused on providing her with motivational interviewing, goal setting, and behavioral activation in order to promote her adherence to insulin. However, Jane was not adhering to her insulin, despite her father having passed away from complications related to diabetes. Scores on Jane’s depression screeners suggested that she had moderate depressive symptoms that were not improving. After a period of 6 months of lack of improvement, the collaborative care manager referred Jane to me for a consultation.

In our initial appointment, Jane reported that she cognitively understood that she had to monitor her blood glucose levels and take her insulin; however, she still has a difficult time adhering to the regimen. I obtained a brief life history from Jane. During the consult, Jane informed me of her father's passing, how she was the youngest of 8 children, and how she was bullied throughout childhood due to weight. In addition, Jane reported observing her parents surrendering to many preventable adverse life circumstances due to lack of education; she reported that her parents often verbalized that it was God’s punishment. Using the original schema model, the schemas related to the domain of disconnection/relatedness came to mind and included emotional deprivation, instability, defectiveness, punitiveness, and social isolation/exclusion. 

Linking schemas with presenting health issue

In having these schemas available to discuss, Jane spontaneously provided examples of life experiences – she also was able to bridge many of her experiences to her current difficulties. During the initial 50 minute period, Jane verbalized that she held the belief that she  was being punished for something horrible she must have done at some point in her life - she was able to link this to the belief that mistakes warrant punishment - the punitiveness schema- and tied this to her observing this from her parents when she was growing up. I engaged Jane in cognitive activities asking her to recall explicit memories that reinforced this belief. Jane stated, "When something went wrong, my parents would often say that God has a plan, and that you can't change God's plan, even when he is punishing us." From this cognitive awareness, Jane reported an underlying belief that "good" and "bad" things happen in an ebb and flow manner. Using limited re-parenting, I provided warmth and understanding, while also providing reassurance and challenging the cognitive belief that punishment is always warranted. "If God wants to punish you, why is it that he would put you in my care to help you with your diabetes?” We also focused on how the failure schema “talked” to the punitiveness schema. By the end of the session, Jane and I had collaboratively developed a case conceptualization and identified targets for our treatment that had not previously been addressed which served as barriers to adhering to her insulin. Subsequently, I spoke to the care manager and encouraged that a focus on small gains be amplified and to be aware of language associated with punishment or shaming. Since that time, Jane substantially increased her blood glucose monitoring and has steadily increased her adherence to insulin.

Schema Therapy and Physician Health and Development

In the United States, physicians, compared to nonphysicians, have a two times higher odds of completing suicide. While no one single factor can likely explain this, I have noted significant levels of unrelenting standards and self-sacrifice. In addition, among physicians there is recent research that suggests that maladaptive schemas are associated with professional boundary violations against patients and suggests that health providers’ schemas impact their decision making when working with patients. This suggests a role for integrating and addressing maladaptive schemas through targeted treatment and wellness programs. 

In my role as a psychologist in a medical setting in primary (continuity care clinic), secondary (hospital service), and tertiary care (consultations to individuals with functional neurological/gastrointestinal disorders, somatic symptom disorders, etc) I have found that I have been able to engage patients whom otherwise would not engage in the existing integrated medical-behavioral models of care. These outcomes are not a coincidence, and while the researcher part of me attempts to keep my equipoise, the clinician part of me are excited about the future and seeing the research catch up to the practice of schema therapy in medical settings.

Why Schema Therapy?

Schema therapy has been extensively researched to effectively treat a wide variety of typically treatment resistant conditions, including Borderline Personality Disorder and Narcissistic Personality Disorder. Read our summary of the latest research comparing the dramatic results of schema therapy compared to other standard models of psychotherapy.

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