Abstract
This paper explores the bidirectional relationship between trauma and Substance Use Disorders (SUDs), emphasising the need for integrated treatment approaches. Trauma exposure, often associated with various psychological disorders, contributes to the high comorbidity observed in SUDs. Early childhood trauma, in particular, is linked to vulnerability in developing SUDs later in life. In response to the challenges of treating SUDs, this paper outlines emerging evidence for schema therapy as a transdiagnostic intervention. Schema therapy, an extension of cognitive behavioural therapy, targets maladaptive schemas and core beliefs by integrating cognitive, behavioural, and experiential techniques. Schema therapy recognises the role of unmet core emotional needs in the development of early maladaptive schemas, offering a holistic approach to address entrenched psychological patterns. Empirical evidence suggests a significant association between early maladaptive schemas and SUDs, highlighting the potential of schema therapy in addressing substance use. Despite limited research, studies demonstrate promising outcomes, including reductions in SUD severity and symptoms of comorbid conditions. Clinical implications include the integration of trauma screening in SUD assessments, adopting a holistic approach to treatment, and exploring schema therapy as a viable intervention through rigorous research methodologies. Ultimately, this paper highlights that the integration of schema therapy into substance use treatment programs holds promise in revolutionising the approach to SUDs, providing a nuanced and effective therapeutic intervention for individuals seeking lasting recovery and improved quality of life.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
1 Introduction
Substance Use Disorders (SUDs) represent a pervasive and alarming public health issue that affects individuals, families, and communities worldwide. The prevalence of SUDs is staggering, with millions of people across the globe grappling with the challenges of addiction. It is estimated that 3.3% of Australians (647,900 people) aged 16–85 years have a 12-month SUD [1], and over 20.3 million people are experiencing a SUD in the US [2].
Concerningly, SUDs are also notoriously challenging to treat due to their multifaceted nature and the complex interplay of biological, psychological, and environmental factors. Indeed, Fleury et al. [3] meta-analysis of 8855 studies demonstrated that only 35% to 54% of individuals with SUDs achieve remission long term. Aside from the impact of the brain’s adaption to the presence of a substance (i.e., tolerance and dependence), comorbidity may be the most significant reason complicating treatment. SUDs are commonly comorbid with a number of mental health issues such as mood disorders, anxiety disorders, and eating disorders [4,5,6], as well as disorders that onset in childhood such as attention-deficit/hyperactivity disorder, oppositional defiance disorder, and conduct disorder [7]. Kingston et al. [8] systematic review of 18 studies found that prevalence estimates of current mental health disorders in substance use treatment clients varied from 47 to 100%.
SUDs also frequently co-occur with trauma, creating a complex interplay that significantly impacts the lives of affected individuals. There are specific diagnostic understandings of trauma (e.g., DSM-5-TR; ICD-11), which require specific types of adverse events for diagnosis of trauma-related disorders, but across the literature a wide range of events have been linked to the experience of trauma [9]. The relationship between trauma and substance use tends to be bidirectional, with trauma increasing the risk of developing SUDs, and substance use often exacerbating the impact of traumatic experiences [10, 11]. Individuals that have experienced early childhood trauma appear to be particularly vulnerable to developing SUDs later in life, with this relationship well documented in the extant literature [12,13,14]. For instance, Santo et al. [15] conducted a systematic review and meta-analysis that demonstrated significant associations between sexual abuse, physical abuse and neglect, and opioid use disorder.
Exposure to trauma is also associated with many psychological disorders [16], which further complicates the psychopathological picture of, and potentially accounts for, the high comorbidity in SUDs. Trauma exposure is embedded in the diagnosis of Post-Traumatic Stress Disorder (PTSD; DSM-5-TR), but also strongly associated with mood disorders [17], anxiety disorders [18], personality disorders [19], obsessive compulsive spectrum disorders [20], and eating disorders [21]. Given this, there is a strong push for integrated treatment approaches which provide holistic care for comorbid conditions in substance use treatment [22].
2 Schema therapy
The prevalence of comorbidity in SUDs underscores the necessity for transdiagnostic interventions capable of comprehensively addressing concurrent conditions [23]. Schema therapy is one such transdiagnostic approach that offers integrated treatment for comorbidity. Schema therapy, an extension of cognitive behavioural therapy, focuses on identifying and restructuring maladaptive schemas and core beliefs [24]. By integrating cognitive, behavioural, and experiential techniques, schema therapy provides a holistic approach to addressing entrenched psychological patterns. Schema therapy aims to recognise and manage negative schemas through fostering emotional regulation and healthier coping mechanisms [24]. Notably, within the framework of schema therapy, unmet core emotional needs which often occur in the context of adverse childhood experiences are understood to contribute to the formation of early maladaptive schemas [25]. These schemas, which are conceptualised as longstanding patterns and traits, often develop as adaptive responses to trauma, continue to influence an individual's thoughts, emotions, and behaviours in an unhelpful way, long after the traumatic event has occurred [26]. Coping responses to schemas are formulated as so-called schema modes, referring to emotional, cognitive, and behavioural states; most modern schema therapy approaches conceptualise presenting symptoms based on people's schema modes [25]. Notably, the central agent of change for schema therapy involves the use of experiential and emotion-oriented techniques to stimulate affect and deliver corrective experiences as well as its unique utilisation of the therapeutic relationship [24, 26]. Schema therapy has been found to be effective for treating mood disorders [27], anxiety disorders [28], personality disorders [29], obsessive compulsive spectrum disorders [30], and eating disorders [31], and can be delivered in individual or group formats [32,33,34].
3 Evidence for schema therapy for substance use disorders
3.1 Schema Modes and Early Maladaptive Schemas in Substance Use Disorders
Since Ball [35] first proposed the relevance of early maladaptive schemas to individuals with SUDs, there has been a gradual emergence of promising empirical evidence demonstrating schema profiles and amplified maladaptive modes for people with SUDs. For instance, Brotchie et al. [36] found that men and women with opioid use disorder scored higher on 11 of 15 early maladaptive schemas (utilising an earlier conceptualisation of Young’s schemas) compared to a non-clinical comparison group. Similarly, Roper et al. [37] found that individuals with alcohol use disorder exhibited higher scores on 14 out of 15 early maladaptive schemas. Over the past decade, analogous results have been reported for individuals with SUDs [38,39,40,41], and many have documented schema profiles in samples of people misusing alcohol [42, 43], cocaine [44], and opioids [45], and heterogeneous samples of SUDs [38, 46,47,48,49,50]. Further, specific early maladaptive schemas have been shown to associate with behaviours relating to SUDs. Recently, Sakulsriprasert et al. [51] conducted a systematic review and meta-analysis (n = 12,577) showing that the schema domains of ‘disconnection and rejection’, ‘impaired limits’, and ‘impaired autonomy’ were closely associated with SUDs.
3.2 Schema Therapy for Substance Use Disorders
Research assessing the impact of schema therapy programs is in its early stages, with limited available evidence. This is partly due to (i) the historical high rates of exclusion of individuals with SUDs from clinical trials, and (ii) the absence of a consistent measure of substance use as a secondary outcome when they are included. Despite this, several studies have reported encouraging results. In their seminal study, Ball and Young [52] reported a case series of three individuals with comorbid personality and SUDs (alcohol, benzodiazepines, and heroin, respectively) who engaged with a 24-week dual focus schema therapy program. All three cases showed some initial improvement, however only one out of the three achieved a maintained reduction of substance use over the course of treatment. Some years later, Ball et al. [53] compared the effectiveness of schema therapy to manualised individual drug counselling for individuals with SUDs and personality disorders. They found that individual drug counselling was more effective in reducing psychiatric symptoms. However, in response to Ball’s [53] study, Lee and Arntz [54] highlighted several significant methodological issues including drop-out rates of over 50% in both groups, and resultant issues with treatment fidelity and dosage in the schema therapy group. Importantly these early studies strongly highlight the need for high quality and high fidelity studies of schema therapy in this population to properly ascertain the efficacy of this intervention.
More recently, Tapia et al. [55] found that schema therapy combined with Eye Movement Desensitisation and Reprocessing significantly reduced addiction severity and symptoms of PTSD and depression in a sample of 15 women. Similarly, Oraki [56] found that in a small sample (n = 20) of men with heroin dependence, 10-week group schema therapy significantly reduced symptoms of depression and relapse rates. Boog et al. [57] examined the effectiveness of schema therapy for 20 men and women with borderline personality disorder and alcohol use disorder. They found that 3 months after cessation of schema therapy 13 out of 19 participants achieved remission from borderline personality disorder. Furthermore, their frequency of alcohol use days and heavy alcohol use days significantly decreased.
In addition to the encouraging outcomes of these studies, schema therapy also returns the benefit of relatively low dropout rates, which is a common problem particularly in substance using populations. Gülüm’s [58] systematic review of eight schema therapy studies reported an average dropout rate of 23% for people with personality disorders, compared to 30% in-person SUD treatment [59]. By addressing multiple comorbid issues in a single treatment episode, schema therapy also provides a unique opportunity to more comprehensively meet the treatment needs of patients, and therefore sustain treatment engagement.
4 Clinical implications and recommendations
First, it is recommended that comorbidity and specifically trauma screening should be integrated into the assessment phase of all people seeking treatment for SUDs. Second, clinicians should adopt a holistic approach to treating SUDs, including addressing co-morbid mental health conditions such as depression and PTSD which likely act to increase vulnerability and precipitate and perpetuate substance use [10, 11]. This is in line with a recent increase in understanding of the benefits of applying trauma focussed treatment for disorders other than PTSD throughout the literature [60]. Third, given the reported schema profiles and modes in people with SUDs and promising initial studies [55,56,57], schema therapy should be further examined as a viable treatment for SUDs through randomised control trials, using larger and more diverse samples. Finally, researchers should prioritise the inclusion of SUD measures as a secondary outcome and be cautious about excluding individuals with SUDs in future trials evaluating schema therapy. This provides a useful mechanism to explore this presenting issue across a diverse range of trials.
5 Conclusion
The integration of schema therapy as a transdiagnostic treatment model into substance use treatment programs holds immense promise in revolutionising the approach to SUDs. By addressing the core beliefs and maladaptive schemas fuelling addiction, schema therapy offers a nuanced and effective therapeutic intervention, which validates the multi-faceted struggles of those seeking treatment. Presently the empirical evidence limited, and large-scale randomised controlled trials need to be undertaken to examine effectiveness of schema therapy for SUDs and comorbidity. However, if evidence supporting its efficacy continues to mount, it will become imperative for clinicians and researchers to embrace schema therapy as a cornerstone of treatment for SUDs. By doing so, we could elevate the standard of care, providing individuals struggling with SUDs a path towards lasting recovery and improved quality of life.
References
Australian Bureau of Statistics, National Study of Mental Health and Wellbeing. 2023: Canberra, ACT, Australia.
Substance Abuse and Mental Health Services Administration, Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. 2019.
Fleury M-J, et al. Remission from substance use disorders: a systematic review and meta-analysis. Drug Alcohol Depend. 2016;168:293–306.
Bahji A, et al. Prevalence of substance use disorder comorbidity among individuals with eating disorders: a systematic review and meta-analysis. Psychiatry Res. 2019;273:58–66.
Lai HMX, et al. Prevalence of comorbid substance use, anxiety and mood disorders in epidemiological surveys, 1990–2014: a systematic review and meta-analysis. Drug Alcohol Depend. 2015;154:1–13.
Toftdahl NG, Nordentoft M, Hjorthøj C. Prevalence of substance use disorders in psychiatric patients: a nationwide Danish population-based study. Soc Psychiatry Psychiatr Epidemiol. 2016;51:129–40.
Groenman AP, Janssen TW, Oosterlaan J. Childhood psychiatric disorders as risk factor for subsequent substance abuse: a meta-analysis. J Am Acad Child Adolesc Psychiatry. 2017;56(7):556–69.
Kingston RE, Marel C, Mills KL. A systematic review of the prevalence of comorbid mental health disorders in people presenting for substance use treatment in Australia. Drug Alcohol Rev. 2017;36(4):527–39.
Karstoft KI, Armour C. What we talk about when we talk about trauma: content overlap and heterogeneity in the assessment of trauma exposure. J Trauma Stress. 2023;36(1):71–82.
Borges G, et al. Traumatic life-events and alcohol and drug use disorders among Mexican adolescents: bidirectional associations over 8 years. Drug Alcohol Depend. 2021;228: 109051.
Simmons S, Suárez L. Substance abuse and trauma. Child Adolesc Psychiatr Clin. 2016;25(4):723–34.
Degenhardt L, et al. The associations between traumatic experiences and subsequent onset of a substance use disorder: findings from the World Health Organization World Mental Health surveys. Drug Alcohol Depend. 2022;240: 109574.
Renaud F, et al. The impact of co-occurring post-traumatic stress disorder and substance use disorders on craving: a systematic review of the literature. Front Psych. 2021;12: 786664.
Rogers CJ, et al. Effects of multiple adverse childhood experiences on substance use in young adults: a review of the literature. Drug Alcohol Depend. 2022;234: 109407.
Santo T Jr, et al. Prevalence of childhood maltreatment among people with opioid use disorder: a systematic review and meta-analysis. Drug Alcohol Depend. 2021;219: 108459.
Hogg B, et al. Psychological trauma as a transdiagnostic risk factor for mental disorder: an umbrella meta-analysis. Eur Arch Psychiatry Clin Neurosci. 2023;273(2):397–410.
Palmier-Claus J, et al. Relationship between childhood adversity and bipolar affective disorder: systematic review and meta-analysis. Br J Psychiatry. 2016;209(6):454–9.
Fernandes V, Osório FL. Are there associations between early emotional trauma and anxiety disorders? Evidence from a systematic literature review and meta-analysis. Eur Psychiatry. 2015;30(6):756–64.
de Aquino Ferreira LF, et al. Borderline personality disorder and sexual abuse: a systematic review. Psychiatry Res. 2018;262:70–7.
Brander G, et al. Systematic review of environmental risk factors for obsessive-compulsive disorder: a proposed roadmap from association to causation. Neurosci Biobehav Rev. 2016;65:36–62.
Rabito-Alcon MF, Baile JI, Vanderlinden J. Mediating factors between childhood traumatic experiences and eating disorders development: a systematic review. Children. 2021;8(2):114.
Fisher A, et al. Guiding principles for managing co-occurring alcohol/other drug and mental health conditions: a scoping review. Int J Ment Health Addict. 2022. https://doi.org/10.1007/s11469-022-00926-7.
Mansell W, et al. Cognitive behavioral processes across psychological disorders: a review of the utility and validity of the transdiagnostic approach. Int J Cogn Ther. 2008;1(3):181–91.
Young JE, Klosko JS, Weishaar ME, Schema therapy. New York: Guilford, 2003. 254: 653–658.
Arntz A, et al. Towards a reformulated theory underlying schema therapy: Position paper of an international workgroup. Cogn Ther Res. 2021;45:1–14.
Boterhoven de Haan KL, et al. A schema therapy approach to the treatment of posttraumatic stress disorder. J Psychother Integr. 2019;29(1):54.
Körük S, Özabacı N. Effectiveness of schema therapy on the treatment of depressive disorders: a meta-analysis. Current approaches in psychiatry/Psikiyatride Guncel Yaklasimlar. 2018;10(4).
Hawke LD, Provencher MD. Schema theory and schema therapy in mood and anxiety disorders: a review. J Cogn Psychother. 2011;25(4):257–76.
Zhang K, et al. The efficacy of schema therapy for personality disorders: a systematic review and meta-analysis. Nordic J Psychiatry. 2023;77:1–10.
Peeters N, van Passel B, Krans J. The effectiveness of schema therapy for patients with anxiety disorders, OCD, or PTSD: a systematic review and research agenda. Br J Clin Psychol. 2022;61(3):579–97.
Joshua PR, et al. Is schema therapy effective for adults with eating disorders? A systematic review into the evidence. Cogn Behav Ther. 2023;52(3):213–31.
Arntz A, et al. Effectiveness of predominantly group schema therapy and combined individual and group schema therapy for borderline personality disorder: a randomized clinical trial. JAMA Psychiat. 2022;79(4):287–99.
Farrell JM, Shaw IA, Webber MA. A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder: a randomized controlled trial. J Behav Ther Exp Psychiatry. 2009;40(2):317–28.
Younan R, Farrell J, May T. ‘Teaching me to parent myself’: The feasibility of an in-patient group schema therapy programme for complex trauma. Behav Cogn Psychother. 2018;46(4):463–78.
Ball SA. Manualized treatment for substance abusers with personality disorders: dual focus schema therapy. Addict Behav. 1998;23(6):883–91.
Brotchie J, et al. Cognitive representations in alcohol and opiate abuse: the role of core beliefs. Br J Clin Psychol. 2004;43(3):337–42.
Roper L, et al. Maladaptive cognitive schemas in alcohol dependence: changes associated with a brief residential abstinence program. Cogn Ther Res. 2010;34:207–15.
Khosravani V, et al. Early maladaptive schemas, behavioral inhibition/approach systems, and defense styles in the abusers of opiate, stimulant, and cannabis drugs and healthy subjects. J Subst Use. 2017;22(3):317–23.
Shorey RC, Stuart GL, Anderson S. Early maladaptive schemas among young adult male substance abusers: a comparison with a non-clinical group. J Subst Abuse Treat. 2013;44(5):522–7.
Shorey RC, Stuart GL, Anderson S. Differences in early maladaptive schemas between a sample of young adult female substance abusers and a non-clinical comparison group. Clin Psychol Psychother. 2014;21(1):21–8.
Zamirinejad S, et al. Predicting the risk of opioid use disorder based on early maladaptive schemas. Am J Mens Health. 2018;12(2):202–9.
Chodkiewicz J, Gruszczyńska E. Maladaptive schemas among people addicted to alcohol: heterogeneity but not specificity? Alcohol Alcohol. 2018;53(6):682–7.
Janson DL, et al. Differences between men and women regarding early maladaptive schemas in an Australian adult alcohol dependent clinical sample. Subst Use Misuse. 2019;54(2):177–84.
Boog M, et al. Schema modes and personality disorder symptoms in alcohol-dependent and cocaine-dependent patients. Eur Addict Res. 2018;24(5):226–33.
Semlali Wafae I, et al. Measurement of early maladaptive schemas in heroin addicts treated with methadone in north of Morocco. Eur J Investig Health Psychol Educ. 2018;8(3):185–96.
Efrati Y, et al. Early maladaptive schemas are associated with adolescents’ substance and behavioral addictions. J Rational-Emot Cognitive-Behav Ther. 2023;41(3):690–709.
Grigorian HL, et al. Mindfulness and early maladaptive schemas among men in treatment for substance use disorder. Mindfulness. 2020;11:1690–8.
Harvey L et al. Early maladaptive schemas and schema modes in an Australian public drug and alcohol population. In: Drug and Alcohol Review. 2019. Wiley 111 River St, Hoboken 07030-5774, NJ USA.
Marengo SM, et al. The relationship of early maladaptive schemas and anticipated risky behaviors in college students. J Adult Dev. 2019;26:190–200.
Mc Donnell E, et al. Exploration of associations between early maladaptive schemas, impaired emotional regulation, coping strategies and resilience in opioid dependent poly-drug users. Subst Use Misuse. 2018;53(14):2320–9.
Sakulsriprasert C, et al. Early maladaptive schemas and addictive behaviours: a systematic review and meta-analysis. Clin Psychol Psychother. 2023;30:1416–32.
Ball SA, Young JE. Dual focus schema therapy for personality disorders and substance dependence: case study results. Cogn Behav Pract. 2000;7(3):270–81.
Ball SA, et al. Randomized trial of dual-focused versus single-focused individual therapy for personality disorders and substance dependence. J Nerv Ment Dis. 2011;199(5):319.
Lee CW, Arntz A. A commentary on the study on dual-focused vs. single-focused therapy for personality disorders and substance dependence by Ball et al. (2011): what can we really conclude? J Nerv Ment Dis. 2013;201(8):712–3.
Tapia G, et al. Treating addiction with schema therapy and EMDR in women with co-occurring SUD and PTSD: a pilot study. J Subst Use. 2018;23(2):199–205.
Oraki M. The effectiveness of the schema therapy on depression and relapse in heroin-dependent individuals. Biquarterly Iranian J Health Psychol. 2019;2(1):9–18.
Boog M, et al. Schema therapy for patients with borderline personality disorder and comorbid alcohol dependence: a multiple-baseline case series design study. Clin Psychol Psychother. 2023;30(2):373–86.
Gülüm IV. Dropout in schema therapy for personality disorders. Res Psychother Psychopathol Process Outcome. 2018. https://doi.org/10.4081/ripppo.2018.314.
Lappan SN, Brown AW, Hendricks PS. Dropout rates of in-person psychosocial substance use disorder treatments: a systematic review and meta-analysis. Addiction. 2020;115(2):201–17.
Dominguez SK, Matthijssen SJ, Lee CW. Trauma-focused treatments for depression. A systematic review and meta-analysis. PLoS ONE. 2021;16(7): e0254778.
Author information
Authors and Affiliations
Contributions
All authors wrote and reviewed the manuscript.
Corresponding author
Ethics declarations
Competing interests
The authors declare no competing interests.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Talbot, D., Harvey, L., Cohn, V. et al. Combatting comorbidity: the promise of schema therapy in substance use disorder treatment. Discov Psychol 4, 64 (2024). https://doi.org/10.1007/s44202-024-00179-6
Received:
Accepted:
Published:
DOI: https://doi.org/10.1007/s44202-024-00179-6