Insights: Early Maladaptive Schemas and Behavioral Addiction – Claudio Vieira
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Behavioral addiction (BA) is a growing problem affecting both the clinical and general population and is more common than we might think. It is a complex construct with several predisposing factors, including biological, psychological, and social aspects. The activation of early maladaptive schemas (EMS) may play a role in the development and perpetuation of BA.
In his recent paper, Early maladaptive schemas and behavioral addictions: A systematic literature review, Clinical Psychology Review 2023, Claudio Vieira explored this relationship across a range of behavioral addictions. We sat down with Claudio, principal clinical psychologist, schema therapist and researcher at Nottingham Trent University, to discuss what a link between EMS and behavioral addiction could mean for how clinicians approach BA, and some key conclusions for clinical practice.
“It’s important to formulate these behaviors in a way that moves away from a shame inducing framework. I really like the approach taken by the Power Threat Meaning Framework – the question is not what is wrong with you, but instead, what happened to you?”
Exploring the link between EMS and behavioral addiction
Tell us about your paper – what was your main objective?
The main objective of this paper was to explore and summarize the literature investigating the relationship between early maladaptive schemas and behavioral addictions. In particular, we examined food, sex, gambling, social media, internet, smartphone, exercise, and video gaming addictions, and then took an overarching view of how they relate to specific schema domains. A wide range of research has been carried out on the relationship between schemas and personality disorders or substance misuse, but not with behavioral addictions. This review was a starting point to look at this under-researched area in more depth.
Behavioral addiction is a very complex concept, incorporating a wide range of problematic behaviors with several predisposing factors from biological, psychological, and social components. It’s much more common than we might think, and there is a high comorbidity between behavioral addictions and poor mental health outcomes. Not just for anxiety, depression, and stress, but also for interpersonal, personality, and emotional difficulties.
One factor that might play a significant role in both developing and maintaining behavioral addiction is the activation of early maladaptive schemas (EMS). Put simply, schemas are the lenses through which we see the world, how we relate to ourselves and others. They inform future relationships, how a person develops or maintains intimate connections with others, how they relate to their close ones, or how they understand themselves when they are feeling vulnerable.
When searching for papers, we found lots of research on early maladaptive schemas and substance misuse, but when you look at the relationship between schemas and behavioral addiction, it became clear that this was a very niche area.
Why should clinicians care about this paper? Why is it relevant now?
Behavioral addiction is a growing problem affecting the general population. Since the COVID pandemic, we’ve been hearing more and more about an increased use of social media, gambling, and problematic pornography usage within the UK population. In my paper, I included a wide range of meta-analysis that attempted to estimate the global prevalence of different types of addictive behaviors, and if you look at the numbers, they’re quite alarming. For smartphone addiction, the prevalence is between 25 and 30%, and if I’m not wrong, it’s between 15 and 20% for social media addiction. For cyber-sex or online pornography, the prevalence is somewhere between 8 and 10%. If you think about this data in the context of general population, we are talking about big numbers.
There was something about the pandemic that made people feel vulnerable. A big portion of the population had to stay at home and didn’t have the chance to connect to people or see their loved ones. Some became unemployed, others developed serious physical illness. It was a very challenging time to stop and to process what we were going through. What we know about schemas is that they are developed and activated when our basic needs are not being met. In addition to practical needs like having enough food and a roof over our heads, there are a wide range of basic emotional needs that need to be satisfied for us to function healthily. Those needs relate to feeling connected to others, feeling safe, accepted, loved, and understood. These needs were disrupted during the pandemic. Many people didn’t feel safe, and their connections were shattered. If you were suffering from anxiety, depression, or stress, your means to get support from others would also have been very limited.
There is another element to consider here: from a political point of view, we’ve had many years of austerity and now people are going through a rough time with the cost-of-living crisis. This has not only reduced access to mental health support and medical care, but has also increased poverty, social injustice, and social inequality, leading to poor mental health outcomes. How can someone prioritize their mental health if they don’t have food to put on the table? There has been a clear crisis in the UK linked to austerity and cost-of-living crisis and the resulting impact on our mental health and services. The pandemic lasted for a couple of years, and while it had and continues to have a great effect on our mental health, austerity has been around for over a decade. It has become a deeply systemic problem. Under such challenges, behavioral addiction might become part of many people’s lives, and these behaviors will need understanding and addressing.
How does this relate to clinical practice?
This research is relevant for clinical practice because with addiction, you might see two groups of clients in the therapy room. Clients who can be very aware and mindful of their difficulties and who come to therapy to say they’ve got a big problem with how much money they are spending every month, with how time they are spending on social media they use daily, or how compulsive pornography viewing is impacting their relationships. But there are also many clients who don’t come to therapy thinking about addiction at all. They might just suggest they’re feeling unhappy, anxious, or stressed all the time. It’s only when you start to have conversations about how they cope with those feelings and what strategies they are using to numb the pain, that the topic of behavioral addiction might come up. Sometimes they say something like, “I feel bad saying it, but when I feel really awful, the only thing that gives me pleasure is to go online and spend £200 on something I don’t need”, or “I go to my fridge and eat so much junk food even though I had a meal an hour ago”.
When you drill down and see addictive behaviors in the context of someone’s coping response to a painful and difficult experience, we can start to formulate these behaviors from a different perspective. Not as something that’s wrong with a person or something they should feel shameful about, but as a behavior which serves the function of alleviating someone’s emotional pain, despite the negative consequences that this behavior might bring to someone’s life.
If I have been rejected in the context of an intimate relationship, if I had a serious altercation with a close friend or family member, if I am going through a difficult grieving period, some behaviors that might look problematic from the outside (such as binge-eating, gambling, compulsive sex, etc.) might be the only strategy that I have to regulate my emotions, particularly if I had not been taught or if I had not had the opportunity to learn healthier ways of managing my feelings.
“Regardless of whether clinicians are interested in schema therapy, understanding behavioral addiction in the context of survival and coping strategies can be very helpful as a way of informing formulations and treatment plans.”
What were the conclusions of the paper?
The overarching conclusion is that there appears to be a relationship between early maladaptive schemas and behavioral addictions, such as gaming, gambling, food, shopping, internet, and compulsive pornography viewing, with most studies highlighting a positive a correlation between these two variables. In terms of a more specific conclusion, it was very clear that disconnection and rejection was the schema domain most strongly related across all addictive behaviors. This domain includes what schema therapists call the ‘top five’ schemas (defectiveness and shame, emotional deprivation, abandonment, mistrust and abuse, social isolation), which are largely related adverse childhood experiences and unmet core emotional needs. When these schemas are activated, you are vulnerable to feel rejected, abandoned, emotionally deprived, abused, taken advantage of, or socially alienated. The schemas in this domain are the ones most strongly related to most psychological mental health difficulties, not just behavioral addiction, including anxiety, depression, and personality difficulties.
For those not as familiar with schema therapy, why do you think the disconnection and rejection domain was most strongly related to behavioral addiction?
The schemas in the disconnection and rejection domain cover the top five schemas related to our unmet core needs and are associated with feeling disconnected from others, unloved, and abandoned. People who engage in behavioral addiction often resort to addictive behaviors as a way of coping with these intense feelings of isolation and unworthiness by compulsively committing to distracting and self-soothing activities, such as binge-eating, gambling, watch pornography, or gaming.
As such, the absence of consequential thinking or a relaxed approach to personal boundaries, along with other challenges and aspects of BA, are often understood as secondary to unmet core needs related to these disconnection and rejection schemas. Also, if you’re raised in an environment where you’re abused, emotionally deprived, or feel very isolated from your peers (all schemas under the disconnection and rejection domain), how will you learn to put limits on yourself? How will you learn about consequential thinking or personal boundaries? How will you learn what you need to do to soothe yourself in a healthy way?
That is why the disconnection and rejection is the most prominent schema domain, not only in behavioral addictions, but in mental health difficulties generally. If that foundation is not there, the rest almost falls to pieces.
Clinical takeaways for practitioners
What can we learn from this paper? What are the key clinical implications that therapists should be aware of?
- It’s more common than we think. One of the first, most pragmatic and practical observations is that behavioral addiction is a real issue. It is prevalent in our society and in general population.
- The value of exploring coping strategies. Sometimes clients will come to us without any idea that they struggle with behavioral addiction at all. They might come with anxiety, relationship difficulties, stress, or depression. We know that as well as how to fix the problem, it is important to think about why and in what context it was developed and be curious about their coping strategies. Patients might say they don’t know how they deal with their problems, or that they don’t have any coping strategies at all. But that’s often not the case. You might uncover that they are binge-eating, spending thousands gambling, watching pornography for hours, or doing something else in times of need to alleviate the pain. Their strategies might be problematic and maladaptive, but they do cope. For some patients, these are the strategies that are keeping them alive. It’s important that clinicians explore these strategies and understand how they are helpful for their clients. It might uncover some kind of behavioral addiction coping style which is helping them manage with something uncomfortable.
- Reframing addiction to see the person as a whole. We can use this learning to move away from the idea that having an addiction means there’s something wrong with you and you are defective. It’s important to understand addiction as a way people protect themselves from pain. That’s the main thing that therapists should be aware of, and the schema therapy model is helpful at exploring the different sides of the self. After completing their own schema formulation, clients are able to say “There is a vulnerable part of me and addiction part of me, which protects me from the pain that the vulnerable side brings to the table. But I am more than my addictive behavior. I’m also vulnerable at times, happy at others. I’m a son, a husband, an employee. My behaviors do not define my identity.”
How could clinicians use these points in order to work more effectively with BA? As a therapist, what would you be paying attention to specifically?
- Focus on your client’s ‘detached, self-soothing coping mode’. In schema therapy, we view individuals as having different aspects of themselves, which is different from different personalities. A person might display vulnerability at times and exhibit aggression or callousness at other times. They might sometimes take reckless actions like engaging in compulsive sex or compulsive shopping, whilst at other times managing their feelings effectively. These different aspects to oneself are what we call coping modes, and they are developed as ways to manage vulnerability, difficult feelings, and interpersonal conflicts. One of the common coping modes associated with addiction is the ‘detached self-soother’, which is the side of ourselves which help us to distance from painful feelings or to cope with difficult situations through substances or using specific behaviors aimed at numbing or alleviating distress.
One of the most common strategies to cope with internal pain or distress is avoidance. This might be through the use of alcohol, gaming, online shopping, or online pornography. And I’m not suggesting that doing any of these things is necessarily problematic, but when a person links the experience of vulnerability with these behaviors and they become the primary or the only strategy to soothe distressing feelings, emotional and interpersonal problems might arise. It becomes a problem when happiness, self-esteem, or self-confidence becomes dependent on compulsive use of social media, or gambling significant amounts of money. These behaviors might also take away the opportunity for a person to understand their vulnerability and learn new ways to cope with feelings. For example, if I cope with not being successful in a job interview by gambling, I’m losing the opportunity to think about what I could do differently next time. If every time I experience emotional pain I disconnect from my feelings, I’m missing a good opportunity to seek appropriate support from friends, family, or mental health services.
Even though the detached self-soother helps to reduce the anxiety in the short term, it has negative consequences in the long run. It might perpetuate the idea that vulnerability equals weakness or that it is too dangerous to tolerate.
I’ve been trying to give my clients a chance to talk and make sense of their detached self-soother in a non-judgmental and compassionate framework. Sometimes people don’t want to talk about the problematic behaviors and sometimes they might not be fully aware of them, or don’t see the behavior as problematic. It’s only when we drill down and start to have conversations about the vulnerable side that is hiding behind the detached self-soother, that the clients become more aware and notice the patterns. When they start noticing those patterns, the connection to that vulnerable side gradually becomes clearer.
- Explore using the Young Schema Questionnaire. Even if you’re not a schema therapist, the Young Schema Questionnaire (YSQ) can still help you understand the patterns your client might be engaging in and how your client relates to themselves and others. You understand the lenses through which they see the world. And you don’t necessarily have to use it to necessarily do schema therapy. You could use it for CBT work around core beliefs, to inform psychodynamic interventions around attachments, or systemic work around family dynamics.
It can be useful for clients too. Before I discuss any results of the questionnaire, I ask them to talk me through the process of completing it. What was it like for them to stop and think about their lives and notice any patterns? Were there any surprises? Did anything come as a shock? By doing this, clients sometimes realize new things. For example, they may discover that their self-esteem and self-confidence is very dependent on how other people perceive them, or that they have very high expectations on themselves and/or others.
Are there any challenges clinicians should be aware of when working with this client group and schema therapy?
Unlike some other treatment models, schema therapy is not just a talking therapy. It is an integrative model which includes significant experiential work. As clinicians, we can sometimes feel more anxious about doing the experiential work than our clients, as it can take us outside our comfort zone as clinicians. When I finished my schema therapy training, I remember feeling anxious about starting imagery exercises and chairwork, but when I introduced the idea to the clients, they were very excited to try them. It is interesting and funny to see that avoidance and anxiety sometimes come more from us than from the clients. More often than not, they are really on board to try what works. They have lived in pain for a long time, and they just want to get help and feel better.
What’s next?
What’s your hope for this paper? What’s your focus going forward in this area?
My hope is that people look at this paper and realize there are a wide range of things we could do in this field. It would be great if this motivated people to engage in empirical research around the relationship between schemas and different addictive behaviors (for example gaming or online shopping), or just to do more research around behavioral addictions in general. It doesn’t necessarily have to be with schema therapy, it can be with any model. The key thing is to become mindful that behavioral addictions are becoming a growing problem and that more and more clients are presenting with these maladaptive coping skills as strategies to alleviate their pain. It’s important to formulate these behaviors in a way that moves away from a shame inducing framework. I really like the approach taken by the Power Threat Meaning Framework – the question is not what is wrong with you, but instead, what happened to you?
My next step is to go ahead with the above plan. I’ve got a paper on online pornography use and its relationship with mental health outcomes submitted and awaiting publication. I am also doing an empirical study on the relationship between early maladaptive schemas and online pornography use. I have just finished the recruitment of a large sample, so I have some data analysis to do now. I also have some qualitative studies in mind, also in the field of pornography use and its relationship with schema activation.
In my previous job I worked with young adults (18-25 years old), and I met a few young people who were engaging in compulsive pornography viewing and who started to view pornography at a very young age. Some, before the age of 10. And it was concerning to see how this was becoming a significant problem in their current intimate relationships and in their overall emotional wellbeing.
I want to explore which schemas are most related to compulsive pornography viewing and I’m also curious about the protective factors that serve as buffer against addiction, so this is my next focus in the field of early maladaptive schemas and behavioral addictions.
Further reading
Alimoradi, Z., Lotfi, A., Lin, CY. et al. Estimation of Behavioral Addiction Prevalence During COVID-19 Pandemic: A Systematic Review and Meta-analysis. Curr Addict Rep 9, 486–517 (2022).
Grant, J. E., Potenza, M. N., Weinstein, A., & Gorelick, D. A. (2010). Introduction to Behavioral Addictions. The American Journal of Drug and Alcohol Abuse, 36(5), 233–241.
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. Guilford Press.
Arntz, A., & Jacob, G. (2013). Schema therapy in practice: An introductory guide to the schema mode approach. Wiley Blackwell.
Alavi, S. S., Ferdosi, M., Jannatifard, F., Eslami, M., Alaghemandan, H., & Setare, M. (2012). Behavioral Addiction versus Substance Addiction: Correspondence of Psychiatric and Psychological Views. International journal of preventive medicine, 3(4), 290–294.