Addictive disorders are intrinsically difficult to treat for several reasons. First, individuals with such disorders are often cross-addicted (e.g., chem-sex addictions; Carnes et al., 2005; Sussman et al., 2011). Second, addictive disorders are highly comorbid with personality disorders (PD) (e.g., Sher et al., 2000; Kienast et al., 2014; Boog et al., 2018), with rates of full diagnostic criteria for PD diagnoses estimated to be as high as 60–65% among patients suffering from addictions (Casadio et al., 2014; Roncero et al., 2019). Such comorbidity is tied to poorer outcomes in the treatment of most disorders (Ball, 1998; Fatseas et al., 2015) including addictions (Padykula and Conklin, 2010; Brorson et al., 2013). Third (and relatedly), the etiology of addictive behaviors (as well as of personality disorders) has been linked to early childhood trauma and neglect and is often associated with poor attachment experiences and subsequent difficulties with emotion regulation (Hektner, 1997; Flores, 2001; Crowell et al., 2009).

Attachment is a highly dynamic, neurobiological process, entwined with temperament, which helps the developing child, adolescent, and adult regulate negative affect and facilitates healthy functional relationships (Cassidy, 1994; Estévez et al., 2017; Mikulincer and Shaver, 2019). Inadequate attachment, which may stem from a variety of personal and environmental variables such as absent or distracted parents, abuse, neglect, poverty, illness, and the like, makes it difficult for the infant or developing child to sooth emotional pain (Rees, 2007). Eventually, an inadequately attached individual must find methods other than attachment to caregivers to tolerate painful feelings (Hoeksma et al., 2004; Miljkovitch et al., 2018). At times, this involves turning to highly engaging behaviors which provide rapid gratification – a pattern which may later develop into addictive disorders (Aldao et al., 2010; Burkett and Young, 2012).

People suffering from addictive disorders often carry with them the experience of childhoods full of escapist attempts at emotion regulation (Betts et al, 2009). These attempts may include retreating to fantasy worlds while parents fought (Estévez et al., 2017), playing video games in place of socializing with friends, or engaging in fantasies about feeling loved or important after (and sometimes during) abusive episodes. As these children become adolescents, they often gain access to even more expedient and/or effective avoidance strategies, such as illicit substances, masturbation, shopping, and gaming (Burkett and Young, 2012). Indeed, some addictive behaviors, particularly behavioral addictions, appear at startlingly young ages (Kuss and Griffiths, 2012; Tomei et al., 2021). Although there is ongoing debate over classifying Compulsive Sexual Behavior Disorder (ICD-11) as a behavioral addiction (Kraus et al., 2016; Sassover and Weinstein, 2022), for the purposes of this discussion, these behaviors are characterized as addictive due to shared criteria and the functioning of coping modes. Moreover, as mentioned earlier, these behaviors can and do manifest in childhood.

Escapist and self-soothing behaviors in childhood or adolescence (where the roots of addiction lie) are reinforced and become more frequent over time. These are later joined by secondary “colluding” behaviors – concealment, denial, minimization – which enable the individual to hide the evolving addiction, avoid criticism, and evade potential curtailment of addictive behaviors which have become more and more central to their lives (Endrass et al., 2018; Liu and Ma, 2018). Over time, thickening intrapsychic walls develop between the individual’s general self-image and their addictive selves; this pattern of “living two lives” makes healthy attachment even more difficult to attain. Loneliness, shame, rejection, and hopelessness increase and fuel the burgeoning addiction (Leach and Kranzler, 2013).

The colluding behaviors that develop as enablers of the addiction are often as entrenched as the addiction itself, becoming intrapsychic barriers to accessing treatment (Moeller et al., 2022). Harsh inner critics (“you are hopeless”), high levels of detachment, and deception of self and others become standard (Luoma et al., 2012). With time, more intensified webs of deceit and avoidance surround the escalating addictive behaviors, which are extremely difficult for the patient to acknowledge publicly (Pickard, 2016). Webs of avoidance and fears of giving up the addiction make it very difficult for patients to admit to needing help (Luoma et al., 2012).

It is critical to note here that problems with early attachment often underlie dysfunctional personality development (Herbers et al., 2014; Miljkovitch et al., 2018; Fraley and Shaver, 2021) alongside addiction. Personality disorder symptoms, (e.g., affective instability, impulsivity) strongly contribute to the thinking and behaviors which “support” addiction. For example, in a large longitudinal study, Thomas et al. (1999) found that one year following treatment, 94% of patients with personality disorders relapsed vs. 56% of those without such disorders (Newton-Howes et al, 2017; Foulds et al., 2018). This suggests that sustained benefits in treating addictive disorders may require models that attend to both attachment and personality (Miljkovitch et al., 2018; Fraley and Shaver, 2021).

Post-Traumatic Stress Disorder (PTSD) also plays a role in complicating treatment for addictions (Najavitis et al., 1997; Brady et al., 2004). One large study estimated that if you change comorbidity from PTSD and addiction to interpersonal trauma (sustaining an injury to attachment system) and addiction, the prevalence rates go from highs of 59% to highs of 99% (Najavitis et al., 1997; Padykula and Conklin, 2010). Treatment approaches that incorporate healing a patient’s interpersonal trauma are needed (Padykula and Conklin, 2010; Tapia et al., 2018).

Current Substance Use Disorders (SUD) and behavioral addiction treatment programs include detoxification, medically managed withdrawal, outpatient (short or long-term), intensive outpatient, individual counseling, groups and short- and longer-term residential facilities (NIDA, 2020a,b). Most of these were originally designed as modifications of the 12-step treatment approach, but have incorporated coping strategies, tools, and other behavioral interventions (Hayes et al., 2004; NIDA, 2020a). Psychopharmacological interventions (e.g., buprenorphine, naltrexone, methadone have also been used on their own or with some counseling (Ali et al., 2017). However, medication alone does not address the root psychological issues driving addictive behaviors (Zajac et al, 2017).

Patients meeting DSM criteria for PTSD may be offered treatment in designated “trauma tracks” such as Eye Movement Desensitization Reprocessing or trauma-informed group therapy (Rosen et al, 2002). Although these treatments show promise for some patients, these often do not address the needs of populations with high comorbidities of more complex mental health issues, requiring more research (Glasner-Edwards and Rawson, 2010; Padykula and Conklin, 2010; Markus and Hornsveld, 2017). They are also not offered to many people who have suffered other types of attachment difficulties or personality problems who may benefit from more integrative treatment.

In recent decades, other treatment models that emerged outside the 12-step tradition have shown promise in treating addictive disorders. The prominent Transtheoretical Model of Behavior Change (TTM), developed in the 1970’s, gained momentum through the 90’s (Prochaska and DiClemente, 1982, 2005; LaMorte, 2019); more recently, Acceptance and Commitment Therapy (ACT) has also been well-received (Luoma et al., 2012; González-Menéndez et al., 2014; Bahrami and Asghari, 2017). Cognitive Behavioral Therapy, Dialectical Behavioral Therapy and Contingency Management have also shown great promise but may not address the needs of patients with comorbid personality disorders well enough for improved outcomes (Davis et al., 2016; Zamboni et al., 2021; Boog et al., 2023). These models address behavior change, skills, and emotion tolerance; however, they are often applied as pieces within more comprehensive, traditional treatment. They also may not address attachment and personality disorders sufficiently to effect lasting change.

For decades, treatment providers have hoped that taking part in intensive 30, 60, or 90-day programs followed by outpatient treatment and community support would lead to long-term recovery for most people (NIDA, 2020a,b). Yet despite their positive short term outcomes (including safety, medical stabilization, connection to outside resources, and greater illness awareness) many treatment models have been largely unsuccessful in sustaining recovery (Ball et al., 2006; Brorson et al., 2013), which seems to require a more holistic or comprehensive approach (Ball, 1998; Kellogg and Tatarsky, 2012). It is estimated as recently as 2020 that treatment “failure” or relapse (defined as use of the same substance or process at the same level and intensity as before treatment) during the first 30 to 180 days in treatment, ranges from 40 to 60 percent (NIDA, 2020a,b). Those relapse numbers remain stable at five years (McLellan et al., 2000; Weisner et al., 2003; Scott et al., 2011). Among patients with comorbid personality disorder, the relapse rate is staggeringly higher (e.g., 94%; Thomas et al., 1999; 90%+ Staiger et al., 2008). We owe it to our patients to do better.

Patients’ engagement in treatment can be adversely affected by therapists’ attitudes toward patients with addictive disorders (Forman et al., 2001). In a study of 317 staff members across 50 addiction treatment programs (Forman et al., 2001), more than a third of those polled expressed critical and even punitive attitudes towards their patients (e.g., wanting more confrontation and believing that noncompliant patients should be discharged) (Crapanzano et al, 2019). This stands in stark contrast to the treatment of other disorders where noncompliance and relapse are accepted and addressed as part of chronic, long-term illness and care (NIDA, 2020a,b).

In an extensive systematic review of relapse factors in the treatment of addiction, which included 122 studies and almost 200,000 patients, Brorson et al. (2013) reported finding an overwhelming focus (96%) on patient factors rather than treatment type in the prediction of outcomes. This is aligned with a traditional medical model of addiction, which views negative outcomes (e.g., drop-out) as the exclusive result of underlying patient psychopathology (Brorson et al., 2013). As Brorson and her colleagues note, what is missing from most studies was any focus on the dynamics between patients and the type of treatment they received (McKellar et al., 2006; Brorson et al., 2013). In one study that did explore these issues, high risk patients (e.g., younger ones, or ones suffering from cognitive deficits) were less likely to drop-out when the treatment environment was appraised as high in support, i.e., when attachment needs were sufficiently met (McKellar et al., 2006). Similarly, Ball et al. (2006) found that one of the top two reasons for dropout was conflict with staff (Moyers and Miller, 2013).

I argue that the primary emphasis of many treatment modalities on behavioral and cognitive interventions leaves much to be desired given comorbid issues of personality and attachment. Patients often cannot attach or remain attached in community support groups or treatment programs; do not share core values with popular support groups; or otherwise, do not remain engaged (Ball et al., 2006; Dingle et al., 2018; Zilberman and Messer, 2020). A more comprehensive, transdiagnostic approach is needed to address the multifactorial nature of addictive disorders (Ball, 1998; Glasner-Edwards and Rawson, 2010; Boog et al., 2018). I propose Schema Therapy as an alternative, evidence-based (for complex, persistent diagnoses), and more integrated approach to treatment.

Schema Therapy (ST) is well positioned to treat addictive disorders comorbid with attachment and personality problems (Sempértegui et al., 2013). It has a substantial evidence base for treating patients with maladaptive behaviors, personality disorders, or complex trauma holistically (Sempértegui et al., 2013; Bamelis et al., 2014; Arntz, 2015; Arntz and Simpson, 2020). It can even address what used to be seen as a “habit” driven by cues or emotional pain, as theorized by Boog et al. (2023) (Boog and Tibbeoel, 2023). It is designed to create safe attachment, more securely engaging patients in a comprehensive treatment process which harnesses corrective emotional experiences to achieve sustained change (Rafaeli et al., 2011) – elements that current addiction treatment models lack (Boog et al., 2018).

Important to note, Samuel Ball, Ph. D., conducted research in Dual-Focused Schema Therapy for addictive disorders in the late 1990’s with mixed but promising results (Ball, 1998). At the time of Ball’s publication, the more empirically supported mode model had not yet been formally introduced, which may partially account for the less-than-optimal results with this population (see “Modes” below) (Ball et al., 2006). Lee and Arntz (2013) criticized this study for its high dropout rates and brief therapy duration (24 sessions), which is less than ideal for a study or a complex population (Arntz and Jacob, 2013; Arntz et al., 2015; Arntz and Simpson, 2020; Gonzalez-Castro and Uluğ, 2022). Addictive disorders and personality disorders arguably require sustained, longer-term treatments to achieve positive outcomes.

Schema Therapy is an intentionally crafted, integrative, evidence-based model developed by Jeffrey Young, PhD, and has continued to evolve into its current practice with major contributions to its mode model by Dr. Young and other researchers and clinicians (Rafaeli et al., 2015; Roediger et al., 2018; Heath and Startup, 2020). It is crafted with core elements of object relations theory, gestalt therapy, third wave CBT interventions and others. It focuses on identifying and modifying early maladaptive schemas (EMS), which are self-defeating emotional and cognitive patterns established from childhood experiences and early interactions with others. These schemas can lead to negative thoughts, feelings, and behaviors throughout one’s life. Schema therapy aims to help individuals understand their schemas, learn to recognize and change maladaptive coping styles, and develop healthier patterns of thinking and behaving (Young et al., 2006). Comprehensive case conceptualizations are formulated from detailed assessments; emotion-focused, cognitive, and behavioral interventions are used to address problematic behavioral patterns (modes) that result from faulty, emotional perceptions, and interpretations of themselves and the world (schemas) (Roediger et al., 2018). Attachment, issues of personality, and dysfunctional behavioral coping modes are central features of this model which make it very promising for the treatment necessary for the problems facing people with addictions. It is a transdiagnostic approach to treatment that has demonstrated positive outcomes with populations that have historically used addictive modes as methods of coping with life. e.g., Personality Disorders (Sempértegui et al., 2013; Arntz et al., 2022; Boog et al., 2023).

In studies with personality disordered patients who are traditionally difficult to retain in treatment, ST has been able to keep patients engaged longer than other treatment models (Sempértegui et al., 2013; Arntz et al., 2015). The model’s use of the therapy relationship as a vehicle to meet core needs and implement evidence-based interventions makes it a promising model for this population (Sempértegui et al., 2013). The overarching goals of schema therapy are to meet core developmental needs; heal dysfunctional schemas; and help the patient strengthen and use their own healthy adult mode over the dysfunctional coping modes to which they default. Addiction is conceptualized in ST as a dysfunctional coping mode: dysfunctional behaviors, emotions and thinking to a significant degree (Thalmayer and Andreas, 2022).

Young’s definition of “schema” is that a schema is a pattern imposed from their experience to help individuals to explain it, to mediate perception and to guide their responses (Young et al., 2006; Baião et al., 2021; Thalmayer and Andreas, 2022). It is a broad organizing principle which makes sense of one’s own life experience. It contains emotions, sensations, and thoughts (Young et al., 2006). Schemas can be positive or negative. ST is concerned with Early Maladaptive Schemas (EMS) which are schemas that are dysfunctional to a significant degree. They are developed in childhood and adolescence through the frustration of core developmental needs integrated with innate temperament (Young et al., 2006; Aloi et al, 2020). Young defines core needs as: secure attachment (safety, stability, nurturance); autonomy (sense of identity); freedom to express valid needs and emotions; spontaneity and play; and realistic limits and self-control (Young et al., 2006).

According to Young, and others, the pain of these EMS’s lead to the development of self-states or schema modes (Rafaeli et al., 2011; Arntz and Jacob, 2013). These modes are split off parts of the self, unconscious to a larger or lesser degree, depending on childhood experiences, temperament, and other factors (Rafaeli et al., 2015). Child Modes, Maladaptive Coping Modes (MCMs) and Inner Critic or Internalized Parent Modes, along with Healthy Adult Modes, are the broad categories conceptualized in the schema model (Arntz and Jacob, 2013; Edwards, 2022).

Child modes are thought of as underdeveloped, “young” parts of the patient that remain undeveloped after the patient failed to sufficiently have their early core needs met (Rafaeli et al., 2015). These modes are often hidden by addictive modes since addiction masks the pain associated with them (Lazarus and Rafaeli, 2021). Child modes can often be described by the pain experienced by this undeveloped self, including lonely child, angry child, abused or abandoned child. Impulsive or undisciplined child modes can develop when the child or adolescent has had overly strict or permissive discipline or limits imposed by care givers (Rafaeli et al., 2015). The pain in these modes is conceptualized here as the activators of the addictive mode cycle (Boog et al., 2018).

As a result of the distressing negative emotions, sensations, impulses, memories, and cognitions activated by EMS concordant with the patient’s coping styles, coping modes develop (Young et al., 2006). These long-standing, often unrecognized, cognitive, affective, interpersonal, and behavioral responses to the triggering of schemas are called maladaptive coping modes (MCMs) (Young et al., 2006). Although these MCMs may effectively regulate the negative affect associated with schema activation in the short term, they are self-defeating and impede the meeting of core needs and the change process (Young and Klosko, 1994; Young et al., 2006; Heath and Startup, 2020). In the long term they are schema reinforcing (Young et al., 2006; Fuhr and Gondara, 2021; Edwards, 2022). Such is the case in an addictive mode.

MCMs are categorized through the three styles of coping: schema surrender, schema avoidance, or schema overcompensation (Edwards et al., 2022). Schema surrender represents a complying or giving into the schema, for example, giving up and surrendering to the idea that you will always be defective so “why try” (Young et al., 2006; Edwards et al., 2022). Schema avoidance or detachment includes various forms of escape or avoidance from the schema or situations that activate the schema, for example, social withdrawal, excessive autonomy, compulsive stimulation-seeking, compulsive self-soothing or thrill-seeking, and psychological withdrawal (Young et al., 2006; Ball et al., 2006). Schema overcompensation involves different forms of “doing or acting the opposite” or countering the schema, for example, aggression or hostility against perceived criticism; excessive self-assertion, recognition, or status-seeking countering feelings of social isolation; manipulation, passive-aggressive rebellion against feeling trapped; and excessive orderliness and control against feelings of vulnerability (Young and Klosko, 1994; Young et al., 2006; Rafaeli et al., 2015). Addictive behaviors would be considered avoidant and detached protector coping modes (Boog et al., 2018).

Lastly, there are internalized modes, such as harsh or demanding inner critics or internalized parent modes (Young et al., 2006; Vîslă et al., 2022). These are thought of by Young as internalized representations of the caregivers, other adults, or the environment. When mobilized, these inner critic modes tend to be schema activating, causing a cycle of dysfunctional coping responses followed by more harsh judgement (Pickering et al., 2018). The individual who has not yet developed methods of coping through their own healthy adult mode is left in cycles of pain, poor coping responses, self-criticism and then more pain (Offergeld et al., 2021; McCarthy et al., 2022).

Schema Therapy utilizes cognitive, behavioral and emotion focused interventions to achieve its goals of meeting core developmental needs in the patient’s current life; achieving healthy attachments; minimizing use of dysfunctional coping modes; and the strengthening the patient’s healthy adult mode (Rafaeli et al., 2015; Thalmayer and Andreas, 2022). The use of empirically proven interventions such as imagery rescripting, cognitive restructuring, psychoeducation, behavioral exposure, empathic confrontation of dysfunctional modes, chair work and the like are employed (Arntz, 2015; Behary, 2020; Thalmayer and Andreas, 2022).

There is a need for a comprehensive and holistic approach in treating addiction, as current treatment approaches often fall short in helping patients achieve long-term recovery and a fulfilling life. Research over the years has shown that there are challenges in terms of retention in treatment programs, relapse rates, and overall long-term recovery. These issues can be attributed, in part, to the way addictions are conceptualized and the lack of holistic approaches that address the underlying factors driving addictive behaviors. It is crucial for patients to have hope and strive for a meaningful life, rather than just focusing on abstinence. It is time for a change in the way addiction is approached and treated to give patients the best chance at sustained recovery and overall well-being (Kellogg and Tatarsky, 2012; Marchand et al., 2019; Goslar et al., 2020).

A more comprehensive approach is needed to effectively address the chronic emotional pain, engagement challenges, and etiology of addiction in patients. This will involve considering factors such as attachment, emotion regulation, trauma, and personality disorders as part of the holistic conceptualization. By taking these aspects into account, clinicians can work towards better outcomes in terms of stability, long-term recovery, and overall well-being for addicted patients.

While current treatment approaches make efforts to address these issues, they frequently lack a holistic and comprehensive perspective. These approaches tend to be siloed and do not focus enough on the therapy relationship, emotion-focused techniques, attachment and core needs, and a schema modes concept (Thalmayer and Andreas, 2022). By incorporating these core components, we can better address the emotional pain, engagement difficulties, and underlying etiology of addiction for a more effective and comprehensive treatment approach.

This adapted version of Schema Therapy (STAT) shows promise in addressing the conceptualization and necessary interventions for individuals with addictive disorders. Early research suggests that using schema therapy for addictive disorders may lead to positive outcomes, but further study and investigation is needed (Kellogg and Tatarsky, 2012; Gonzalez-Castro and Uluğ, 2022; Thalmayer and Andreas, 2022; Boog et al., 2023). It is our responsibility to explore innovative, propitious approaches that offer the potential for improved, significant and lasting improvements in the lives of our patients struggling with addictions, and STAT presents one such promising approach.

The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author/s.

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the patients/ participants or patients/participants legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

EL: Conceptualization, Writing – original draft, Writing – review & editing.