Positive Constructs in Schema Therapy: A Scoping Review

ABSTRACT

Central to the schema therapy model is the development of early maladaptive schemas due to unmet emotional needs in childhood. Recently, focus has shifted towards positive constructs in schema therapy, including early adaptive schemas or positive schemas and positive schema modes, such as the “healthy adult” and “happy child.” This scoping review explores theoretical perspectives, assessment, and therapeutic use of these positive constructs in schema therapy. The PRISMA‐ScR methodology was followed, using predefined search terms and databases (OVID, EBSCO, Mednar). After identifying 345 studies, 144 remained post‐deduplication. Articles were screened by two reviewers, and disagreements were settled by consensus among the research team. A total of 47 records were included. A growing interest in positive constructs within schema therapy was found since 2011. The healthy adult and the happy/contented child were the most frequently discussed constructs, followed by early adaptive schemas and positive coping. Key findings include a strong relationship between the healthy adult mode and psychological well‐being, while negative correlations exist with psychopathology. Assessment focuses on questionnaires like the Schema Mode Inventory and Young Positive Schema Questionnaire, however empirical evidence for positive schema therapy interventions is lacking. Limitations include diverse publication types and preliminary findings. Recommendations for further research include clarifying the healthy adult mode construct, exploring positive coping, and integrating positive constructs into schema therapy for improved therapeutic outcomes.

1. Introduction

Schema therapy (ST) was founded by Young et al. (2003) in the early nineties. As a student of Beck, he worked with cognitive therapy and cognitive schemas were an essential part of the cognitive therapy model (Beck 1967, 1979). Young noticed that cognitive therapy was not equally effective for all patients, particularly less effectivity was observed in patients with personality disorders (PDs). In response, Young introduced a new, extended model that he initially called schema‐focused therapy (Young 1990), and later ST (Young et al. 2003). It is considered to be one of the most effective therapies for people with PDs in both individual and group formats (Arntz et al. 2022; Farrell et al. 2009; Storebø et al. 2020). ST has also been found to be effective in treating other psychiatric disorders, such as depression (Renner et al. 2013), anxiety disorders (Peeters et al. 2022), and eating disorders (Kopf‐Beck et al. 2024; Joshua et al. 2023).

In extension to cognitive behavioral therapy, ST incorporates several constructs and techniques from other theoretical and therapeutic orientations, such as attachment theory, and psychodynamic and experiential therapies. Central to the ST model is the assumption that when basic emotional needs are not adequately met in childhood, early maladaptive schemas (EMSs) will develop, in interaction with biological and cultural factors. EMSs are described as broad, pervasive themes or patterns of memories, emotions, cognitions, and bodily sensations about oneself and one's relationships with others, that develop during childhood or adolescence, are elaborated throughout life, and are dysfunctional to a significant degree (Young et al. 2003). This model is supported by research showing a strong relationship between adverse childhood experiences and the development of EMSs, and further, mediation of the relationship between these childhood experiences and PDs by EMSs (Carr and Francis 2010; Pilkington et al. 2021).

People use various strategies to cope with EMSs. Coping styles are usually adaptive to some extent and can be viewed as normal attempts of a child to cope in a difficult or even toxic and traumatic environment. But they may become maladaptive over time if they perpetuate an EMSs, even when conditions change, and more adaptive coping strategies and/or schemas are available (Martin and Young 2010). There are three maladaptive schema coping styles: resignation, avoidance, and inversion. In the context of schema handling, resignation represents a coping mechanism whereby an individual concedes to the influence and fully beliefs the EMSs. Avoidance, on the other hand, is characterized by efforts to evade or circumvent EMSs activation. Inversion is defined by the application of mental strategies to believe that the opposite messages of the EMSs are true (Arntz et al. 2021).

Individuals with severe PDs may exhibit a tendency to often flip between their emotional states, as different EMSs and different coping styles are triggered. In order to address this issue in psychotherapy, Young et al. (2003) developed the construct of schema modes. Schema modes are the combinations of the activated schemas, coping responses, and emotions, being momentary reflections of the individual's emotional, cognitive, and behavioral state (Young et al. 2003). Schema modes help both the patient and the therapist to understand the current state of the patient (Arntz and Jacob 2017). There are, in essence, three groups of modes—child, parent, and coping modes. In addition to dysfunctional schema modes, there are also functional or positive modes, that is the healthy adult mode (HA) and the happy child mode (Young et al. 2003).

Within ST, the main focus has been on reducing EMSs, meeting core emotional needs, and building the HA to effect positive change (Bach and Bernstein 2019; Yakın and Arntz 2023; Young et al. 2003). Rather than a focus on the reduction of the negative aspects of human distress, the boosting of positive strengths and healthy aspects of the self, in addition to traditional ST, has been gaining increasing attention as psychological therapies develop (Taylor and Arntz 2016). It was suggested that in ST, it is essential to be more holistic and consider both the adaptive and maladaptive aspects of an individual (Louis et al. 2023; Louis et al. 2018). To maximize the effectiveness of therapy, it is important to understand the contribution of positive constructs to clinical outcomes (Yakın and Arntz 2023). Accordingly, increasing attention has been paid to positive schemas as well as positive modes.

Theoretical positive schemas are also known as early adaptive schemas (EASs) and were first introduced by Lockwood and Perris (2012). They argued that when core emotional needs are met, healthy patterns result, and that these internal representations are EASs. As it is with EMSs they defined an EASs as “a broad, pervasive theme or pattern, comprised of memories, emotions, cognitions, and neurobiological reactions regarding oneself and one's relationship with others, developed during childhood or adolescence, elaborated throughout one's lifetime, and leading to healthy functioning and adaptive behavioral dispositions.” (Lockwood and Perris 2012, p. 54). EASs represent the healthy aspects of the individual, such as positive functions, adaptive behavioral dispositions, and healthy responses of oneself and or with others (Louis et al. 2018; Maher et al. 2023; Yakın and Arntz 2023). To‐date 14 EASs have been identified, that were empirically supported to be grouped in four categories that are believed to represent the four core emotional needs (Louis et al. 2024). Table 1 lists the different second‐order EASs domains and therefore representations of the four core emotional needs.

Table 1.

Core emotional needs and its related early adaptive schemas.

Core emotional needa	Early adaptive schema	Meaning
Connection and acceptance	Emotional fulfillment	You feel that your emotional needs are being met in the form of warmth, affection, and understanding. You know that there are people who love you for who you are.
	Social belonging	In general, you have a sense of belonging in groups. You feel accepted by others.
	Emotional openness/spontaneity	You are quite capable of showing your emotions to others. You feel that others see you as someone who can share feelings.
	Healthy self‐interest/self‐care	You find it important to listen to your own needs while also considering the needs of others. You allow yourself time to relax and take time for yourself.
Healthy autonomy and Performance	Healthy self‐reliance/competence	You have confidence in yourself and your abilities to solve problems that occur in everyday life
	Healthy boundaries/developed self	You and your loved ones are involved with each other. You have also built your own life
	Stable attachment	You have confidence that others are there for you
Healthy limits	Healthy self‐control/self‐discipline	When you have a goal, you set out to achieve it. You don't give up easily, even if it takes effort
	Success	You feel that you are as good as others when it comes to functioning
Healthy standards and reciprocity	Realistic expectations	You can have achievable expectations of yourself; it doesn't have to be perfect
	Self‐directedness	You value yourself and what you have accomplished. Even if others think differently, you can still appreciate your accomplishments
	Empathic consideration	You respect the wishes and opinions of others, even if they differ from your own. If a decision is made that you do not like, you can accept it
	Self‐compassion	You allow yourself to make a mistake. You are able to forgive yourself
	Basic health and safety/optimism	You are confident in your health and safety and assume that things will generally work out

^a These four groups were reported in Louis et al. 2018, 2020, 2023, 2024.

The perception of an EAS as being positive is dependent upon the context in which it is presented. The positive schema “healthy standards” can restrict achievement in certain very high‐achievement settings. Furthermore, a discrepancy may arise when the EAS of a therapist does not align with that of the patient. This can be exemplified by a scenario where the therapist exhibits a strong EAS “empathic consideration”, while the patient manifests an antisocial PD.

To‐date, two positive modes have been described in the ST model. These are the healthy adult (HA) and the happy or contented child mode. The HA develops when core emotional needs have been consistently met, and it embodies psychological maturity and makes informed and healthy decisions in life (Phillips et al. 2020; Yakın and Arntz 2023). When in HA, people think and feel in an adaptive way about themselves and do things that are good for them (Aalbers et al. 2021). It consists of a healthy self‐view and balanced consideration of others’ needs (Jacob et al. 2015). The HA detects and regulates emotions and impulses, understands reality, maintains a coherent and positive self‐concept, and is self‐directed (Bach and Bernstein 2019). It serves an “executive” or parental function to the self (Martin and Young 2010; Young et al. 2003). The other positive or functional schema mode is the happy (also known as contented) child mode. When in this mode, people feel loved, connected, contented, safe and playful (Shaw 2020; Young et al. 2003). It consists of positive emotions towards the self and in relation to others (Shaw 2020). The happy child mode is a component of healthy well‐being (Edwards 2022).

Positive constructs in the ST model, namely positive schema modes, coping, and EASs, have been described separately. There is a lack of understanding on how these positive constructs relate to each other. A scoping review was selected as the most appropriate methodology for this question, as it allows for the identification of knowledge gaps, the scope of a body of literature, and the clarification of concepts (Munn et al. 2018; Tricco et al. 2018; Tricco et al. 2016). The purpose of this scoping review is to provide an overview of positive constructs within ST and its underlying constructs in the literature. The specific objectives of this scoping review are to provide an overview of:

• 1.The theoretical perspectives on and relationships between positive constructs in the ST model;
• 2.The assessment of positive constructs in the ST model;
• 3.How the positive constructs in the ST model are used in therapeutic interventions.

In order to reach these goals, we conducted a systematic search of the published grey and black literature on positive constructs in ST and its underlying constructs. Grey literature refers to information that is produced outside of traditional publishing and distribution channels. It has the benefit of providing insight into niche or emerging research areas, recording research findings that produce null or negative results, and staying more current (Rothstein and Hopewell 2009).

2. Methods

2.1. Protocol

The methodology for this scoping review was based on the PRISMA Extension for Scoping Reviews (PRISMA‐ScR)(Tricco et al. 2018). The final checklist includes twenty essential reporting items and two optional items, more detailed information on the items can be found in PRISMA‐ScR (Tricco et al. 2018).

2.2. Eligibility Criteria

This scoping review began with the establishment of a research team consisting of individuals with expertise in positive constructs in ST in the Netherlands (AMC, MO, AV, JB & LvD). See Table 2 for the years of experience of the research team in ST and in positive constructs in ST. The authors have all contributed to the academic discourse on ST, more specifically, positive constructs, through their publication of articles on these topics. In addition to this, they have authored (chapters of) books and have presented at international conferences. Two are ISST‐certified supervisors (JB and AMC), and one of them (JB) was editor‐in‐chief of an international handbook on ST. The team advised on the broad research question to be addressed and the overall study protocol, including the identification of search terms and the selection of databases to be searched.

Table 2.

Years of experience of the research team members.

Research team member	Years of experience in ST	Years of experience in positive constructs in ST
AV	17	11
JB	19	8
AMC	20	11
MO	10	7
LvD	10	7

This review considered studies that explored positive constructs and its underlying constructs within ST. It has been noted that there is no universally accepted definition of these positive constructs. Therefore, after extensive discussion with the aforementioned research team, we have compiled a list of constructs that fit within the overarching theme of positive aspects in ST. It was important to the research group that all major elements known within ST were represented, namely schemas, coping, and schema modes. The keywords determined were: positive schema, early adaptive schema, adaptive/healthy/positive coping, healthy adult (mode), happy child (mode), and contented child (mode).

To obtain a comprehensive review of all literature in the field of positive aspects in ST, this scoping review included all qualitative, quantitative, and mixed methods studies and evaluations, as well as systematic, scoping, and literature reviews and development of conceptual models in both articles and (chapters of) books. Study protocols, conference abstracts, and presentations were not included, as evidence suggests that information contained in conference abstracts may not be reliable or adequate (Hartling et al. 2017; Van Driel et al. 2009).

2.3. Information Sources

A comprehensive search was conducted via the OVID and EBSCO platform. Through OVID, we searched Embase, APA PsycINFO, and Medline. Via EBSCO, we conducted a search in CINAHL ultimate. Additionally, Mednar was searched for unpublished studies and grey literature. The final search was conducted on September 20, 2024, with no limits on study date or country of origin.

2.4. Search

We formulated and combined search terms concerning: “positive schema” OR “early adaptive schema” OR “healthy adult mode” OR “happy child mode” OR “contented child mode” OR (“healthy adult” AND schema therapy OR schema focused therapy) OR (“happy child” AND schema therapy OR schema focused therapy) OR (“contented child” AND schema therapy OR schema focused therapy) OR (“adaptive coping” AND schema therapy OR schema focused therapy) OR (“healthy coping” AND schema therapy OR schema focused therapy) OR (“positive coping” AND schema therapy OR schema focused therapy). Appendix A provides a complete overview on the search strategies used in each search engine.

2.5. Selection of Sources of Evidence and Data Charting Process

A search was conducted in OVID (259), EBSCO (36), and Mednar (50). A total of 345 articles were retrieved. After deduplication, 144 records remained. At the title/abstract stage, articles were included if they were written in English language and described original research on or constructs of ST, more specifically when it concerned the extended ST model as originally described by Young in ST. All search results were independently screened by two reviewers (LvD & AMC) for title/abstract; in case of doubt the other members of the research group (JB, MO & AV) were involved to reach consensus. 76 records were removed, of which 60 as they were not related to ST, 13 because the article was not in English, and 3 were study protocols only. After this procedure, 68 records remained at the title/abstract level.

At the full‐text stage, the records were read by two reviewers (LvD & AMC); again all conflicts were resolved by consensus in the research group. Records were included if one or more of the constructs was a main focus: positive schema, early adaptive schema, healthy adult (mode), happy child (mode), contented child (mode), healthy coping, adaptive coping and/or positive coping. For empirical articles, it was considered a main focus if the positive construct was mentioned in the research question and/or the hypothesis of the article. Chapters from books and non‐empirical articles were included if one of the positive constructs was in the title, or if it was mentioned in the introduction of the chapter. In total 48 records remained, of which three articles were discussed with the aforementioned research group because there were doubts if they met the inclusion criteria. One article was excluded on the grounds that the term “healthy adult” was not employed in a schema therapeutic context. The other two articles were included. See Figure 1.

Figure 1.

Eligibility data.

2.6. Synthesis of Results

All records were loaded into EndNote. Then all irrelevant records were deleted. Relevant characteristics of the files were entered in an Excel file. These characteristics were authors, title of the article, year of publication, country, whether it was a chapter of a book or an article, relationships between positive constructs, how the construct was measured and described interventions. Other characteristics were which positive construct was mentioned.

3. Results

3.1. Characteristics of the Included Publications

In total, 47 records were included, see Table 2 for an overview. The results of the search showed that most of the literature found was published as an article (n = 27; 57.45%), while the other records were book chapters. A total of 51.06% (n = 24) of the articles were empirical studies. (Table 3).

Table 3.

Included articles and the positive constructs that are mentioned.

Article	HA	Happy Child	Contented Child	Positive schema	Early Adaptive Schema	Positive/healthy/adaptive coping
(Aalbers et al. (2021))	Ѵ	—	—	—	—	Ѵ
(Allen and Tully‐Wilson (2023))	Ѵ	—	—	—	Ѵ	Ѵ
(Arntz and Jacob (2017))	Ѵ	—	—	—	—	—
(Atkinson and Perris (2020))	Ѵ	Ѵ	—	—	—	—
(Atkinson (2012))	Ѵ	Ѵ	Ѵ	—	—	Ѵ
(Bach and Farrell (2018))	Ѵ	Ѵ	—	—	—	—
(Behary et al. (2023b))	Ѵ	—	—	—	—	—
(Behary et al. (2023b))	Ѵ	—	—	—	—	—
(Bernstein et al. (2019))	Ѵ	—	—	—	—	—
(Chi et al. (2022a))	—	—	—	Ѵ	Ѵ	—
(Chi et al. (2022b))	—	—	—	Ѵ	Ѵ	—
(Cousineau (2012))	Ѵ	Ѵ	—	—	—	—
(Damiris and Allen (2023))	—	—	—	—	Ѵ	—
(Faustino and Louis (2024))	Ѵ	—	—	Ѵ	Ѵ	—
(Goddard et al. (2022))	Ѵ	Ѵ	—	—	—	—
(Grażka et al. (2023))	Ѵ	Ѵ	—	—	—	Ѵ
(Haeyen (2019))	Ѵ	Ѵ	—	—	—	—
(Huckstepp et al. (2023))	—	—	—	—	Ѵ	Ѵ
(Jacob et al. (2015c))	Ѵ	—	—	—	—	—
(Jacob et al. (2015a))	Ѵ	Ѵ	—	—	—	—
(Jacob et al. (2015b))	Ѵ	Ѵ	—	—	—	—
(Jacob et al. (2015d))	Ѵ	Ѵ	—	—	—	—
(Jacobs et al. (2021))	Ѵ	Ѵ	—	—	—	Ѵ
(Khalily et al. (2011))	Ѵ	Ѵ	—	—	—	—
(Lockwood and Perris (2012))	Ѵ	—	—	—	Ѵ	—
(Lockwood and Samson (2020))	Ѵ	Ѵ	—	—	—	—
(J. P. Louis et al. (2018))	—	—	—	Ѵ	Ѵ	—
(John P Louis et al. (2020))	—	—	—	Ѵ	Ѵ	—
(John P Louis et al. (2020))	—	—	—	Ѵ	Ѵ	—
(John Philip Louis et al. (2023))	Ѵ	—	—	Ѵ	Ѵ	—
(Maher et al. (2023))	—	—	—	Ѵ	Ѵ	—
(Maurer and Rafaeli (2020))	Ѵ	—	—	—	—	—
(Mitchell et al. (2024))	—	—	—	Ѵ	Ѵ	—
(Oldershaw and Startup (2020))	Ѵ	—	—	—	—	—
(Paetsch et al. (2022))	—	—	—	Ѵ	Ѵ	Ѵ
(Peled et al. (2017))	Ѵ	Ѵ	—	—	—	—
(Phillips et al. (2020))	Ѵ	Ѵ	—	—	—	Ѵ
(Rafaeli et al. (2010))	Ѵ	—	Ѵ	—	—	—
(Roediger et al. (2018))	Ѵ	—	—	—	—	—
(Semeniuc et al. (2023))	Ѵ	Ѵ	—	—	—	—
(Simeone‐DiFrancesco et al. (2015))	Ѵ	Ѵ	—	—	—	Ѵ
(Taylor and Arntz (2016))	Ѵ	Ѵ	—	Ѵ	Ѵ	—
(Thrift and Irons (2020))	Ѵ	—	—	—	—	—
(Videler et al. (2020))	Ѵ	—	—	Ѵ	Ѵ	—
(Yakın and Arntz (2023))	Ѵ	Ѵ	—	Ѵ	—	Ѵ
(Yakın et al. (2020))	Ѵ	Ѵ	—	—	—	—
(Yin et al. (2022))	Ѵ	—	—	—	—	—

Note: Ѵ the positive concept is mentioned in the record; — the positive is not mentioned in the record.

3.1.1. Study Characteristics

All literature was published after 2011. Previously, positive constructs in ST were also mentioned, especially the HA and the happy child, but this was not the focus of the records at that point (Young 1994; Young 1999; Young et al. 2003). The rise of interest in positive constructs in ST started after 2011. A positive upward trend is evident, with the number of records published increasing. In the first 5‐year period (2010–2014), seven documents were published with a significant focus on the positive constructs in ST. In the subsequent 5‐year period (2015–2019), 11 articles were published. And in the period from 2020 to the search date in 2024, already 29 articles had been published.

Most of the first authors work in Europe (n = 23; 48.94%), but North America (8), Asia (10) and Australia (6) were also represented.

3.1.2. Characteristics of Positive Constructs

The healthy adult is the most frequently discussed subject. The records concerning positive constructs are largely non‐empirical, with the exception of studies on positive schemas, the majority of which do have an empirical basis. In 37 of the 47 articles (78.72%), at least one reference is made to the healthy adult, 14 of these are empirical (37.84%). The next most frequently discussed subject is the happy or contented child, which is mentioned in 21 articles (44.68%; of which 10 (47.62%) empirical), followed by positive schemas or EASs (n = 17; 36.17%) of these 14 (82,35%) are empirical studies, and positive, functional and healthy coping (n = 10; 21.28%) with 8 empirical records but none of them is a study specifically on positive, functional or healthy coping. It is noteworthy that of the 17 articles on EASs, only two were published before 2020. The others were published in recent years. 63.83% (n = 30) published about two or more positive constructs, where constructs that have a similar meaning are regarded as a single construct. This is the case with the happy and contented child mode, positive and early adaptive schemas, and with positive, healthy and adaptive coping.

3.2. Theoretical Perspectives on and Relationships Between Positive Constructs

3.2.1. Healthy Adult and Happy/Contented Child

The construct of healthy modes is frequently discussed in the literature within our scope (Cousineau 2012; Goddard et al. 2022; Grażka et al. 2023; Jacobs et al. 2021; Phillips et al. 2020; Rafaeli et al. 2010; Semeniuc et al. 2023). This refers to the healthy adult and the happy/contented child modes. Furthermore, research indicates that individuals with psychopathology often exhibit lower scores on healthy modes. This phenomenon has been observed in individuals with eating disorders (Goddard et al. 2022), clinically suicidal individuals (Grażka et al. 2023), avoidant personality disorder (Peled et al. 2017), and with dysfunctional scales on a personality questionnaire (Khalily et al. 2011). Similarly, the highest scores on the healthy adult and happy child scales are correlated with positive factors such as trait emotional intelligence (Jacobs et al. 2021), and are associated with resilience and optimism, among other factors, which contribute to psychological well‐being (Khalily et al. 2011).

The HA and happy/contented child modes share a number of characteristics. The most notable similarity is the feeling of psychological health in both modes. This indicates integrated, wise, and healthy functioning, as well as playful, spontaneous, and creative behaviors (Yakın et al. 2020). It is suggested that individuals with a strong happy child mode also exhibit a strong HA (Jacob et al. 2015a).

Three records describe the healthy mode triad or healthy mode cycle (Atkinson 2012; Atkinson and Perris 2020; Simeone‐DiFrancesco et al. 2015). In addition to the previously discussed constructs of the happy child and HA, the vulnerable child is added here to complete the triad. It is proposed that within the context of couples therapy, the healthy mode occurs when both partners flexibly shift between the three modes. The healthy adult is willing to take risks, learn new ideas, and ensure that their self‐concept is updated, which reinforces their ability to reflect on schemas (Atkinson 2012). The healthy mode triad is supposed to ensure that the two individuals in a relationship are differentiated and honored, while also integrating both partners into a unified whole that defines the relationship (Atkinson and Perris 2020). Furthermore, it might ensure that there is open communication, particularly about both individual and joint needs (Simeone‐DiFrancesco et al. 2015). One empirical study found that the healthy mode triad could be seen as one factor, with the healthy adult and happy child representing the other end of the spectrum from the vulnerable child in individuals with eating disorders (Goddard et al. 2022).

3.2.2. Healthy Adult and Positive Schemas/EASs

The terms “positive schemas” and EASs are used interchangeably to refer to the same construct. For the sake of clarity, the term “EASs” will be employed throughout this text.

As mentioned before, Lockwood and Perris (2012) posit that EASs emerge during early childhood when core emotional needs are met. This process is assumed to result in the development of the HA. EASs are regarded by some authors as schemas underlying the HA (Yakın and Arntz 2023) or even as part of the HA (Faustino and Louis 2024). By developing and activating EASs, it is hypothesized that the HA can be strengthened (Allen and Tully‐Wilson 2023; Videler et al. 2020). Another strategy is to focus on reactivating EASs that were previously active during one's life span. This is believed to result in the reactivation of previously dormant aspects of the HA. Furthermore, it is suggested to facilitate the accessibility of the HA during experiential exercises and contribute to the healthy‐adult perspective (Videler et al. 2020). EASs can be incorporated into therapeutic interventions assumingly to reinforce the HA through a variety of positive techniques (Taylor and Arntz 2016). Finally, it is proposed that EASs can be employed to develop additional positive modes, thereby achieving a more balanced ratio of positive to negative modes (Louis et al. 2023).

3.2.3. Healthy Adult and Positive Coping

The term “positive coping” encompasses all forms of healthy, functional, and adaptive coping strategies. Five studies have investigated the potential association between positive coping and HA. It was found that in a non‐clinical group of individuals, there was a negative association between the HA and the angry child mode. It is suggested that this association represents adaptive coping behavior (Aalbers et al. 2021). Processing important emotions associated with schemas may help create healthy adaptive coping strategies (Atkinson 2012). Healthy forms of coping may proceed through the HA (Phillips et al. 2020) or may be a component of the HA (Simeone‐DiFrancesco et al. 2015; Yakın and Arntz 2023). It is unclear whether the various forms of positive coping represent an identical construct, as the precise definition of positive, healthy, and adaptive coping has yet to be established.

3.2.4. Positive Schemas/EASs and Positive Coping

The connection between positive schemas and positive coping is suggested to be stronger in middle age due to the accumulation of life experience and knowledge. This is supposed to be accompanied by healthy coping (Allen and Tully‐Wilson 2023). It is also possible that the development of effective coping strategies may lead to the growth of self‐compassion and self‐confidence. This might have a positive effect on a number of specific positive schemas (Huckstepp et al. 2023). Positive coping strategies may possibly facilitate the satisfaction of core needs (Yakın and Arntz 2023).

The existing literature does not describe any relation between the happy/contented child mode and positive schemas or positive coping strategies.

3.3. Assessment of Positive Constructs

The healthy adult and happy child modes are typically measured using the Schema Mode Inventory (SMI; (Lobbestael et al. 2010)(in Aalbers et al. 2021; Yakın et al. 2020) or the SMI 2 (Bamelis et al. 2014; Bamelis et al. 2011) (in Bach and Farrell 2018; Grażka et al. 2023; Jacobs et al. 2021; Khalily et al. 2011). In addition, the Schema Mode Inventory for Eating Disorders Short Form (SMI‐EDSF: (Simpson et al. 2018) (in Goddard et al. 2022), the Client Modes Rating Scale (CMRS; (Mittelman‐Kirshenfeld 2012) in (Peled et al. 2017), and the Young‐Atkinson Mode Inventory (YAMI; (J. Young 2005)(in Phillips et al. 2020) were also used. The positive construct “contented child mode” is not measured within our scope.

The measurement of EASs is conducted using the Young Positive Schema Questionnaire (YPSQ; (J. P. Louis et al. 2018)in Allen and Tully‐Wilson 2023; Chi et al. 2022b; Damiris and Allen 2023; Huckstepp et al. 2023; John P Louis et al. 2020; Louis et al. 2023; Louis et al. 2020; Maher et al. 2023; Paetsch et al. 2022). Additionally, the YPSQ has been translated into Chinese (Chi et al. 2022), German (Paetsch et al. 2022), and Portuguese (Faustino and Louis 2024).

None of the articles within our scope discuss measuring positive coping or related constructs.

3.4. Interventions

Regarding the interventions, again most records (n = 18) describe interventions aimed at strengthening the HA. None of the interventions are studied for their effects yet. These interventions range from art therapy (Haeyen 2019) to interventions that enhance emotional intelligence (Jacobs et al. 2021), activating EASs to strengthen the HA (Videler et al. 2020), emotionally processing traumatic or aversive childhood memories to create awareness and take responsibility (Yakın et al. 2020), and practicing with the HA in the metaverse (Yin et al. 2022). Other interventions include positive imagery (Behary et al. 2023a; Maurer and Rafaeli 2020), couples therapy (Atkinson 2012; Atkinson and Perris 2020; Simeone‐DiFrancesco et al. 2015), self‐help (Jacob et al. 2015; Roediger et al. 2018), cognitive, behavioral, and experiential techniques (Arntz and Jacob 2017), role play with feedback, writing assignments, and flash cards (Behary et al. 2023a). Other authors suggest integrating Acceptance and Commitment Therapy techniques (Cousineau 2012; Roediger et al. 2018), adding positive parenting (Lockwood and Samson 2020), activating emotions (Oldershaw and Startup 2020), group interventions (Taylor and Arntz 2016), developing a compassionate mind (Thrift and Irons 2020) and working on the balance between the top‐down and bottom‐up processes of healthy adult reparenting, i.e. dominance versus reciprocity (Yakın and Arntz 2023). It has been suggested that therapists can help their patients get back to the HA by bringing the focus back to the therapeutic relationship in the present and observing the process from a meta perspective, acceptance and compassion for self, focus on patient resources, and grounding strategies that focus on the body (Semeniuc et al. 2023). The positive emotional state of the happy child is suggested to enhance the playfulness of the HA, thereby improving the quality of life and increasing positive affect (Bach and Farrell 2018). Another suggestion is to enhance enthusiasm or facilitate the transition to a HA (Simeone‐DiFrancesco et al. 2015).

A review of the literature within our scope reveals a lower number of interventions designed to promote the happy child mode. Some interventions are classified as aimed at part of the “healthy modes” or “healthy mode triad,” and target the happy child mode as well as the HA (and the vulnerable child mode). This is particularly evident in the case of couples therapy (Atkinson 2012; Atkinson and Perris 2020; Simeone‐DiFrancesco et al. 2015). Some authors have focused specifically on the happy child mode. This is the case in self‐help (Jacob et al. 2015a, 2015d) and group ST (Taylor and Arntz 2016).

It is proposed that the implementation of interventions serves to reinforce both the HA as the happy child modes (Cousineau 2012). This is assumed to provide a foundation for the development of new behavior. One of the primary objectives of ST is to reinforce these modes (Taylor and Arntz 2016). Consequently, it is considered crucial to use interventions to achieve this goal.

Additionally, preliminary proposals have been put forth regarding the implementation of EASs. All of these avenues remain to be explored empirically. For instance, it is proposed that raising awareness of EASs and experiential techniques may assist in strengthening EASs (Damiris and Allen 2023). Strength‐based interventions may be employed to foster self‐compassion and self‐confidence through increasing cognitive flexibility and healthy coping strategies (Huckstepp et al. 2023). It is also recommended that the past be understood and that the emotional needs that have been frustrated be identified (Lockwood and Samson 2020). Furthermore, it is proposed that adaptive parenting should be promoted (Louis et al. 2020; Louis et al. 2020), and that previous positive experiences should be focused on (Maher et al. 2023). Furthermore, it has been suggested to employ group therapy (Taylor and Arntz 2016) and that a modified case conceptualization should be used (Videler et al. 2020). Lastly, it is suggested that the entire lifespan should be taken into perspective (Videler et al. 2020).

4. Discussion

The objective of this scoping review was to provide an overview of the current knowledge of positive constructs within ST, that is positive schema, early adaptive schema, adaptive/healthy/positive coping, HA, happy child mode, and contented child mode.

The first research question was to identify the theoretical perspectives and relationships between positive constructs within the ST model. Our findings indicate that the healthy modes, specifically the HA and the happy/contented child mode, are the most frequently discussed within the scope of our study. These modes are characterized by a shared perception of psychological well‐being. The findings indicated a negative correlation between the healthy modes and individuals with psychopathology, while positive correlations were observed between these modes and positive factors such as resilience and optimism, which contribute to psychological well‐being. Furthermore, the addition of the vulnerable child to the healthy modes resulted in the formation of the healthy mode triad or healthy mode cycle. In the context of couples therapy, the HA identifies and invites the core relationship needs of the vulnerable child and the happy child. One empirical study indicated that the healthy mode triad could be conceptualized as a single factor, with the HA and happy child mode representing the other end of the spectrum from the vulnerable child mode.

With regard to the relationship between EASs and the HA, it is postulated that the emergence of EASs is a consequence of the satisfaction of core emotional needs, which in turn gives rise to the HA. It can be posited that EASs underly the HA. It is proposed that the HA can be accessed via the EASs. Given that there are significantly fewer healthy modes (two) than EASs (fourteen), some have suggested to facilitate the development of more positive modes. With regard to coping and the HA, it is suggested that healthy coping may be part of the HA or may occur through the HA. Additionally, it was proposed that when there is a strong HA and a relatively weak angry child mode, this may indicate adaptive coping.

The last relationship examined concerning the first research question was that between EASs and positive coping. The development of novel, positive coping skills has the potential to facilitate growth in self‐confidence and self‐compassion, which in turn could serve to reinforce EASs. Additionally, positive coping strategies can facilitate the fulfillment of fundamental needs, which serves as the foundation for the emergence of EASs. As individuals gain life experience and accumulate knowledge over time, they may also develop more positive and adaptive coping skills. The existing literature does not describe any relation between the happy/contented child mode and positive schemas or positive coping strategies.

The second research question was to ascertain how the assessment of positive constructs within the ST model is conducted. It was found that the HA and happy child mode are typically assessed using the SMI (Lobbestael et al. 2010) or the SMI 2 (Bamelis et al. 2014; Bamelis et al. 2011), although the SMI‐EDSF (Simpson et al. 2018), CMRS (Mittelman‐Kirshenfeld 2012), and the YAMI (Young 2005) have also been employed in this regard. The assessment of positive schemas, or EASs, is conducted using the YPSQ (Louis et al. 2018). None of the articles within the scope of this study reported on assessing positive coping or related constructs.

The final research question examines how positive constructs within the ST model are employed in the context of therapy. It was found that none of the interventions had been empirically supported. However, numerous recommendations for interventions were put forth, particularly those aimed at reinforcing the HA. These included a variety of therapeutic approaches, such as individual and couples therapy, as well as art therapy and the use of the metaverse for treatment purposes. There is a scarcity of attention paid to the happy child mode. The interventions described are self‐help and group ST. The happy child mode is addressed within the context of the healthy mode cycle in the domain of couples therapy.

With regard to interventions aimed at EASs, there are no empirical studies yet so there are merely suggestions for future research. The recommendations are highly diverse, encompassing a range of approaches, including an enhanced comprehension of an individual's history, positive parenting strategies, taking a lifespan perspective, and group ST.

The findings of this review must be interpreted in light of some limitations. Firstly, this review encompasses a diverse range of publication types. Therefore, this scoping review should be considered as a map of current research and literature, rather than a synthesis of outcomes and clinical efficacy. Secondly, it is important to consider these findings as preliminary for understanding overlap between the positive constructs in ST.

A strength of this scoping review is the use of a transparent and methodical approach to screening and data extraction in compliance with the PRISMA‐ScR guidelines (Tricco et al. 2018). Also, studies from all over the world were included, representing various cultures. Lastly, this scoping review has the advantage of considering all forms of empirical studies, as well as unpublished or grey literature. It is therefore likely that this review represents a comprehensive map of the ways in which positive constructs in ST are considered.

For future developments, we suggest to further clarify the HA. In the literature, there is a diversity of conceptualizations pertaining to the notion of the HA. Some authors posit that the HA emerges from unmet needs and is shaped by early maladaptive schemas (Yin et al. 2022). Other authors, for example Khalily et al. (2011), employ the concept of the HA in a theoretical manner as a factor of the SMI. Lastly, some authors posit that the HA is constituted by EASs (Yakın and Arntz 2023), similar to Young's original idea that modes consist of activated schemas, being the momentary reflections of the individual's emotional, cognitive, and behavioral state (Young et al. 2003). Given that schemas emerge during early childhood, it is important to consider whether they can develop at a later stage in life. The general assumption is that the HA can still be built. A model may be considered on how these constructs fit together. It remains unclear whether all authors are employing the same definition of the construct of HA, or whether there are, in fact, multiple conceptualizations of this concept. Research aimed at clarifying this may also encourage the investigation of various positive modes that are part of the construct of HA.

Furthermore, no research has yet been conducted on the construct of positive coping, including adaptive or healthy coping. This represents a gap in the existing research, and we therefore encourage further investigation of this positive construct in future studies. It is possible that positive coping strategies may contribute to recovery and an enhanced quality of life. As with the traditional ST approach, the mapping of negative schema coping can be extended to include positive coping strategies, which could prove to be a valuable addition. Furthermore, it would be beneficial to examine the interrelationship between positive coping and other positive constructs within the ST framework. Some hypotheses have been proposed regarding the relationship between positive coping and the HA or EASs. However, these hypotheses need further elaboration and empirical foundation.

A gap was also identified in the lack of empirically tested interventions that focus on positive constructs within ST. Research on this topic could provide insights into whether focusing on increasing positive schemas and modes, in addition to focusing on decreasing negative schemas and modes, contributes to the effectiveness of ST. A subsequent step would be to study which interventions are most efficacious and cost‐effective.

In this review, the construct of positive parenting (Louis et al. 2020) was not included because it is not included in the original ST model (Young et al. 2003). It might however, be a very relevant construct. Positive parenting strategies are what parents should implement in order to facilitate positive developmental outcomes. These strategies results in the meeting of core emotional needs and thus to facilitate the development of EASs (Louis et al. 2020; Louis et al. 2020). The traditional ST model employs the construct of modes, with parent modes forming a subset of this framework. Positive parenting can be utilized as a positive addition to the existing (negative) parent modes, and thus can serve as an essential component for building EASs, strengthening positive coping, and increasing positive modes. Furthermore, it can provide insights for the development of more effective ST interventions. Future research could include positive parenting as a positive construct in ST, which in turn, can inspire psychotherapeutic interventions (Louis et al. 2021).

This article presents an overview of the current knowledge regarding the relationship between the positive constructs in ST, the methods used to measure them, and the potential interventions. A possible next step would be to integrate these positive constructs in the core ST model. This model can then be subjected to further scrutiny and testing.

For clinical practice, this article provides an overview of the positive constructs within ST, how they are related, how they can be measured, and how interventions can be applied. This may contribute to the more frequent application of positive constructs in clinical practice, and thus the development of helpful interventions. Following the search period within our scoping review, two articles were published that studied the effects of treatment focused on HA and positive schemas. A single‐case experimental design study into a treatment protocol for strengthening the HA mode (Versluis et al. 2025) showed that this intervention had a positive effect on increasing self‐compassion, well‐being, and adaptive schema modes during treatment, at both individual and group levels. A multiple baseline design study, that evaluated the effects of an adapted ST approach that integrates positive schemas, found that for positive schemas, at group level, significant increases were observed in positive core beliefs and reductions in negative beliefs (van Donzel et al. 2025). The preliminary evidence from these small‐scale studies suggests that the incorporation of positive constructs into ST has the potential to contribute to the effective treatment PDs. We know that not everyone benefits from ST; there are clients who see little or no effect from therapy (Woodbridge et al. 2022; Woodbridge et al. 2023). The addition of positive schemas may open up a pathway that was previously untracked, allowing the core needs and attached schemas and modes to be reached. Moreover, the incorporation of positive constructs into ST may prove beneficial for specific demographic groups. For instance, this approach could benefit individuals who demonstrated better functioning in earlier stages of life (Videler et al. 2020), older adults whose emotional needs are not being met due to circumstances (Videler et al. 2020), or patients near the end of their therapeutic journey (Claassen and Broersen 2019).

To the best of our knowledge, this is the first scoping review of the various positive constructs within ST. The results indicate that there are several ways of thinking about the interrelationship of the constructs and the implementation of interventions. Consequently, we urge for further research into the efficacy and effectiveness of integrating positive constructs into ST.

Funding

The authors received no specific funding for this work.

Ethics Statement

Approved by Ethics Review Board Tilburg University: TSB_RP1209.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix positive constructs in ST a scoping review.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.