Schema therapy for chronic depression: Results of a multiple single case series

Schema therapy versus treatment as usual for outpatients with difficult-to-treat depression: study protocol for a parallel group randomized clinical trial (DEPRE-ST)

BACKGROUND

About one third of patients with depression are in a condition that can be termed as "difficult-to-treat". Some evidence suggests that difficult-to-treat depression is associated with a higher frequency of childhood trauma and comorbid personality disorders or accentuated features. However, the condition is understudied, and the effects of psychotherapy for difficult-to-treat depression are currently uncertain. The aim of this trial is to investigate the beneficial and harmful effects of 30 sessions of individual schema therapy versus treatment as usual for difficult-to-treat depression in the Danish secondary, public mental health sector.

METHODS

In this randomized, multi-centre, parallel-group, superiority clinical trial, 129 outpatients with difficult-to-treat depression will be randomized (1:1) to 30 sessions of individual schema therapy or treatment as usual; in this context mainly group-based, short-term cognitive behaviour or psychodynamic therapy. The primary outcome is the change from baseline in depressive symptoms 12 months after randomization, measured on the observer-rated 6-item Hamilton Rating Scale for Depression. The secondary outcomes are health-related quality of life assessed with the European Quality of Life 5 Dimensions 5 Level Version, functional impairment assessed with the Work and Social Adjustment Scale, psychological wellbeing assessed with the WHO-5 Well-being Index, and negative effects of treatment assessed with the Negative Effects Questionnaire. Exploratory outcomes are improvement on patient self-defined outcomes, personal recovery, anxiety symptoms, anger reactions, metacognitive beliefs about anger, and perseverative negative thinking. Outcomes will be assessed at 6, 12, and 24 months after randomization; the 12-month time-point being the primary time-point of interest. Outcome assessors performing the depression-rating, data managers, statisticians, the data safety and monitoring committee, and conclusion makers for the outcome article will be blinded to treatment allocation and results. To assess cost-effectiveness of the intervention, a health economic analysis will be performed.

DISCUSSION

This trial will provide evidence on the beneficial and harmful effects, as well as the cost-effectiveness of schema therapy versus treatment as usual for outpatients with difficult-to-treat depression. The results can potentially improve treatment for a large and understudied patient group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05833087. Registered on 15th April 2023 (approved without prompts for revision on 27th April 2023).

Brief individual experiential schema therapy in adult outpatients with cluster C personality disorders: Does it work?

This study investigated the effectiveness of brief individual experiential schema therapy (ST) in 12 adult outpatients with cluster C personality disorders (PD) using randomised multiple baseline design. Waitlist period was followed by five explorative sessions, 18 experiential ST sessions, two treatment follow-up (FU) booster sessions and a 6-month FU assessment. Overall well-being (ORS), behavioural treatment goals and negative core beliefs were assessed 60-91 times, global symptomatic distress (BSI) six times. PD severity (SCID-5-PD) was pre-post-analysed. Randomisation and non-parametric tests showed large significant effects (d = 1.08-2.38, r = .53-.66) on all outcomes at treatment-FU and 6-month FU assessment. This is the first study providing preliminary evidence of effectiveness of brief individual experiential ST for patients with cluster C PD, tentatively challenging the common tenet that long treatment duration is required. Due to limitations, replication is recommended.

A single case series of imagery rescripting of intrusive autobiographical memories in depression

BACKGROUND AND OBJECTIVES

Intrusive memories are a common feature of depression, thought to be related to the onset and maintenance of the disorder. Intrusive memories have been successfully targeted in posttraumatic stress disorder through imagery rescripting. Yet there is limited evidence for the effectiveness of this technique in depression. We examined whether 12 weekly sessions of imagery rescripting was associated with reductions in depression, rumination and intrusive memories in a sample of patients with major depressive disorder (MDD).

METHODS

Fifteen clinically depressed participants completed 12 weeks of imagery rescripting treatment while completing daily measures of depression symptoms, rumination and intrusive memory frequency.

RESULTS

There were significant reductions on pre-post treatment and daily assessment measures of depression symptoms, rumination and intrusive memories. Reductions in depression symptoms represented a large effect size, while 13 participants (87%) showed reliable improvement and 12 participants (80%) demonstrated clinically significant improvement and no longer met diagnostic criteria for MDD.

LIMITATIONS

The sample size was small, however the intensive daily assessment protocol ensured the viability of within-person analyses.

CONCLUSIONS

Imagery rescripting as a stand-alone intervention appears to be effective at reducing depression symptoms. Additionally, the treatment was well tolerated by clients and observed to overcome several traditional treatment barriers in this population.

Efficacy and acceptability of third-wave psychotherapies in the treatment of depression: a network meta-analysis of controlled trials

Introduction

In recent decades, various new psychotherapy approaches have been developed in an effort to overcome issues of non-response, referred to as "third-wave psychotherapies." How third-wave therapies perform in comparison to each other, to classical CBT, or other common comparators in the treatment of depression has not yet been systematically assessed.

Methods

We firstly determined the scope of the term "third-wave" by conducting a systematic search. The identified approaches were then used as search terms for the systematic review and network meta-analysis (NMA). We searched MEDLINE, CENTRAL, PsychINFO and Web of Science from inception until 31 July 2022. We assessed randomized controlled trials comparing third-wave psychotherapies to each other, CBT, treatment as usual (TAU), medication management, active control conditions, or waitlist (WL) in adult populations with depressive disorders. The treatments included were acceptance and commitment therapy, behavioral activation, cognitive behavioral analysis system of psychotherapy, dialectical behavioral therapy, mindfulness-based cognitive therapy, meta-cognitive therapy, positive psychotherapy and schema therapy. The primary outcome was depression severity (efficacy) at study endpoint, and the secondary outcome was all-cause discontinuation (acceptability). This review was registered in PROSPERO, identifier CRD42020147535.

Results

Of 7,971 search results, 55 trials were included in our NMA (5,827 patients). None of the third-wave therapies were more efficacious than CBT but most were superior to TAU [standardized mean differences (SMD) ranging between 0.42 (95% CI -0.37; 1.19) and 1.25 (0.48; 2.04)]. Meta-cognitive therapy (MCT) was more efficacious than three other third-wave therapy approaches. None of the third-wave treatments were more acceptable than WL or CBT. Twenty-seven percent of the trials were rated as low risk of bias. Confidence in the evidence was largely low according to GRADE. Inconsistency emerged for a small number of comparisons.

Interpretations

Third-wave therapies are largely efficacious and acceptable alternatives to CBT when compared to TAU, with few differences between them. The evidence so far does not point toward superiority or inferiority over CBT. Patient-level research may offer possibilities for tailoring individual psychotherapies to the needs of individual patients and future trials should make this data available. The evidence base needs to be broadened by sufficiently powered trials.

Early Maladaptive Schemas and Schema Modes in clinical disorders: A systematic review

PURPOSE

Although schema therapy has been predominantly applied to treat personality disorders, interest into its application in other clinical disorders is growing. Central to schema therapy are Early Maladaptive Schemas (EMS) and Schema Modes. Since existing EMS and Schema Modes were primarily developed in the context of personality disorders, their relevance for clinical disorders is unclear.

METHODS

We conducted a systematic review of the presence of EMS and Schema Modes in clinical disorders according to DSM criteria. Per disorder, we evaluated which EMS and Schema Modes were more pronounced in comparison with clinical as well as non-clinical control groups and which EMS and Schema Modes were most highly endorsed within the disorder.

RESULTS

Although evidence concerning EMS was scarce for several disorders, and only few studies on Schema Modes survived inclusion criteria, we identified meaningful relationships and patterns for EMS and Schema Modes in various clinical disorders.

CONCLUSIONS

The present review highlights the relevance of EMS and Schema Modes for clinical disorders beyond personality disorders. Depending on the theme of the representation, EMS act as vulnerabilities both across diagnoses and for specific disorders. Thus, EMS and resulting Schema Modes are potential, valuable targets for the prevention and treatment of clinical disorders.

What role do early life experiences play in eating disorders? The impact of parenting style, temperament and early maladaptive schemas

OBJECTIVE

Given that most eating disorders develop in adolescence and early adulthood, early life experiences are said to play a key role in the aetiology of eating disorders. There are well-documented relationships between early maladaptive schemas and eating disorders, early maladaptive schemas and temperament and temperament and perceived parenting style. The present study aimed to test a hypothesis that perceived parenting style predicts temperament, which predicts early maladaptive schemas, which predict eating disorder symptoms in young people.

METHOD

An online survey measured perceived parenting style, temperament, early maladaptive schemas and eating disorder symptoms in 397 people with disordered eating between the ages of 18 and 29. Path analysis was used to investigate the relationship between these elements.

RESULTS

The results found support for this hypothesis. Perceived maladaptive parenting ratings for mothers were a stronger predictor of temperament, and only two temperament factors were adequate predictors of early maladaptive schemas.

CONCLUSIONS

Overall, the present study found preliminary support for a linear relationship where perceived parenting style predicts temperament, which predicts early maladaptive schema levels, which predicts eating disorder symptoms. The present study was the first to propose and test this model; however, further research is required to confirm the nature and extent of this relationship.

Association Between Personality Traits and Functional Limitations in Older Adults with Affective Disorders: A Cross Sectional Study

OBJECTIVES

Personality traits and affective disorders are both related to functional limitations. It is unknown whether personality traits have an additional effect on functioning in older adults with affective disorders. We studied the association between personality traits and functioning within this group.

METHODS

We performed a cross-sectional study of 180 older patients referred to outpatient specialized geriatric mental health care centers with a depressive, anxiety and/or somatic symptom disorder according to DSM-criteria. We studied the association between the Big Five personality traits and functional limitations assessed with the WHO-DAS II, adjusting for potential confounders, including the severity of various affective disorders.

RESULTS

The 180 patients (57.1% female, mean age 69.2 years) had an average WHO-DAS II score of 31.3 (SD 15.1). Lower scores on Conscientiousness were associated with more overall functional limitations (p = .001), particularly limitations in self-care (p = .001) and household activities (p = .001). Lower Extraversion scores were associated with more limitations in getting along with others (p = .001).

CONCLUSIONS

Personality traits are related to functional limitations independent of the severity of affective disorders in older adults.

CLINICAL IMPLICATIONS

Personality traits may be used as predictive factors for functioning in older adults with affective disorders.

Trauma-focused treatment for traumatic stress symptoms in unaccompanied refugee minors: a multiple baseline case series

Introduction

Unaccompanied refugee minors (URMs) are at increased risk of developing mental health problems, such as symptoms of posttraumatic stress disorder (PTSD) and depression. In addition, URMs face several barriers to mental health care. Few studies have evaluated trauma-focused interventions for URMs that target these issues. The current study evaluated a multimodal trauma-focused treatment approach for URMs. It aimed to provide an initial indication of the effectiveness of this treatment approach and to provide a qualitative evaluation assessing treatment satisfaction of the participating URMs.

Methods

A mixed-methods study was conducted among ten URMs, combining quantitative data with qualitative data through triangulation. Quantitative data were collected using a non-concurrent multiple baseline design in which repeated, weekly assessments were carried out during a randomized baseline period, during treatment, and during a 4-week follow-up period. Questionnaires assessing PTSD (Children's Revised Impact of Event Scale) and symptoms of depression (The Patient Health Questionnaire-9, modified for adolescents) were used. In addition, treatment satisfaction was measured post-treatment using a semi-structured interview.

Results

During the qualitative evaluation, all but one URM noted they found the trauma-focused treatment approach useful and felt the treatment had positively impacted their wellbeing. However, the results of the quantitative evaluation did not show clinically reliable symptom reductions at posttest or follow-up. Implications for clinical practice and research are discussed.

Discussion

The current study presents our search in developing a treatment approach for URMs. It adds to the current knowledge about methodological considerations in evaluating treatments for URMs, the potential effects of trauma-focused treatments on URMs, and the implementation of treatments for URMs.Clinical trial registration: The study was registered in the Netherlands Trial Register (NL8519), 10 April 2020.

Parental burnout and depression among Iranian mothers: The mediating role of Maladaptive Coping modes

OBJECTIVE

Depression in mothers impacts children negatively. Understanding the antecedents and the underlying mechanisms of depression is essential in helping clinicians target depressive symptoms effectively. This study investigated the relationship between parental burnout and depression in mothers and examined the mediation role of Maladaptive Coping modes.

METHOD

A total of 224 mothers participated in this study and completed the Parental Burnout Assessment scale, Patient Health Questionnaire, and items related to coping modes in Schema Mode Inventory.

RESULTS

Data analysis with structural equation modeling revealed that depression and parental burnout were positively and significantly related. Bootstrap analysis showed that all coping modes except the Self-Aggrandizer mode act as mediators between parental burnout and depression in mothers. Detached Protector mode had the strongest indirect effect on depression.

CONCLUSION

The results suggest Maladaptive Coping modes mediate the association between parental burnout and depression. The present finding provides evidence that Maladaptive Coping modes can be considered probable mediational mechanisms that relate depression to parental burnout in mothers and may serve as potential interventional targets.

Exploring the Relationship between Early Adaptive Schemas and Sexual Satisfaction

Rationale

Early maladaptive schemas (EMS) develop from unmet core emotional needs during childhood and adolescence. EMS influence the way individuals perceive themselves and others, while also sharing associations with various sexual difficulties. Contrastingly, Early Adaptive Schemas (EAS) develop when core emotional needs are met. Yet, the potential influence of EAS on sexual wellbeing remains underinvestigated.

Objective

The current study assessed the relationship between EAS and sexual satisfaction as a primary component of sexual wellbeing.

Method

The study design was an online, cross-sectional survey. Participants included 732 adults (Mage = 32.05, SDage = 9.30), who completed self-report questionnaires assessing sexual satisfaction and EAS.

Results

Two, three-step hierarchical regressions evaluated the effect of EAS on sexual satisfaction, controlling for several potentially confounding variables. Results indicated that the only EAS that was associated with sexual satisfaction in both men and women was Realistic Expectations. EAS of Social Belonging and Success were associated with sexual satisfaction for women alone, whereas Self-Compassion was for men.

Conclusion

Findings provide preliminary evidence that EAS are associated with sexual satisfaction. As such, schema therapy may be a useful therapeutic framework for improving sexual satisfaction, when indicated.

Emotionally focused couple therapy in cancer survivor couples with marital and sexual problems: a replicated single-case experimental design

Objective

The current research examined the effect of Emotionally Focused Couples Therapy (EFCT) on perceived intimacy, affect, and dyadic connection in cancer survivor couples with relationship challenges.

Method

In this longitudinal replicated single-case study, positive and negative affect, intimacy, partner responsiveness, and expression of attachment-based emotional needs were reported every 3 days before and during treatment. Thirteen couples, with one partner having survived colorectal cancer or breast cancer, participated for the full duration of the study. Statistical analysis of the data was performed using randomization tests, piecewise regression, and multilevel analyses.

Results

Adherence to the therapeutic protocol was tested and found adequate. Compared with baseline, significant positive effects on affect variables were found during the therapeutic process. Positive affect increased and negative affect decreased. Partner responsiveness, perceived intimacy, and the expression of attachment-based emotional needs improved, but only in the later phase of treatment. Results at the group level were statistically significant, whereas effects at the individual level were not.

Discussion

This study found positive group-level effects of EFCT on affect and dyadic outcome measures in cancer survivors. The positive results warrant further research, including randomized clinical trials, to replicate these effects of EFCT in cancer survivor couples experiencing marital and sexual problems.

Schema therapy for patients with borderline personality disorder and comorbid alcohol dependence: A multiple-baseline case series design study

This study tested the effectiveness of schema therapy (ST) for borderline personality disorder (BPD) and comorbid alcohol dependence (AD). Twenty patients participated in a case series study with multiple baselines. The baseline phase consisted of treatment as usual. It was followed by a case conceptualization phase, an experiential techniques phase and a behavioural change phase. Patients showed a significant decrease in BPD and AD symptoms; change was mainly accomplished in the experiential techniques phase, with medium to large effect sizes. Three months after termination of therapy, 68% of the patients had remitted from BPD, and the number of drinking days decreased clearly. This study shows that, although treatment is challenging in this group of patients, meaningful change can be obtained in patients with BPD and AD using ST.

Loneliness is associated with maladaptive schema modes in patients with persistent depressive disorder

OBJECTIVES

Though loneliness represents a public health concern, this complex unpleasant feeling is commonly neglected in psychiatric care and may constitute a new treatment target in clinical groups particularly prone to feeling lonely and socially isolated, e.g., persistent depressive disorder (PDD). Schema modes encompass a set of distinct cognitive-affective patterns that may contribute to loneliness and social isolation. Aim of this study was to examine the interplay between subjective loneliness and objective social network size with schema modes in patients with PDD as well as healthy controls (HC).

METHOD

Sixty-two PDD patients (DSM-5; 35 female, M_age = 40.5, SD = 12.4) and 71 HC (60 female, M_age = 28.1, SD = 10.1) were assessed cross-sectionally using the following self-report measures: UCLA Loneliness Scale, Social Network Index (SNI), and Schema-Mode-Inventory, revised version (SMI-r). Correlational and multiple linear regression analyses were performed.

RESULTS

PDD patients reported significantly higher scores of loneliness and maladaptive schema modes and a smaller social network than HC. Loneliness was significantly positively associated with the modes Vulnerable Child, Detached Protector, Bully and Attack, and Punitive Parent, and negatively with Contented Child and Healthy Adult in both groups. In contrast, social network size was only positively associated with the Contented Child mode.

CONCLUSION

Loneliness is highly prevalent in PDD and in contrast to social network size associated with maladaptive schema modes. Therapeutically addressing these schema modes with specific techniques may represent a mechanism-based intervention for patients suffering from loneliness and should be investigated in clinical trials.

Attachment mediates the link between childhood maltreatment and loneliness in persistent depressive disorder

BACKGROUND

A central concept of attachment theory is that early experiences with close attachment figures shape the way we interact with and relate to other social partners throughout life. As such, early experiences of childhood maltreatment (CM) have been suggested as a key precursor of adult insecure attachment representations. As CM has been linked to feelings of loneliness in adulthood, this study examines whether insecure attachment could explain the relationship between CM and loneliness. Also, the moderating role of a diagnosis of persistent depressive disorder (PDD) is investigated, a disorder characterized by high levels of CM and loneliness.

METHOD

60 patients with PDD (DSM-5) and 60 gender- and age-matched non-clinical control participants (NC) completed self-report questionnaires measuring attachment, loneliness, and CM. Mediation analyses (PDD as a moderator) were performed.

RESULTS

PDD patients reported higher levels of CM, attachment anxiety, attachment avoidance, and loneliness than NC. CM was positively associated with loneliness in both groups. Mediation analyses demonstrated that the relationship between CM and loneliness was mediated by avoidant, but not anxious attachment, regardless of a diagnosis of PDD.

LIMITATIONS

Caution when interpreting these results is crucial as the study lacked a clinical control group, relied on self-report measures, and the cross-sectional design limits the ability to draw causal inferences.

CONCLUSIONS

All constructs studied were present to a greater degree in PDD. Above, findings provide initial evidence that avoidant attachment may explain the relationship between CM and loneliness. Potentially, adult avoidant attachment may lead to and maintain feelings of loneliness, regardless of PDD.

Affective Neuroscience Personality Scales and Early Maladaptive Schemas in Depressive Disorders

Aim: The aim of this study was to assess the interrelationships of Young’s early maladaptive schemas with indicators of specific neural emotional systems conceptualized in Panksepp’s theory in a group of people suffering from depressive disorders. Materials and methods: The Affective Neuroscience Personality Scales (ANPS) v. 2.4. and J. Young’s Early Maladaptive Schema Questionnaire (YSQ-S3-PL) were used. Ninety (90) individuals aged 18–58, including 45 people treated for depression (DD group), were qualified to participate in the experiment. Results: The subjects in the DD group scored statistically significantly lower than the subjects from the control group (CG group) on the three ANPS scale domains, namely SEEKING, PLAY, and ANGER. The subjects with depressive symptoms scored significantly higher in the YSQ-S3-PL questionnaire on two domains of early maladaptive schemas, i.e., “Impaired autonomy and performance” and “Other-directedness”. Regression analysis results indicate that impairment of the emotional SEEKING system explains most of the variability in the following typical domains of depression: “Disconnection and rejection”, “Impaired autonomy and performance”, and “Other-directedness”. For score variability in the domain area of “Impaired limits”, the ANGER system was found to be most significant, and the FEAR system proved the same for “Overvigilance and Inhibition”. Conclusions: 1. Two domains of early maladaptive schemas are significant for the onset of depressive symptoms, namely “Impaired autonomy and performance” and “Other-directedness”, linked to difficulties in engaging in behaviors to meet one’s own needs. 2. Impairment of the neural emotional SEEKING system most significantly explains the variability in depression-typical areas of early maladaptive schemas.

Minority stress and the inner critic/oppressive sociocultural schema mode among sexual and gender minorities

Several adverse psychological outcomes among sexual and gender minorities (SGM) are well documented in the literature. Notwithstanding the emergence of these data, SGM still receive little attention regarding psychological interventions, which include Schema Therapy (ST), an emerging integrative psychotherapy approach. Even though revisions have been proposed to expand ST’s understanding of emotional needs, schemas, domains, and schema modes, there is a gap in our understanding of SGM. Based on that, the main goal of this theoretical essay is to propose a specific ST intervention for SGM, addressing sociocultural aspects aiming at promoting a healthy functioning that can interpose oppression and internalized prejudice. To this end, we will present (a) the minority stress theoretical framework; (b) the ST model applying to SGM clients; and (c) a few strategies of ST intervention for SGM clients, highlighting the need for strengthening individuals’ healthy schema mode. It should be noted that, despite clinical work being relevant, there are social variables supporting and maintaining maladaptive structures. We hope the therapeutic interventions proposed promote dialogue on this subject and encouraging positive societal changes.

J. Young’s Early Maladaptive Schemas and Symptoms of Male Depression

Aim: There are more non-specific, hence harder to diagnose, symptoms in the picture of male depression. These symptoms are strongly linked to social norms and roles traditionally assigned to men. The aim of this study was to assess the interrelationship of early maladaptive schemas that affect the formation of self-image as a man with indicators of male depression. Materials and methods: The Gender-Sensitive Depression Screening (GSDS-26) by A.M. Möller-Leimkühler and the Early Maladaptive Schema Questionnaire by J. Young (YSQ-S3-PL) were used. A group of 75 men (aged 18 to 50) were qualified to take part in the research. Results: The total score of the GSDS-26 scale and individual indicators of male depression are strongly positively correlated with the severity of all five domains of the YSQ-S3-PL questionnaire. The highest correlation coefficient value was obtained in the following areas: “Disconnection and rejection” (0.741), “Other-directedness” (0.711), and “Overvigilance and inhibition” (0.711). In case of the GSDS-26 total score and the following indicators—Elevated stress, Aggressiveness, Emotional control, Risky behavior, and Classic symptoms of depression—positive statistically significant associations were confirmed with each of the 18 schemas from the YSQ-S3-PL questionnaire. Multiple regression results revealed that the following domains were significant for symptoms typical of male depression: “Disconnection and rejection” and “Impaired autonomy and performance”. The “Impaired limits” area was found to be statistically significant only for symptoms of classic depression. Conclusions: (1) The GSDS-26 scale scores show positive associations with each domain of the YSQ-S3-PL questionnaire. (2) The following areas seem to be more important for atypical depressive symptoms in men: “Disconnection and rejection” and “Impaired autonomy and performance”, while for classic depression: “Impaired limits” was more important. (3) In therapeutic work with male depressive symptoms, it is useful to focus on dominant maladaptive schemas alongside beliefs about stereotypical male roles.

Metta-Based Therapy for Chronic Depression: a Wait List Control Trial

Objectives

Current treatments for chronic depression have focused on reducing interpersonal problems and negative affect, but paid little attention to promoting prosocial motivation and positive affect. Following this treatment focus, the objective of the present study was to examine whether the combination of metta (Loving Kindness) group meditation and subsequent tailored individual therapy focusing on kindness towards oneself and others (metta-based therapy, MBT) shows greater improvements in depressive symptoms than a wait list control group in patients with chronic depression.

Methods

Forty-eight patients with DSM-5 persistent depressive disorder were randomly assigned to MBT or a wait list control condition. Outcome was assessed after group meditation, after subsequent individual therapy, and at 6-month follow-up. The primary outcome measure was an independent blind rating of depressive symptoms at post-test. Secondary outcome included changes in self-reported depression, behavioral activation, rumination, social functioning, mindfulness, compassion, and clinician-rated emotion regulation.

Results

Mixed-design analyses showed significant differences between MBT and WLC in changes from pre- to post-test in clinician-rated and self-rated depression, behavioral activation, rumination, social functioning, mindfulness, and emotion regulation. Most of the changes occurred during group meditation and were associated with large effect sizes. Improvements were maintained at 6-month follow-up.

Conclusions

The results provide preliminary support for the effectiveness of MBT in treating chronic depression.

Trial Registration

ISRCTN, ISRCTN97264476.

Adapting group schema therapy for older adults with personality disorders: lessons learnt

A first empirical study into group schema therapy in older adults with mood disorders and personality disorder (PD) features has shown that brief group schema therapy has potential to decrease psychological distress and to change early maladaptive schemas (EMS). Effect sizes however were smaller than those found in similar studies in younger adults. Therefore, we set out to adapt the treatment protocol for older adults in order to enhance its feasibility and outcome in this age group. We examined this adapted protocol in 29 older adults (mean age 66 years) with PDs from four Dutch mental health institutes. The primary outcome was symptomatic distress, measured by the Brief Symptom Inventory. Secondary outcomes were measured by the Young Schema Questionnaire, the Schema Mode Inventory, and the short version of the Severity Indices of Personality Problems. Contrary to our expectations, the adapted treatment protocol yielded only a small effect size in our primary outcome, and no significant improvement in EMS, modes and personality functioning. Patients pointed out that they were more aware of their dysfunctional patterns, but maybe they had not been able yet to work on behavioural change due to this schema therapy treatment being too brief. We recommend more intensive treatment for older patients with PDs, as they might benefit from more schema therapy sessions, similar to the treatment dosage in younger PD patients. They might also benefit from a combination of group therapy and individual treatment sessions.

Key learning aims

(1)

Childhood Memories in Eating Disorders: An Explorative Study Using Diagnostic Imagery

Together with socio-cultural components, the family environment and early parent-child interactions play a role in the development of eating disorders. The aim of this study was to explore the nature of early parent-daughter relationships in a sample of 49 female inpatients with an eating disorder. To acquire a detailed image description of the childhood experiences of the patient, we used diagnostic imagery, a schema therapy-derived experiential technique. This procedure allows exploring specific contents within the childhood memory (i.e., emotions and unmet core needs), bypassing rational control, commonly active during direct verbal questioning. Additionally, patients completed self-report measures to assess for eating disorder severity, general psychopathology, and individual and parental schemas pervasiveness. Finally, we explored possible differences in the diagnostic imagery content and self-report measures in two subgroups of patients with anorexia nervosa and bulimia nervosa. The results showed that the most frequently reported unmet needs within the childhood memories of patients were those of safety/protection, care/nurturance, and emotional expression, referred specifically to the maternal figure. Overall, mothers were described as more abandoning, but at the same time particularly enmeshed in the relationship with their daughters. Conversely, patients perceived their fathers as more emotionally inhibited and neglecting. Imagery-based techniques might represent a powerful tool to explore the nature of early life experiences in eating disorders, allowing a more detailed case conceptualization and addressing intervention on early-life vulnerability aspects in disorder treatment.

Early maladaptive schemas and depression in adulthood: A systematic review and meta-analysis

BACKGROUND

Improved understanding of the specific cognitive risk factors associated with depression is needed to inform prevention and treatment approaches. Recent research has examined the relationship between early maladaptive schemas (EMSs) and depression, but the findings were yet to be integrated using meta-analytic methods. The aim of this review was to synthesize the evidence on the relationship between depression and EMS.

METHOD

A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, by searching the PsycINFO, PubMed and CINAHL databases. Included studies were peer-reviewed journal articles that examined the relationship between one or more EMS and depression in adulthood in participants aged 18 years or older.

RESULTS

A total of 51 studies were included (k = 743; pooled N = 17,830). All 18 EMSs were positively correlated with depression, with effect sizes ranging from small (r = .23 [.17, .29]; Entitlement) to large (r = .53 [.46, .60]; Social Isolation; r = .50, 95% CI [.45, .54]; Defectiveness/Shame).

CONCLUSION

The evidence suggests that individuals who feel like they do not belong, or that they are flawed, bad or unlovable, report higher levels of depression. However, most studies used cross-sectional designs, and further longitudinal research is needed to establish the direction of the relationship between EMS and depression. These findings can guide preventative and treatment approaches. Focusing treatment on the Social Isolation and Defectiveness/Shame EMS may aid in relieving depressive symptoms.

Mindfulness-based schema therapy and forgiveness therapy among women affected by infidelity: A randomized clinical trial

OBJECTIVE

Infidelity causes mental health problems, family disruptions, rumination about events and changes in women's beliefs about the disloyal person. This study aimed to compare the effectiveness of mindfulness-based schema (MBS) therapy and forgiveness therapy in emotional responses, cognitive distortions and self-compassion of women affected by infidelity. Method: It was an experimental research with a pretest-posttest and follow-up design. Eighty-one women affected by infidelity were randomly assigned to two experimental groups and one control group. The experimental groups received interventions for ten 90-minute weekly sessions. Participants completed the questionnaires in the pretest, post-test and follow-up. Repeated measures analysis of variance was used for statistical analysis. Results: Both experimental groups were significantly different from the control group (p<.01). Forgiveness therapy was more effective in emotional responses and self-compassion in the post-test (p<.01) and follow-up (p<.001) stages. MBS therapy was more effective in cognitive distortions in the post-test and follow-up stages (p<.001). Participants of experimental groups were responders and satisfied with treatment and had a good therapeutic relationship. Conclusion: Given the type of problems faced by women affected by infidelity, forgiveness therapy and MBS therapy can be used to reduce mental sufferings and communication problems.

A preliminary study: designing and validating projective images of Young's early maladaptive schema (EMS) domains

BACKGROUND

This study aims to design and validate ten projective images of Young's Early Maladaptive Schema (EMS) domains. For this purpose, two questions are to be addressed. (1) How is the factorial structure of the projective images of EMS domains? (2) Do the images designed in the domains of disconnection and rejection, impaired autonomy and performance, impaired limits, other-directedness, and over-vigilance and inhibition have sufficient validity?

METHODS

This is an applied mixed-methods exploratory study, in which the statistical population consisted of psychologists from Tehran Province in the qualitative section (n = 8) as well as other individuals aged between 18 and 65 years (mean age = 33) from Qazvin in the quantitative section (n = 102) in 2018. The research questions were analyzed through principal axis factoring with a varimax rotation, confirmatory factor analysis, Pearson correlation coefficient, and Cronbach's alpha.

RESULTS

According to the results, ten images and five domains of Young's EMSs contribute to a simple structure. Accounting for 70.35% of the total variance of EMSs, the five dimensions include disconnection and rejection, impaired autonomy and performance, impaired limits, other-directedness, and over-vigilance and inhibition.

CONCLUSIONS

The results indicated that the designed projective images yielded acceptable construct validity.

Schema therapy versus cognitive behavioral therapy versus individual supportive therapy for depression in an inpatient and day clinic setting: study protocol of the OPTIMA-RCT

BACKGROUND

Major depressive disorder represents (MDD) a major cause of disability and disease burden. Beside antidepressant medication, psychotherapy is a key approach of treatment. Schema therapy has been shown to be effective in the treatment of psychiatric disorders, especially personality disorders, in a variety of settings and patient groups. Nevertheless, there is no evidence on its effectiveness for MDD in an inpatient nor day clinic setting and little is known about the factors that drive treatment response in such a target group.

METHODS

In the current protocol, we outline OPTIMA (OPtimized Treatment Identification at the MAx Planck Institute): a single-center randomized controlled trial of schema therapy as a treatment approach for MDD in an inpatient and day clinic setting. Over the course of 7 weeks, we compare schema therapy with cognitive behavioral therapy and individual supportive therapy, conducted in individual and group sessions and with no restrictions regarding concurrent antidepressant medication, thus approximating real-life treatment conditions. N = 300 depressed patients are included. All study therapists undergo a specific training and supervision and therapy adherence is assessed. Primary outcome is depressive symptom severity as self-assessment (Beck Depression Inventory-II) and secondary outcomes are clinical ratings of MDD (Montgomery-Asberg Depression Rating Scale), recovery rates after 7 weeks according to the Munich-Composite International Diagnostic Interview, general psychopathology (Brief Symptom Inventory), global functioning (World Health Organization Disability Assessment Schedule), and clinical parameters such as dropout rates. Further parameters on a behavioral, cognitive, psychophysiological, and biological level are measured before, during and after treatment and in 2 follow-up assessments after 6 and 24 months after end of treatment.

DISCUSSION

To our knowledge, the OPTIMA-Trial is the first to investigate the effectiveness of schema therapy as a treatment approach of MDD, to investigate mechanisms of change, and explore predictors of treatment response in an inpatient and day clinic setting by using such a wide range of parameters. Insights from OPTIMA will allow more integrative approaches of psychotherapy of MDD. Especially, the identification of intervention-specific markers of treatment response can improve evidence-based clinical decision for individualizing treatment.

TRIAL REGISTRATION

Identifier on clinicaltrials.gov : NCT03287362 ; September, 12, 2017.

Schema Therapy for Chronic Depression Associated with Childhood Trauma: A Case Study

Chronic depression lasting longer than 2 years is often undertreated. Research suggests that maladaptive cognitive schemas mediate the association between childhood trauma and later depression. Schema Therapy (ST) is an integrative treatment approach that targets maladaptive cognitive schemas through cognitive, behavioral, interpersonal, and experiential interventions. ST has been studied in patients with chronic depression with good results. The purpose of this case study is to detail how an ST treatment was used to treat chronic depression in a woman, “Amy,” with a childhood trauma history. Amy presented with a persistent depressive disorder that had lasted over 40 years. An ST approach was chosen in light of the chronicity of Amy’s symptoms and her childhood trauma history. Standardized measures including the Beck Depression Inventory were used to assess progress throughout treatment. We provide a comprehensive summary of the 22-session ST case conceptualization and treatment, through which Amy’s depressive symptoms evidenced a 73 percent reduction. Amy qualitatively reported reduced depressive rumination and avoidance behaviors as well as increased frequency of positive mood.

A plea for more attention to mental representations

In this invited essay I plead for a renewed attention to mental representations in research into psychopathology and its treatment. With the cognitive revolution in the second half of the previous century most psychological models of psychopathology were based on people's capacity to form mental representations of the world. However, much research effort was put into investigating cognitive biases instead of investigating mental representations, and attention shifted towards such biases, including claims that they are causal in psychopathology. Similar claims were made about emotion regulation difficulties. Moreover, in many treatment models that were developed the focus was more on cognitive biases and emotion regulation, than on underlying representations. In this essay I argue that the causal status of cognitive biases, emotion regulation, and similar phenomena is overestimated, and that in clinical reality such phenomena can be best conceptualized as output of activated mental representations. Moreover, I argue that the disappointing effectiveness and protection to relapse of many current psychological treatments are related to not addressing the underlying mental representation. Next I discuss aspects of mental representations that are important for understanding and treating psychopathology, after which I discuss the clinical implications. I sketch how better understanding the specificities of mental representations can help us to improve psychological treatments, and I make some suggestions for future research.

Positive schemas in schema therapy with older adults: clinical implications and research suggestions

BACKGROUND

Schema therapy is an effective treatment for borderline personality disorder and other complex disorders. Schema therapy is feasible in older adults, and the first empirical support for its effectiveness in later life was provided in older patients with a cluster C personality disorder. The central concept of the schema therapy model is the early maladaptive schema (EMS). Early adaptive schemas (EAS) give rise to adaptive behaviour, and they also emerge during childhood, when core emotional needs are adequately met by primary caregivers.

AIMS

To examine the concept of EAS and its application in schema therapy with older adults.

METHOD

Literature review and case example: the role of EAS in schema therapy with older adults is discussed and suggestions for integrating EAS in schema therapy in later life are proposed.

RESULTS

Directing attention in therapy to EAS may help strengthen the healthy adult mode, and it might also help change a negative life review. Working with positive schemas may be an important avenue for re-awakening positive aspects of patients, reinforcing the therapeutic relationship, creating a positive working atmosphere, and also for facilitating the introduction of experiential schema therapy techniques.

CONCLUSIONS

This review suggests that positive schemas may be important vehicles of therapeutic change when working with older people. There is a need for validating the Young Positive Schema Questionnaire (YPSQ) in older adults, and for examining whether integrating EAS in schema therapy with older adults indeed has a positive effect on therapy outcome.

Integrated treatment for patients with comorbid depression and personality disorders

PURPOSE OF REVIEW

To provide an update on the epidemiology and the clinical consequences of depression complicated by comorbid personality disorders, and to discuss optimal treatment options.

RECENT FINDINGS

Studies have confirmed the frequent co-occurrence of depression and personality disorders. These comorbid states are consistently associated with unfavourable clinical indicators such as duration of episode, symptom severity and recurrence of depression, as well as a negative effect on treatment outcome. Nevertheless, this is a neglected theme and there are hardly any well designed treatment studies available.

SUMMARY

We advocate considering depression and personality as being more closely related and argue in favour of the development of integrated treatment options tailored to understanding symptoms as being interwoven with a variety of long-standing disturbing personality patterns. Both clinically and conceptually, psychodynamic and schema-focused approaches provide good opportunities to adjust available therapies and they could optimize outcomes in this complex patient group. Given the risk of treatment resistance and chronicity, a combination of psychotherapy and medication should always be considered.

Cognitive Group Therapy Based on Schema-Focused Approach for Reducing Depression in Prisoners Living With HIV

Depression is one the most common mental disorders in prisons. People living with HIV are more likely to develop psychological difficulties when compared with the general population. This study aims to determine the efficacy of cognitive group therapy based on schema-focused approach in reducing depression in prisoners living with HIV. The design of this study was between-groups (or "independent measures"). It was conducted with pretest, posttest, and waiting list control group. The research population comprised all prisoners living with HIV in a men's prison in Iran. Based on voluntary desire, screening, and inclusion criteria, 42 prisoners living with HIV participated in this study. They were randomly assigned to an experimental group (21 prisoners) and waiting list control group (21 prisoners). The experimental group received 11 sessions of schema-focused cognitive group therapy, while the waiting list control group received the treatment after the completion of the study. The various groups were evaluated in terms of depression. ANCOVA models were employed to test the study hypotheses. Collated results indicated that depression was reduced among prisoners in the experimental group. Schema therapy (ST) could reduce depression among prisoners living with HIV/AIDS.

Patient predictors of response to cognitive behaviour therapy and schema therapy for depression

OBJECTIVE

Few studies have examined differential predictors of response to psychotherapy for depression. Greater understanding about the factors associated with therapeutic response may better enable therapists to optimise response by targeting therapy for the individual. The aim of the current exploratory study was to examine patient characteristics associated with response to cognitive behaviour therapy and schema therapy for depression.

METHODS

Participants were 100 outpatients in a clinical trial randomised to either cognitive behaviour therapy or schema therapy. Potential predictors of response examined included demographic, clinical, functioning, cognitive, personality and neuropsychological variables.

RESULTS

Individuals with chronic depression and increased levels of pre-treatment negative automatic thoughts had a poorer response to both cognitive behaviour therapy and schema therapy. A treatment type interaction was found for verbal learning and memory. Lower levels of verbal learning and memory impairment markedly impacted on response to schema therapy. This was not the case for cognitive behaviour therapy, which was more impacted if verbal learning and memory was in the moderate range.

CONCLUSION

Study findings are consistent with the Capitalisation Model suggesting that therapy that focuses on the person's strengths is more likely to contribute to a better outcome. Limitations were that participants were outpatients in a randomised controlled trial and may not be representative of other depressed samples. Examination of a variety of potential predictors was exploratory and requires replication.

Optimizing psychotherapy dosage for comorbid depression and personality disorders (PsyDos): a pragmatic randomized factorial trial using schema therapy and short-term psychodynamic psychotherapy

BACKGROUND

Patients with comorbid depression and personality disorders suffer from a heavy disease burden while tailored treatment options are limited, accounting for a high psychological and economic burden. Little is known about the effect of treatment dosage and type of psychotherapy for this specific co-morbid patient population, in terms of treatment-effect and cost-effectiveness. This study aims to compare treatment outcome of 25 versus 50 individual therapy sessions in a year. We expect the 50-session condition to be more effective in treating depression and maintaining the effect. Secondary objectives will be addressed in order to find therapy-specific and non-specific mechanisms of change.

METHODS

In a mono-center pragmatic randomized controlled trial with a 2 × 2 factorial design, 200 patients with a depressive disorder and personality disorder(s) will be included. Patients will be recruited from a Dutch mental health care institute for personality disorders. They will be randomized over therapy dosage (25 vs 50 sessions in a year) and type of therapy (schema therapy vs short-term psychodynamic supportive psychotherapy). The primary clinical outcome measure will be depression severity and remission. Changes in personality functioning and quality of life will be investigated as secondary outcomes. A priori postulated effect moderators and mediators will be collected as well. All patients are assessed at baseline and at 1, 2, 3, 6, 9-12 months (end of therapy) and at follow up (6 and 12 months after end of treatment). Alongside the trial, an economic evaluation will be conducted. Costs will be collected from a societal perspective.

DISCUSSION

This trial will be the first to compare two psychotherapy dosages in patients with both depression and personality disorders. Insight in the effect of treatment dosage for this patient group will contribute to both higher treatment effectiveness and lower costs. In addition, this study will contribute to the limited evidence base on treating patients with both depression and personality disorders. Understanding the processes that account for the therapeutic changes could help to gain insight in what works for whom.

TRIAL REGISTRATION

This trial has been registered on July 20th 2016, Netherlands Trial Register, part of the Dutch Cochrane Centre ( NTR5941 ).

Comparison of early maladaptive schemas between borderline personality disorder and chronic depression

Borderline personality disorder (BPD) and chronic depression (CD) are common and challenging mental disorders. Maladaptive cognitive schemas have been proposed to increase vulnerability to both disorders. In order to elucidate the role of maladaptive cognitive schemas in BPD and CD, this study compared psychiatric outpatients with BPD (N = 30) and CD (N = 30) in terms of early maladaptive schemas (EMSs). The groups were compared using the Young Schema Questionnaire short form-extended (YSQ-S2-extended) and the 15D health status questionnaire. BPD patients showed higher endorsement on the majority of EMSs, poorer social functioning, and greater concurrent distress than CD patients. However, after controlling for concurrent effects of psychological distress, the groups did not differ in 14 out of the 18 EMSs. These findings point to significant similarities in maladaptive beliefs between the 2 disorders and do not support broad, specific patterns of EMSs associated with either disorder. The results highlight the need for further study of the role of maladaptive schemas in the development and treatment of chronic mental disorders.

Exploring mechanisms of change in schema therapy for chronic depression

BACKGROUND AND OBJECTIVES

The underlying mechanisms of symptom change in schema therapy (ST) for chronic major depressive disorder (cMDD) have not been studied. The aim of this study was to explore the impact of two potentially important mechanisms of symptom change, maladaptive schemas (proxied by negative idiosyncratic core-beliefs) and the therapeutic alliance.

METHODS

We drew data from a single-case series of ST for cMDD. Patients with cMDD (N = 20) received on average 78 repeated weekly assessments over a course of up to 65 individual sessions of ST. Focusing on repeated assessments within-individuals, we used mixed regression to test whether change in core-beliefs and therapeutic alliance preceded, followed, or occurred concurrently with change in depressive symptoms.

RESULTS

Changes in core-beliefs did not precede but were concurrently related to changes in symptoms. Repeated goal and task agreement ratings (specific aspects of alliance) of the same session, completed on separate days, were at least in part associated with concurrent changes in symptoms.

LIMITATIONS

By design this study had a small sample-size and no control group.

CONCLUSIONS

Contrary to what would be expected based on theory, our findings suggest that change in core-beliefs does not precede change in symptoms. Instead, change in these variables occurs concurrently. Moreover, alliance ratings seem to be at least in part colored by changes in current mood state.

Group schema therapy for eating disorders: study protocol

BACKGROUND

The treatment of eating disorders is a difficult endeavor, with only a relatively small proportion of clients responding to and completing standard cognitive behavioural therapy (CBT). Given the prevalence of co-morbidity and complex personality traits in this population, Schema Therapy has been identified as a potentially viable treatment option. A case series of Group Schema Therapy for Eating Disorders (ST-E-g) yielded positive findings and the study protocol outlined in this article aims to extend upon these preliminary findings to evaluate group Schema Therapy for eating disorders in a larger sample (n = 40).

METHODS/DESIGN

Participants undergo a two-hour assessment where they complete a number of standard questionnaires and their diagnostic status is ascertained using the Eating Disorder Examination. Participants then commence treatment, which consists of 25 weekly group sessions lasting for 1.5 h and four individual sessions. Each group consists of five to eight participants and is facilitated by two therapists, at least one of who is a registered psychologist trained on schema therapy. The primary outcome in this study is eating disorder symptom severity. Secondary outcomes include: cognitive schemas, self-objectification, general quality of life, self-compassion, schema mode presentations, and Personality Disorder features. Participants complete psychological measures and questionnaires at pre, post, six-month and 1-year follow-up.

DISCUSSION

This study will expand upon preliminary research into the efficacy of group Schema Therapy for individuals with eating disorders. If group Schema Therapy is shown to reduce eating disorder symptoms, it will hold considerable promise as an intervention option for a group of disorders that is typically difficult to treat.

TRIAL REGISTRATION

ACTRN12615001323516. Registered: 2/12/2015 (retrospectively registered, still recruiting).

Schema therapy for emotional dysregulation in personality disorders: a review

PURPOSE OF REVIEW

To give an update on the most recent studies regarding the role of schema therapy in the treatment of emotion dysregulation related to personality disorders.

RECENT FINDINGS

In personality disorders, a lack of emotion regulation can be found. Schema therapy treats emotion dysregulation with a series of techniques, such as imagery rescripting, limited reparenting, chairwork, and cognitive restructuring to remove dysregulatory mechanism.

SUMMARY

Schema therapy is one of the most efficient therapies for personality disorders. However, there is a lack of recent studies on how it treats emotion dysregulation. Although the treatment of emotional dysregulation is not the core of schema therapy, it is certainly important inside this theoretical framework. The mode model helps clinicians address their work toward the reduction of dysfunctional modes, whereas fostering functional modes.

Negative mood-induction modulates default mode network resting-state functional connectivity in chronic depression

BACKGROUND

The aim of this study was to investigate the effects of sad mood on default mode network (DMN) resting-state connectivity in persons with chronic major depressive disorder (cMDD).

METHODS

Participants with a diagnosis of cMDD (n=18) and age, gender and education level matched participants without a diagnosis of depression (n=18) underwent a resting-state fMRI scan, before and after a sad mood induction. The posterior cingulate cortex (PCC) was used as a seed for DMN functional connectivity across the two resting-state measurements.

RESULTS

Mood ratings decreased in both groups following the sad mood induction procedure. PCC connectivity with the parahippocampal gyrus, the superior temporal gyrus and the anterior inferior temporal cortex increased in cMDD patients following the sad mood induction, whereas it decreased in non-patient controls. PCC connectivity with the anterior prefrontal cortex and the precuneus decreased in cMDD patients following the sad mood induction, whereas it increased in non-patient controls.

LIMITATIONS

Limitations of this study include the relatively small sample size and lack of a clinical control group.

CONCLUSIONS

These findings are in line with neurobiological models of depression suggesting that the observed changes in DMN connectivity following the sad mood induction might reflect a failure to exert cognitive control over negative memory retrieval in patients with cMDD.

Schema Therapy for Emotional Dysregulation: Theoretical Implication and Clinical Applications

The term emotional dysregulation refers to an impaired ability to regulate unwanted emotional states. Scientific evidence supports the idea that emotional dysregulation underlies several psychological disorders as, for example: personality disorders, bipolar disorder type II, interpersonal trauma, anxiety disorders, mood disorders and post-traumatic stress disorder. Emotional dysregulation may derive from early interpersonal traumas in childhood. These early traumatic events create a persistent sensitization of the central nervous system in relation to early life stressing events. For this reason, some authors suggest a common endophenotypical origin across psychopathologies. In the last 20 years, cognitive behavioral therapy has increasingly adopted an interactive-ontogenetic view to explain the development of disorders associated to emotional dysregulation. Unfortunately, standard Cognitive Behavior Therapy (CBT) methods are not useful in treating emotional dysregulation. A CBT-derived new approach called Schema Therapy (ST), that integrates theory and techniques from psychodynamic and emotion focused therapy, holds the promise to fill this gap in cognitive literature. In this model, psychopathology is viewed as the interaction between the innate temperament of the child and the early experiences of deprivation or frustration of the subject's basic needs. This deprivation may lead to develop early maladaptive schemas (EMS), and maladaptive Modes. In the present paper we point out that EMSs and Modes are associated with either dysregulated emotions or with dysregulatory strategies that produce and maintain problematic emotional responses. Thanks to a special focus on the therapeutic relationship and emotion focused-experiential techniques, this approach successfully treats severe emotional dysregulation. In this paper, we make several comparisons between the main ideas of ST and the science of emotion regulation, and we present how to conceptualize pathological phenomena in terms of failed regulation and some of the ST strategies and techniques to foster successful regulation in patients.

Emotion Regulation in Schema Therapy and Dialectical Behavior Therapy

Schema therapy (ST) and dialectical behavior therapy (DBT) have both shown to be effective treatment methods especially for borderline personality disorder. Both, ST and DBT, have their roots in cognitive behavioral therapy and aim at helping patient to deal with emotional dysregulation. However, there are major differences in the terminology, explanatory models and techniques used in the both methods. This article gives an overview of the major therapeutic techniques used in ST and DBT with respect to emotion regulation and systematically puts them in the context of James Gross' process model of emotion regulation. Similarities and differences of the two methods are highlighted and illustrated with a case example. A core difference of the two approaches is that DBT directly focusses on the acquisition of emotion regulation skills, whereas ST does seldom address emotion regulation directly. All DBT-modules (mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness) are intended to improve emotion regulation skills and patients are encouraged to train these skills on a regular basis. DBT assumes that improved skills and skills use will result in better emotion regulation. In ST problems in emotion regulation are seen as a consequence of adverse early experiences (e.g., lack of safe attachment, childhood abuse or emotional neglect). These negative experiences have led to unprocessed psychological traumas and fear of emotions and result in attempts to avoid emotions and dysfunctional meta-cognitive schemas about the meaning of emotions. ST assumes that when these underlying problems are addressed, emotion regulation improves. Major ST techniques for trauma processing, emotional avoidance and dysregulation are limited reparenting, empathic confrontation and experiential techniques like chair dialogs and imagery rescripting.

[Schema therapy with children and adolescents – a conceptual and evidence-based overview]

The paper highlights the essential pillars of schema therapy as well as outlining the basic concepts of early maladaptive schemas, domains, emotional core needs, and the mode model. We present an overview of the important features of the schema therapy and look at the special schematic therapeutic relationship work, thereby focusing on emotional processes, needs-oriented biography work, age-appropriate psycho-education, and schema coaching for parents. Clinical recommendations are given based on the recent evidence.