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

Schema therapy in adults with autism spectrum disorder: A scoping review

BACKGROUND

Schema therapy (ST) in adults with autism spectrum disorder (ASD) have gained increasing interest in clinical practice and research. However, to date, there has been no synthesis of the literature on ST as treatment for adults with ASD. Through a scoping review, we aim to summarize the emerging research and literature on ST for adults with ASD.

METHODS

A comprehensive literature search of three electronic databases was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Publications were included that examined ST in adults with ASD and non-clinical adults with autistic traits.

RESULTS

Systematic searches identified a total of 11 publications, all published since 2014, with the majority being conducted by Dutch and Japanese researchers. Of the 11 publications, 1 described an ST-informed social interaction training, 1 was an ST protocol, 2 described conceptual ST models, 2 were case examples, 2 examined early maladaptive schemas (EMSs) and 3 investigated the effectiveness of ST interventions. In summary, the theoretical exploration, practical examples of the application of ST and research findings with preliminary evidence of ST, EMSs and schema modes (SMs) in adults with ASD point towards the potential of ST for the treatment of adults with ASD.

DISCUSSION

The current scoping review highlights preliminary research findings and offers valuable suggestions for clinicians treating adults with ASD. This review underscores the need for development of and research in specialized ST protocols and programmes tailored to adults with ASD with chronic mental conditions, such as personality disorders (PDs).

The effectiveness of individual schema therapy in older adults with borderline personality disorder: A multiple-baseline case series design

OBJECTIVE

The aim of this study was to explore the effectiveness of schema therapy (ST) in older adults with borderline personality disorder (BPD).

METHODS

Multiple baseline case series design with five BPD patients, with a mean age of 66. After a baseline phase with random length, patients received weekly ST sessions for a year, followed by follow-up sessions during 6 months. Participants rated the credibility of negative core beliefs weekly; various secondary outcome measures were assessed every 6 months (severity of BPD, early maladaptive schemas, schema modes, personality functioning, maladaptive personality traits, psychological distress and quality of life), and BPD diagnosis was assessed before baseline and after follow-up. Data were analysed with mixed regression analyses and paired t-tests.

RESULTS

Results revealed that ST led to a significant decrease in credibility of negative core beliefs, with high effect sizes. All participants remitted from their BPD diagnosis.

CONCLUSION

This is the first study exploring the effectiveness of ST for BPD in older adults, and it suggests that ST can be a powerful intervention for this group of patients.

Dialectical Core Schemas Mediate the Relationships Between Dissociative Experiences and Symptomatology in a Community Sample

BACKGROUND

Maladaptive cognitions about the self and others are associated with a wide array of dysfunctional responses and psychopathological symptoms in non-clinical and clinical samples. Dissociative experiences (e.g., depersonalization and derealization) as a coping response to stressful situations lie on a continuum from healthy to unhealthy but are generally elevated in individuals experiencing mental illness. However, the extent to which Dialectical Core Schemas explain the relationship between dissociative experiences and symptomatology is unclear. Therefore, this study aimed to investigate the mediating role of Dialectical Core Schemas on the relationship between dissociative experiences and symptomatology.

METHODS

A community sample of 179 participants were recruited (M_age = 21.2 years, SD = 8.2). Data were gathered through self-report questionnaires using a cross-sectional design.

RESULTS

Maladaptive core schemas about self and others correlated positively with all dissociative experiences (e.g., depersonalization/derealization, amnesia), while adaptive core schemas about the self correlated negatively with depersonalization/derealization and distractibility. Maladaptive core schemas mediated the relationship between dissociative experiences and symptomatology.

CONCLUSIONS

The relationships between dissociative experiences and symptomatology are bi-directional. Exploring the mediating factors may help clinicians and researchers better understand how to enhance case conceptualization and clinical decision-making.

Early Adaptive Schemas and Sexual Wellbeing in Women: Exploring Differences in Menopausal Status

There is limited research concerning the relationship between early adaptive schema, from Young's Schema Theory, and women's sexual wellbeing. Schema Theory posits that early adaptive schema start forming in early childhood from core emotional needs being met, and positively influence individuals' concept of self, relationships with others, and their behaviours. Building on this theory, the current study explored the relationship of early adaptive schema and adult women's sexual wellbeing at pre-, peri-, and post-menopause. Four hundred and sixty-seven women, mostly partnered and heterosexual, from over ten countries, participated in an online survey measuring relationships between early adaptive schema and sexual wellbeing, measured by sexual functioning and sexual satisfaction. The strength of association of early adaptive schema and sexual well-being were evaluated in addition to known predictors. The results showed higher early adaptive schema were associated with higher sexual wellbeing, measured by sexual satisfaction and sexual functioning,with medium-to-large effect sizes, at pre and peri-menopause, and produced a non-significant result for post-menopause. The association of early adaptive schema continued after known factors were accounted for. The results support the use of early adaptive schema to promote sexual wellbeing for women at pre- and peri-menopause.

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.

A Randomized Controlled Trial Study of a Multimodal Intervention vs. Cognitive Training to Foster Cognitive and Affective Health in Older Adults

Research over the past few decades has shown the positive influence that cognitive, social, and physical activities have on older adults' cognitive and affective health. Especially interventions in health-related behaviors, such as cognitive activation, physical activity, social activity, nutrition, mindfulness, and creativity, have shown to be particularly beneficial. Whereas most intervention studies apply unimodal interventions, such as cognitive training (CT), this study investigates the potential to foster cognitive and affective health factors of older adults by means of an autonomy-supportive multimodal intervention (MMI). The intervention integrates everyday life recommendations for six evidence-based areas combined with psychoeducational information. This randomized controlled trial study compares the effects of a MMI and CT on those of a waiting control group (WCG) on cognitive and affective factors, everyday life memory performance, and activity in everyday life. Three groups, including a total of 119 adults aged 65-86 years, attended a 5- or 10-week intervention. Specifically, one group completed a 10-week MMI, the second group completed 5-week of computer-based CT followed by a 5-week MMI, whereas the third group paused before completing the MMI for the last 5 weeks. All participants completed online surveys and cognitive tests at three test points. The findings showed an increase in the number and variability of activities in the everyday lives of all participants. Post hoc analysis on cognitive performance of MMI to CT indicate similar (classic memory and attention) or better (working memory) effects. Furthermore, results on far transfer variables showed interesting trends in favor of the MMI, such as increased well-being and attitude toward the aging brain. Also, the MMI group showed the biggest perceived improvements out of all groups for all self-reported personal variables (memory in everyday life and stress). The results implicate a positive trend toward MMI on cognitive and affective factors of older adults. These tendencies show the potential of a multimodal approach compared to training a specific cognitive function. Moreover, the findings suggest that information about MMI motivates participants to increase activity variability and frequency in everyday life. Finally, the results could also have implications for the primary prevention of neurocognitive deficits and degenerative diseases.

Predicting the role of coping factors on pandemic-related anxiety

The year 2020 saw the emergence of a worldwide pandemic caused by the novel coronavirus COVID-19. Measures against further spread of the virus were taken nearly everywhere in the world. Many countries also imposed social distancing rules and lockdowns on their population. This situation has caused a lot of fear and insecurity, along with reactance and even unrest in some countries. In this study, we measured the psychological concepts of resilience, reactance, positive schemas, social solidarity, and anxiety among psychiatric patients and in how far these factors influence their psychopathological anxiety during the pandemic. The aim was to better understand in what ways these factors influence pandemic anxiety to be able to reduce its negative psychological effects. Findings show a significant effect of positive schemas and social solidarity on the level of pandemic anxiety in a sample of psychiatric patients, but no correlation between resilience or reactance and pandemic anxiety. Based on these insights, the inclusion of positive schemas and social solidarity for therapy should be considered. Looking deeper into the relation between positive schemas and pandemic anxiety could provide insight into the different ways that schemas influence people's anxiety and determine whether some of them are particularly important.

Embedding the silver thread in all-age psychological services: training and supervising younger therapists to deliver CBT for anxiety or depression to older people with multi-morbidity

Providers of cognitive behavioural therapy (CBT) in adult mental health services in the UK are expected to deliver therapy suitable for adults of all ages. However, older people commonly present with co-morbidities that challenge delivery of single-diagnosis CBT protocols. Added to this, the difference in age between therapy-provider and service-user can compromise collaboration. In this paper, I consider two key areas of relevance for training and supervising CBT therapists for work with older people, namely multi-morbidities and intergenerational relations. The evolving evidence base for CBT with older people is summarised and a commentary provided on previous ‘old age’ case studies from the Cognitive Behaviour Therapist (tCBT). Strategies for collaborative relationships are discussed, as are strategies for ‘embedding the silver thread’. I conclude with recommendations for future directions for CBT training and supervision.

Key learning aims

(1)

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)

The effectiveness of adapted schema therapy for cluster C personality disorders in older adults - integrating positive schemas

INTRODUCTION

Schema therapy (ST) is an efficacious psychotherapy for personality disorders (PDs) in adults. The first empirical support for the effectiveness of ST in older adults with cluster C PDs was provided recently. ST partly focusses on the positive, but there is an increasing awareness of imbalance in the ST community because of the emphasis on negative schemas versus attention to positive schemas. Positive schemas may be important vehicles of therapeutic change in psychotherapy with older people, as it may help strengthen the healthy adult mode, and it might also help change a negative life review. Suggestions were made to increase the efficacy and feasibility of ST in older adults, including adjusting the case conceptualisation, modifying the experiential techniques, making use of the patient's wisdom and reactivating positive schemas. The aim of the current study is to investigate the feasibility and effectiveness of adapted individual ST for older adults.

METHODS/DESIGN

A multiple baseline design is used with positive and negative core beliefs as primary outcome measures. Ten older adults (age > 60 years) with cluster C PDs are treated with schema therapy, with weekly sessions during one year. This treatment phase is preceded by a baseline phase varying randomly from 4 to 8 weeks. After treatment, there is a 6-month follow-up phase with monthly booster sessions. Symptomatic distress, schema modes, early maladaptive schemas (EMS) and early adaptive schemas (EAS) are secondary outcome measures. PD will be diagnosed before baseline and after treatment phase. EAS are assessed with the Dutch version of the Young Positive Schema Questionnaire (YPSQ).

DISCUSSION

To the best of our knowledge, this is the first empirical study in which positive schemas are integrated in ST treatment to examine the efficacy of an adapted form of ST for older adults. This is in line with wider developments supporting the integration of positive schema's into ST. It offers the possibility to improve the effectiveness of ST in older adults.

TRIAL REGISTRATION

The Netherlands National Trial Register NL8346, registered 1 February 2020.