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"schema therapy"
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Design of an RCT on cost-effectiveness of group schema therapy versus individual schema therapy for patients with Cluster-C personality disorder: the QUEST-CLC study protocol
Background
Given the high prevalence of Cluster-C Personality Disorders (PDs) in clinical populations, disease burden, high societal costs and poor prognosis of comorbid disorders, a major gain in health care can be achieved if Cluster-C PDs are adequately treated. The only controlled cost-effectiveness study published so far found Individual Schema Therapy (IST) to be superior to Treatment as Usual (TAU). Group ST (GST) might improve cost-effectiveness as larger numbers can be treated in (>50%) less time compared to IST. However, to date there is no RCT supporting its (cost-) effectiveness. The overall aim of this study is to assess the evidence for GST for Cluster-C PDs and to improve treatment allocation for individual patients. Three main questions are addressed: 1) Is GST for Cluster-C PDs (cost-)effective compared to TAU? 2) Is GST for Cluster-C PDs (cost-) effective compared to IST? 3) Which patient-characteristics predict better response to GST, IST, or TAU?
Methods
In a multicenter RCT, the treatment conditions GST, IST, and TAU are compared in 378 Cluster-C PD patients within 10 sites. GST and IST follow treatment protocols and are completed within 1 year. TAU is the optimal alternative treatment available at the site according to regular procedures. Severity of the Cluster-C PD is the primary outcome, assessed with clinical interviews by independent raters blind for treatment. Functioning and wellbeing are important secondary outcomes. Assessments take place at week 0 (baseline), 17 (mid-GST), 34 (post-GST), 51 (post-booster sessions of GST), and 2 years (FU). Patient characteristics predicting better response to a specific treatment are studied, e.g., childhood trauma, autistic features, and introversion. A tool supporting patients and clinicians in matching treatment to patient will be developed. An economic evaluation investigates the cost-effectiveness and cost-utility from a societal perspective. A process evaluation by qualitative methods explores experiences of participants, loved ones and therapists regarding recovery, quality of life, and improving treatment.
Discussion
This study will determine the (cost-)effectiveness of treatments for Cluster-C PDs regarding treatment type as well as optimal matching of patient to treatment and deliver insight into which aspects help Cluster-C-PD patients recover and create a fulfilling life.
Trial registration
Dutch Trial Register:
NL9209
. Registered on 28-01-2021,
Journal Article
Schema Therapy in Collectivist Societies: Understanding Japanese Narcissism, Armor Mode, and the Demanding Community Mode
Japanese narcissism refers to a culturally embedded form of narcissistic personality that emerges within collectivist societies, particularly in Japan, where self-worth is maintained through emotional over-adaptation, perfectionism, self-sacrifice, and conformity to internalized moral obligations. Within the framework of Schema Therapy, this construct is characterized by dominant coping modes, such as Armor mode and Demanding Community mode, that suppress vulnerable emotional states and promote socially sanctioned compliance. Although narcissistic personality disorder (NPD) has been extensively studied in individualistic Western cultures, its manifestation in collectivist cultures remains underexplored. Japanese narcissism offers a culturally contextualized model that integrates psychoanalytic and Schema Therapy perspectives to explain thin-skinned narcissistic vulnerability, disguised as adaptive functioning. Clinical observations and case analyses indicate that patients often develop Armor mode (fusing Detached Protector and Perfectionistic Over-controller functions) and Demanding Community mode (internalizing collective moral expectations). These adaptive-appearing modes mask core maladaptive schemas—Emotional Deprivation, Defectiveness/Shame, Enmeshment, and Self-Sacrifice—while being mistaken for mature or healthy functioning. Historically, such patterns have been reinforced by moral-collectivist ideals, exemplified by the Imperial Rescript on Education, which valorized loyalty, endurance, and self-denial. Japanese narcissism may therefore represent a culturally specific clinical configuration, suggesting the need for contextually adapted Schema Therapy interventions that recognize both the harmony-preserving and narcissism-reinforcing functions of adaptive behavior. This framework contributes to the cross-cultural extension of Schema Therapy by theorizing how narcissistic structures manifest in collectivist societies, and highlights the need for empirical validation of culturally sensitive treatment protocols.
Journal Article
The effectiveness of an online video-based group schema therapy in improvement of the cognitive emotion regulation strategies in women who have undergone bariatric surgery
Background
Adaptive cognitive emotion regulation (CER) strategies toward eating play a very important role in obesity and according to schema therapy, patients with obesity learn that don't respond to their emotional stimuli by eating. Thus, this study aimed to evaluate the effectiveness of an online video-based group schema therapy in improvement of the CER strategies and body mass index (BMI) in women who had undergone bariatric surgery.
Methods
Forty women who had undergone sleeve gastrectomy were selected and randomly divided into two groups of control and experimental. The experimental group received 10 weekly 90-min sessions of group schema therapy, the control group did not receive any intervention at all. Both groups completed the CER strategies questionnaire during pre-test, post-test and follow-up stages, and the data were analyzed using a multivariate analysis of covariance (MANCOVA) through SPSS software (version 20).
Results
Our results indicated that the experimental group demonstrated significantly higher adaptive CER strategies (
P
= 0.0001, F = 31.15) and significantly lower maladaptive CER strategies (
P
= 0.001, F = 9.42), significantly lower BMI (
P
= 0.001, F = 23.48), as compared to the control condition, following the group schema therapy after the follow-up stage.
Conclusion
The findings demonstrated that group schema therapy could lead to an increases in adaptive CER strategies and a decrease in maladaptive CER strategies and BMI in women who had undergone bariatric surgery.
Trial registration
IRCT, IRCT20180523039802N2. Registered 5 August 2020,
http://www.irct.com/IRCT20180523039802N2
.
Journal Article
G-FORCE: the effectiveness of group psychotherapy for Cluster-C personality disorders: protocol of a pragmatic RCT comparing psychodynamic and two forms of schema group therapy
Background
Cluster-C personality disorders (PDs), characterized by a high level of fear and anxiety, are related to high levels of distress, societal dysfunctioning and chronicity of various mental health disorders. Evidence for the optimal treatment is extremely scarce. Nevertheless, the need to treat these patients is eminent. In clinical practice, group therapy is one of the frequently offered approaches, with two important frameworks: schema therapy and psychodynamic therapy. These two frameworks suggest different mechanisms of change, but until now, this has not yet been explored. The purpose of the present G-FORCE trial is to find evidence on the differential (cost)effectiveness of two forms of schema group therapy and psychodynamic group therapy in the routine clinical setting of an outpatient clinic and to investigate the underlying working mechanisms and predictors of outcome of these therapies.
Methods
In this mono-centre pragmatic randomized clinical trial, 290 patients with Cluster-C PDs or other specified PD with predominantly Cluster-C traits, will be randomized to one of three treatment conditions: group schema therapy for Cluster-C (GST-C, 1 year), schema-focused group therapy (SFGT, 1.5 year) or psychodynamic group therapy (PG, 2 years). Randomization will be pre-stratified on the type of PD. Change in severity of PD (APD-IV) over 24 months will be the primary outcome measure. Secondary outcome measures are personality functioning, psychiatric symptoms and quality of life. Potential predictors and mediators are selected and measured repeatedly. Also, a cost-effectiveness study will be performed, primarily based on a societal perspective, using both clinical effects and quality-adjusted life years. The time-points of assessment are at baseline, start of treatment and after 1, 3, 6, 9, 12, 18, 24 and 36 months.
Discussion
This study is designed to evaluate the effectiveness and cost-effectiveness of three formats of group psychotherapy for Cluster-C PDs. Additionally, predictors, procedure and process variables are analysed to investigate the working mechanisms of the therapies. This is the first large RCT on group therapy for Cluster-C PDs and will contribute improving the care of this neglected patient group. The absence of a control group can be considered as a limitation.
Trial registration
CCMO,
NL72826.029.20
. Registered on 31 August 2020, first participant included on 18 October 2020.
Journal Article
Schema Therapy for Patients with Bipolar Disorder: Theoretical Framework and Application
Bipolar disorder (BD) is a severe mood disorder characterized by episodes of depression and hypomania or mania. Despite its primarily biological roots, the onset and course of the disorder have also been related to psychosocial factors such as early adverse experiences and related maladaptive schemas. Several researchers proposed a schema therapeutic model to treat patients with BD. In this paper, we further develop the theoretical model and elaborate on seven elements that were found effective in the psychosocial interventions with individuals with BD: monitoring mood and early symptoms of relapse, recognizing and management of stressful situations and interpersonal conflicts, creating a relapse prevention plan, stabilizing the sleep/wake cycle and daily routine, encouraging the use of medication, and reducing self-stigma and substance use. Apart from that, we describe the elements of the schema work with patients who suffer from BD. Illustrative clinical cases accompany the theoretical framework. The research of the schema therapy with patients with severe mental illnesses has only recently started developing. The presented paper also aims to encourage further research in this area and highlight potentially beneficial research goals.
Journal Article
Schema therapy with cognitive behaviour day-treatment in patients with treatment-resistant anxiety disorders and obsessive-compulsive disorder: an uncontrolled pilot study
Treatment resistance in patients with anxiety disorders and obsessive-compulsive disorder (OCD) might be caused by dysfunctional personality traits or, more specifically, early maladaptive schemas (EMSs) and schema modes, that can be treated with schema therapy (ST).
To explore possible effectiveness of ST-CBT day-treatment in patients with treatment-resistant anxiety disorders and OCD in an uncontrolled pilot study.
Treatment-resistant patients with anxiety disorders or OCD (
= 27) were treated with ST-CBT day-treatment for 37 weeks on average including 11.5 therapy hours per week. The Symptom Questionnaire-48, Young Schema Questionnaire-2 and Schema Mode Inventory were completed before and after treatment.
General psychopathology, EMSs and schema modes significantly improved after treatment. Spearman's correlations between pre- to post-treatment difference scores of general psychopathology, EMSs and schema modes were significant and high. The level of pre-treatment EMSs and schema modes did not predict post-treatment general psychopathology.
Symptom reduction was strongly correlated with improvement of EMSs and schema modes. Stronger pre-treatment EMSs and schema modes did not hinder improvement of symptoms. ST-CBT day-treatment is promising for patients with treatment-resistant anxiety disorders and OCD. Further controlled research is needed to substantiate evidence for schema therapy in patients with treatment-resistant anxiety disorders and OCD.
Journal Article
Clinical effectiveness, cost-effectiveness and process evaluation of group schema therapy for eating disorders: study protocol for a multicenter randomized controlled trial
Background
Eating disorders (EDs), such as (atypical) Anorexia (AN) and Bulimia Nervosa (BN), are difficult to treat, causing socioeconomic impediments. Although enhanced cognitive behavioral therapy (CBT-E) is widely considered clinically effective, it may not be the most beneficial treatment for (atypical) AN and BN patients who do not show a rapid response after the first 4 weeks (8 sessions) of a CBT-E treatment. Alternatively, group schema therapy (GST) may be a valuable treatment for this ED population. Even though GST for EDs has yielded promising preliminary findings, the current body of evidence requires expansion. On top of that, data on cost-effectiveness is lacking. In light of these gaps, we aim to describe a protocol to examine whether GST is more (1) clinically effective and (2) cost-effective than CBT-E for (atypical) AN and BN patients, who do not show a rapid response after the first 4 weeks of treatment. Additionally, we will conduct (3) process evaluations for both treatments.
Methods
Using a multicenter RCT design, 232 Dutch (atypical) AN and BN patients with a CBT-E referral will be recruited from five treatment centers. Clinical effectiveness and cost-effectiveness will be measured before treatment, directly after treatment, at 6 and at 12 months follow-up. In order to rate process evaluation, patient experiences and the degree to which treatments are implemented according to protocol will be measured. In order to assess the quality of life and the achievement of personalized goals, interviews will be conducted at the end of treatment. Data will be analyzed, using a regression-based approach to mixed modelling, multivariate sensitivity analyses and coding trees for qualitative data. We hypothesize GST to be superior to CBT-E in terms of clinical effectiveness and cost-effectiveness for patients who do not show a rapid response to the first 4 weeks of a CBT-E treatment.
Discussion
To our knowledge, this is the first study protocol describing a multicenter RCT to explore the three aforementioned objectives. Related risks in performing the study protocol have been outlined. The expected findings may serve as a guide for healthcare stakeholders to optimize ED care trajectories.
Trial registration
clinicaltrials.gov (NCT05812950).
Journal Article
A new model for basic needs: comparison of the second order factorial structures of young schema questionnaire and its relationship with symptoms of psychopathology
This study investigates the structure of Young’s early maladaptive schemas, core emotional needs, and their associations with psychopathological symptoms. Early maladaptive schemas and psychopathological symptoms were assessed in three clinical samples from Turkey (
N
1
= 1312,
N
2
= 999,
N
3
= 999). First-order Principal Component Analysis (PCA) identified 17 schemas, eight of which closely mirrored Young's original schemas. A second-order PCA revealed four schema domains: Impaired Autonomy, Disconnection, Impaired Limits, and Overvigilance. Confirmatory Factor Analyses were employed on distinct samples to compare the PCA model with alternative models, and the PCA model exhibited superior fit across various indices. The study reveals varying relationships between schemas and diverse psychopathological symptoms, providing nuanced insights for tailoring psychotherapeutic strategies and interventions. Symptoms related to interpersonal sensitivity had the strongest connections to schemas, and the factor representing vulnerability to harm and pessimism schemas had the most number of strong connections with psychopathological symptoms. While the study sheds light on the schemas in a Turkish context, future research is essential to validate these findings and explore the predictive aspects of schemas. In essence, this research contributes to understanding of schemas within the Turkish cultural context and its implications for clinical practice.
Journal Article
Implementation of a schema therapy awareness group for adult male low secure patients with comorbid personality difficulties: reflections and challenges
Purpose
The purpose of this study/paper is to describe the implementation of a six-month schema therapy awareness (STA) group. Research supporting individual schema therapy (ST) as an effective intervention for personality disorder is growing steadily within a number of settings including with forensic patients. Alongside individual ST, positive results have been reported for group ST. However, to the best of the authors’ knowledge, no current published research exists with regard to the use of group ST within forensic populations and more specifically within a low secure environment.
Design/methodology/approach
This paper describes the implementation of a six-month schema therapy awareness (STA) group with individuals situated within a low secure environment.
Findings
For individuals transitioning into the community from a secure setting, the focus of risk management should attempt to move away from external controls towards more of a reliance on internal factors. In ST, this is achieved by understanding the role of schema modes (and underlying schemas) that are linked to an individual’s offences/risk and developing this understanding into a coherent and accessible formulation for the individual to make changes.
Research limitations/implications
Further robust research evaluating clinical change is recommended as the next step.
Practical implications
The group protocol is described along with the challenges and potential solutions experienced during the implementation. This provides an opportunity for other professionals to replicate this approach in the future.
Originality/value
With regard to group ST within forensic populations, the research is sparse at present and this study focusses on practical application of theory and the challenges of operationalising a STA group.
Journal Article