Schema Therapy for Personality Disorders: A Qualitative Study of Patients’ and Therapists’ Perspectives

De Klerk, N., Abma, T. A., Bamelis, L. L., & Arntz, A. (2016). Schema therapy for personality disorders: A qualitative study of patients’ and therapists’ perspectives. Behavioural and Cognitive Psychotherapy, 45(1), 31-45. https://doi.org/10.1017/s1352465816000357

Summary by: Fathimath Faseeha

In recent years, schema therapy has become increasingly popular among mental health practitioners in treating individuals with a variety of psychological issues, especially in treating personality disorders. However, despite the popularity and effectiveness, there has been little research conducted in studying the perspectives of patients and therapists with regards to schema therapy. Therefore, the current qualitative research aims to explore the experiences and perspectives of both patients and therapists involved in schema therapy for treating personality disorders, focusing primarily on borderline personality disorder and avoidant personality disorders.

To achieve this, the research conducted in-depth interviews with 16 patients and 16 therapists from an ongoing randomized controlled trial of group schema therapy for on borderline personality disorder and avoidant personality disorders in Norway. Participants shared their experiences and thoughts on the therapy process, the therapeutic relationship, change mechanisms, and outcomes. The study uses thematic analysis to examine semi-structured interview data from 16 patients and 16 therapists. The researchers employed a collaborative analysis approach involving the perspectives of both therapists who have experience in schema therapy and researchers who were not directly involved in practicing schema therapy to ensure interpretive depth and objectivity.

The results of this study were divided into three aspects; first, aspects of schema therapy that patients and therapists found helpful, second, aspects they found unhelpful and, third, recommendations given by both groups for improving schema therapy. For helpful aspects, therapeutic relationships were seen as positive, intense and substantially different from other forms of psychotherapy by both therapists and patients. The therapeutic frame of schema therapy was also mentioned by both groups as helpful where patients recognized this frame as a tool that helped them to understand their emotions and behaviors while therapists believed that this frame helped them to structure their sessions. Specific schema therapy techniques such as imagery were mentioned by both groups as a helpful aspect. For unhelpful aspects, the study revealed that patients stated that they felt a time pressure in schema therapy which was unhelpful, however, therapists had varying opinions about this aspect.  Additionally, lack of information, lack of practical application and lack of shared focus between therapists and clients were also seen by the participants as unhelpful aspects. For recommendations, providing clear information in advance was mentioned by the patients as an important aspect that needs to be incorporated into schema therapy. Therapists recommended establishing proper connection between the present and past in the imagery, giving more responsibility for patients in the final phase of therapy and providing more experiential training as recommendations to improve schema therapy.

While the study has limitations such as less sample size and low generalizability, the study provides important insights into the perspectives of patients and therapists when it comes to schema therapy. The authors also state that this is the first qualitative study that explores both patient’s and therapist’s experiences and perspectives of schema therapy, therefore, this study serves as an important foundation for future research to further expand the understanding of schema therapy. Additionally, the recommendations identified by the therapists and patients of this study can also add valuable insight to develop and increase the effectiveness of schema therapy. 

A Randomized Controlled Neuroimaging Trial of Cognitive Behavioral Therapy for Fibromyalgia Pain

Lee, J., Lazaridou, A., Paschali, M., Loggia, M. L., Berry, M. P., Ellingsen, D., Isenburg, K., Anzolin, A., Grahl, A., Wasan, A. D., Napadow, V., & Edwards, R. R. (2023). A randomized controlled neuroimaging trial of cognitive behavioral therapy for fibromyalgia pain. Arthritis & Rheumatology, 76(1), 130–140. https://doi.org/10.1002/art.42672

Summary by: Hagai Berenson

This study addresses the pervasive and debilitating nature of fibromyalgia (FM), a condition marked by widespread pain and significant negative emotional impact.

High levels of pain catastrophizing - a maladaptive cognitive-emotional response characterized by an exaggerated negative orientation toward actual or anticipated pain, Which also associates with increased pain severity, emotional distress, and functional impairment is often correlated to the condition of FM.

The authors discuss the role of cognitive behavioral therapy (CBT) as a mind-body intervention aimed at reducing pain catastrophizing and improving overall functioning in FM patients. While previous research has demonstrated the clinical benefits of CBT in managing chronic pain conditions, the specific neural mechanisms through which CBT exerts its effects on pain catastrophizing remain unclear.

To investigate these mechanisms, the study was designed as a randomized controlled trial with a neuroimaging component.

The study enrolled 114 adult women diagnosed with fibromyalgia, aged between 18 and 75 years and were randomized into two groups:

CBT Group: 64 participants received an 8-week individual CBT program. This intervention focused on identifying and modifying maladaptive thoughts and behaviors related to pain.

Education Control (EDU) Group: 34 participants received an 8-week fibromyalgia education program, matched in duration and structure to the CBT intervention. The control group received education about fibromyalgia and chronic pain without the active cognitive restructuring components inherent in CBT.

98 of the 114 participants in this study also completed a neuroimaging assessment on a baseline level and post intervention.

These Participants engaged in a task designed to elicit pain catastrophizing thoughts while undergoing fMRI scanning. This involved reflecting on personalized pain-related statements to activate relevant brain regions associated with catastrophizing.

The primary objective was to assess the impact of an eight-week individual CBT program on pain catastrophizing and to explore the associated changes in brain functional connectivity, particularly focusing on the default mode network (DMN) and its interaction with somatomotor and salience network regions.

The assessment was made in two parts:

Questioners filled by all participants at baseline and post-CBT intervention:

Pain Catastrophizing Scale (PCS): Assessed the degree of catastrophic thinking related to pain.

Brief Pain Inventory (BPI): Evaluated pain severity and the extent to which pain interfered with daily activities.

Fibromyalgia Impact Questionnaire Revised (FIQR): Measured the overall impact of fibromyalgia on the individual's functioning and well-being.

For the neuroimaging assessment, the focus was on examining functional connectivity patterns, particularly involving the ventral posterior cingulate cortex (vPCC), a key node in the default mode network (DMN). The analysis aimed to identify changes in connectivity between the vPCC and other brain regions implicated in pain processing and emotional regulation, such as the somatomotor and salience networks.

The results showed that participants in the CBT group experienced significantly greater reductions in pain catastrophizing, pain interference, and overall fibromyalgia symptom impact compared to the education control group. Mediation analysis further revealed that reductions in pain catastrophizing partially explained the improvements in functional outcomes, suggesting that changes in maladaptive thinking patterns were a key mechanism through which CBT exerted its effects. Neuroimaging findings supported these behavioral outcomes, showing decreased functional connectivity after CBT between the ventral posterior cingulate cortex (vPCC)—a central hub of the default mode network—and regions in the somatomotor and salience networks. These neural changes were not observed in the control group, indicating that CBT may help recalibrate brain activity associated with excessive self-referential and pain-focused processing.

Mindfulness-based cognitive therapy for patients with chronic, treatment-resistant depression: A pragmatic randomized controlled trial

Cladder-Micus, M. B., Speckens, A. E. M., Vrijsen, J. N., Donders, A. R. T., Becker, E. S. & Spijker, J. (2018). Mindfulness-based cognitive therapy for patients with chronic, treatment-resistant depression: A pragmatic randomized controlled trial. Depression and Anxiety, 35(10), 914-924. https://doi.org/10.1002/da.22788

Summary by: Anne Lisa Weighardt

Chronic and treatment-resistant depression is a serious problem in mental health care. Even if depressed patients receive evidence-based treatment, around 20% still develop a chronic course. This has an impact on both the personal life of a patient and society according to health care costs and workplace losses. New treatment strategies for this specific population are necessary as some patients do not respond to treatment. Cladder-Micus et al. (2018) investigated in their study the effectiveness of Mindfulness-based cognitive therapy (MBCT) + treatment-as-usual (TAU) compared to TAU only for chronically depressed patients. They used a pragmatic, multicenter, randomized-controlled design.

106 patients took part in the study. These patients were chronically depressed, had moderate to high levels of depressive symptoms and had not responded to previous pharmacotherapy and evidenced-based psychological treatments like cognitive behavioral therapy (CBT) or interpersonal therapy (ITP). The participants were randomized to either MBCT + TAU or TAU only. The MBCT condition included eight weekly sessions lasting 2.5 hours each, along with a day of practice. The results were analyzed in two different ways: intention-to-treat (ITT) and per-protocol (PP). The level of depression symptoms as the primary outcome measure was in both analysis in the MBCT + TAU condition lower than in the TAU condition, with small to medium effect sizes. But a significant difference was only found in the PP analyze (–4.24, 95% CI [–8.38 to –0.11], d = 0.45, P = 0.04), not in the ITT analyze (–3.23, 95% CI [–7.02 to 0.56], d = 0.35, P = 0.09) (Cladder-Micus et al., 2018). These results can be partly explained by the relatively high drop-out in the MBCT +TAU condition.

The primary reason for drop-out was physical problems. However, future research should explore the barriers to completing treatment (e.g. by conducting qualitative interviews). A shorter duration of the current depressive episode and a higher unemployment rate reported by non-completers, compared to completers, could indicate the following: a longer duration might heighten psychological burden, which in turn motivates patients to acquire new skills. Compared to TAU, MBCT + TAU had significant effects on the secondary outcomes, which were higher remission rates, less rumination, higher quality of life, more mindfulness skills, and more self-compassion. The improvement in mindfulness skills and self-compassion might indicate that patients with chronic, treatment-resistant depression are capable of acquiring mindfulness meditation techniques and developing a more caring attitude toward themselves. These secondary outcomes should be interpreted preliminary, because of the power analysis focus on changes in depressive symptoms.

However, these results may indicate that even if there are no or only small improvements in depressive symptoms, MBCT + TAU has effects that are beneficial for this severely ill population. Besides the analysis of the effectiveness of MBCT, possible moderators of treatment effect were also analyzed. The moderation analysis showed that patients with high levels of rumination had a significantly larger reduction in depressive symptoms in the MBCT + TAU condition compared to TAU.

This research suggests that MBCT might be especially beneficial for chronic, treatment-resistant depressed patients, who have high levels of rumination. This finding should be considered preliminary and needs replication and further examination. Although the effects of MBCT on depressive symptoms were only significant in the PP analysis, the secondary outcomes showed possible advantages for chronic, treatment-resistant patients. When interpreting the results, it is important to remember that the group of patients is a seriously ill population and therefore even small effects on depressive symptoms associated with effects on rumination, quality of life, mindfulness, and self-compassion could have an impact.

Psychotherapy for depression: A randomized clinical trial comparing schema therapy and cognitive behavior therapy

Carter, J. D., McIntosh, V. V., Jordan, J., Porter, R. J., Frampton, C. M., & Joyce, P. R. (2013). Psychotherapy for depression: A randomized clinical trial comparing schema therapy and cognitive behavior therapy. Journal of Affective Disorders, 151(2), 500–505. https://doi.org/10.1016/j.jad.2013.06.034

Summary by: Serra Bıtrak

The article I presented is called “Psychotherapy for Depression: A Randomized Clinical Trial Comparing Schema Therapy and Cognitive Behavior Therapy.” by Carter and colleagues (2013). Since the article focuses on Schema Therapy and Cognitive Behavior Therapy, it is important to mention the differences between CBT and ST. We can say that ST mostly concentrates specifically on the schema and what prevents individuals from getting their core needs met. The literature proposes that to make a lasting change, the schema must be modified, especially for people dealing with more persistent problems such as chronic depression. Therefore, based on the literature, the study aimed to compare the efficacy of ST with the traditional CBT for individuals with a major depressive episode. 

The study design was a randomized clinical trial study with 100 adult participants. The participants were recruited from either referrals from General Practitioner’s (GP’s) and mental health services or they could also self-refer. The recruitment took place between the years 2004 to 2008. Sixty nine percent of the participants were women. They were assessed and treated in an outpatient clinical research unit in the Department of Psychological Medicine, University of Otago, New Zealand. The exclusion criteria were moderate or severe alcohol or drug dependence, a history of mania, schizophrenia, major physical illness which would interfere with treatment, and failure to respond to a recent (past year) trial of CBT or ST.

As for the procedure, they did an initial screening by phone, followed by a baseline assessment which used Structured Clinical Interview for DSM-IV Axis I disorders (SCID-PQ), and after that, participants were randomly assigned to weekly therapy sessions for either CBT or ST for 6 months, followed by monthly sessions which were 6 more months. To assess the therapists’ competency, Cognitive therapy rating scale for CBT and its modified form for ST was used by choosing random sessions. Then, to measure participants' depression levels, Montgomery-Asberg Depression Rating Scale (MADRS) and Beck Depression Inventory was used. The first is a clinician-rated scale while the other is self-rated.

The results showed that there were no significant differences between the two therapies at the end of weekly therapy sessions or at the end of the whole therapy (i.e. end of monthly sessions). In terms of participants who reached remission or recovery, again, there was no significant difference. And also, they checked if having a comorbid personality disorder would affect the outcome, but there was no difference for that either.

Therefore, in conclusion, it can be said that this was the first randomized clinical trial comparing the two therapy modalities, and this is of course a limitation, because the results may not be very generalizable, so a replication is needed. And even though there wasn’t a significant difference, these results mean that CBT and ST are comparable when it comes to their effectiveness. Since their approaches are different, depending on the individual’s needs, they now have an option and can prefer one or the other.

Cognitive behavioral therapy versus compassion focused therapy for adult patients with eating disorders with and without childhood trauma: A randomized controlled trial in an intensive treatment setting

Vrabel, K. R., Waller, G., Goss, K., Wampold, B., Kopland, M., & Hoffart, A. (2024). Cognitive behavioral therapy versus compassion focused therapy for adult patients with eating disorders with and without childhood trauma: A randomized controlled trial in an intensive treatment setting. Behaviour Research and Therapy, 174, 104480. https://doi.org/10.1016/j.brat.2024.104480

Summary by: Gizem Sönmez

Can Compassion Focused Therapy Help Heal Eating Disorders?

A new study shows that treating eating disorders with compassion focused therapy might be just as powerful as using traditional cognitive behavioral therapy. And this method was even better for people who’ve experienced childhood trauma.

Many people struggle with eating disorders, such as anorexia or bulimia. These are serious mental health conditions that affect how people eat, think about food, and view their bodies.

The most common therapy used is called Cognitive Behavioral Therapy (CBT). It helps people change negative thoughts and behaviors. CBT works well for many, but not for everyone, especially those who’ve had trauma in childhood, such as abuse or neglect. These people often feel shame, are very self-critical, and have trouble accepting kindness from others or even from themselves. So researchers started with this question: “Can therapy that focuses on compassion work better for people with trauma?”

Compassion Focused Therapy (CFT) is particularly suitable for individuals who struggle with intense feelings of shame and self-criticism, and who find it challenging to experience or express kindness and warmth toward themselves or others. This approach supports them in developing a greater sense of safety and emotional warmth in both their self-relationship and their interactions with others.

 What Did the Researchers Do?

They studied 130 adults with eating disorders who had not improved with past treatments. Half of them had a history of childhood trauma.

Participants were randomly assigned to two types of therapy:

1. CBT – Focuses on changing thoughts and behaviors linked to the eating disorder.
2. Compassion-Focused Therapy for Eating Disorders (CFT-E) – A newer therapy that helps people develop self-compassion, manage shame, and feel safe with emotions.

Both therapies were given in an intensive 13-week inpatient program in Norway. People had individual and group therapy, meals, and support. Researchers followed up for one year after treatment.

 What Did They Find?

• Both therapies were effective.
  Eating disorder symptoms dropped significantly during treatment in both groups.
• But there was a key difference:
  People with childhood trauma who got CFT-E were more likely to keep improving one year later.
• CBT worked better for improving some social skills.
  But CFT-E was better at reducing PTSD symptoms linked to ch,idhood trauma.

 Why Compassion Matters?

This study highlights the importance of self-kindness and compassion, especially for individuals who have experienced significant emotional pain due to childhood trauma. Compassion-Focused Therapy for Eating Disorders (CFT-E) supports individuals in several important ways:

• It helps them understand their feelings of shame.
• It teaches them how to treat themselves with care and gentleness.
• It supports them in reducing harsh self-criticism.
• It encourages the development of healthier strategies for managing difficult emotions.

Overall, CFT-E promotes emotional healing by fostering a more compassionate relationship with oneself.

 What Makes This Study Strong?

• It’s the first randomized controlled trial comparing CBT and CFT-E for eating disorders.
• The researchers used a real-world setting with very distressed patients.
• The therapy lasted long enough (13 weeks) to see real effects.

Conclusion

This study happened at one clinic in Norway, so results might not apply everywhere. There was no control group, so we can’t say how much change came just from being in treatment. More research is needed, especially in younger people and with different types of eating disorders

Yet, it’s a promising study. Compassion-focused therapy might be helpful for someone who has an eating disorder, especially with a history of trauma. CBT is still effective, but for people struggling with shame and self-hatred, learning to be kinder to themselves might make a lasting difference.

Positive Cognitive Behavior Therapy in the Treatment of Depression: A Randomized Order Within-subject Comparison With Traditional Cognitive Behavior Therapy

Geschwind, N., Arntz, A., Bannink, F., & Peeters, F. (2019). Positive Cognitive Behavior Therapy in the Treatment of Depression: A Randomized Order Within-subject Comparison With Traditional Cognitive Behavior Therapy. Behaviour Research and Therapy, 116, 119–130. https://doi.org/10.1016/j.brat.2019.03.005

Summary by: Wies van der Leest

Positive Cognitive Behavioral Therapy: A Comparative Experimental Evaluation

Recently, interest has arisen in placing elements of positive psychology into traditional cognitive behavioral therapy (CBT) for depression treatment. The study by Geschwind, Arntz, Bannink, and Peeters (2019) shows an empirical investigation into the effectiveness of Positive Cognitive Behavioral Therapy (P-CBT). P-CBT is a variant of CBT that emphasizes well being, positive emotions, and solution-focused strategies. The main objective of the study was to determine whether P-CBT results in bigger improvements of depressive symptoms and positive mental health indices compared to Traditional CBT (T-CBT).

The Experimental Design

The study was conducted using a within-subjects crossover design. It involved 49 patients diagnosed with Major Depressive Disorder (MDD). Each participant received both treatment modalities. The treatment consisted of eight sessions of P-CBT and eight sessions of T-CBT, administered in a randomized order. The design was chosen to improve statistical power and control for individual differences, mostly because of the complications in recruiting participants from a clinical population, that suffer from a moderate to severe depression.

The T-CBT followed the usual protocols that include identifying and restructuring dysfunctional thoughts and behaviors. P-CBT included solution-focused brief therapy and positive psychology exercises, for example, gratitude practices and visualizing the best possible self.

 

The Measures and Methodology

The Quick Inventory of Depressive Symptoms (QIDS-SR-16) was used as the primary outcome measure. It was completed by the participants on a weekly basis. The secondary outcomes, subjective happiness (SHS), including positive and negative affect (PANAS), optimism (LOT-R), and overall mental health (MHC-SF), were assessed every four sessions. For intention-to-treat analysis, mixed regression modeling was used accounting for time, treatment order, and phase.

 

The Key Findings

The most remarkable result was that the participants experienced a significantly greater decrease in symptoms during the P-CBT phase, particularly when following T-CBT first. The results indicate that P-CBT may be a helpful follow-up or extension to T-CBT. Participants who began with T-CBT and afterwards followed the P-CBT showed the largest pre-post effect size (Cohen’s d = 2.71), in comparison to the participants starting with P-CBT (d = 1.85).

Moreover, P-CBT was associated with increased rates of clinically significant and reliable changes in depression, negative affect, and happiness. Furthermore, more participants accomplished normative levels of optimism and positive affect after the P-CBT phase. Additionally, the perceived dropout rates were lower for those who started with P-CBT, demonstrating greater acceptability.

 

Implications and Considerations

The findings imply that emphasizing strengths and positive emotions may decrease depressive symptoms with a larger effectivity than problem-focused methods, specifically in later treatment stages. Remarkably, participants transitioned more effortlessly from T-CBT to P-CBT, possibly due to P-CBT’s future-oriented, uplifting nature. Nevertheless, limitations include potential carry-over effects from the crossover design, lack of treatment fidelity checks, infrequent outcome measures and limited experience with P-CBT of the therapists.

 

Conclusion

Geschwind et al.’s (2019) study offers strong preliminary evidence supporting the effectiveness of Positive Cognitive Behavioral Therapy as standalone treatment and as an addition to traditional CBT. Even though further research is necessary, predominantly randomized controlled trials, this study shows significant improvement in validating approaches that highlight well-being and resilience combined with symptom reduction in treating depression.

Dialectical Behavior Therapy for Posttraumatic Stress Disorder (DBT-PTSD) Compared with Cognitive Processing Therapy (CPT) in Complex Presentations of PTSD in Women Survivors of Childhood Abuse: A Randomized Clinical Trial

Bohus, M., Kleindienst, N., Hahn, C., Müller-Engelmann, M., Ludäscher, P., Steil, R., Fydrich, T., Kuehner, C., Resick, P. A., Stiglmayr, C., Schmahl, C., & Priebe, K. (2020). Dialectical Behavior Therapy for Posttraumatic Stress Disorder (DBT-PTSD) Compared with Cognitive Processing Therapy (CPT) in Complex Presentations of PTSD in Women Survivors of Childhood Abuse: A Randomized Clinical Trial. JAMA Psychiatry, 77(12), 1235–1245. https://doi.org/10.1001/jamapsychiatry.2020.2148

Summary by: Liron Saban

Introduction

Childhood abuse increases the risk of PTSD and BPD. Existing PTSD therapies may not be efficient for complex cases involving emotional dysregulation. DBT-PTSD was developed to solve these issues with a phase-based approach.

Methods

Trial Design and Participants

The study conducted at three university outpatient clinics in Germany. Women with PTSD linked to childhood abuse and at least three BPD criteria were included. 193 participants were randomized (98 DBT-PTSD; 95 CPT).

Interventions

• DBT-PTSD: Phase-based therapy incorporating DBT principles, trauma-focused CBT, and compassion-focused elements.
• CPT: Standard cognitive processing therapy adjusted to the study format.

Diagnostic Procedures

PTSD diagnosed with CAPS-5. BPD and other disorders diagnosed via structured interviews. High interrater reliability was reported.

Outcome Measures

• Primary: CAPS-5 score at 15 months.
• Secondary: PTSD Checklist, BSL-23, Beck Depression Inventory, Global Assessment of Functioning, and Dissociation Tension Scale.

Assessments and Missing Data

Evaluations at 0, 3, 6, 9, 12, and 15 months. Used multiple imputation methods for missing data.

Statistical Analysis

Mixed linear models and additional categorical analyses (remission, reliable improvement, recovery).

Results

Patient Flow

955 screened; 193 included in analysis. Dropout: 39% in CPT vs. 25.5% in DBT-PTSD (significant).

Treatment Integrity

Both groups showed good adherence and therapist competence.

Primary Outcome

CAPS-5 scores improved significantly in both groups. DBT-PTSD showed a significantly greater reduction (effect size d = 0.33, P = .02).

Secondary Outcomes

DBT-PTSD outperformed CPT in:

• PTSD symptom checklist scores (d = 0.57).
• Dissociation (duration and intensity).
• Borderline symptoms and self-harming behaviors.
• Depression severity (small advantage).
  Functional gains were moderate and similar in both groups.

Discussion

DBT-PTSD was more effective than CPT in treating complex PTSD symptoms in women with childhood abuse history. Lower dropout rates and better remission and recovery rates were observed with DBT-PTSD.

Strengths

The randomized controlled trial design is a strength, as it minimizes bias and ensures a high level of internal validity. Both treatment arms (DBT-PTSD and CPT) were delivered by well-trained therapists, ensuring consistency and treatment fidelity.

Limitations

Possible developer allegiance bias. Generalizability limited to adult women with severe PTSD and BPD traits. Long-term outcomes were not assessed.

Conclusions

Both DBT-PTSD and CPT are effective, but DBT-PTSD is superior for complex PTSD in women with childhood abuse and emotional dysregulation. Further research is needed to assess broader applicability and long-term efficacy.