Preface

Schema therapy is a treatment that revolves around cognitions, behaviors, experiences and psychodynamics. It is used for clients who have a chronic psychological disorder. It has been shown to be effective in people with borderline personality disorder and for people who are paranoid, narcissistic and theatrical. Positive effects have also been found in people with personality disorders and depression. The question is whether schema therapy is also effective when someone is chronically depressed. Chronic depression has stronger negative consequences on the quality of life, results in more suicide attempts and admissions and leads to higher economic costs compared to depressive episodes.

Therapy for chronic depression

Most treatments for chronic depression involve antidepressants, cognitive therapy, cognitive behavioral psychotherapy or a combination of psychotherapy and medication. There is also emotion-focused therapy in which a client is helped to identify his or her emotions and behavior. Because of the fact that in many forms of therapy the effects are only temporarily effective. Therefore, there often have to be subsequent, maintaining treatments.

Basic concepts of schema therapy

Old maladaptive schemas

According to the original schema therapy model, early maladaptive schemas (EMS) are at the core of psychopathology. These schemas are seen as stable and long-term beliefs of oneself and of the world. These schemas remain hidden until they are triggered by a life event that causes a powerful emotional response. Given that the EMS are the core of psychopathology, a therapy would be to make these schemas more adaptive.

Coping strategies

Clients with strong EMS develop dysfunctional coping strategies for dealing with negative emotions. There are three types of coping associated with these schemas, namely avoidance behavior (behaviors to avoid activation of the schema), surrender (behaviors that match the schema) and overcompensation (behaviors that are opposite of the schema). 

Adjustment of schema therapy for chronic depression

It is likely that chronic depression is caused by multiple interacting factors. There are four risk factors for chronic depression which are empirically supported. These factors are: early adverse life events, personality, cognitive factors, and interpersonal factors. The effect of distant risk factors (early adverse life events and personality) on chronic depression affects the proximal (nearby) risk factors (EMS and dysfunctional attitudes). The nearby risk factors are triggered by recent life events and are maintained by avoidant coping strategies and by interpersonal behavior related to avoidance of social situations. This creates a shortage of social support and this ensures that depression is maintained. A recent life event can therefore activate an EMS and this can lead to a chronic depression. Figure 1 in the article shows the cognitive schema model of chronic depression.

Early adverse life events

Early adverse life events represent the experiences that one experiences as a child, such as abuse or neglect. In other studies it has been shown that the more often someone has experienced such events in his or her childhood, the greater the chance on depression. However, this does depend on the way in which a child cognitively generates an event (so creates a schema of it). So, EMS mediates between early adverse life events and the depression and therefore the treatment should focus on these EMS. Schema therapy can help with this, because this therapy causes the client to imagine the traumatic experience and thus to relive the trauma. This reduces the impact of the trauma on the client.

Cognitive factors

People with depression have been shown to have dysfunctional thoughts. These thoughts come up automatically. It has also been found that people with chronic depression have worse EMS and that these schemas remain fairly stable during outpatient treatment for their depression. Schema therapy ensures that these negative thinking patterns are broken. The ultimate goal is then to reduce the schematic processes that are dominated by the EMS. With the use of cognitive and emotional techniques, the patient will come to see that their schemas are false.

Personality pathology

In the group of people with chronic depression there is more comorbidity of a personality disorder and chronic depression than within the group with episodic depression. Schema therapy has been developed specifically for clients with a chronic problem, often with a personality disorder. It has been shown that there is a positive effect for people with borderline personality disorder and Cluster-C personality disorder if it occurs together with chronic depression.

Interpersonal factors

Depressed clients are described as socially avoidant and inassertive. Because they are socially avoidant, they receive less social support from others. These people also avoid conflict. Schema therapy ensures that these patterns are broken, so that the client will no longer avoid conflicts. This is reached through certain techniques that allow the client and the therapist to identify the EMS that leads to these unhealthy interpersonal thougts and behaviors.

Similarities and differences with other treatments

Schema therapy uses many techniques that are also used with other therapies. Schema therapy is based on cognitive therapy and schema therapy used the cognitive techniques from it. There are also differences between these two therapies. In addition to cognitive techniques, schema therapy includes experiential techniques to identify schemas and modify schemas. This is not what cognitive therapy does. Schema therapy is used to change the schemas from different perspectives. Schema therapy is about past events and cognitive therapy is about present events.
Schema therapy leads to that a link is made between past events and recent problems. This is not what cognitive therapy does.

Treatment protocol

Schema therapy for the chronically depressed people can be divided into three phases. In the first two phases the sessions are weekly and in the last phase the frequencies of the sessions are reduced and the client gains more autonomy and responsibility.

Phase 1: Exploration (sessions 1 to 10)

In this phase, there are three goals. First, the client must understand the concept of schemas and look for the most dominant scheme. The client shows the relationship between the most dominant schema, the problems and the history. The therapist helps the client to experience the feeling associated with the schema through techniques.
The client has to tell about an event from his or her youth and the therapist watches for affective reactions of the client. Then, general images are used and these images become progressively more specific. In this phase, unlike phase 2, no rewriting of the images is needed.

Phase 2: Change

In this phase, the goal is to change the EMS, to change emotional experiences and to change dysfunctional behavior. There are four different techniques used for these goals:

• Cognitive techniques: The cognitive techniques are used to ensure that the client becomes more rational and objective about the world and about his or herself.

• Experiential techniques: The experiential techniques are used to work on emotional experiences. A distinction can be made between imagery and chair dialogue. In imagery, the intention is that the client will take different perspectives in the event of problems. The client will learn to cope with experiences of despair and disability and will be able to better express what he or she wants. The other technique is the chair dialogue. Each chair represents a different 'I' for the client. 

• Therapeutic alliance: The therapist confronts the client with the behavior that the client shows during the sessions created by the underlying EMS through the empathic confrontations. This allows the client to learn to take different positions. The therapist then looks at how the client has fallen short in his or her youth and then the therapies tries to compensate for this. However, in this phase the therapists needs to be aware of independence.

• Behavioral techniques: Behavioral techniques involve role play and assertiveness training. With behavioral techniques, the client learns to turn cognitions and emotions into action.

Phase 3: Relapse prevention

During this phase, the client and the therapist make plans to prevent relapse in the future. They analyse situations that could trigger a relapse and make a plan how to deal with it.

Conclusion

There is no empirical evidence for that schema therapy is effective for clients with chronic depression. It has been shown that it addresses the underlying risk factors of chronic depression. It is likely that the effects are positive and long-lasting.