Strengthening the Healthy Adult Mode: a Case Experimental Study Exploring the Effects of a New Schema Therapy Protocol in an Adult Outpatient Population.
Condition: Trauma, Psychological; Personality Disorders; Chronic Psychiatric Disorder
MeSH terms: Personality Disorders; Mental Disorders; Problem Behavior; Psychological Trauma
Study type: Interventional

Summary: 
      Background: Strengthening the Healthy Adult schema mode is the ultimate goal in Schema
      Therapy, working as an assumed mechanism of long-term change through improved positive mental
      health. Evidence-based interventions to directly strengthen this Healthy Adult mode are
      sparse.

      Objective: To study the feasibility, acceptability and effectiveness of the treatment
      protocol 'Schema Therapy and the Healthy Adult' (ST-HA) during the final stage of schema
      therapy in adult outpatients with personality- or chronic psychopathology. Method: In this
      study a single case experimental design (n = 8) with multiple measures will be used, to
      determine the effects of the ST-HA protocol on self-compassion, well-being, positive affect
      and Healthy Adult functioning. For each participant a no-treatment randomized baseline period
      (2-5 weeks) will be compared with treatment (ST-HA, 10 weekly sessions) and post-treatment
      follow-up (at 1- and 3-months). Assessments include brief diaries regarding self-compassion
      and Healthy Adult functioning (daily from baseline to end of intervention, and 7-days at 1-
      and 3-months follow-up) and standardized questionnaires for measuring weekly changes in
      self-compassion, well-being and adaptive schema modes. During phase changes additional
      measures of trait self-compassion, positive affect, adaptive schema modes and symptomatic
      distress will be administered.
    

Detailed description: 
      Schema therapy (ST; Young, 1990, Young et al., 2003) is an effective treatment for
      personality disorders and other chronic psychopathology, leading to significant improvement
      in functioning in most patients. The model of psychopathology that underlies ST is based on
      the assumption that when core emotional needs - especially those related to attachment
      stability - are insufficiently met in childhood, there is an increased chance that
      long-standing patterns of maladaptive thinking, feeling, behaving and coping (called schemas)
      will develop (i.e. Hawke & Provencher, 2011; Flink et al., 2019; Lockwood & Peris, 2012).
      When schemas are activated, the individual switches into a specific
      emotional-cognitive-behavioral state, called schema mode.

      Schema therapy formulated in mode terms aims to build a Healthy Adult mode in patients by
      correcting dysfunctional self-representations which originate from unmet childhood needs
      (child modes), thereby replacing internalized critic modes with adaptive coping behavior
      (e.g. Arntz & Jacob, 2012; Claassen & Pol, 2013, 2014; Lobbestael et al., 2007; Young et al.,
      2003). This healthy, adultlike part of the self helps patients to meet their emotional needs
      and seems related to a longer-term view of emotional well-being (Roediger, Stevens, &
      Brockman, 2018). Recent studies demonstrate that building the Healthy Adult mode is crucial
      for long-term outcomes in patients with schema-driven perception and behavior, working as a
      mechanism of change through improved positive emotion regulation strategies to cope with
      (childhood) adversity (Louis et al., 2018; Westerhof & Wolterink, 2018; Yakin et al., 2020).
      A more explicit focus on healthy emotional functioning and regulation within ST seems
      therefore important. One useful emotional-approach coping strategy associated with healthy
      adult functioning is self-compassion (Trompetter et al., 2016; Yakin et al., 2019).
      Self-compassion is defined as being kind toward oneself (Neff, 2003b) and being able to use
      self-reassurance and soothing when presented with negative affect or adversities (Gilbert,
      2010; Gilbert et al., 2017; Kirschner et al. 2019). It is facilitated by early experiences of
      care and warmth from an attachment ﬁgure, which contributed to a sense of safeness in which
      individuals develop a soothing-affective system (Brophy et al., 2020; Gilbert, 2014; Gilbert
      & Proctor, 2006; Mackintosh et al., 2018). This system exerts its protective function by
      stimulating physiological processes associated with stress reduction and positive affiliation
      affects (i.e. feeling loved, safe and securely attached) (Depue & Morrone-Strupinsky, 2005;
      Engen & Singer, 2015; Porges, 2007). Promoting the soothing-affective system subsequently
      helps reducing threat-related negative emotional states and excessive drive-related arousal
      (i.e. activation of dysfunctional schema modes) by increasing compassionate self-reassuring
      abilities, which are characterized by a caring, warm, and accepting attitude toward the self
      (Gilbert, 2010; Petrocchi et al., 2019; Thimm, 2017). Self-compassion therefore increases
      positive self, while reducing negative self (Mackintosch et al., 2018; Kirschner et al. 2019)
      via addressing dysfunctional schema modes. That is, the healthy side of patients is aware of
      self-undermining messages, can challenge them, hereby reducing their impact by practicing
      self-compassion with focus on attunement to emotional needs. Self-compassion and the ability
      to cultivate positive emotions in ourselves can thus be viewed as strategy to 'broaden- and
      build' healthy adult behavior (Fredrickson, 2001). Positive emotions allow us to discard
      habitual modes and instead look for flexible, new ways of thinking and acting (Fredrickson,
      2003, 2004; Fredrickson et al., 2008). This broadened mindset can accumulate and compound to
      build biological (e.g. cardiac vagal tone) as well as cognitive (e.g. mindfulness), social
      (e.g. positive relations) and psychological (e.g. life-purpose) resources (Cloninger, 2006;
      Cloninger & Zohar, 2011). Experiencing positive emotions subsequently increases functional
      coping in a needs-based, value-driven, flexible way, serving as 'compass' for healthy adult
      behavior over lifetime (Bahner, 2016; Deci & Ryan, 2000; Plumb et al., 2009; Schreurs &
      Westerhof, 2013).

      Against this background, interventions focusing on the integration of schema therapy and
      compassion based therapy seems promising. To our best knowledge the protocol 'Schematherapy
      and the Healthy Adult' (ST-HA, Broersen & Claassen, 2019) is the first direct intervention
      meant to strengthen patients' healthy adult functioning by developing compassion and care for
      well-being in the face of (childhood) adversity. The current study explores the
      effectiveness, acceptability and feasibility of the ST-HA protocol in adult outpatients with
      personality- or chronic psychopathology during final stage ST, in which there is a focus on
      positive mental health, resilience and preparing therapy termination. It is hypothesized that
      administering the ST-HA protocol: (1) will increase self-compassion, well-being, positive
      affect and adaptive schema modes over the intervention and follow-up period, measured by
      daily diary data and standardized measurements; (2) will be accompanied by self-reported
      symptom-reduction over the intervention and follow-up period; and (3) will be acceptable and
      feasible in adult outpatients.
    

Intervention name(s): Schema Therapy and the Healthy Adult
Intervention type(s): Behavioral
Intervention description(s): The protocol 'Schematherapy and the Healthy Adult' (ST-HA, Broersen & Claassen, 2019) is a direct intervention meant to strengthen patients' healthy adult functioning by developing compassion and care for well-being in the face of (childhood) adversity.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: In this study a single case experimental design (n = 8) with multiple measures will be used, to determine the effects of the ST-HA protocol on self-compassion, well-being, positive affect and Healthy Adult functioning. For each participant a no-treatment randomized baseline period (2-5 weeks) will be compared with treatment (ST-HA, 10 weekly sessions) and post-treatment follow-up (at 1- and 3-months).
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Schema Therapy; Positive Psychology; Self-compassion; Personality disorder; Well-being; Positive Affect; Healthy Adult mode