An Inquiry into Possible Mechanisms of Change

in Schema Therapy for Chronic Depression

Nathan Thoma, PhDInstructor of Psychology, Weill Cornell Medical College

Diplomate of the Academy of Cognitive Therapy

May 2012

• What is Chronic Depression? – Any of three DSM IV Diagnoses:

Dysthymic Disorder Chronic Major Depressive Disorder

Double Depression:Episodic MDD + DD

• Etiology and Unique Features: Diathesis and Stress

– Chronic vs Episodic Depression

• determinants do not necessarily differ

qualitatively, but quantitatively

• Greater childhood adversity (Riso et al., 2000)

• Greater biological sensitivity (Riso et al., 2000)

• Interaction effects: environment x genetics

– BDNF polymorphisms may make children more likely to

exhibit negative emotionality when in the context of parental

depression and marital dischord (Hayden et al., 2010)

• Etiology and Unique Features: Diathesis and Stress

– 20 Year Longitudinal study has found specific risk factors for chronicity of depression (Angst et al., 2011)

• childhood family problems to be correlated with chronicity of depression

• Childhood anxious personality

• Adolescent low self-esteem and poor sense of mastery

– Clearly, vulnerabilities start early.

• Is Chronic Depression an Axis I or Axis II problem?

– High rates of PD, especially Cluster C in Chronic Depression (Klein et al., 2002; Maddux et al., 2009)

• A Schema Therapy Conceptualization of Chronic Depression

– Early Maladaptive Schemas

• Though chronic depression is an axis I disorder, evidence supports axis II factors, including early adverse psychosocial experiences

• The EMSs most prominent and specific to chronic depression have yet to be determined

• The Emotional Deprivation has been found to mediate the relation between physical abuse and anhedonic symptoms (Lumley et al., 2007)

• Social Isolation and Self-Sacrifice have been found to mediate the relation between emotional maltreatment and anhedonic symptoms (Lumley et al., 2007)

• Other EMSs of particular theoretical interest:

– Defectiveness, Subjugation, Unrelenting Standards, Negativity/Pessimism

• A Schema Therapy Conceptualization of Chronic Depression

– Modes

• Punitive/Demanding Parent

– e.g., self criticism, “shoulds”

• Detached Protector

– e.g., experiential avoidance, numbness, defeated hopelessness, shutting down and “giving up”

• Compliant Surrendurer

– e.g., lack of assertiveness

• Vulnerable Child

– e.g., chronic loneliness, feeling empty

• Healthy Adult

– We want to strengthen this!

• Mechanisms: Interventions in Schema Therapy for Chronic Depression

• Cognitive

• Behavioral

• Experiential

• Limited Reparenting

• Mechanisms: Process-Outcome Approaches to Investigation

– Difficulty in measuring mediation when there are so many interventions at play over a protracted period of time

– Feasibility dictates narrowing the phenomena under study to that which may be most relevant

– The most novel interventions in Schema Therapy relative to standard CBT:

– Experiential interventions

» Imagery Rescripting

» Mode Dialogues/Chair Work

• Mechanisms of Experiential Interventions: Evidence from Emotion Focused Therapy for Depression

– What causes change in “experiential” interventions?

– High “Experiencing” (using the Experiencing Scale; M. Klien et al., 1986) in mid-treatment is related to positive outcome (Pos et al., 2009)

• Low levels of experiencing =

– problems are external, there and then, not a lot of connection to affect

• High levels of experiencing =

– attending to internal experience

– contacting emotion

– taking in information from the emotion to make new meanings

– often then coming to new understanding of self and world

• Mechanisms of Experiential Interventions: Evidence from Emotion Focused Therapy for Depression

– What about emotion? Is it important?

– Emotional arousal predicts outcome

• High but not dysregulated levels of emotional arousal are related to outcome (Missirlian et al., 2005).

• U-shaped relationship between arousal and outcome

• Optimal level of 25% of session at high emotional arousal is correlated with good outcome (Carryer et al. 2010)

• Mechanisms of Experiential Interventions: Evidence from Emotion Focused Therapy for Depression

– Which emotions are important to be aroused?

– Looking at good in-session outcome

– Stages of progress through emotion categories are found

(from Pascual-Leone & Greenberg, 2009)

• Mechanisms of Experiential Interventions: Evidence from Emotion Focused Therapy for Depression

– Which emotions are important to be aroused?

– Looking at good in-session outcome

– Stages of progress through emotion categories are found

(from Pascual-Leone & Greenberg, 2009)

secondary emotions

• Mechanisms of Experiential Interventions: Evidence from Emotion Focused Therapy for Depression

– Which emotions are important to be aroused?

– Looking at good in-session outcome

– Stages of progress through emotion categories are found

(from Pascual-Leone & Greenberg, 2009)

secondary emotions

maladaptive emotions

• Mechanisms of Experiential Interventions: Evidence from Emotion Focused Therapy for Depression

– Which emotions are important to be aroused?

– Looking at good in-session outcome

– Stages of progress through emotion categories are found

(from Pascual-Leone & Greenberg, 2009)

secondary emotions

maladaptive emotions

(need)

• Mechanisms of Experiential Interventions: Evidence from Emotion Focused Therapy for Depression

– Which emotions are important to be aroused?

– Looking at good in-session outcome

– Stages of progress through emotion categories are found

(from Pascual-Leone & Greenberg, 2009)

secondary emotions

maladaptive emotions

(need)

adaptive emotions

• Mechanisms of Experiential Interventions in Schema Therapy for Chronic Depression

– How to translate prior research in experiential therapies to the present research question?

– From scratch: use Task Analysis (Pascual-Leone & Greenberg, 2009b)

• qualitative to quantitative measure development method

• based on comparing good outcome with poor outcome cases

– Or use existing models and measures:

• Classification of Affective Meaning States (Pascual-Leone & Greenberg, 2005)

• Degree of Transformation Scale (Pascual-Leone, 2009)

• Client Expressed Emotional Arousal Scale III (Warwar & Greenberg, 1999)

• Experiencing Scale (M. Klein et al., 1986)

• Mechanisms: Imagery Rescripting

– Commonality with EFT models?

– Same overall sequence of

• activating original maladaptive emotion scheme/ early maladaptive schema

• then activating adaptive emotion scheme/ healthy adult who meets child’s needs

– Unique feature: activation of the attachment system as client cares for younger self?

• Mechanisms: Imagery Rescripting – toward measurement

– Start by defining within-session success of imagery rescripting

– Outcome:

• self-compassion and de-blaming of self

• holding other accountable

• sense of safety and protectedness

• either observer rating or post-session self-report

– Process:

• Emotional arousal

• Observed engagement in the exercise

• Subjective vividness of the images to the client

• Whether Adult Self played healthy parent or Therapist entered image

• Observer rated measurement of specific stages

– Categorical, ordinal, or summative scale?

» perhaps a stage-like ordinal scale, moderated by above variables

• Mechanisms: Mode Dialogues

– Research has validated specific stages for various chair dialogues for EFT

• critic vs experiencer

– Starts with self-criticism

– Shame is activated

– Needs are accessed

– Assertiveness is activated

– Ends in healthy negotiation between the two sides

• client vs parent (or other unresolved relationship)

– Similar stages

– Ends in either a change in the view of the other or in holding the other accountable

• Mechanisms: Mode Dialogues

– Various elements in mode dialogues?•Self-awareness through giving voice to the modes

•Allowing for clear differentiation

•Allowing client to see the function of the various modes

•Relinquishing defenses that maintain long-term distress

•Allowing the vulnerable child to experience needs

•Empowering the healthy adult to take a more assertive and powerful role

•Quieting or standing up to the critical/demanding parent

- But are there any specific stages?

•At any given point, where to go next?

•And should conflict between modes aim for vanquishing the punitive parent?

•What about change in view of other?

•Or negotiation with internalized critic?

• Possible Directions for Research

– Select a specific kind of intervention used in Schema Therapy

– Choose a positive in-session outcome related to the intervention, and relate this to positive post-treatment outcome (e.g., depression score)

– Compare sessions with good vs. bad in-session outcomes

– Develop greater specificity of the theory of the process

• Utilize existing empirical evidence from other therapies and areas of psychology

– Develop or select relevant, existing measures

• Train coders as necessary

– Muscle through all the process coding!

– Repeat.

• Knowledge of how to skillfully conduct the therapy is increased

• Evidence justifying its use is generated

Thanks!