An Inquiry into
Possible Mechanisms of Change
in Schema Therapy
for Chronic Depression
Nathan Thoma, PhD
Instructor of Psychology, Weill Cornell Medical College
Diplomate of the Academy of Cognitive Therapy
May 2012
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What is Chronic Depression?
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Any of three DSM IV Diagnoses:
Dysthymic Disorder
Chronic Major Depressive Disorder
Double Depression:
Episodic MDD + DD
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Etiology and Unique Features: Diathesis and
Stress
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Chronic vs Episodic Depression
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determinants do not necessarily differ
qualitatively, but quantitatively
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Greater childhood adversity (Riso et al., 2000)
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Greater biological sensitivity (Riso et al., 2000)
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Interaction effects: environment x genetics
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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)
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Etiology and Unique Features: Diathesis and
Stress
–
–
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20 Year Longitudinal study has found specific risk
factors for chronicity of depression (Angst et al., 2011)
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childhood family problems to be correlated with chronicity
of depression
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Childhood anxious personality
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Adolescent low self-esteem and poor sense of mastery
Clearly, vulnerabilities start early.
Is Chronic Depression an Axis I or Axis II
problem?
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High rates of PD, especially Cluster C in Chronic
Depression (Klein et al., 2002; Maddux et al., 2009)
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A Schema Therapy Conceptualization of Chronic
Depression
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Early Maladaptive Schemas
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Though chronic depression is an axis I disorder, evidence
supports axis II factors, including early adverse psychosocial
experiences
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The EMSs most prominent and specific to chronic depression
have yet to be determined
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The Emotional Deprivation has been found to mediate the
relation between physical abuse and anhedonic symptoms (Lumley
et al., 2007)
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Social Isolation and Self-Sacrifice have been found to mediate
the relation between emotional maltreatment and anhedonic
symptoms (Lumley et al., 2007)
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Other EMSs of particular theoretical interest:
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Defectiveness, Subjugation, Unrelenting Standards,
Negativity/Pessimism
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A Schema Therapy Conceptualization of Chronic
Depression
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Modes
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Punitive/Demanding Parent
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Detached Protector
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e.g., lack of assertiveness
Vulnerable Child
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e.g., experiential avoidance, numbness, defeated hopelessness,
shutting down and “giving up”
Compliant Surrendurer
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e.g., self criticism, “shoulds”
e.g., chronic loneliness, feeling empty
Healthy Adult
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We want to strengthen this!
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Mechanisms: Interventions in Schema
Therapy for Chronic Depression
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Cognitive
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Behavioral
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Experiential
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Limited Reparenting
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Mechanisms: Process-Outcome Approaches
to Investigation
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Difficulty in measuring mediation when there are so many
interventions at play over a protracted period of time
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Feasibility dictates narrowing the phenomena under study to
that which may be most relevant
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The most novel interventions in Schema Therapy relative to
standard CBT:
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Experiential interventions
»
Imagery Rescripting
»
Mode Dialogues/Chair Work
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Mechanisms of Experiential Interventions: Evidence
from Emotion Focused Therapy for Depression
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What causes change in “experiential” interventions?
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High “Experiencing” (using the Experiencing Scale; M. Klien et al., 1986)
in mid-treatment is related to positive outcome (Pos et al., 2009)
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Low levels of experiencing =
–
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problems are external, there and then, not a lot of connection to affect
High levels of experiencing =
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attending to internal experience
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contacting emotion
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taking in information from the emotion to make new meanings
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often then coming to new understanding of self and world
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Mechanisms of Experiential Interventions: Evidence
from Emotion Focused Therapy for Depression
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What about emotion? Is it important?
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Emotional arousal predicts outcome
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High but not dysregulated levels of emotional arousal are
related to outcome (Missirlian et al., 2005).
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U-shaped relationship between arousal and outcome
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Optimal level of 25% of session at high emotional arousal
is correlated with good outcome (Carryer et al. 2010)
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Mechanisms of Experiential Interventions: Evidence
from Emotion Focused Therapy for Depression
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Which emotions are important to be aroused?
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Looking at good in-session outcome
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Stages of progress through emotion categories are found
(from Pascual-Leone & Greenberg, 2009)
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Mechanisms of Experiential Interventions: Evidence
from Emotion Focused Therapy for Depression
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Which emotions are important to be aroused?
–
Looking at good in-session outcome
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Stages of progress through emotion categories are found
secondary emotions
(from Pascual-Leone & Greenberg, 2009)
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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
secondary emotions
maladaptive emotions
(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
secondary emotions
maladaptive emotions
(need)
(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
secondary emotions
maladaptive emotions
(need)
adaptive emotions
(from Pascual-Leone & Greenberg, 2009)
•
Mechanisms of Experiential Interventions in Schema
Therapy for Chronic Depression
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How to translate prior research in experiential therapies to the
present research question?
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From scratch: use Task Analysis (Pascual-Leone & Greenberg,
2009b)
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qualitative to quantitative measure development method
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based on comparing good outcome with poor outcome cases
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Or use existing models and measures:
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Classification of Affective Meaning States (Pascual-Leone & Greenberg,
2005)
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Degree of Transformation Scale (Pascual-Leone, 2009)
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Client Expressed Emotional Arousal Scale III (Warwar & Greenberg,
1999)
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Experiencing Scale (M. Klein et al., 1986)
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Mechanisms: Imagery Rescripting
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Commonality with EFT models?
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Same overall sequence of
–
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activating original maladaptive emotion scheme/ early
maladaptive schema
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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?
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Mechanisms: Imagery Rescripting – toward
measurement
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Start by defining within-session success of imagery rescripting
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Outcome:
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self-compassion and de-blaming of self
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holding other accountable
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sense of safety and protectedness
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either observer rating or post-session self-report
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Process:
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Emotional arousal
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Observed engagement in the exercise
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Subjective vividness of the images to the client
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Whether Adult Self played healthy parent or Therapist entered image
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Observer rated measurement of specific stages
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Categorical, ordinal, or summative scale?
»
perhaps a stage-like ordinal scale, moderated by above variables
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Mechanisms: Mode Dialogues
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Research has validated specific stages for various
chair dialogues for EFT
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critic vs experiencer
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Starts with self-criticism
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Shame is activated
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Needs are accessed
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Assertiveness is activated
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Ends in healthy negotiation between the two sides
client vs parent (or other unresolved relationship)
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Similar stages
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Ends in either a change in the view of the other or in holding
the other accountable
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Mechanisms: Mode Dialogues
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Various elements in mode dialogues?
•Self-awareness through
giving voice to the modes
•Allowing for clear differentiation
-
•Allowing the vulnerable child to
experience needs
•Allowing client to see the function
of the various modes
•Empowering the healthy adult to
take a more assertive and powerful
role
•Relinquishing defenses that
maintain long-term distress
•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
•What about change in view of other?
•Or negotiation with internalized critic?
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Possible Directions for Research
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Select a specific kind of intervention used in Schema Therapy
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Choose a positive in-session outcome related to the intervention, and
relate this to positive post-treatment outcome (e.g., depression
score)
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Compare sessions with good vs. bad in-session outcomes
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Develop greater specificity of the theory of the process
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Utilize existing empirical evidence from other therapies and areas of
psychology
Develop or select relevant, existing measures
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Train coders as necessary
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Muscle through all the process coding!
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Repeat.
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Knowledge of how to skillfully conduct the therapy is increased
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Evidence justifying its use is generated
Thanks!