A total of four patients (three girls and one boy) were included in the current study. All patients were referred by the GP to the community mental health care centre (Virenze-Riagg Maastricht) for treatment. Each patient underwent an assessment process, which involved a standardised intake involving a semi-structured clinical interview (i.e., Kid-SCID; Hien et al. 1994; Dutch version: Roelofs et al. 2015a), and an evaluation by a psychiatrist. The outcome of the Kid-SCID interview, the psychiatrists’ evaluation information from teachers and clinical observations made during assessment were all used by the multidisciplinary team in making the final clinical diagnoses. Inclusion criteria for the GST program were suffering from personality problems (i.e., having a research classification of a personality disorder not otherwise specified), IQ >80, age >14 years, and having a structured daily life (work or school). Contraindications for participating in the GST were acute psychotic symptoms or acute suicidal behaviours. The age of the four patients ranged between 16 and 18 at time of inclusion. All patients received medication treatment at the start of GST, which was left unchanged during treatment.
Patient 1: Emma
Emma is a 16 year-old female who grew up in an intact family with three children. Prior to referral she had received extensive treatment at another institution where they noted depressive symptoms, sensitivity for environmental influences and persistent suicidal thoughts. That treatment consisted of psychotropic medication, and supportive and structuring treatment sessions. At time of inclusion, she was diagnosed with dysthymia, identity problems, parent–child relational problems and learning disorder not otherwise specified on axis I. She did not experience a strong bond with her father and her mother was protective towards Emma. In particular, Emma was afraid of being disapproved by others and hurting others’ feelings. On axis II she was diagnosed with a personality disorder not otherwise specified. Emma had unstable interpersonal relationships and an unstable self-image. She experienced mood changes, showed impulsive behaviors, and reported suicidal thoughts. Problems with her primary support group, problems related to the social environment and educational problems were identified on axis IV. Her global assessment of functioning score was 31–40. Both parents were involved in the treatment.
Patient 2: Mary
Mary is a 17 year-old female, who was referred for therapy due to relapse of depression. She grew up in an intact family with two children. Before participating in the GST program, she joined a group therapy for children with obesity and received cognitive-behavioural therapy for depression and psychotherapy for identity problems. She has been treated in our centre for 7 years with intermittent periods of no therapy. At time of inclusion, she was diagnosed with depression, identity problems, parent–child relational problems, relational problems related to a mental disorder or general medical condition and reading disorder on axis I. Mary struggled with her obesity, severe depressive symptoms, sleep problems, and an unstable self-image. She did not have peer relationships and experienced intense mood changes. She harmed herself when she felt bad and made suicidal gestures during therapy. She could not connect to her father for meeting core emotional needs and her mother tried to be available but had her own physical and mental problems. On axis II, she was diagnosed with borderline personality disorder. Problems with obesity were present on axis III. Problems with primary support group and educational problems were identified on axis IV. Her global assessment of functioning score was 41–50 at time of inclusion. Both parents were involved in the treatment.
Patient 3: Isabel
Isabel is an 18 year-old female who was referred for treatment for depression and self-injury. She grew up in an intact family with three children. She had previous psychological treatment but was not able to be open at that time. At time of intake, she was in her last year of secondary school. She was diagnosed with dysthymic disorder, panic disorder without agoraphobia, generalized anxiety disorder and identity problems on axis I. She felt like she could not connect to other people emotionally, had frequent suicidal thoughts and the depressive symptoms were present for longer than 1 year. There were concerns about her social and emotional wellbeing, view of the self and her minimal connection with peers. She had a low self-esteem, which was related to bullying at elementary school. At times, she would disconnect from everyone around her. On axis II the she was diagnosed with personality disorder not otherwise specified. There were no classifications on axes III and IV. Her global assessment of functioning score was 41–50 at time of inclusion. Both parents were involved in the treatment.
Patient 4: Josh
Josh is an 18 year-old male who was referred for GST. At time of intake, he was not in school and had little contact with his parents, because of longstanding problems within the family. He lived on his own but with assistance (i.e., someone was available to help him out). In 2013, he was admitted for 9 weeks to a mental health care institution because of alcohol dependency and abuse of cannabis and cocaine. At the beginning of 2013, he made a suicide attempt. He was diagnosed with dysthymic disorder, identity problems, parent–child relational problems and relational problems related to a mental disorder or general medical condition on axis I. Histrionic features of cluster B personality disorder were seen (i.e., dramatic behaviors and exaggerated emotional expressions), along with borderline and narcissistic features. He experienced mood changes as well. He did not have much peer contact but did have some short relationships with other (young) men. On axis II, he was diagnosed with a personality disorder not otherwise specified. There was no diagnosis on axis III. Problems with primary support group, problems related to the social environment and educational problems were identified on axis IV. His global assessment of functioning score was 41–50. His parents were musicians and their own psychiatric problems interfered with their involvement in the treatment.
There were two times during the year when new patients could join the group. The therapy lasted a minimum of 6 months and a maximum of 1.5 years. Four out of the six patients (and their parents), who started treatment simultaneously gave their consent to participate in the study. These four patients stayed in the group for 1 year. Eligible patients were prepared for group participation with a few individual meetings to become familiar with the schema model (schemas, modes, coping) and the schema therapy language. Before and after participating in the GST, patients completed a set of questionnaires (see instruments). The Therapy Session Mode Inventory was administered at the beginning of each individual treatment session and at the end of treatment.
The GST program consisted of weekly group sessions complemented by individual treatment sessions with a frequency of once per week or per 2 weeks, depending on the need of the adolescent. The individual sessions were supportive of the group sessions. That is, during individual therapy, the patient could discuss what he or she had learned or experienced in the group and there was time to talk about relevant personal issues as well. The GST largely followed the protocol by Farrell and Shaw (2012). In short, the main phases were bonding and emotional regulation, schema mode change, and finally autonomy and changing behaviour. The aim of GST was to reduce maladaptive modes and develop and strengthen functional modes. The strategies comprise specific cognitive, experiential, and behavioural techniques. Cognitive schema change work involves techniques to identify and change automatic thoughts, identify cognitive distortions, and to empirically test maladaptive rules that have been developed from schemas. Experiential interventions include work with visual imagery, mode dialogues, creative work to symbolize positive experiences, limited-reparenting and the healing experiences of a validating psychotherapist. Behavioral techniques involve pattern breaking work to ensure that changes generalize to behaviors outside of the therapy setting. During the first phase the therapeutic relationship was built. In both individual and group sessions there was a focus on building connections between the therapist and the patient, and among the patients in the group. During group sessions, there were always two therapists, one schema therapist and a creative therapist who alternately took the lead while the other followed closely interactions among the patients as well as individual responses. In this stage, limited reparenting and experiential exercises were helpful to let patients experience what it is like to focus on the experience of a feeling rather than the cognitive process of talking about feelings. Setting limits, an important aspect of limited reparenting, was utilized in this stage to make agreements on issues like self-injurious behaviour, being late, and missing sessions. During the second and third phases the focus of therapy was on the six basic needs: safety, connectedness, autonomy and individuality, realistic boundaries, expression of emotions, and spontaneity and play. Each session started with a relaxation exercise and ended with patients choosing one or several colours that fit their feelings at that moment. A number of mode focused interventions were employed in each session based upon the presenting modes and needs of the patients. If desired, patients could bring in current problem situations.
Parental involvement consisted of group meetings once every 2 weeks that were guided by two therapists who were not the GST therapists. These sessions focused on education about the schema model so that parents would be familiar with schema therapy language. The most important modes were explored in terms of ‘mode clashes’, situations where conflict occurred between parents and the adolescent. The parents were trained to be aware of their own (maladaptive) schema and schema mode activation and were given tools to use when their schema modes conflict with their child’s. Emotion coaching skills were taught, which involve being sensitive to the need of the adolescent and using emotional moments as opportunities to become more connected with the child and to teach the adolescent how to regulate emotions.
All therapists were trained in (group) ST for at least 50 h of training. The training levels of the individual therapists ranged from standard to advance in the Dutch ST Registry as well as for the International Society for Schema Therapy (ISST). All therapists were biweekly supervised by an ISST certified supervisor and there was weekly intervision.
Quality of Life
The 10-item version of the Kidscreen (Kidscreen-10; Ravens-Sieberer et al. 2010) comprises one general dimension of quality of life. Each question is rated on a five-point Likert-type scale with responses reflecting the intensity of an attitude (i.e., ‘not slightly’ to ‘extremely’) or its frequency (‘never’ to ‘always’). Parents were also asked to rate the same items for their child. Higher scores indicate higher levels of health-related quality of life. The Kidscreen-10 appears to be a reliable and valid measure of quality of life in children and adolescents (Ravens-Sieberer et al. 2010).
Symptoms of Psychopathology
The Strengths and Difficulties Questionnaire (SDQ; Goodman 1997) is a self-report instrument designed to assess behavioral and emotional problems in children and adolescents. The SDQ was completed by the adolescent and their parent(s) (about their child). The SDQ comprises 25 items that can be allocated to five subscales: conduct problems, attention and hyperactivity problems, emotional problems, peer problems, and prosocial behavior. The four problem subscales can be combined into a total psychopathology score. Items are rated on a three-point Likert type scale with anchors ‘not true’ and ‘definitely true’, thus higher scores reflect higher levels of psychopathology symptoms. Support has been documented for the reliability and validity of the SDQ (Goodman 2001) and for the self-report version of this scale (Muris et al. 2004).
An age-downward version of the original Schema Mode Inventory for adults (SMI; Young et al. 2007; Lobbestael et al. 2010) was used (SMI-A; Roelofs et al. 2015b). Like the adult version, the SMI-A consists of 124 items covering 14 schema modes including vulnerable child, angry child, enraged child, impulsive child, undisciplined child, happy child, compliant surrender, detached protector, detached self-soother, self-aggrandizer, bully and attack, punitive parent, demanding parent, and healthy person. Items are scored on a six-point Likert type scale ranging from ‘never or hardly ever’ to ‘always’. The overall score on the various modes can be obtained by summing the scores and dividing it by the number of items of that scale. Higher scores are indicative of a stronger presence of the modes. Psychometric properties of the SMI-A have been supported (Roelofs et al. 2015b).
Therapy Session Mode Inventory
For the purpose of the current study, a therapy session mode inventory was constructed. Forming a subset of all SMI-A items, this instrument comprised all schema modes by means of a single characteristic item for each separate schema mode, resulting in a total of 14 items (Roelofs et al. 2015b). For all items, respondents were required to rate on a 10-point Likert-type scale the degree to which each item (e.g. “I feel weak and hopeless”) was true for them for the last week, ranging from “applies to me completely” to “doesn’t apply to me at all”. In addition to the individual modes, three items were constructed to evaluate their relationship with their parents. These items referred to feelings of shame when talking with parents about problems, parents noticing when the adolescent is worried, and parents taking the adolescent’s feelings into account. Respondents were asked to complete this instrument during each of the individual sessions.
Early Maladaptive Schemas
The Young Schema Questionnaire for Adolescents (YSQ-A; Van Vlierberghe et al. 2010) is a 75-item self-report questionnaire that can be employed to comprehensively assess early maladaptive schemas in adolescents. The YSQ-A is a simplified version of the Young Schema Questionnaire for adults (YSQ; Young and Brown 2003). It assesses 15 schemas (Young et al. 2003) each represented by five items that are scored on a five-point Likert type scale with anchors ranging from ‘completely untrue for me’ to ‘describes me perfectly’. Factor analytic research (Roelofs et al. 2011; Van Vlierberghe et al. 2010) has demonstrated that the YSQ-A taps five domains of early maladaptive schemas: disconnection and rejection (including the schemas: mistrust/abuse, emotional deprivation, defectiveness/shame, social isolation/alienation, and abandonment/instability), impaired autonomy (schemas: dependency/incompetence, vulnerability to harm/illness, enmeshment/undeveloped self, and failure to achieve), impaired limits (schemas: entitlement/grandiosity and insufficient self-control/discipline), other-directedness (schemas: subjugation and self-sacrifice), and overvigilance/inhibition (schemas: emotional inhibition, unrelenting standards). Research has supported the positive psychometric qualities of the YSQ-A as satisfactory (Roelofs et al. 2011; Van Vlierberghe et al. 2010).
The Schema Coping Inventory (SCI; Rijkeboer and Lobbestael, manuscript in preparation) assesses the three schema coping styles: overcompensation, avoidance, and surrender. The inventory consists of 12 items with each coping style represented by four items. Each item is scored on a 7-point Likert-type scale with anchors ‘completely disagree’ to ‘completely agree’. Unpublished data indicate a three-factor structure for this instrument and internal consistency.
Evaluation form of the GST
To evaluate the GST, an adapted version of the Schema Therapy Competency Rating Scale (STCRS; Young and Fosse 2008) was used. This version comprises 14-item tapping general therapeutic skills (e.g., limited reparenting), conceptualization and education (e.g., schema exploration and assessment), and schema change (e.g., schema strategy for change). This form was filled in after finishing the GST. Patients were required to rate on a 7-point scale the degree to which each item applied to their therapist competence, ranging from “very bad” to “excellent”.
In order to analyse the course of schema modes during therapy, we determined for each patient and mode separately whether a significant trend over time could be detected. The scores on the individual schema modes, as reflected on 10-point Likert scales, represent a time series for which we expect either negative linear trend (for the unhealthy modes) or a positive linear trend (for the healthy modes). To examine statistical evidence for the existence of these expected trends, we fitted an autoregressive time series model for each patient and for each type of mode (unhealthy vs. healthy) separately, using AR1 to model the serial correlation. Although this clearly involves multiple testing, we opted not to correct for this, as conventional methods for correcting multiple testing all have an adverse effect on statistical power. As our study is exploratory rather than confirmatory in nature, our main goal is to highlight the existence of possible trends, and therefore our primary concern here is to guard against inflation of the Type II error rate. The significant changes that were found were discussed in interviews to get a better understanding of the changes that occurred during therapy from the perspective of the adolescent. In the interviews, patients were asked how they thought that their modes have changed during therapy.
To analyse change in quality of life, psychopathology, schema modes, early maladaptive schemas, and schema coping from pre- to post-treatment, scores at both measurement points as reported by adolescents and their parents (if available) were considered in the light of norm scores or findings from previous research. To analyse quality of life, scores from the KIDSCREEN-10 were converted to T-scores (i.e., M = 50, SD = 10). For the SDQ, the available cut-off scores were used to determine whether observed differences between pre- and post-treatment were meaningful (see Goodman 1997). For the SMI-A, YSQ, and SCI no published normative data is available. In order to interpret change on these variables from pre- to post treatment, data from previous studies in our research group were used (i.e., Roelofs et al. 2010; Roelofs et al. 2015b; Wijk-Herberink et al. in preparation). Percentile scores were computed for the SMI-A, YSQ, and SCI, which can be obtained from the first authors. Actual scores of the four patients were compared to these percentile scores. Clinically relevant change was defined as a change of at least two decile steps (i.e., 20 % change, for example a change from percentile 50–30). In addition, for the SMI-A, we relied on normative data for various patient groups from previous research with the SMI in adults (i.e., Lobbestael et al. 2010). We first determined the change in schema modes from pre-treatment to post-treatment and compared these changes to the range of scores for the various patient groups. To analyse changes in YSQ scores from pre- to post-treatment, data obtained in non-clinical adolescents was used (Roelofs et al. 2010). For the YSQ as well, the change in scores from pre- to post-treatment was assessed and compared to the range of scores that correspond with healthy controls.