Since the current study is an explorative study, we did not use a power analysis, instead we included as many participants as possible in a predetermined timeframe. A total of 77 patients were included in the period between January 2022 and June 2023 (see Figure 1). Patients were eligible for inclusion in the study if they met the following criteria: (1) aged between 18 and 65 years, (2) currently diagnosed with a personality disorder, mood disorder, or anxiety disorder according to the Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5, American Psychiatric Association, 2013), and (3) had undergone at least one evidence-based treatment (CBT) for the aforementioned diagnosis in primary or secondary care. Patients were excluded from the study if they met any of the following criteria: (1) insufficient proficiency in the Dutch language, (2) a recent suicide attempt within the past three months or current active suicidal ideation, (3) diagnosed with a psychotic and/or bipolar disorder, (4) hospitalized due to self-mutilation within the past three months, (5) diagnosed with a complex dissociative disorder and/or experiencing dissociative symptoms, or (6) diagnosed with a substance use disorder, excluding tobacco, according to the DSM-5 criteria.

The treatment approach utilized in this study is Re-Focus, a shortened and manualized version of group schema therapy (ST) specifically designed for patients with PDs, therapy-resistant depression, and/or anxiety disorders. The first author of this paper was one of the two psychologists closely involved in developing this protocol. The development of Re-Focus draws upon the evidence-based ST treatment for personality disorders (Masley et al., 2011; Jacob and Arntz, 2013; van Vreeswijk and Broersen, 2013). The therapy is conducted in a closed group format, comprising 16 sessions and administered by two clinical psychologists trained in ST and Re-Focus. Each group accommodates a maximum of eight patients.

While incorporating all components of the original ST treatment, Re-Focus adopts a more condensed format. The manualized group therapy consists of 16 150-min weekly sessions. During the initial phase of therapy, a few sessions are dedicated to building connections and fostering a safe group climate. Participants are also educated about the schema mode model, with a focus on their top three modes. Each week, participants are asked to fill out schema mode diaries in which they also score the severity of their top three modes. Experiential and interpersonal techniques, such as limited reparenting, chair work, empathic confrontation, and imagery rescripting, are employed. These techniques aim to increase participants’ awareness of their modes and process negative experiences. This first phase comprises 6 sessions.

The second phase of the group primarily focuses on behavior change. Role plays involving healthy adult vs. parent modes, coping modes, cognitive techniques such as cost–benefit analysis and pie charts, and behavioral experiments are utilized in this phase. Participants are encouraged to integrate what they have learned in therapy into their daily lives. Therapists also promote the development of independence, autonomy, and healthy assertiveness skills for participants to recognize and meet their own emotional needs. The second phase consists of 7 sessions.

In the final phase of treatment, the focus shifts to awareness of change, finding ways to sustain these changes, and continuing the process of change. There is also time dedicated to bidding farewell to each other and the therapy. The third and last phase comprises 3 sessions (Farrell et al., 2012; Van Vreeswijk and Broersen, 2017; Reubsaet, 2018).The main difference with the protocols designed by van Vreeswijk et al. are that Re-Focus combines both experiential and cognitive techniques, it focuses more on modes than on schemas and is more divided into treatment phases, which is currently part of the standard model for individual ST. Also, the combination of both techniques is comprised into a shorter form.

Treatment integrity was ensured by adhering to the treatment manual and participating internal intervision sessions focused on the treatment protocol.

The Young Schema Questionnaire (YSQ, Dutch version) is a 205-item self-report questionnaire assessing 15 early maladaptive schemas (Young, 1990). Each item is phrased as a negative core belief regarding oneself and one’s relations to others and is rated along a 6-point Likert scale. The YSQ has adequate to high psychometric properties, with a Cronbach’s alpha from 0.70 to 0.96 for all the 15 scales (Oei and Baranoff, 2007).

The Schema Mode Inventory version 1.1 (SMI, Dutch version) is a 118-item self-report questionnaire assessing 14 schema modes (Lobbestael et al., 2010). Each item is rated along a 6-point Likert scale. Schema modes can be divided into four categories: child modes, dysfunctional coping modes, dysfunctional parent modes, and the healthy adult mode (Young et al., 2003). Research indicates that the SMI has adequate to high psychometric properties with a Cronbach’s alpha of 0.87 for the total score and acceptable internal consistencies of the 14 subscales (Cronbach α’s from 0.79 to 0.96) (Lobbestael et al., 2010).

The Symptom Questionnaire-48 (SQ-48, Dutch version) is a 48-item self-report questionnaire assessing general psychological wellbeing (Carlier et al., 2017). Each item is rated along a 5-point Likert scale. Five subscales cover aspects of psychopathology (depression, anxiety, somatization, and agoraphobia) and four subscales cover aspects of behavior (aggression, cognitive problems, social phobia, work, and vitality/optimism). Each item is rated along a 5-point Likert scale. Research indicates that the SQ-48 has adequate to high psychometric properties with a Cronbach’s alpha ranging from 0.78 to 0.98 across the different subscales (Carlier et al., 2017).

Informed consent was obtained from all patients and ethical approval was granted by the Commission for Scientific Research and Participation (CSRP) of Vincent van Gogh Institute. All therapists employed at Centiv, a primary mental healthcare facility, were duly informed about the study with regards to participant recruitment during the intake phase. A screening process was conducted during intake to assess whether the patients met the inclusion criteria. Prior to participating in the study, all patients were required to provide informed consent. Treatment consisted of 16 weekly 150-min sessions. All questionnaires were administered at pre-, and post-treatment stage. These measures were an integral part of the therapy process and/or standard routine outcome monitoring (ROM). In accordance with the Young Schema Questionnaire (YSQ) and Schema Mode Inventory (SMI), patients possessed awareness of their predominant three schemas and modes that were the focal points during the initial stage of treatment. Patients retained the autonomy to discontinue their treatment or withdraw from participation in the study at any point in time. A number of seven patients dropped out during the study.

To examine changes in general symptoms, schemas, and schema modes over time, we conducted repeated measures analysis of variance (mixed method ANCOVA) for each variable across two trial periods: pre- and post-treatment. Reliability was assessed using Cronbach’s alpha. This statistical measure reflects the internal consistency of the utilized scales. To assess the effect size, we calculated (generalized) Eta Squared for the Young Schema Questionnaire (YSQ), Schema Mode Inventory (SMI), and Symptom Questionnaire-48 (SQ-48). Effect sizes ranging from 0.01 to 0.05 are considered small, those between 0.06 and 0.13 are considered moderate, and effect sizes above 0.14 are considered large (Field, 2013). To address potential confounding factors, we controlled for DSM classification in the analyses by including it as a between-subject effect factor (covariate) and performed post hoc tests.” For the second aim of this study, we decided not to perform drop-out analyses when the attrition rate is below 10%. All statistical tests were two-tailed with a significance level of 5%. The statistical software JASP (Department of Psychological Methods, University of Amsterdam, Amsterdam, Netherlands) for Windows was employed for data analysis.

A number of 77 patients participated in the study. Of these, 25 percent were male. The age of the participants ranged between 20 and 66 years (M = 38, SD = 12.17). Approximately 21 percent had a PD (N = 15), 33 percent an anxiety disorder (N = 23) and the remaining 56 percent was diagnosed with a depressive disorder (N = 32). Seven participants withdrew from the study due to preference for individual therapy, or need to intensify therapy. Among the patients who did not complete therapy, two were diagnosed with a recurrent mood disorder; two with a recurrent anxiety disorder, and three with a PD. The participants who dropped out were excluded from the analyses and therefore the analyses were conducted solely on those who completed the treatment. The dropout rate in this study was 10% (see also Table 1).

All measures show a consistent pattern across all three diagnostic groups, with a tendency for reduction in scores throughout the treatment process. There were no significant differences between the DSM-5 classifications regarding changes in the aforementioned measures, except for the maladaptive modes where there was a significant interaction effect (see Table 2). Post-hoc tests revealed significant differences between patients with a mood disorder when compared to patients with either an anxiety disorder (p < 0.001) or PD (p < 0.001) at the second timepoint, as shown in Table 2. Patients with a mood disorder experienced more positive changes in maladaptive modes compared to patients with anxiety disorders and PDs. Effect sizes between pre-therapy and post-therapy scores, measured by the statistic eta² were large for all measures, and these values are included in Table 2. Reliability scores for all measures were acceptable (see Table 3)

Regarding the second aim of this study, we found that approximately 10 percent of patients dropped out of therapy, indicating lower dropout rates than those reported in other studies using regular or short-term ST (Jacob and Arntz, 2013; Renner et al., 2013; Skewes et al., 2015).

The present study has several limitations. Firstly, it lacked a randomized design, resulting in the absence of a comparative control group. Consequently, it is impossible to attribute the observed effects solely to the therapy. Secondly, a follow-up period was not incorporated, preventing the assessment of the long-term sustainability of the observed effects. Due to the study’s design, results may also be influenced by other factors, such as group effects versus individual therapy, the absence of a waiting list, and the passage of time. Future research should aim to control for these factors to attribute effects specifically to the treatment.

The early findings of our pilot study suggest that patients with heterogeneous psychiatric conditions in primary care, who continue to experience symptoms or relapses after receiving standard care such as Cognitive Behavioral Therapy (CBT), may benefit from short-term group Schema Therapy (ST), specifically Re-Focus. These results imply that individuals with these disorders might find applicable treatment in primary care settings using a shorter and standardized version of ST. If future research confirms the viability of this treatment approach, it could facilitate more accurate guidance of patients toward the most appropriate form of therapy, resulting in reduced waiting times and lower costs for mental healthcare. This study also contributes to a growing body of literature that suggests that short-term ST shows promise as an intervention for patients with personality pathology and other disorders.

In conclusion, the results of this study demonstrate promising outcomes for short-term schema therapy. The relatively low attrition rates and significant improvements in various outcome measures suggest that this approach could be effective in enhancing psychological well-being and addressing schema-related issues. Furthermore, the treatment appears to be applicable across different diagnostic categories, emphasizing its potential as a versatile therapeutic approach. However, further research is needed to explore the reasons behind attrition and to confirm the long-term sustainability of these positive treatment effects. Furthermore, additional qualitative material is available and will be presented in a further study on the qualitative aspects of the Re-Focus.