httpsdoi.org10.11771534650120954275Clinical Case Stud

https://doi.org/10.1177/1534650120954275
Clinical Case Studies
2021, Vol. 20(1) 22 –38
© The Author(s) 2020
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/1534650120954275
journals.sagepub.com/home/ccs
Original Manuscript
Schema Therapy for Chronic
Depression Associated with
Childhood Trauma: A Case Study
Kate L. Herts1,2 and Susan Evans1,2
Abstract
Chronic depression lasting longer than 2 years is often
undertreated. Research suggests that
maladaptive cognitive schemas mediate the association between
childhood trauma and later
depression. Schema Therapy (ST) is an integrative treatment
approach that targets maladaptive
cognitive schemas through cognitive, behavioral, interpersonal,
and experiential interventions.
ST has been studied in patients with chronic depression with
good results. The purpose of
this case study is to detail how an ST treatment was used to

treat chronic depression in a
woman, “Amy,” with a childhood trauma history. Amy
presented with a persistent depressive
disorder that had lasted over 40 years. An ST approach was
chosen in light of the chronicity
of Amy’s symptoms and her childhood trauma history.
Standardized measures including the
Beck Depression Inventory were used to assess progress
throughout treatment. We provide
a comprehensive summary of the 22-session ST case
conceptualization and treatment, through
which Amy’s depressive symptoms evidenced a 73 percent
reduction. Amy qualitatively reported
reduced depressive rumination and avoidance behaviors as well
as increased frequency of
positive mood.
Keywords
depression, chronic depression, schema therapy, childhood
trauma
1 Theoretical and Research Basis for Treatment
Depressive disorders are a leading cause of global di sease
burden (Ferrari et al., 2013). Consistent
with past research, we use the term “chronic depression” to
describe dysthymia, chronic major
depression, double depression and recurrent major depression
without instances of complete
remission, because past research has failed to show systematic
underlying differences in etiology
(Hölzel et al., 2011). It is estimated that 20% of all depressed
individuals and up to 47% of
patients in outpatient mental health settings are chronically
depressed, with symptoms lasting at
least 2 years (Torpey & Klein, 2008).

Cognitive Behavioral Therapy (CBT) is currently the gold
standard psychotherapy treatment
for major depression, as well as anxiety and other disorders
(David et al., 2018). However, few
1Weill Cornell Medicine, New York, NY, USA
2New York Presbyterian Hospital, New York, NY, USA
Corresponding Author:
Kate L. Herts, Weill Cornell Medicine, 240 E 69th St, New
York, NY 10065, USA.
Email: [email protected]
954275CCSXXX10.1177/1534650120954275Clinical Case
StudiesHerts and Evans
research-article2020
https://us.sagepub.com/en-us/journals-permissions
https://journals.sagepub.com/home/ccs
mailto:[email protected]
http://crossmark.crossref.org/dialog/?doi=10.1177%2F15346501
20954275&domain=pdf&date_stamp=2020-09-04
Herts and Evans 23
studies have specifically examined the efficacy of
psychotherapy in the treatment of chronic
depression. Cuijpers and colleagues (2010) conducted a meta-
analysis of 16 randomized con-
trolled trials of the impact of psychotherapy on chronic
depression and found that psychotherapy
has only a small (though statistically significant) effect as
compared to control groups. In addi-
tion, combined treatment with an SSRI was more effective than

either treatment alone (Cuijpers
et al., 2010). A recent systematic review found only 10 studies
that examined pharmacotherapy,
psychotherapy, or their combination in the treatment of chronic
major depression (Spijker et al.,
2013). The best evidence was found for Cognitive Behavioral
Analysis Systems of Psychotherapy
(CBASP), an individual cognitive behavior treatment
specifically developed for the treatment of
chronic depression, in combination with the antidepressant
nefazadone, which together demon-
strated moderate to large effects (Spijker et al., 2013). Taken
together, this research suggests that
psychotherapy may be less effective in treating chronic
depression as compared to discrete epi-
sodes of major depressive disorder. Indeed, research has shown
that for many patients, chronic
depression is undertreated (Kocsis et al., 2008) or not fully
responsive to treatment (Torpey &
Klein, 2008).
Impact of Childhood Trauma
Research suggests that childhood trauma is a significant
predictor of depression in adulthood.
Data from a longitudinal cohort in the Netherlands demonstrated
that among adults with a diag-
nosis of major depression, a retrospectively reported history of
emotional abuse, emotional
neglect and physical abuse in childhood were significant
predictors of chronic depression
(Hovens et al., 2012; Wiersma et al., 2009). A recent meta-
analysis of studies examining child-
hood trauma as a predictor of later depression found that
experiencing emotional abuse or neglect
in childhood carried stronger risk for depression as compared to

other traumatic events (e.g.,
sexual abuse; Mandelli et al., 2015).
Beck and colleague’s (1979) cognitive model of depression
posits that patients with depres-
sion have maladaptive core beliefs, or schema, through which
they view themselves, their
experiences and the future. Research demonstrates that
maladaptive cognitive schemas in the
Disconnection and Rejection domain mediate the relationship
between childhood trauma and
later depression in college students (e.g., Rezaei et al., 2016).
This domain encompasses sche-
mas characterized by abandonment, defectiveness and shame,
emotional deprivation, mistrust
and abuse, social introversion and isolation/withdrawal.
Treatment that specifically targets
maladaptive schemas in the Disconnectio n and Rejection
domain may thus be particularly
helpful for depressed patients with a childhood trauma history.
Post-traumatic stress disorder (PTSD) is often comorbid with
depression in the aftermath of
trauma. In a study of over 350 trauma-exposed adults,
Contractor and colleagues (2018) found
that the negative alterations in cognitions and mood present in
PTSD accounted for significant
variance between PTSD and non-somatic depression, though it
is notable that other research
(e.g., Byllesby et al., 2017) suggests that a general distress
factor provides a better explanation
for the comorbidity between these disorders. Gurak and
colleagues (2016) describe the treat-
ment of a young adult woman with comorbid PTSD and
recurrent MDD, as well as a childhood
trauma history. The patient benefited from cognitive processing

therapy interventions, which
helped her restructure maladaptive trauma-related core beliefs
that were contributing to feel-
ings of guilt (Gurak et al., 2016). The patient ultimately saw a
significant reduction in depres-
sive symptoms over the course of integrative trauma treatment
(Gurak et al., 2016). Taken
together, these findings suggest that treating maladaptive
trauma-related cognitions as well as
general, non-trauma specific distress as in ST can be impactful
for trauma-exposed patients
with depression.
24 Clinical Case Studies 20(1)
Schema Therapy for Chronic Depression
Schema Therapy (ST), developed by Jeffrey Young (1999) and
colleagues, is an integrative
approach that expands beyond traditional cognitive behavioral
therapy (CBT) and combines
interpersonal and experiential strategies to address a variety of
chronic psychological disorders.
ST is grounded in attachment theory and uses Gestalt theory and
practice such as imagery to
access emotion. The therapy therefore combines cognitive,
behavioral, interpersonal and experi-
ential techniques to address current negative life patterns (i.e.,
attachment to unavailable part-
ners) by connecting them to schemas that were formed in
childhood and adolescence. Schemas
may be defined as self-defeating emotional and cognitive
patterns that begin early in develop-
ment and continue throughout life. ST differs from Beck’s

original therapy for depression (Beck
et al., 1979) in that there is a greater emphasis on the
therapeutic relationship (includes limited
reparenting), on affect and the understanding of childhood
origins.
Since its development there is some empirical evidence of the
effectiveness of ST for treating
personality disorders (PD), particularly in Europe where ST is
the first treatment of choice for
PD. While the effectiveness of CBT is well documented for the
treatment of depression, there
continues to be a percentage of patients who do not respond,
may be partial remitters, or patients
who relapse. ST is a promising alternative treatment for
depression, particularly for patients with
comorbid personality disorders. For example, Seavey and Moore
(2012) describe a case of an
18-year-old man with first episode Major Depressive Disorder
and personality disorder not oth-
erwise specified who went into full remission from depression
after ST. In addition, patients with
trauma-related depression have benefited from Acceptance and
Commitment Therapy (e.g.,
Hiraoka et al., 2016), which similarly to ST, diverges from CBT
in its central reliance on experi-
ential exercises.
In recent years, ST has been applied and studied in patients with
chronic forms of depression
with good results. Malogiannis et al. (2014) for example,
studied 12 chronically depressed
patients who received ST over 60 sessions. The authors found
that five patients showed reduced
symptoms at end of treatment and at the 6 month follow up
period and only one relapsed, while

two who had initially only partially improved ultimately
recovered fully. In a more recent study
by Renner et al. (2016), 25 patients with chronic depression
who underwent a course of ST expe-
rienced a significant reduction in symptoms as compared with a
wait-list control group. The
authors concluded that their findings provide evidence that ST
may be an effective treatment for
patients with chronic depression.
Objective
The purpose of the current case report is to provide an example
of how ST interventions can be
used to enhance cognitive behavioral treatment of chronic
depression. We achieve this aim by
detailing the case of a patient, with a history of childhood
trauma and chronic depression, who
partially responded to CBT and went on to achieve full
remission through ST. We examine likely
schemas underlying the patient’s persistent symptoms and
through restructuring them incite
changes in the patient’s maladaptive cognitive and behavioral
life patterns. Finally, we provide
clinical practice recommendations for providers caring for
patients who may benefit from ST.
2 Case Introduction
Cornell Cognitive Therapy Clinic
The Cornell Cognitive Therapy Clinic (CTC) located in
Manhattan, NY, is an outpatient clinic in
a large academic medical center and serves a diversity of
patients. While the CTC sees primarily

Herts and Evans 25
patients diagnosed with depressive and anxiety disorders, the
program accepts a range of patients
with DSM-V disorders. Patients are often referred to the CTC
from other practitioners both
within the medical center and from neighboring practices and
institutions in the area. The CTC
is one of the few insurance-based therapy programs in the
metropolitan areas and accepts most
major insurance plans as well as Medicaid, which opens the
clinic services to lower-income
patients. Therapists in the CTC include four predoctoral
psychology interns who are completing
their last year of PhD graduate training in clinical psychology
and one postdoctoral psychology
fellow who has completed the full requirements for a PhD.
Supervisors in the program are
licensed clinical psychologists who have advanced training in
CBT and have clinical practices of
their own.
Case Description
“Amy” is a married, Caucasian female in her 60s, domiciled
with her husband and teenaged
daughter, working for a Jewish religious organization, who
initially presented to the CTC in fall
2017 seeking treatment for chronic depression and anxiety. She
had a history of over ten years of
psychodynamic treatment. At the CTC, Amy was initially
treated with 20 sessions of weekly
CBT with a psychology intern. Treatment focused on cognitive
restructuring and behavioral cop-

ing skills, for example, mindfulness, to help Amy manage
anxiety about her daughter’s health
and wellbeing. At the time of transfer to psychotherapy with the
first author, then a postdoctoral
fellow, Amy reported improvements in the severity of her
anxiety and depressive symptoms over
the course of CBT treatment (see details below). However, she
continued to experience some
anxiety and depressive symptoms, including low mood for much
of the day on more days than
not. In collaboration with Amy and the second author, the
supervisor on the case, a course of ST
was pursued in light of the chronic nature of Amy’s symptoms
and her childhood trauma history.
The goal of treatment was to help Amy identify and mitigate the
impact of lifelong schemas and
related maladaptive behaviors on her current functioning, in the
service of inciting complete
remission from mood and anxiety symptoms.
3 Presenting Complaints
At the initial intake to the Cognitive Therapy Clinic, prior to
beginning CBT treatment, Amy met
full diagnostic criteria for generalized anxiety disorder, a major
depressive episode and persistent
depressive disorder. Amy’s anxiety consisted primarily of
obsessive worry about the health and
wellbeing of herself, her husband and her daughter. She
reported little to no ability to control this
worry. Amy also endorsed avoidance of situations that she
perceived as dangerous to her family,
such as allowing her daughter to fly to Israel. When she was
presented with such situations, she
experienced panic symptoms including shortness of breath and
fear of going crazy/losing con-

trol, though her symptoms did not meet full diagnostic criteria
for a panic attack. Her avoidance
negatively impacted her relationship with her daughter, with
whom she desperately desired
closeness and further served to prevent her daughter from
gaining developmentally appropriate
independence. In addition, Amy’s primary mode for coping with
worry was to play out the worst-
case scenario in her mind, so that she would be prepared for it.
This served to increase her anxiety
and depressive symptoms, as well as to increase her desire to
closely watch over her daughter.
Amy’s score on the Beck Anxiety Inventory (described below)
was a 15, on the borderline of
minimal and mild anxiety symptoms (the cutoff is 16 for mild
anxiety symptoms). Amy reported
that her anxiety had increased over the past decade as she got
older and closer to the “age where
people die.”
At that initial intake, Amy was also experiencing depressive
symptoms including low mood
more days than not since the age of 14, frequent tearfulness
both with and without a trigger,
hopelessness, low self-esteem, sleep difficulties, difficulty
concentrating and passive suicidality.
Amy’s passive suicidal ideation occurred approximately once
per week and consisted of thoughts
such as “I can’t live like this anymore. I’m too emotionally
exhausted.” When she felt depressed,
she engaged in ruminative thinking about past losses, such as

her father’s death, which served to
reinforce her depressive cognitions. Amy’s pessimism and low
mood caused frequent conflict
with her husband, who didn’t see a reason for her to be so sad.
This conflict, in turn, reinforced
her belief that she would lose those close to her. Her score on
the Beck Depression Inventory-II
(described below) was a 16, indicative of mild depressive
symptoms. Despite the persistence of
her low mood, Amy reported other periods of her life when she
did not meet full diagnostic cri-
teria for a major depressive episode (e.g., she did not have sleep
difficulties or difficulty concen-
trating in college).
Upon presentation.to treatment with this writer, Amy had
completed CBT and had seen a
notable decrease in her symptoms (see Figure 1). She no longer
met diagnostic criteria for a
major depressive episode, reporting improvements in sleep,
concentration and feelings of hope-
lessness. She continued to experience low mood for much of the
day on most days, low self-
esteem and passive suicidality, as well as resultant rumination
and marital conflict. Her Beck
Depression Inventory-II score had decreased to an 11, indicative
of minimal depressive symp-
toms and reflecting a 25 percent change over the course of CBT.
Amy’s anxiety symptoms had
also decreased. Though she continued to experience obsessive
ruminations, particularly about
her daughter’s wellbeing, she felt that they were more
controllable using her newly developed
cognitive restructuring skills. She said that she was successfully
able to use cognitive restructur-
ing to reduce catastrophizing about half of the time. The

frequency of her panic symptoms had
also decreased. Her score on the Beck Anxiety Inventory was a
six, indicative of a 60 percent
change and placing her anxiety symptoms firmly in the mild
range. However, she also continued
to engage in the maladaptive avoidance behaviors described
above.
In sum, through a course of CBT, Amy was able to reach
remission from a major depressive
episode and to decrease her symptoms of generalized anxiety
disorder. However, she continued
to experience a persistent depressive disorder characterized by
consistent low mood, low self-
esteem and passive suicidality; and to engage in maladaptive
coping behaviors such as rumina-
tion, catastrophizing and avoidance behaviors. ST is intended to
treat patients who, like Amy,
Figure 1. Assessment of depressive and anxiety symptoms
during CBT treatment.
Herts and Evans 27
have largely recovered from anxiety and depressive episodes
that can be treated through CBT,
but who still have persistent subclinical symptoms that are
maintained by maladaptive cognitive
and behavioral patterns. Amy was thus appropriate for ST and
was consented into treatment.
4 History
Amy had a trauma history including extensive loss, sexual

abuse, emotional abuse and emotional
neglect in childhood. Her grandparents , to whom she was close,
both died of old age when she
was 7 years old. Her father died unexpectedly from a heart
attack when she was 12. Amy reported
that her mother became increasingly depressed and unable to
care for her and her two older sib-
lings following her father’s death, spending most of her time
alone in her room and rarely inter-
acting with the children. Amy took on the role of caring for her
mother for a few years, until
Amy’s oldest brother and his friend moved home to help. When
Amy was 14 years old, she was
sexually molested by her brother’s friend. Amy told her mother,
who accused her of lying. Later
that year, Amy’s brother died in a car accident. Following her
brother’s death, Amy’s mother
often expressed out loud that she wished it had been Amy who
died instead. Amy described her
teenage years as a time of no oversight, rife with emotional
neglect and abuse by her mother.
Amy said that she first became depressed after her brother died
at age 14 and had anxiety since
childhood. Her depressive symptoms had never fully remitted,
indicative of a course of chronic
depression that lasted for over 40 years. Amy’s anxiety waxed
and waned over time, but became
worse in her 50s, which she attributed to ageing and becoming
increasingly worried about death.
5 Assessment
The Beck Anxiety Inventory, Beck Depression Inventory-II and
the Columbia Suicide Severity
Rating Scale were administered weekly for routine outcome

monitoring during treatment and at
each of 2 biweekly and 2 monthly follow-up sessions.
Beck Anxiety Inventory
The Beck Anxiety Inventory (BAI; Beck & Steer, 1990) is a 21-
item scale that was developed to
address the need for an instrument that would reliably
discriminate anxiety from depression
while displaying convergent validity. Each item on the scale
describes a symptom of anxiety. The
respondent is asked to rate how much he or she has been
bothered by each symptom over the past
week on a 4-point scale ranging from 1 to 3. The items are
summed to obtain a total score that
can range from 0 to 63. The scale obtained high internal
consistency and item-total correlations
ranging from 0.30 to 0.71 (median = 0.60) and studies have
demonstrated its convergent and
discriminant validity.
Beck Depression Inventory-II
The Beck Depression Inventory-Second Edition (BDI II; Beck et
al., 1996) is a 21-item scale and
one of the most widely used self-report measures of depression.
The psychometric properties of
the original BDI are well established, and the BDI-II also
appears to be psychometrically strong.
Columbia-Suicide Severity Rating Scale
The Columbia Suicide Severity Rating Scale (C-SSRS; Posner
et al., 2011) demonstrated good
convergent and divergent validity with other multi-informant
suicidal ideation and behavior

scales and had high sensitivity and specificity for suicidal
behavior classifications compared with
another behavior scale and an independent suicide evaluation
board. Both the ideation and behav-
ior subscales were sensitive to change over time. The intensity
of ideation subscale demonstrated
moderate to strong internal consistency.
The Young Schema Questionnaire and the Young Parenting
Inventory were administered at
baseline to aid in case conceptualization.
Young Schema Questionnaire
The Young Schema Questionnaire (YSQ-L2; Young & Brown,
2001) is the long form of the self-
report measure that assesses 18 maladaptive schemas. Patients
rate themselves on how well each
item describes them on a 6-point Likert scale. In studies, alpha
co-efficients for each schema
range from 0.83 to 0.96 and test-retest coefficients range from
0.50 to 0.82 in non-clinical sam-
ples. Convergent and discriminant validity and primary factors
mapping onto Young’s schemas
have been established (Young et al., 2003).
Young Parenting Inventory (YPI)
The Young Parenting Inventory (YPI; Young, 1994) is one of
the primary means of identifying
childhood origins of schemas. The YPI is a 72-item

questionnaire in which respondents rate their
mothers and fathers separately on a variety of behaviors that
may contribute to schemas. The YPI
uses a 6-point Likert scale.
6 Case Conceptualization
An ST Case Conceptualization covers five major areas: (1)
current symptoms and life problems,
for example, maladaptive behavioral patterns; (2) the
developmental origins of these problems;
(3) current schemas and schema modes, with related
maladaptive behaviors; (4) the therapy
relationship; and (5) the focus of treatment and plan for change
(Young, 2007). As described
above, Amy presented to ST with generalized anxiety disorder
and persistent depressive dis-
order. She reported “obsessive worries” about her own, her
husband and her daughter’s health
and wellbeing, low mood on most days, low self-esteem and
passive suicidality. Amy’s anxiety
and depressive symptoms led to significant distress as well as
maladaptive behaviors including
reassurance seeking to reduce anxiety, irresponsible spending
on beauty treatments to combat
feelings of defectiveness and avoidance behavior to minimize
anxiety-provoking situations. For
example, Amy avoided driving out of fear of an accident. In
addition, when her daughter had a
sports injury that required minor surgery, Amy catastrophized
and worried about her resultant
death and sought reassurance from her husband and her
daughter’s doctors. This served to strain
her relationship with her daughter, which was further
distressing for Amy. In addition, Amy had
a general cognitive style characterized by rumination and

catastrophizing, which led to conflict
in her marital relationship.
The developmental origins of these symptoms and maladaptive
cognitive and behavioral
patterns is best described as an unmet need for feeling
connected, accepted and safe in childhood
following the deaths of her grandparents, father and brother all
before age 14. Amy’s mother’s
own resultant depression led her to be unable to care for Amy
and meet her emotional needs.
Amy’s feeling of safety and acceptance further deteriorated
after she was molested by her brother’s
friend and not believed by her mother.
These unmet needs resulted in Amy’s current schemas: (1)
Abandonment; (2) Social Isolation;
(3) Defectiveness; (4) Vulnerability to Harm or Illness; and (5)
Negativity/Pessimism.
Herts and Evans 29
Abandonment/Instability Schema
The Abandonment schema involves the belief that significant
others will not be able to provide
ongoing emotional and practical support because they are
unreliable, will die, or will abandon the
patient (Young et al., 2003). During treatment, Amy worried
that someone in her immediate fam-
ily would die and that her daughter would abandon her in favor
of a boyfriend. Her avoidance
behavior on behalf of herself and her family, such as when she
did not want to allow her daughter

to travel abroad, led her daughter to pull away from her. Her
rumination and resultant low mood,
as well as her reassurance seeking, led to marital conflict. For
Amy, the experiences of her daugh-
ter pulling away and her husband engaging in conflict both
served to maintain this schema.
Social Isolation/Alienation
This schema reflects the belief that one is isolated and different
from other people (Young et al.,
2003). Amy believed that God had singled her out for a life of
loss and sorrow that kept her emo-
tionally separate from other people. When she shared her
ruminations with her husband, he rein-
forced the belief that she is different from others by
invalidating her resultant low mood. However,
Amy continually voiced her ruminations in search of
reassurance.
Defectiveness/Shame
In line with this schema, Amy exhibited worry that she is
defective and would be unlovable if
exposed. This resulted in low self-esteem and made her feel
insecure and ashamed around others,
particularly around aspects of her appearance and about her
depression. Amy said that her mother
frequently criticized her appearance in childhood, and she spent
considerable money on main-
taining her appearance, for example, by going to an expensive
hair salon. She felt very ashamed
of this, as she and her husband otherwise felt financially
insecure.
Vulnerability to Harm or Illness

This schema was reflected in Amy’s catastrophic fears that an
unpreventable tragedy would
result in a family member’s death. For her daughter and her
husband, these fears focused on
medical and external catastrophes, such as her husband having a
heart attack, or her daughter
being in an airplane crash. For herself, Amy worried about
becoming debilitated with depression
and committing suicide if anything were to happen to her
daughter. When Amy attempted to
protect her daughter, she prevented her from engaging in age
appropriate behaviors, such as
attending field trips, which both angered her daughter and
prevented her from gaining increased
independence. In addition, this avoidance prevented Amy from
experiencing her daughter safely
returning from trips, which would have served to combat this
schema.
Negativity/Pessimism
Amy described a lifelong focus on the negative aspects of life
and minimization of the positive,
which is characteristic of a Negativity/Pessimism schema
(Young et al., 2003). Despite the tre-
mendous loss she experienced as a child, Amy had many
strengths and sources of positivity in
her life, including a strong group of friends, a loving husband
and daughter and a meaningful
career where she felt valued. When she discounted these
positive forces, it angered her husband
and contributed to marital conflict. Further, Amy worried that
she would pass along her depres-
sion to her daughter, who also had many strengths.

These schemas are commonly associated with an enhanced
“vulnerable child” mode, in which
the patient experiences negative emotions such as sadness and
fear (Young et al., 2003). Indeed,
in experiential exercises Amy was easily able to access her
vulnerable child mode. In the therapy
relationship, Amy was passive and friendly and frequently
sought reassurance about her worries
and her performance in treatment. The overarching aim of
treatment was to bolster Amy’s
“healthy adult” mode, in which she could nurture, affirm and
protect the vulnerable child within.
The tools of ST were used to achieve this, specifically, the
cognitive, behavioral, interpersonal
and experiential interventions described below. It was expected
that these interventions would
result in a significant reduction in Amy’s ongoing anxiety and
depressive symptoms on the routine
outcome measures, as well as a qualitative improvement in her
functioning.
7 Course of Treatment and Assessment of Progress
Course of Treatment
Amy completed 18 sessions of ST and four follow-up sessions
over the course of 9 months.
Treatment began with psychoeducation about ST and assessment
of Amy’s schemas. Thereafter,
treatment incorporated cognitive, behavioral, interpersonal and
experiential interventions. The

follow-up phase of treatment, described below, began once
Amy’s depression had remitted.
Interpersonal interventions (employed throughout treatment).
The primary interpersonal intervention
utilized was limited reparenting, which describes using the
therapeutic relationship to provide
patients with what they needed, but did not get from their
parents, in childhood (Young et al.,
2003). For Amy, this meant providing unconditional acceptance
and positive regard; consistency
in keeping appointments, timeliness and responsiveness to
questions; and supplying the healthy
adult voice through Socratic questioning in cognitive
interventions and in real time during early
schema dialogue exercises. The following dialogue
demonstrates how the therapist provided the
healthy adult voice. In this exercise, Amy was asked to first
speak from her vulnerable child voice,
then to switch chairs and respond from her healthy adult voice.
Amy [as vulnerable child]: I’m just so scared. I can’t protect the
people I love. Something
terrible could happen at any time and I could lose them.
Therapist: I’d now like you to move to this chair, here. In this
chair, you embody the healthy
adult part of yourself. Am I speaking with the healthy adult
within Amy?
Amy [as healthy adult]: Yes.
Therapist: Great. Healthy Adult, the Vulnerable Child has just
told us that they are very scared
of losing someone they love. What can you say to them to
provide comfort and care?

Amy: I. . .I don’t know.
Therapist: That’s ok. Is it ok if I speak for you this time?
Amy: Sure.
Therapist [faces the vulnerable child chair]: Amy, as a child,
it’s not your job to protect the
people you love. It’s their job to protect you. I know they
haven’t done that for you and I’m
sorry. But now I am here to protect you and the people you love
and I promise to do so.
Therapist [faces Amy in the healthy adult chair]: Amy, can you
summarize what I just said in
your own words?
Amy [as healthy adult, faces vulnerable child chair]: Ok. You
don’t have to worry that terrible
things will always happen. I know you’ve been scared, but I am
here to protect you now.
It’s not your job to be the protector anymore. I am here and I
will keep you safe.
Psychoeducation and assessment (Sessions 1–4). The initial
phase of treatment involved additional
assessment of Amy’s schemas using the YSQ-L2 and the YPI.
Items that Amy endorsed were
queried for better understanding. For example, Amy said that
“people have not been there to meet
Herts and Evans 31
my emotional needs” was “mostly true of me.” The therapist
asked for examples of this, which
led Amy to describe her mother’s emotional neglect and her

current perception that nobody truly
knows how defective she is.
The therapist also led Amy in a guided imagery exercise to help
identify the childhood origins
of her schemas. In the exercise, the patient is asked to imagine
an upsetting situation with one of
their parents and how they wish their parent had responded.
They are then asked to wipe out that
image and think of a current situation in which they have had
the same emotional experience
(Young et al., 2003). Amy described being sad and infuriated
when, in a moment of conflict, her
mother told her that she wished Amy had died instead of her
brother. She said that she needed her
mother to recognize that Amy was grieving her brother’s death,
too and that she wanted to be
allowed to “fall apart sometimes,” the way her mother always
seemed to due to her depression.
At the conclusion of the assessment phase of treatment, the
therapist provided psychoeduca-
tion about ST and collaboratively created the case
conceptualization with Amy. Psychoeducation
included assigning Amy to read “A Client’s Guide to Schema
Therapy” (Bricker & Young, 2004)
and sections of “Reinventing Your Life” (Young & Klosko,
1994), a self-help book based on
Schema Therapy, that described Amy’s schemas. The therapist
and Amy then discussed how each
schema applied to Amy’s life at present. The decision to
collaboratively complete the case con-
ceptualization was made to increase rapport, set the basis for a
collaborative treatment relation-
ship and to gain further insight into Amy’s perceptions of her
history and current functioning.

Amy participated actively in completing the conceptualization.
Cognitive interventions (main focus in sessions 5–10). In the
middle section of treatment, cognitive,
behavioral and experiential interventions were used whenever
needed, though in general cognitive
interventions were taught prior to behavioral and experiential
interventions. Core beliefs, or sche-
mas, were identified at the outset of treatment during the
assessment phase. The focus of cognitive
interventions was to restructure these beliefs using cognitive
restructuring driven by Schema
Diaries (Young, 1993) and Schema Flashcards (Young et al.,
2003). Schema Diaries allow a
patient to track their thoughts, feelings and behaviors in the
present day and then connect them to
their schemas and childhood origins. The patient is then guided
to come up with a healthy alterna-
tive belief and behavior. Schema Flashcards are completed for
situations and feelings that arise
repeatedly, so that the patient can have easy access to a healthy
belief and behavioral instruction.
Amy completed schema diaries and flashcards throughout
treatment. The content of her diaries
was largely about worry about her daughter. For example, after
meeting her daughter’s boyfriend,
Amy worried that he would break up with her and she would
become depressed, ultimately com-
mitting suicide. Other events that elicited schema-related
beliefs also involved threats to those
close to her, such as when a dear friend had a heart attack and
when her husband lost his job.
Early in treatment, Amy was unable to come up with healthy
alternative beliefs and behaviors
on her own and required the therapist’s assistance through

limited reparenting. However, over
the course of treatment Amy became adept at completing
Schema Diaries and Flashcards and
reported that the cognitive restructuring that resulted from them
was highly effective at mitigat-
ing her anxiety. The therapist also regularly engaged Amy in
cognitive restructuring of schema-
related beliefs that arose in session, first by providing examples
of restructured thoughts and then
through Socratic questioning to guide Amy to restructure her
own thinking.
Behavioral interventions (Main focus in sessions 10–12).
Behavioral interventions included design-
ing behavioral experiments to test maladaptive, schema-related
beliefs, as well as imaginal expo-
sures to feared experiences. Examples of behavioral
experiments are Amy being more vulnerable
with close friends to test the belief that they would reject her
(they did not); and allowing
her daughter increased independence to see if she would be hurt
or abandon her (she did not).
Imaginal exposures focused on feared events happening to her
daughter, such as her getting in a
minor car accident. Amy did not complete imaginal exposure
homework over the course of three
sessions and reported that it was too distressing. The therapist
and Amy thus collaboratively
decided to shift the focus of treatment to experiential
interventions.

Experiential interventions (Main focus in sessions 13–17).
There were two types of experiential
interventions used in treatment, guided imagery and schema
dialogues. First, a guided imagery
exercise was conducted to help Amy visualize a safe place that
she could return to mentally when
schemas were activated. Amy imagined a room in her childhood
home and reported that conduct-
ing the safe place imagery exercise was comforting. The
purpose of imagery and schema dia-
logue exercises was to help Amy express schema-related beliefs
and emotions and learn to
respond to them from a healthy adult perspective. Schema
dialogue exercises used imagery to
help Amy imagine an upsetting childhood situation, such as her
father’s death and speak about
her needs from the part of her that represented her “vulnerable
child” mode. She was then asked
to switch chairs and respond to the “vulnerable child” from her
“healthy adult” mode. Amy
reported feeling many symptoms of panic and anxiety while in
vulnerable child mode, such as
perceived tachycardia and sweating. In the dialogue below, Amy
successfully responds to the
vulnerable child within her with minimal help from the
therapist.
Amy [as vulnerable child]: Everyone dies and there is nobody to
take care of me. I can’t take
care of myself. I’m going to go crazy. I should just die, too.
Therapist: I’d now like you to move to this chair, here. Please
take a moment to access the
healthy adult part of yourself – the part that cares for your
daughter. Am I speaking with the
healthy adult within Amy?

Amy [as healthy adult]: Yes.
Therapist: Great. Healthy Adult Amy, the Vulnerable Child has
just told us that she wants to
die because there is nobody to care for her. Please respond so as
to comfort and care for her.
Amy [as healthy adult, faces vulnerable child chair]: I know you
have had a lot of loss and I
am so sorry about that. But I am here now and I promise to take
care of you. You’re not
going crazy; you’re just a child and you need adults to care for
you—that’s ok. I will be that
adult for you. I don’t want you to die—you have so much life
left to live and things are only
going to get better for you. I promise—I’ve seen it.
Figure 2. Assessment of depressive and anxiety sympto ms
during ST treatment.
Herts and Evans 33
Schema dialogue sessions concluded with processing the
exercise and conducting the safe
place imagery exercise to help Amy regulate her emotions prior
to leaving the session. Unlike
exposure, Amy participated fully in schema dialogue exercises.
Imagery was also used to help Amy identify the schemas that
were driving current maladap-
tive behavioral patterns. For example, imagery was helpful
when Amy was catastrophizing that
her daughter would get in a plane crash and die if she flew to

Israel. Amy was first asked to close
her eyes and engage in mindfulness of the emotions she was
feeling: panic and despair. She was
then guided to imagine a time in her childhood when she had
felt the same way. Amy responded
that her father had died shortly after flying back from visiting
her grandparents. Through this
exercise, it became clear that Amy’s Abandonment and
Vulnerability to Harm or Illness schemas
were activated by her daughter’s upcoming trip because she fel t
abandoned and terrified by her
father’s unexpected death from a heart attack. By identifying
these schemas it was possible to
create an effective schema diary to address their current trigger.
Assessment of Progress
Figure 2 depicts Amy’s scores on the BDI and BAI throughout
the course of Schema Therapy.
Amy’s scores on the BAI remained low throughout treatment,
with a range from three to six,
indicative of minimal anxiety symptoms. At termination, her
score (BI = 3) had seen a 50 per-
cent change since the commencement of ST (BAI = 6). Amy’s
scores on the BDI ranged from
three at termination to 11 at the commencement of ST,
indicative of minimal depressive symp-
toms with a 73 percent change over the course of ST treatment.
It is notable that Amy’s descrip-
tion of her symptoms in session was more severe than was
reflected on the BDI and BAI,
particularly at the start of ST. Amy’s anxiety symptoms may
have been more accurately assessed
by a measure that focuses more on worry (as opposed to
somatic, as in the BAI) symptoms
of anxiety. Amy’s low scores on the BDI may have been

indicative of a relatively low level of
depressive symptoms as compared to other times in Amy’s life,
rather than a minimal level of
absolute depressive symptoms. It is a limitation of this report
that the authors did not identify
other quantitative metrics to better capture the negative
functional impact of Amy’s depressive
and anxiety symptoms.
On the CSSRS, Amy consistently endorsed passive suicidal
ideation, but denied suicidal plan,
intent, or means. In addition, at termination she reported
decreased frequency of this ideation
from weekly to approximately once per month. Finally, her
passive suicidal ideation was no lon-
ger general (e.g., I can’t take this anymore), but rather only
arose when triggered by the thought
of her daughter dying, for example, when Amy saw a news
report about a teenager being killed
in a park. When triggered, Amy would think “I can’t go on if
she dies” but would quickly identify
this as her Vulnerability to Harm or Illness schema being
activated and engage in cognitive
restructuring.
Qualitatively, Amy reported that her persistent depression lifted
over the course of treatment and
that she was happier than she had ever been. She was no longer
experiencing low mood on most
days and felt more hopeful about the future. Further, she was
proud of herself for “graduating”
from treatment and reported increased self-esteem as a result.
Amy expressed amazement that
less than 1 year of ST had helped her remit from 40 years of
chronic depression. She no longer
engaged in depressive rumination and noticed an accordant

improvement in her relationship with
her husband. Amy also reported that her “obsessive worries”
were now only occasional (less than
daily) and that she was consistently able to successfully cope
with them using cognitive tech-
niques learned in ST, rather than catastrophizing. She had
reduced her avoidance behaviors and
was allowing her daughter increased independence, such as
sleeping over at friends’ houses.
Amy said that this had both improved their relationship and
reduced Amy’s fear that something
bad would befall her daughter, as her daughter returned from
the sleepovers and other endeavors
unharmed. The therapist observed that in addition, Amy had
increased self-efficacy to manage
her mental health, with which Amy agreed.
8 Complicating Factors
At the time of Amy’s treatment, there was significant media
attention on antisemitism. In October
2018, the New York Times published an article called “Is it
Safe to be Jewish in New York?”
(Bellafante, 2018) in which they reported that antisemitic events
had comprised half of all hate
crimes in New York that year. These ranged from drawing
swastikas on public property to physi-
cal assaults against Hasidic Jews (Bellafante, 2018). That same
month, George Soros, a promi-
nent Jewish philanthropist, was mailed a pipe bomb just days
before 11 congregants were killed

in a mass shooting at the Tree of Life Synagogue in Pittsburgh
(Robertson et al., 2018). Amy, in
her work at a Jewish religious organization, became very scared
that she would be threatened or
attacked at work. She also feared for her family’s physical and
emotional wellbeing. The very
real, ongoing and public nature of antisemitic activity strongly
reinforced Amy’s Vulnerability to
Harm or Illness schema. In contrast to past traumas, from which
Amy’s healthy adult voice could
reassure her of her current safety, there was likely a true
increased risk of unknown proportion to
Amy, particularly at work. Thus, problem solving was
introduced to help Amy identify steps she
could take to keep herself safe, for example, by rearranging the
furniture at work so she was not
directly in front of the door. Problem solving interventions were
coupled with cognitive restruc-
turing to help Amy de-catastrophize the likelihood of harm
occurring from her initial prediction
of 95 percent. About 3 months into treatment, Amy received
multiple threatening phone calls at
work over the course of a two-day period. She effectively
reported this to her boss and the police
and followed their instructions for how to proceed with
answering calls. This adaptive behavior
was highlighted to reinforce Amy’s healthy adult mode.
9 Access and Barriers to Care
Amy complained of financial distress throughout treatment. Her
husband, who had long been a
successful business executive, was unemployed and having
difficulty finding work. In addition,
she herself had a six-month period of unemployment that ended
shortly before beginning treat-

ment with this writer. This was so stressful for Amy that at
times she considered leaving her
husband and finding a more financially stable partner.
Unsurprisingly, Amy was reluctant to pay
the $40 copay for ongoing therapy for an extended period of
time and this almost prevented her
from entering ST, which typically lasts between 6 months and 2
years. The therapist encouraged
Amy to discuss the copay with her husband to see if they
realistically could continue to pay it and
offered to file a request for a fee reduction with the clinic
director if the answer was no. The thera-
pist also provided the rationale that ST, if effective, might
result in a remission of symptoms and
enhance the quality of her life, which Amy had never
experienced in over a decade of past ther-
apy. Amy and her husband ultimately decided to work the copay
into their ongoing budget in
order to prioritize Amy’s mental health.
10 Follow-up
Follow-up: Relapse Prevention and Final Termination (Sessions
18–22)
Amy reported that her depressive and anxiety symptoms had
decreased significantly by session
15 and remained consistently low throughout the rest of
treatment. This was in line with her
scores on the BDI (see Figure 2). Thus, we ended standard
treatment to begin both relapse pre-
vention planning and tapering treatment at session 18. Relapse
prevention planning consisted of
reviewing the cognitive, behavioral and imagery skills learned
in treatment, as well as the

Herts and Evans 35
learning from other experiential interventions. Tapering
consisted of meeting every other week
from sessions 18 to 20, and then monthly for sessions 21 and
22. This allowed Amy to practice
skills outside of therapy and process termination with the
therapist after having a break from
treatment. Amy said that the cognitive restructuring skills that
she learned in ST were of great
value to her, as was the learning from experiential
interventions. Upon initially tapering treat-
ment, Amy expressed great sadness and an uptick in
maladaptive thoughts related to the
Abandonment schema. The therapist guided Amy to respond to
those thoughts using her Healthy
Adult voice, which instructed her that this was a healthy
goodbye wholly unlike past situations
where those close to her died. At the final termination session,
the therapist and Amy celebrated
Amy’s great progress and Amy expressed pride that she was
ready to “graduate” from therapy.
11 Treatment Implications of the Case
Chronic depression is a psychiatric condition with significant
impact on the function and quality
of life of millions of people. While medication and CBT are
effective for a percentage of people
suffering from chronic depression, there are many who remain
refractory to these gold standard
approaches to care. Of significance, is that early life events,
including the death of a parent or
sibling, as well as childhood trauma (i.e., abuse, neglect) may

play a role in the development of
chronic depression as mediated through maladaptive schemas.
Targeting early disconnection
schemas such as abandonment, mistrust/abuse and emotional
deprivation stemming from these
experiences may be of critical importance in optimizing
treatment for patients with chronic
depression.
Amy’s case demonstrates a partial response to a standard CBT
approach focusing on cognitive
restructuring, behavioral activation and coping skills for
chronic depression. Nonetheless, Amy
continued to endorse feelings of low self-esteem and
hopelessness at the end of treatment and she
remained obsessively worried about the health of her family,
including her daughter. Her worries
were associated with maladaptive behavioral patterns aimed at
keeping her daughter safe from
harm, but in fact they reinforced an enmeshed and dependent
relationship. The major treatment
implication of this case is through furthering her work in ST,
Amy was able to experience and
process her core sense of vulnerability and to cultivate healthier
and more adaptive beliefs includ-
ing that the significant relationships in her life were secure and
stable.
This case also demonstrates the importance of constructing a
case conceptualization to guide
the therapy process. Early on in ST, the therapist and Amy
examined specific life situations that
revealed patterns of obsessive thoughts around the safety of
family members. It was important
for Amy to understand that early life events and traumas
contributed to the development of her

core beliefs that “the world is a dangerous place” and “you
can’t trust people for being there in a
stable and consistent way.” She was able to understand how
these beliefs were linked to a certain
assumptions, “If I don’t watch out and worry all the time,
something bad will happen” and also
specific rules, “I have to protect everyone.” The
conceptualization allowed Amy to develop a
deeper awareness of how her constant anxiety, worry and
obsessive efforts to protect her daugh-
ter and other family members functioned to maintain her
underlying fears of abandonment, loss
and feeling unsafe.
Amy improved from a course of CBT and further benefitted
from the experiential processing
and healing of early life wounds that was addressed in ST.
Nonetheless, it should be noted that
Amy continued to endorse passive suicidal ideation at the end
of treatment. We know that Amy
internalized the harsh/critical voice of her mother telling her
that she wished Amy had died
instead of her brother. It remains unclear if Amy’s passive
suicidal ideation will remain intrac-
table or if it will diminish with time if she continues to
experience greater self-confidence and a
sense of safety in the world.
12 Recommendations to Clinicians and Students
ST should be considered in patients who exhibit chronic
maladaptive life patterns that are linked

to early life events and are not currently impaired by symptoms
concurrent with an active anxiety
or depressive disorder. In patient who do have an active anxiety
or depressive disorder, a tradi-
tional course of CBT may be the most appropriate therapeutic
option. Other indications for con-
sidering ST are for patients, such as Amy, who may have
experienced a partial remission of
symptoms from a standard course of CBT and remain mildly
symptomatic and continue to
engage in maladaptive behavioral patterns. ST may also be
considered for patients suffering from
personality disorders, including borderline and narcissistic
personality disorder.
Supervision Techniques
The supervisee should work with a clinician who has trained in
ST, has experience supervising
other clinicians and who will be able to guide them in
understanding the underlying conceptual
model behind ST in concert with learning about the eighteen
schemas and maladaptive copying
styles that maintain schemas. The trainee started by reading
Schema Therapy: A practitioner’s
guide (Young et al., 2003). Learning to conduct ST parallels the
course of patient treatment;
therefore, the supervisee began with understanding the
assessment and education phase of ST.
The supervisee first learned to take a life history and identify
current problematic life patterns
and patient goals. The supervisor instructed the beginning
schema therapist to administer and
score the YSI and query the patient on individual high scores to
further elucidate potential sche-
mas. It was useful to conduct imagery exercises with the

supervisee, including the assessment
imagery exercise. The supervisee was able to draw on her
experience of memories with her own
parents as the supervisor guided her through the exercise.
Cognitive, behavioral and experiential
strategies were practiced in supervision. For example, the
supervisee brought in a schema diary
that their patient completed to review with the supervisor to get
specific feedback. It was particu-
larly helpful to role play the experiential techniques in
supervision. For example, the supervisor
first modeled how to conduct the imagery exercises aimed at
accessing greater affect and insight
into schemas. Then the supervisee practiced guiding the
supervisor through an imagery exercise.
As treatment progressed, supervisor and supervisee practiced
dialogues (sometimes using chair
work) to differentiate between the schema side and the healthy
side. Time in supervision was
allotted to debriefing the supervisee’s experience with these
techniques and particularly the more
experiential strategies such as imagery exercises and schema
dialogues.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or
publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD

Kate L. Herts https://orcid.org/0000-0002-7967-327X
References
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979).
Cognitive therapy of depression. Guilford Press.
Beck, A. T., & Steer, R. A. (1990). Beck anxiety inventory
manual. The Psychological Corporation.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Comparison
of the Beck depression inventories-IA and
II in psychiatric outpatients. Journal of Personality Assessment,
67, 588–597.
https://orcid.org/0000-0002-7967-327X
Herts and Evans 37
Bellafante, G. (2018, October 31). Is it safe to be Jewish in New
York? The New York Times. https://
www.nytimes.com/2018/10/31/nyregion/jewish-bias-safety-
nyc.html?searchResultPosition=2
Bricker, D. C., & Young, J. E. (2004). A client’s guide to
schema therapy. Cognitive Therapy Center of
New York.
Byllesby, B. M., Elhai, J. D., Tamburrino, M., Fine, T. H.,
Cohen, G., Sampson, L., Shirley, E., Chan, P.
K., Liberzon, I., Galea, S., & Calabrese, J. R. (2017). General
distress is more important than PTSD’s
cognition and mood alterations factor in accounting for PTSD
and depression’s comorbidity. Journal
of Affective Disorders, 211, 118–123.

Contractor, A. A., Greene, T., Dolan, M., & Elhai, J. D. (2018).
Relations between PTSD and depression
symptom clusters in samples differentiated by PTSD diagnostic
status. Journal of Anxiety Disorders,
59, 17–26.
Cuijpers, P., van Straten, A., Schuurmans, J., van Oppen, P.,
Hollon, S. D., & Andersson, G. (2010).
Psychotherapy for chronic major depression and dysthymia: A
meta-analysis. Clinical Psychology
Review, 30(1), 51–62.
David, D., Cristea, I., & Hofmann, S. G. (2018). Why cognitive
behavioral therapy is the current gold standard
of psychotherapy. Frontiers in Psychiatry, 9(4). doi:
10.3389/fpsyt.2018.00004
Ferrari, A. J., Charlson, F. J., Norman, R. E., Patten, S. B.,
Freedman, G., Murray, C. J., Vos, T., &
Whiteford, H. A. (2013). Burden of depressive disorders by
country, sex, age, and year: Findings from
the global burden of disease study 2010. PLoS Medicine,
10(11), e1001547.
Gurak, K. K., Freund, B., & Ironson, G. (2016). The use of both
prolonged exposure and cognitive pro-
cessing therapy in the treatment of a person with PTSD,
multiple traumas, depression, and suicidality.
Clinical Case Studies, 15(4), 295–312.
Hiraoka, R., Cook, A. J., Bivona, J. M., Meyer, E. C., &
Morissette, S. B. (2016). Acceptance and commit-
ment therapy in the treatment of depression related to military
sexual trauma in a woman veteran: A
case study. Clinical Case Studies, 15(1), 84–97.

Hölzel, L., Härter, M., Reese, C., & Kriston, L. (2011). Risk
factors for chronic depression - A systematic
review. Journal of Affective Disorders, 129, 1–13.
Hovens, J. G., Giltay, E. J., Wiersma, J. E., Spinhoven, P.,
Penninx, B. W., & Zitman, F. G. (2012). Impact
of childhood life events and trauma on the course of depressive
and anxiety disorders. Acta Psychiatrica
Scandinavica, 126(3), 198–207.
Kocsis, J. H., Gelenberg, A. J., Rothbaum, B., Klein, D. N.,
Trivedi, M. H., Manber, R., Keller, M. B.,
Howland, R., & Thase, M. E. (2008). Chronic forms of major
depression are still undertreated in
the 21st century: Systematic assessment of 801 patients
presenting for treatment. Journal of Affective
Disorders, 110, 55–61.
Malogiannis, I. A., Arntz, A., Spyropoulou, A., Tsartsara, E.,
Aggeli, A., Karveli, S., Vlavianou, M.,
Pehlivanidis, A., Papadimitriou, G. N., & Zervas, I. (2014).
Schema therapy for patients with chronic
depression: A single case series study. Journal of Behavior
Therapy and Experimental Psychiatry, 45,
319–329.
Mandelli, L., Petrelli, C., & Serretti, A. (2015). The role of
specific early trauma in adult depression: a
meta-analysis of published literature. Childhood trauma and
adult depression. European Psychiatry,
30(6), 665–680.
Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova,
K. V., Oquendo, M. A., Currier, G. W.,
Melvin, G. A., Greenhill, L., Shen, S., & Mann, J. J. (2011).

The Columbia-Suicide Severity Rating
Scale: Initial validity and internal consistency findings from
three multisite studies with adolescents
and adult. The American Journal Psychiatry, 168(2), 1266–
1277.
Renner, F., Arntz, A., Peeters, F. P. M. L., Lobberstael, J., &
Huibers, M. J. H. (2016). Schema therapy
for chronic depression: results of a multiple single case series.
Behav Ther Ex Psychiatry, 51,
66–73.
Rezaei, M., & Ghazanfari, F. (2016). The role of childhood
trauma, early maladaptive schemas, emo-
tional schemas and experimental avoidance on depression: A
structural equation modeling. Psychiatry
Research, 246, 407–414.
Robertson, C., Mele, C., & Tavernise, S. (2018, October 27). 11
Killed in Synagogue Massacre; Suspect
Charged with 29 Counts. The New York Times.
https://www.nytimes.com/2018/10/27/us/active-
shooter-pittsburgh-synagogue-
shooting.html?searchResultPosition=4
https://www.nytimes.com/2018/10/31/nyregion/jewish-bias-
safety-nyc.html?searchResultPosition=2
https://www.nytimes.com/2018/10/31/nyregion/jewish-bias-
safety-nyc.html?searchResultPosition=2
https://www.nytimes.com/2018/10/27/us/active-shooter-
pittsburgh-synagogue-shooting.html?searchResultPosition=4
https://www.nytimes.com/2018/10/27/us/active-shooter-
pittsburgh-synagogue-shooting.html?searchResultPosition=4

Seavey, A., & Moore, T. M. (2012). Schema-focused therapy for
major depressive disorder and personality
disorder: A case study. Clinical Case Studies, 11(6), 457–473.
Spijker, J., van Straten, A., Bockting, C. L., Meeuwissen, J. A.,
& van Balkom, A. J. (2013). Psychotherapy,
antidepressants, and their combination for chronic major
depressive disorder: A systematic review.
The Canadian Journal of Psychiatry, 58(7), 386–392.
Torpey, D. C., & Klein, D. N. (2008). Chronic depression:
Update on classification and treatment. Current
psychiatry reports, 10(6), 458–464.
Wiersma, J. E., Hovens, J. G., van Oppen, P., Giltay, E. J., van
Schaik, D. J., Beekman, A. T., & Penninx, B. W.
(2009). The importance of childhood trauma and childhood life
events for chronicity of depression in
adults. Journal of Clinical Psychiatry, 70(7), 983–989.
Young, J. E. (1993). The schema diary. Cognitive Therapy
Center of New York.
Young, J. E. (1999). Cognitive therapy for personality
disorders: A schema-focused approach (rev.ed.).
Professional Resources Press.
Young, J. E. (2007). Schema therapy case conceptualization
form. Schema Therapy Institute.
Young, J. E., & Brown, G. (2001). Young schema questionnaire:
Special Edition. Schema Therapy
Institute.
Young, J. E., & Klosko, J. S. (1994). Reinventing your life: The
breakthrough program to end negative

behavior and feel great again. Penguin Putnam Inc.
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema
therapy: A practitioners guide. The Guilford
Press.
Young, J. E., Wattenmaker, D., & Wattenmaker, R. (2003).
Schema therapy flashcard. Schema Therapy
Institute.
Author Biographies
Kate L. Herts is an assistant professor of Psychology in Clinical
Psychiatry at Weill Cornell Medicine and
an Assistant Attending Psychologist at New York Presbyterian
Hospital. Dr. Herts completed her Bachelor
of Arts at Brown University and earned her PhD in Clinical
Psychology from the University of California,
Los Angeles.
Susan Evans is a professor of Psychology in Clinical Psychiatry
at Weill Cornell Medicine and an Attending
Psychologist at New York Presbyterian Hospital. She is the
Director of Education in Psychology and
Director of the Cornell Cognitive Therapy Clinic. She received
her PhD from the New School for Social
Research.

httpsdoi.org10.11771534650120954275Clinical Case Stud

Recommended

Recommended

More Related Content

Similar to httpsdoi.org10.11771534650120954275Clinical Case Stud

Similar to httpsdoi.org10.11771534650120954275Clinical Case Stud (20)

More from PazSilviapm

More from PazSilviapm (20)

Recently uploaded

Recently uploaded (20)

httpsdoi.org10.11771534650120954275Clinical Case Stud