Comparing the Effectiveness of Young's Schema Therapy and Intensive Short-Term Dynamic Psychotherapy on Psychological Resilience in Kidney Patients

Introduction

Chronic kidney disease is a major public health problem with increasing clinical, psychological, social, and economic consequences. Its global burden has grown alongside major risk factors such as diabetes, hypertension, obesity, and unhealthy lifestyle patterns (Chen et al., 2023; Kovesdy, 2022). Beyond biological deterioration and treatment burden, kidney disease often imposes long-term limitations on daily functioning, family roles, employment, social participation, and perceived control over life. These difficulties may expose patients to persistent stress, anxiety, depressive symptoms, social withdrawal, and reduced quality of life (Cogley et al., 2022; Knowles et al., 2023).

Kidney patients, particularly those who require repeated medical follow-up or dialysis, are commonly confronted with dietary restrictions, physical fatigue, uncertainty about disease progression, financial pressure, and repeated contact with health-care systems (Beetham et al., 2022; García-Martínez et al., 2021). These chronic stressors may weaken psychological adjustment. Psychological resilience is therefore a clinically relevant construct in this population. Resilience refers to the capacity to maintain or regain psychological balance after stress, adversity, or trauma (Connor & Davidson, 2003). In chronic disease, resilience is not simply a personality trait; it can be understood as a modifiable psychological resource that helps patients manage uncertainty, tolerate distress, sustain hope, and use adaptive coping strategies (García-Martínez et al., 2021; Ikram et al., 2022).

Low resilience may intensify the subjective burden of chronic kidney disease. Patients with lower resilience may perceive illness-related limitations as less controllable, may show greater vulnerability to anxiety and depressive responses, and may have more difficulty maintaining treatment adherence and social functioning (Ikram et al., 2022; Knowles et al., 2023). Strengthening resilience can therefore be considered an important target for psychological interventions in kidney care. Interventions that modify maladaptive emotional and cognitive patterns may improve coping capacity and promote more stable adaptation to chronic illness.

Intensive short-term dynamic psychotherapy is a psychodynamic intervention that focuses on identifying and processing avoided emotions, reducing maladaptive defenses, and increasing awareness of unconscious conflicts (Abbass et al., 2012; Davanloo, 2000). In this model, psychological symptoms are partly maintained by defensive avoidance of painful emotions and unresolved internal conflicts. Treatment aims to help patients directly experience and regulate emotions rather than avoid them through defensive patterns. By increasing emotional tolerance, insight, and adaptive affect regulation, intensive short-term dynamic psychotherapy may enhance the patient's capacity to face stressors associated with chronic illness (Abbass et al., 2012).

Schema therapy is an integrative treatment model that combines cognitive-behavioral, attachment, experiential, Gestalt, and psychodynamic elements (Young et al., 2003). It is based on the assumption that early maladaptive schemas develop when core emotional needs are not adequately met during childhood or adolescence. These schemas may shape persistent beliefs about the self, others, and the world and may contribute to maladaptive coping styles. Schema therapy targets these deep cognitive-emotional patterns and aims to strengthen the healthy adult mode, modify maladaptive schemas, and promote more adaptive responses to distress (Young et al., 2003). Evidence from health-related and clinical populations suggests that maladaptive schemas can be associated with depression and psychological vulnerability in kidney- and liver-related contexts (Karagöl & Törenli Kaya, 2022).

Both intensive short-term dynamic psychotherapy and schema therapy appear theoretically relevant for improving resilience. However, they may operate through different mechanisms. Intensive short-term dynamic psychotherapy primarily emphasizes emotional experience, defense restructuring, and tolerance of anxiety, whereas schema therapy emphasizes modification of early maladaptive schemas and maladaptive coping modes (Abbass et al., 2012; Young et al., 2003). Direct comparison of these two approaches in kidney patients is limited. Determining whether one intervention is superior, or whether both are similarly effective, may help clinicians select appropriate psychological treatments for patients facing chronic kidney disease.

The present study aimed to compare the effectiveness of intensive short-term dynamic psychotherapy and schema therapy on psychological resilience in kidney patients. The main research question was whether these two therapeutic approaches differ in their effect on psychological resilience across pretest, posttest, and three-month follow-up assessments.

Methods

Study Design and Participants

This quasi-experimental study used a pretest-posttest design with a three-month follow-up and a control group. The statistical population consisted of kidney patients in Mashhad, Iran, in 2023. Forty-five participants were selected through convenience sampling and then allocated to three equal groups of 15 participants each: Young's schema therapy, intensive short-term dynamic psychotherapy, and control. Because recruitment was based on convenience sampling rather than population-based random sampling, the study is reported as quasi-experimental. The first experimental group received Young's schema therapy in eight sessions, the second experimental group received intensive short-term dynamic psychotherapy in fifteen sessions, and the control group received no intervention during the study period.

Sample Size and Allocation

The sample size was determined according to the available eligible patients and equal allocation across the three study arms (n = 15 per group). No formal a priori statistical power analysis was reported; therefore, the sample size should be interpreted as a feasibility-based sample and this issue is acknowledged as a methodological limitation. Group allocation was performed after recruitment to keep the three study arms equal in sizeInclusion criteria were age between 25 and 40 years, at least a high-school diploma, willingness to participate, absence of severe personality disorder, no concurrent psychological treatment during the study, and absence of psychotic-level depression. Exclusion criteria included absence from more than two treatment sessions, unwillingness to continue participation, and withdrawal of consent.

Interventions

The schema therapy intervention consisted of eight sessions based on Young's protocol (Young et al., 2003). The sessions included introduction to the treatment structure, coping styles, schema modes, validation of early emotional experiences, cognitive and experiential techniques, imagery rescripting, empathic confrontation, strengthening of healthy modes, and planning of adaptive target behaviors. The intervention was delivered according to a predefined session outline to improve procedural consistency across participants. The intensive short-term dynamic psychotherapy intervention consisted of fifteen sessions and was organized according to core ISTDP principles (Abbass et al., 2012; Davanloo, 2000). The first session included treatment rules and an initial trial therapy interview. Subsequent sessions focused on identifying and challenging tactical defenses, including vague language, indirect speech, intellectualization, rumination, rationalization, generalization, distraction, denial, externalization, ambiguity, procrastination, obsessive doubt, somatization, acting out, defiance, defensive crying, and other regressive defenses. The final sessions were used to consolidate treatment gains and plan follow-up assessment. Treatment content was also organized around a predefined therapeutic sequence; however, no independent treatment-fidelity rating was conducted.

Measure

Psychological resilience was assessed using the Connor-Davidson Resilience Scale (CD-RISC; Connor & Davidson, 2003). The scale includes 25 items scored on a five-point Likert scale from 0 to 4. It assesses personal competence, tolerance of negative affect, positive acceptance of change, self-control, and spiritual influences. Higher scores indicate greater resilience. In previous Iranian validation work, acceptable reliability has been reported (Khoshouei, 2009). In the present study, Cronbach's alpha for the scale was 0.742.

Ethical Considerations

The study was reviewed and approved by the Ethics Committee of Islamic Azad University, Neyshabur Branch (IR.IAU.NEYSHABUR.REC.1403.039). Participation was voluntary, and written informed consent was obtained from all participants. Participants were informed that they could withdraw from the study at any stage without penalty. The confidentiality of participant information was maintained during data collection, analysis, and reporting.

Statistical Analysis

Data were analyzed using descriptive statistics, repeated-measures analysis of variance, and Bonferroni post hoc tests in SPSS version 27. Normality was assessed using the Shapiro-Wilk test, homogeneity of variances using Levene's test, and equality of covariance matrices across repeated measures using Mauchly's test of sphericity. Statistical significance was set at P < 0.05. Effect sizes were reported as partial eta squared (ηp²), and pairwise comparisons were interpreted using Bonferroni-adjusted probability values. B

Results

The mean ages of participants in the intensive short-term dynamic psychotherapy, schema therapy, and control groups were 36.67, 36.80, and 35.93 years, respectively. One-way analysis of variance showed no significant age difference among the three groups (F = 0.909, P = 0.411). In the intensive short-term dynamic psychotherapy group, 80.0% of participants were women and 20.0% were men. In both the schema therapy and control groups, 73.3% were women and 26.7% were men.

Table 1 presents the mean and standard deviation of psychological resilience by group and measurement stage. Baseline scores were similar across the three groups. After treatment, resilience increased in both intervention groups but remained nearly unchanged in the control group. The gains in the intervention groups were maintained at the three-month follow-up.

The assumptions required for repeated-measures analysis were examined. The Shapiro-Wilk test indicated that the distribution of the study variable was acceptable at the evaluated stages and groups. Levene's test supported homogeneity of variances, and Mauchly's test indicated that the covariance assumption for repeated measures was satisfied.

Repeated-measures analysis showed significant main effects of group and time and a significant group-by-time interaction for psychological resilience (Table 2). The effect sizes were interpreted as partial eta squared values, indicating large effects for group, time, and the group-by-time interaction.

Bonferroni comparisons showed that resilience scores increased significantly from pretest to posttest and from pretest to follow-up. The difference between posttest and follow-up was not statistically significant, indicating that the improvement remained stable over time.

Group comparisons indicated no significant difference among groups at pretest. At posttest and follow-up, both intervention groups differed significantly from the control group. However, schema therapy and intensive short-term dynamic psychotherapy did not differ significantly from each other at either posttest or follow-up.

Discussion

The present study compared the effectiveness of schema therapy and intensive short-term dynamic psychotherapy on psychological resilience in kidney patients. The findings showed that both interventions significantly improved resilience compared with the control condition. The effect was maintained at the three-month follow-up, suggesting that the therapeutic gains were not limited to immediate posttreatment assessment. However, the two active treatments did not differ significantly from each other. Therefore, the hypothesis that one treatment would be superior to the other for improving resilience was not supported. The effectiveness of intensive short-term dynamic psychotherapy may be explained by its focus on emotional processing and defense restructuring (Abbass et al., 2012; Davanloo, 2000). Kidney patients may experience fear, anger, helplessness, sadness, or uncertainty related to disease progression and treatment burden (Cogley et al., 2022; Knowles et al., 2023). When such emotions are avoided or defended against, psychological distress may become chronic and coping capacity may decline. By helping patients recognize defenses and directly process previously avoided emotions, intensive short-term dynamic psychotherapy can increase tolerance of anxiety, strengthen emotional awareness, and improve adaptive coping. These processes are closely related to resilience because resilient functioning requires the capacity to experience stress without becoming overwhelmed or rigidly avoidant.

The effectiveness of schema therapy may be explained by its focus on early maladaptive schemas and coping modes (Young et al., 2003). Chronic illness can activate deeply rooted beliefs related to vulnerability, defectiveness, dependence, failure, emotional deprivation, or loss of control. Such schemas may influence how patients interpret medical symptoms, treatment demands, interpersonal support, and future prospects. Schema therapy helps patients identify these patterns, challenge maladaptive beliefs, and strengthen the healthy adult mode. This may improve perceived self-efficacy, emotional stability, and flexible problem-solving, all of which contribute to psychological resilience.

Although the two treatments differ in their theoretical foundations and techniques, both may converge on common therapeutic outcomes relevant to resilience. Both approaches can increase self-awareness, reduce maladaptive avoidance, improve emotional regulation, and support more adaptive responses to stress (Abbass et al., 2012; Young et al., 2003). The absence of a significant difference between the two active treatments may also be related to the relatively small group sizes, the shared nonspecific therapeutic factors common to structured psychotherapy, and the possibility that resilience is influenced by broad emotional regulation and coping processes rather than by one treatment-specific pathway alone. In clinical settings, the choice between schema therapy and intensive short-term dynamic psychotherapy may therefore depend on patient preference, therapist training, treatment availability, and the dominant psychological difficulties presented by the patient. The results have practical implications for psychological care in kidney patients. Routine medical care often focuses primarily on biological markers, dialysis schedules, medication adherence, and physical complications. However, the present findings support the inclusion of structured psychological interventions as part of comprehensive kidney care. Strengthening resilience may help patients maintain treatment engagement, tolerate uncertainty, and preserve functioning despite chronic illness demands. These implications are exploratory and require confirmation in larger randomized studies with clinically characterized renal subgroups and active attention-control conditions.

This study has several limitations. First, the sample size was relatively small and was selected by convenience sampling from kidney patients in one city, which limits generalizability. Second, no formal a priori power analysis was reported, and the sample size should therefore be interpreted as feasibility-based. Third, resilience was measured using a self-report questionnaire; future studies should include clinical interviews, observer-rated measures, and behavioral indicators of adaptation. Fourth, the follow-up period was limited to three months. Longer follow-up periods are needed to determine whether treatment effects remain stable over six months or one year. Fifth, the study did not include blinding, an attention-control condition, or independent treatment-fidelity assessment. Sixth, detailed clinical kidney-related variables such as CKD stage, dialysis modality, disease duration, comorbid diabetes or hypertension, and medication status were not analyzed. Seventh, the study was not prospectively registered as a clinical trial. Finally, the study did not examine potential mediators such as emotion regulation, schema change, defense mechanisms, or treatment alliance. Future research should use multicenter randomized designs, larger samples, longer follow-up periods, clinical kidney-related indicators, and mediation analyses to clarify how each treatment improves resilience. A central limitation is that the design cannot separate treatment-specific effects from nonspecific therapist contact, expectancy effects, or repeated-assessment effects. In conclusion, within the limits of a small feasibility-based quasi-experimental study, Young's schema therapy and intensive short-term dynamic psychotherapy were both associated with improvements in self-reported psychological resilience among kidney patients compared with a no-treatment control condition. No statistically significant difference was observed between the two active treatments at posttest or follow-up; however, this finding should not be interpreted as evidence of equivalence because the study was not designed as an equivalence trial and the two interventions differed in treatment dose. Future studies should use larger randomized samples, active control conditions, treatment-fidelity monitoring, renal clinical indicators, and longer follow-up periods.

Declarations

Ethics Approval and Consent to Participate

This study was approved by the Ethics Committee of Islamic Azad University, Neyshabur Branch (IR.IAU.NEYSHABUR.REC.1403.039). Written informed consent was obtained from all participants before enrollment.

Authors' Contributions

This article was extracted from the doctoral dissertation of the first author. Shirin Esmaili contributed to study implementation, data collection, initial analysis, and manuscript drafting. Mustafa Bolghan-Abadi supervised the study, contributed to conceptualization and methodology, and critically revised the manuscript. Ahmad Mansouri served as advisor and contributed to interpretation of findings and critical revision of the manuscript. All authors read and approved the final version of the manuscript.

Funding

The authors received no specific grant from any public, commercial, or not-for-profit funding agency for this research.

Conflict of Interest

The authors declare that they have no conflict of interest.

Data Availability

The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request, subject to ethical and privacy restrictions.

Artificial Intelligence Statement

Artificial intelligence tools were used only for language editing, formatting, and consistency checking during manuscript preparation. The authors reviewed, revised, and approved the final manuscript and take full responsibility for the accuracy, integrity, and originality of the submitted work.

Acknowledgments

The authors thank the patients who participated in this study and all individuals who assisted with implementation of the intervention sessions.