Group‐based schema therapy for difficult‐to‐treat depression: A qualitative evaluation of active ingredients

OBJECTIVES: Difficult-to-treat depression (DTD) is characterized by persistent symptoms despite adequate prior treatment. Group-based schema therapy (GST) is increasingly used in this population, yet empirical knowledge of its active ingredients remains limited. DESIGN: This qualitative study explored patients' perspectives on factors facilitating or hindering recovery during GST. METHODS: Semi-structured interviews were conducted with 13 patients with DTD after completing GST and analysed using inductive thematic analysis. Transcripts were independently coded by different researchers until consensus and data saturation were reached. RESULTS: Facilitating factors included group processes such as cohesion, mutual support and experiencing recognition, experiential techniques, including imagery and chair work, and therapists' active engagement. Increased awareness of maladaptive schema modes, particularly the critical mode, and strengthening adaptive modes were also perceived as beneficial. Barriers included difficult group dynamics, the burden of homework and the complexity of the schema model. Beyond common group therapeutic factors, patients identified experiential techniques as central to GST effectiveness. CONCLUSIONS: By altering dysfunctional patterns, evoking corrective emotional experiences and promoting the Healthy Adult mode, GST supported recovery in patients with DTD. These findings are consistent with previous research on (group) ST for other disorders and offer guidance for further refinement and tailoring of GST for DTD.