Effectiveness of Integrated Treatment Focused on Schema and Cinema Therapy in the Treatment of Avoidant Personality Disorder

Studies have estimated the percentage of people with personality disorders in the entire population to be close to 10% and in some cases 25% (1). Meanwhile, avoidant personality disorder is a relatively common disorder, which has an estimated prevalence of approximately 2.4% in the entire population (2). Avoidant personality disorder, such as borderline personality disorder, has a lot of similarities with other personality disorders and axis one disorders, especially mood disorders, anxiety and physical symptoms (1). Patients with avoidant personality disorder are not able to focus on the therapeutic relationship, and avoidance makes the process of attracting therapeutic participation in them due to the transference and cross-transference processes a difficult and long task (6).
In this regard, and in recent years, schema therapy has entered the field of psychotherapy as a method for treating complex psychological problems and has expanded greatly (8). Schema therapy is an integrated and multifaceted approach that considers the psychological elements that make up personality traits as a result of the combination of emotional temperament with basic emotional needs and early childhood experiences that are perpetuated through confirmation bias, ineffective coping styles and manifest themselves in adult life (9).
On the other hand, from the perspective of schema therapy, art therapy methods, including cinema therapy, can be conceptualized as "schema stimulation techniques" that may be more difficult to reach through conventional treatments. Cinematherapy is one of the contemporary cognitive approaches, and is considered as a creative intervention, in which the therapist uses watching a movie as a metaphor to promote awareness and change. As an indirect and non-verbal cognitive approach, cinema therapy can stimulate people's thinking and feelings (13) and act as a tool to bring out the hidden aspects of the emotional world of patients, which is similar to the use of dreams in the psychoanalytic approach to penetrate deep into the psyche (12).
Examining the research records related to the research topic showed that the schema therapy approach is effective in the treatment of avoidant personality disorder (14, 8) and other personality disorders (15, 16). Also, the research conducted on the effectiveness of cinema therapy on the improvement of psychological disorders has been reported by Raymond, Wibowo & Jafar (2018) (17) and Dunham & Dermer (2020) (18). Peled et al. (2017) showed in a research that 60 sessions of mindfulness-based schema therapy resulted in a significant reduction of symptoms in patients with cluster c personality disorders, including avoidant personality disorder (19). van den Broek et al. (2011) also reported in a study that was conducted using a single subject method; the combination of schema therapy and art therapies, including cinema therapy, is effective in invoking schema mentalities in people with personality disorders (13). According to the search conducted and the review of seminars, congresses and scientific-research journals of psychology, the point of interest compared to borderline personality disorder and other cluster c personality disorders is that, in the field of avoidant personality disorder treatment, especially single studies Subject, in the research background of Iran and the world, we are facing research poverty. Therefore, in the present research, the researcher intends to answer the question of whether schema therapy based on mentality and cinema therapy is effective in treating the symptoms of avoidant personality disorder?

The present study is of a single test with a multiple baseline design and three-month follow-up. The statistical population included all clients, ranging 20-35 years old, who referred to Armana Psychological services and counseling center from 11/01/1399 to 04/15/1400 (from 01/20/2021 to 07/06/2021). By a purposive sampling, four of the clients with psychiatric diagnose of avoidant personality disorder which were diagnosed by Millon Clinical Multiaxial Inventory and structured clinical interview for personality disorders were selected. The participants responded to the Millon Inventory at the base-line position, the seventh, fourteenth, twenty-first, twenty-eighth, and thirty-fourth session, and at three times with a month interval between each time after finishing the intervention. The treatment intervention was held in thirty-four sixty-minute sessions.

The data analysis was performed by visual analysis of the chart, recovery percentage, the effect size and reliable change index, and the percentage of overlapping and non-overlapping data. The three-month follow-up demonstrated that mentality-based schema therapy with cinema therapy significantly decreased the symptoms of avoidant personality disorder in the participants at the end of the treatment and follow-up.

The results of the present study show that clients have been successful in reducing the signs and symptoms of their avoidant personality traits. Therefore, it can be said that the client's score in treatment has changed to such an extent that his position has moved from the group of people with dysfunction due to avoidant personality disorder to the group of people with normal functioning. Regarding the percentage of improvement, considering that the scores of each person in the baseline have the role of the control group and the criterion is the comparison of the individual's own scores over time and at different stages before and during the intervention. is facing Therefore, it can be said that the first references have progressed reliably. Among the other reasons that can be stated to explain the lower rate of improvement of the first referral than the other three referrals is the presence of depressive personality disorder as a co-occurring disorder.
The results of the present research on the effectiveness of schema therapy and cinema therapy in reducing symptoms of avoidant personality disorder in sufferers are consistent with research (14, 19, 32). In explaining the above results, it should be said that patients with avoidant personality disorder do not feel comfortable in the communication and intimacy process when talking (Peld et al., 2017), which can be problematic in the treatment room and in their living environment due to avoidant behaviors. Schema therapy, which considers the therapeutic relationship as an essential part in all stages of treatment, uses two important characteristics and techniques of borderline parenting and empathic confrontation to satisfy the needs of damaged childhood (6).
On the other hand, we know that avoidance in all dimensions is one of the most important and dominant characteristics of people with avoidant personality disorder. Experiential (emotional) techniques used in schema therapy increase the efficiency of therapeutic techniques and subsequently increase positive treatment results. Watching your behavior pattern on the movie screen creates a perspective of your situation by maintaining the necessary emotional distance and away from the threat. This transient perception helps a person take a step back and see the past from behind (25). In order to explain the small recovery of the clients according to the findings of the research, it can be said that the treatment protocol based on Arntz's mentality (2012) for clients suffering from avoidant personality disorder, which is the main basis of the treatment program of this research, was developed in 50 sessions, the first 40 sessions of which are Its weekly and 10 final sessions include monthly reinforcement sessions. Even Arntz (2012) (30) and Yang et al. (2006) (10) suggest more sessions if needed. In other words, schema therapy for personality disorders is a long-term treatment and requires flexibility in the way of holding meetings, the number of meetings and the duration of meetings. Among the limitations of the current research, he pointed out the spread of the corona disease and the obstacles created related to this disease in the type and quality of therapeutic communication and the holding of meetings, as well as the lack of control of external variables affecting the treatment process; Therefore, to increase confidence in the results, it is suggested to repeat the research after the end of the Corona pandemic and without the obstacles mentioned in the limitations. Mentality-based schema therapy and cinema therapy could be effective in decreasing the symptoms of avoidant personality disorder.