Introduction
Personality disorders are persistent psychological disorders characterized by maladaptive patterns of emotion, cognition, and interpersonal relationships (APA, 2022). Among these, dependent personality disorder—which falls within Cluster C—is characterized by an intense need for support, fear of abandonment, difficulty making independent decisions, and submissive behaviors (Hansen et al., 2024). Affected individuals tend to refrain from voicing disagreement and instead allocate responsibility for significant decisions to others, thereby fostering close relationships. In addition to the aforementioned reduction in personal autonomy, these characteristics have been associated with anxiety, depression, emotion regulation problems, and unhealthy relationships (d'Huart et al., 2023).
Research indicates that the clinical features of dependent personality disorder are associated with early maladaptive schemas, including dependency/inadequacy, abandonment, and obedience (Salgó et al., 2021). These schemas are formed during childhood and persist in adulthood as stable cognitive and emotional patterns. In recent years, schema therapy has been introduced as one of the effective approaches in the treatment of personality disorders (Zhang et al., 2023). The development of this approach has led to the creation of contextual schema therapy, which incorporates the classic tenets of schema therapy along with the concepts of mindfulness, acceptance, and psychological flexibility (Roediger & Stevens, 2019). In this approach, schema modes are considered active emotional-cognitive states in the present, and the therapist tries to correct maladaptive patterns through emotional acceptance, cognitive distancing, limited reparenting, and strengthening the "healthy adult" mode (Roediger et al., 2018).
Despite the numerous studies conducted in the field of schema therapy, there is a paucity of research examining the effectiveness of contextual schema therapy on dependent personality disorder. To date, no research on this topic has been reported from Iran. Therefore, the present study aimed to investigate the effectiveness of contextual schema therapy on the improvement of clinical features and maladaptive schemas in individuals with dependent personality disorder.


Method
The present study was quasi-experimental in nature, employing a pre-test, post-test, and three-month follow-up design with the inclusion of a control group. The statistical population comprised patients referred to psychotherapy and psychiatric centers in Mashhad. The sample population comprised 24 individuals diagnosed with dependent personality disorder. These individuals were selected purposively based on power analysis and randomly assigned to an experimental and a control group (12 people in each group) (Borm et al., 2007). The diagnosis of dependent personality disorder was determined through the utilization of two primary instruments: the Structured Clinical Interview for DSM-5-TR and the Millon Clinical Multiaxial Inventory-III (MCMI-III). The research instruments included a demographic questionnaire, the Millon Clinical Multiaxial Inventory-III, and the Young Schema Questionnaire – Short Form Version 3 (YSQ-S3). The reliability and validity of these instruments have been confirmed in previous studies (Calvete et al., 2005; Millon, 2011). The therapeutic intervention was designed based on the protocol of Roediger et al. (2018) and consisted of 16 individual 90-minute sessions held weekly. The control group did not receive any intervention during the course of the study. Data were analyzed using repeated-measures analysis of variance (ANOVA) and the Bonferroni post-hoc test. Prior to analysis, the statistical assumptions of normality, homogeneity of variances, and sphericity were examined and confirmed.
Findings
The descriptive results indicated that the two groups were homogeneous in terms of demographic characteristics, with no significant differences observed in age, gender, education, and marital status (P>0.05). Additionally, a comparative analysis revealed that the mean scores of clinical features and early maladaptive schemas in the experimental group exhibited a decline following the intervention, in contrast to the control group (P<0.05). The findings of the repeated measures analysis of variance revealed that contextual schema therapy significantly reduced clinical features associated with dependent personality disorder (η²= 0.77, p<0.001, F= 73.54). Additionally, the interaction effect of group and time was found to be significant (η²= 0.67, p<0.001, F= 44.26). In the context of maladaptive schemas, the outcomes of the Wilks' lambda test demonstrated a substantial discrepancy in the impact of time (P<0.001, F= 7.57, Wilks' lambda= 0.07), group (P<0.001, F= 26.74, Wilks' lambda= 0.01) , and the interaction of time and group (P<0.001, F= 7.89, Wilks' lambda= 0.03). The effect sizes of the variables ranged from 0.29 to 0.77, indicating moderate to high effectiveness of the intervention. The results of the Bonferroni test further demonstrated that in the experimental group, there was a significant decrease in scores from the pre-test to the post-test and follow-up phases (p<0.01). However, no significant difference was observed between the post-test and the follow-up (p>0.05). These findings suggest that the treatment effects remain stable during the three-month follow-up period.
Discussion
The findings of the present study demonstrated that the implementation of contextual schema therapy can lead to a reduction in clinical features and maladaptive schemas in individuals diagnosed with dependent personality disorder. These results are consistent with the findings of previous studies on the effectiveness of schema-based therapies (Wibbelink et al., 2023; Zhang et al., 2023). This finding can be explained by the presence of schemas in individuals with dependent personality disorder, which are activated in emotional and interpersonal situations, perpetuating dependent and avoidant behaviors. Contextual schema therapy, which utilizes techniques such as mindfulness, emotional acceptance, and cognitive restructuring, assists clients in identifying and modifying their maladaptive patterns. This process has been shown to enhance psychological flexibility, fortify the healthy adult mode, and mitigate emotional dependency (Hayes & King, 2024). The findings suggest that contextual schema therapy can be used as an effective intervention in psychotherapy and counseling centers. Notwithstanding the positive outcomes, the study's limitations—namely the modest sample size and short follow-up duration—should be addressed in future research. Consequently, it is recommended that subsequent studies assess the efficacy of this intervention in larger samples and with extended follow-up periods.