(Vi)-rushed Into Online Group Schema Therapy Based Day-Treatment for Older Adults by the COVID-19 Outbreak in the Netherlands

Highlights • Therapists were positively surprised by the online capabilities and resilience of older patients to adapt to the online treatment program. Prejudices on limited effectiveness of online psychotherapy in older adults were counteracted.• COVID-19 related social distancing measures appeared to trigger feelings of rejection in patients with borderline personality traits, while it falsely validated indoor behavior of patients with avoidant personality traits.• Patients felt being taken seriously, especially because during the online group sessions they all received detailed comments on their homework (sent by email and discussed online).• Where the nonverbal sessions initially felt relaxing and fun, patients told us that these sessions also stimulated their mutual responsiveness (in schema therapy language “facilitated their happy child mode”).


INTRODUCTION
A fter the World Health Organization declared the COVID-19 outbreak a pandemic on March 11, 2020, mental healthcare providers in the Netherlands restricted face-to-face contacts to emergency cases only. Societal measures like social distancing and self-isolation are important for older persons as they face the highest COVID-19 mortality rates. But lack of time spent with others may lead to more loneliness and an increase in affective symptoms. 1 The need to switch to online health therapies for this patient group is therefore self-evident.
As e-health services are gradually growing in mental healthcare, geriatric psychiatry departments are generally lagging, based on assumptions that older persons lack necessary computer skills and are not familiar with the online world. 2,3 Converting our Schema-Therapy-based day-treatment into an online program was also challenging as online psychotherapy generally focusses on individual (verbal) psychotherapy sessions. 2,4 Our program is based on verbal and nonverbal group activities, given twice per week over a 20-week period. The program is entirely based on schema therapy and aims to treat older (≥60 years) persons suffering from chronic and/or treatment resistant affective disorders and comorbid personality problems. Schema therapy is an integrative treatment approach that combines cognitive, behavioral, experiential, and psychoanalytic therapy techniques into one therapy model. Schema therapy is an evidencebased treatment for borderline personality disorders, and has been adapted for other disorders, including late-life affective disorders. 5 The COVID-19 pandemic forced us to develop online schema therapy. In doing so, we were able to continue to provide online group sessions.
The objective of this paper is to present first impressions on feasibility of transforming a psychotherapy day-treatment program for older persons into an online program.

Participants
Our day-treatment was originally developed for patients aged 60 years and older suffering from an affective disorder (depressive, anxiety or somatic symptom), with comorbid personality problems considered to maintain affective symptoms and/or predispose for relapse. The standard intake procedure at our outpatient clinic includes psychiatric and neurocognitive diagnostics. Patients referred to day-treatment are additionally assessed with the SCID-5-PD to assess the presence of a personality disorder according to DSM-5 criteria and fill out the 118-item self-report Schema Mode Inventory (SMI 6 ) and the 205-item self-report Young Schema Questionnaire (YSQL2 7 ). The SMI measures 14 different schema modes, that is, momentary states triggered by the actual circumstances and interactions. The YSQL2 quantifies the presence of 16 different schemas that are presumed to have their origin in the patients' youth.
For the treatment to be effective, a patient has to have introspective abilities and the desire to change. These preconditions are assessed by a psychologist pretreatment. During treatment, progress is evaluated every 4 weeks with the patient and their relatives. In this paper, we describe 4 patients who started the online day-treatment together. All patients went through the normal outpatient intake procedure. For 2 patients the whole pretreatment phase was conducted online.

Treatment Program
Our psychotherapy day-treatment program is based on the schema therapy framework. In geriatric psychiatry, we focus on three (instead of five) most prominent maladaptive schemas to minimize cognitive burden. 8 Treatment is given twice weekly in an open group, with a maximum of 8 patients at the same time over a 20-week period. To maintain a safe treatment environment, treatment adherence is considered mandatory and has been discussed prior to start.
Treatment days are comprised of verbal and nonverbal therapies ( Table 1). All therapists (psychologists, nurse practitioner, art therapist and psychomotor therapist) have been trained in schema therapy. During sessions, the walls are conventionally covered with posters of the patients presenting their three most prominent, maladaptive schemas. All expressions, emotions, and behavior are interpreted within the schema therapy framework with reference to the patients' own schema's and modi.
(Vi)-rushed Into Online Group Schema Therapy Based Day-Treatment for Older Effectiveness of treatment is monitored by the 30item Inventory of Depressive Symptoms, the Geriatric Anxiety Inventory, the Whitley Index (measuring hypochondriasis), in addition to the YSQL2 and SMI at baseline, halfway treatment (10 weeks) and end of treatment (20 weeks).
Individual contacts are restricted to medication check-ups with a psychiatrist and monthly evaluation visits (patient and their relatives).

Transformation Into an Online Program
The original program was transformed into an online program using "Webex," with minimal changes. Prior to commencement of the online group therapy, the therapy manual was sent by mail (including all forms, information sheets, and questionnaires) as well as the material needed for art therapy. The nurse-practitioner called the patient to setup and test Webex. The psychologist ensured the patients understood and obeyed privacy rules. Privacy rules included the use of a specific therapy room (no living or bedroom), no other people in that room during therapy and no recordings.
The nonverbal components (art therapy, psychomotor therapy) were reduced in length, and behavioral therapy (given after a session of cognitive therapy) was replaced by an additional psychomotor therapy session (see Table 1). Psychomotor therapy focuses on the bodily experiences in interaction, contact, and emotions.
Since online group therapy hampers informal patient-therapist contact, we added one individual session per week to jointly monitor the patient's process.

Patient Characteristics
Three female and one male patient aged between 64 and 70 years participated. Psychiatric diagnoses were 1) recurrent, mild depressive disorder, and borderline personality disorder, 2) generalized anxiety disorder, 3) recurrent depressive disorder, panic disorder, and avoidant personality disorder with narcissistic features, and 4) recurrent depressive disorder and a personality disorder NOS with borderline, avoidant, and schizotypical features.

Experiences of Patients
Thus far, treatment adherence was 100%. Patients felt being taken seriously (see quotes, supplemental digital material). First, because during the online group sessions they all received detailed comments on their homework (sent by email and discussed online). Second, by having brief weekly individual contacts (either by phone or video call) with one of the therapists. While individual contacts with therapists are restricted as much as possible during our regular day-treatment program, such contacts are still quite normal during coffee breaks and lunches.
Where the nonverbal sessions initially felt relaxing and fun, patients told us that these sessions also stimulated their mutual responsiveness (in schema therapy language "facilitated their happy child mode").
After two weeks, patients reported to lack informal contact with each other. Since face-to-face day therapy offers many informal contact moments, we added a so called "break out time" without the presence of a therapist.

Experiences of Therapists
In the (diagnostic) pretreatment phase, no alterations appeared to be necessary. Mutual acquaintance, checking motivation for change and mentalization capabilities and setting up the individual treatment plan ran smoothly by videoconferencing.
Therapists had time to prepare the psychotherapy sessions, as they received homework per email and thus were able to challenge maladaptive thoughts and behavior more efficiently. While therapists considered the digital whiteboard as helpful, patients preferred to remove the whiteboard as its use reduced the size of the patients' webcam feeds.
After patients got comfortable with working online and became more responsive to each other, the group schema therapy also ran smoothly. Therapists felt that experiential interventions, like guided imagination, were well received.
The psychomotor therapy turned out to be much easier than expected, active movements (gymnastics), relaxation, and mindful exercises (e.g., Tai Chi) were well received by the patients. The shared-screen (Vi)-rushed Into Online Group Schema Therapy Based Day-Treatment for Older functions enabled patients to participate in imaginary experiential experiences like touching "through the screen" or practicing with proximity/distance by moving toward/away from the screen.

CONCLUSION
To our knowledge, no papers on an online multidisciplinary day-treatment program for older adults have been reported. Therapists were initially skeptical regarding feasibility but were ultimately more than satisfied with the results of our online program (see quotes supplemental digital content). The first eligible patients were all prepared to take part and communicate online. However, our patients were relatively well-educated and could be classified as "younger-old," which limit firm conclusions with respect to feasibilty. On the other hand, participation only requires basic e-mail skills and 98% of households in the Netherlands have a broadband internet connection.
Schema therapy is considered most effective in groups, as patients trigger maladaptive schemas in each other. 9 During online therapy, we experienced that a brief internet disruption, disconnecting a patient for a few minutes from the group, already triggered the feeling of being rejected. Furthermore, COVID-19 related social distancing measures appeared to trigger feelings of rejection in patients with borderline personality traits, while it falsely validated indoor behavior of patients with avoidant personality traits.
Sending homework for the verbal therapies as well as exercises for the nonverbal therapies the day before the session enabled us to conduct therapy more efficiently. This might increase adherence to the therapy protocol and even enhance effectiveness.
The outbreak of COVID-19 pushed us to overcome all prejudices toward online (group) psychotherapy. 10 Important lessons we learned were 1) digital literacy of older persons is sufficient for online therapy, 2) brief individual contact is important to monitor the patients' process, and 3) nonverbal therapies as well as informal break-out time facilitates the group therapy process. We hope that our positive experience will motivate others to start such initiatives when face-to-face day-treatment is not possible and will motivate researchers to further study its effectiveness.