7 October 2026
Through a process called cognitive reappraisal, cognitive behavioral therapy (CBT) helps patients change negative processing of their emotions. In contrast, schema therapy (ST), an emerging treatment, actively encourages and supports patients in expressing their emotions. Another pillar of ST theory is that healthy attachment is essential during childhood, and that maladaptive cognitions and behaviors arise when this need is not met. Accordingly, attachment styles play a large role in ST, but a smaller role in CBT.
It stands to reason, then, that CBT and ST target different mechanisms of change. In a recently published study, the research team led by Samy Egli and Theresa Badenbach from the Max Planck Institute of Psychiatry in Munich and Johannes Kopf-Beck from the Ludwig-Maximilians-University Munich, together with researchers from the University of Liverpool and the University of Amsterdam, analyzed data from a clinical trial which was conducted at the Max Planck Institute. In this trial, 198 patients were randomly assigned from inpatient and day-clinic settings to receive either CBT or ST for seven weeks. The researchers then measured attachment, cognitive reappraisal, emotional suppression and overall depressive symptoms after these seven weeks, as well as six months after the end of treatment.
The results showed: In all participants, depressive symptoms decreased, on average from a severe to mild intensity. In addition, emotional suppression, anxious attachment and avoidant attachment decreased, while cognitive reappraisal increased in all participants. For all outcomes, there was no significant difference between the two groups – CBT and ST seem to work equally well on the chosen mechanisms and depressive symptoms.
Interestingly, against the hypotheses of the research team, the investigated mechanisms did not precede the improvements in depressive symptoms – in contrast, analyses showed that increased cognitive reappraisal and reduced emotional suppression actually occurred after symptom improvement. This suggests that they are not, in fact, mechanisms through which psychotherapy treats symptoms – but rather should be worked on once symptoms have improved. This observation should be verified in further studies.
“All in all, we showed that in psychiatric treatments including CBT or ST, emotion regulation and attachment as well as depressive symptoms were reduced”, says Samy Egli, Head of Psychology at the Max Planck Institute and co-lead author of the study. “We need more research in order to understand the exact mechanisms by which these improvements happen – this will help us to better target the type of psychotherapy to the patient’s needs in the future and to reduce psychological distress more quickly and more effectively”.
Egli, S., T. Badenbach, A. van Emmerik, A. Stefan, OPTIMA Study Group, and J. Kopf-Beck. 2026. “ Mechanisms of Change in the Treatment of Depression: On the Role of Attachment, Reappraisal and Suppression.” Clinical Psychology & Psychotherapy 33, no. 5: e70345. https://doi.org/10.1002/cpp.70345.