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Functional Modes and Social Well-Being as a Protector of Mental Health during COVID-19

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Title: Functional Modes and Social Well-Being as a Protector of Mental Health during COVID-19
Language: English
Authors: Eline Lolkema, Karin Timmerman, Gert-Jan Prosman, Roel Pietersen, Gerben J. Westerhof
Source: British Journal of Guidance & Counselling. 2025 53(5):703-712.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 10
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Well Being, Coping, COVID-19, Pandemics, Personality Problems, Predictor Variables, Hospitals, Patients, Psychotherapy, Schemata (Cognition), Program Effectiveness, Resilience (Psychology), Foreign Countries
Geographic Terms: Netherlands
Assessment and Survey Identifiers: Brief Symptom Inventory
DOI: 10.1080/03069885.2025.2460836
ISSN: 0306-9885
1469-3534
Abstract: Objective: This study investigates how well-being and adaptive coping post-inpatient schema-focused therapy (SFT) predict mental health during COVID-19 in individuals with Personality Disorders (PD), 2-8 years after treatment. Method: Using a naturalistic, prospective within-subject design, 52 PD-diagnosed participants completed assessments post-treatment and at long-term follow-up, with 20 pre-COVID and 32 during COVID. Measures included Schema Mode Inventory, Mental Health Continuum Short Form, and Brief Symptom Inventory. Correlations and hierarchical multivariate regression were used. Results: COVID-19 was associated with lower social and psychological well-being. Social well-being at treatment completion and functional modes predicted changes. Conclusion: Inpatient SFT enhances long-term resilience by improving social well-being and functional modes, benefitting well-being during COVID-19. Clinical significance: COVID-19 has significantly impaired mental health, particularly for individuals with complex PD. This article seeks insight into factors that contribute to resilience in individuals with PD who underwent treatment 2-8 years prior, especially during stressful periods, like COVID-19.
Abstractor: As Provided
Entry Date: 2026
Accession Number: EJ1499289
Database: ERIC
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  Value: <anid>AN0190648268;bjg01oct.25;2026Jan06.06:05;v2.2.500</anid> <title id="AN0190648268-1">Functional modes and social well-being as a protector of mental health during COVID-19 </title> <p>Objective: This study investigates how well-being and adaptive coping post-inpatient schema-focused therapy (SFT) predict mental health during COVID-19 in individuals with Personality Disorders (PD), 2-8 years after treatment. Method: Using a naturalistic, prospective within-subject design, 52 PD-diagnosed participants completed assessments post-treatment and at long-term follow-up, with 20 pre-COVID and 32 during COVID. Measures included Schema Mode Inventory, Mental Health Continuum Short Form, and Brief Symptom Inventory. Correlations and hierarchical multivariate regression were used. Results: COVID-19 was associated with lower social and psychological well-being. Social well-being at treatment completion and functional modes predicted changes. Conclusion: Inpatient SFT enhances long-term resilience by improving social well-being and functional modes, benefitting well-being during COVID-19. Clinical significance: COVID-19 has significantly impaired mental health, particularly for individuals with complex PD. This article seeks insight into factors that contribute to resilience in individuals with PD who underwent treatment 2–8 years prior, especially during stressful periods, like COVID-19.</p> <p>Keywords: Personality disorders; positive psychology; COVID-19; inpatient schema-focused therapy; long-term follow-up</p> <hd id="AN0190648268-2">Clinical significance</hd> <p>A scientific brief from the WHO ([<reflink idref="bib47" id="ref1">47</reflink>]) on the impact of the COVID-19 pandemic on mental health reported a significant increase in mental health problems in the general population, specifically an increase in depressive disorders (27.6%), anxiety disorders (25.6%), suicidal thoughts (10.8%), suicide attempts (4.7%), and self-harm (9.6%). Additionally, access to proper mental health care was reduced (WHO, [<reflink idref="bib47" id="ref2">47</reflink>]). This indicates that the pandemic acts as a significant stressor for the general population. Although pre-existing mental health problems appear to be a risk factor, there is a lack of research on the pandemic's impact on individuals with mental illnesses, such as Personality Disorders (PDs). Preti et al. ([<reflink idref="bib33" id="ref3">33</reflink>]) suggested that individuals with PDs are particularly prone to be affected by the pandemic. PDs manifest themselves through impairment in self-regulation and interpersonal functioning, areas heavily impacted by the COVID-19 pandemic. This article investigates whether the effects of the pandemic are evident in individuals who have been in inpatient treatment for severe personality disorders before the pandemic.</p> <p>The prevalence of PDs worldwide is estimated at 6% (Tyrer et al., [<reflink idref="bib43" id="ref4">43</reflink>]). Among individuals with a PD, 40-80% have comorbid disorders such as mood and anxiety disorders, substance use disorders, and post-traumatic stress disorders (Davey, [<reflink idref="bib9" id="ref5">9</reflink>]; Samuels, [<reflink idref="bib36" id="ref6">36</reflink>]). Individuals with PD are likely to experience problems in interpersonal functioning which affects both the domestic and occupational areas of their lives (American Psychiatric Association, [<reflink idref="bib1" id="ref7">1</reflink>]; Davey, [<reflink idref="bib9" id="ref8">9</reflink>]; Ettner et al., [<reflink idref="bib15" id="ref9">15</reflink>]; Hengartner et al., [<reflink idref="bib20" id="ref10">20</reflink>]; Kvarstein et al., [<reflink idref="bib24" id="ref11">24</reflink>]; Lim et al., [<reflink idref="bib26" id="ref12">26</reflink>]; Skodol et al., [<reflink idref="bib38" id="ref13">38</reflink>]; Whisman et al., [<reflink idref="bib46" id="ref14">46</reflink>]). PDs also result in low scores on well-being and mental health, as well as high annual societal costs in different areas (Franken et al., [<reflink idref="bib16" id="ref15">16</reflink>]; Gustavsson et al., [<reflink idref="bib18" id="ref16">18</reflink>]; Hoffman et al., [<reflink idref="bib21" id="ref17">21</reflink>]; Luppa et al., [<reflink idref="bib29" id="ref18">29</reflink>]; Rössler et al., [<reflink idref="bib35" id="ref19">35</reflink>]; Soeteman et al., [<reflink idref="bib40" id="ref20">40</reflink>]; Soeteman et al., [<reflink idref="bib41" id="ref21">41</reflink>]). This emphasises the importance of effective, long-term treatment that enhances resilience in individuals with PDs enabling them to better cope with new stressors in their lives.</p> <p>Mental well-being is an important aspect of resilience. Mental health is characterised by both the absence of psychopathology and the presence of mental well-being (WHO, [<reflink idref="bib48" id="ref22">48</reflink>]). Beyond merely the absence of mental illness, mental well-being contributes to better functioning, increased productivity, resilience, improved stress recovery, and the prevention of mental problems (Bohlmeijer et al., [<reflink idref="bib4" id="ref23">4</reflink>]). Therefore, mental well-being is essential for mental health and functioning, particularly in stressful situations.</p> <p>Westerhof and Keyes ([<reflink idref="bib45" id="ref24">45</reflink>]) describe mental well-being as a combination of emotional, psychological, and social well-being. Emotional well-being refers to happiness and satisfaction with life, psychological well-being refers to positive individual functioning in terms of self-realisation, and social well-being refers to positive societal functioning and being of social value (Westerhof & Keyes, [<reflink idref="bib45" id="ref25">45</reflink>]). The well-being of individuals with PDs is found to be lower than that of healthy controls (Stanga et al., [<reflink idref="bib42" id="ref26">42</reflink>]), the general population (Franken et al., [<reflink idref="bib16" id="ref27">16</reflink>]), and individuals with a major depressive disorder without PDs (Skodol et al., [<reflink idref="bib38" id="ref28">38</reflink>]).</p> <p>Treatment can support individuals with PDs in reducing their pathology and promoting their mental well-being (Chakhssi et al., [<reflink idref="bib7" id="ref29">7</reflink>]). However, when individuals with PDs do not sufficiently benefit from outpatient treatment, they are often referred to inpatient treatment (Reiss et al., [<reflink idref="bib34" id="ref30">34</reflink>]; Schaap et al., [<reflink idref="bib37" id="ref31">37</reflink>]; Wolterink & Westerhof, [<reflink idref="bib49" id="ref32">49</reflink>]). This provides more intensive opportunities for individuals with complex PDs to address their problems, as the environment of the setting, including social workers and fellow clients, is also considered a therapeutic factor (Muste et al., [<reflink idref="bib30" id="ref33">30</reflink>]).</p> <p>Schema-Focused Therapy (SFT) is one of the preferred choices for evidence-based treatment of PDs (GGZ Standaarden, [<reflink idref="bib17" id="ref34">17</reflink>]; Jacob & Arntz, [<reflink idref="bib22" id="ref35">22</reflink>]; Tyrer et al., [<reflink idref="bib43" id="ref36">43</reflink>]; Young et al., [<reflink idref="bib52" id="ref37">52</reflink>]). Within this framework, focussing on decreasing dysfunctional modes and increasing functional modes is considered best practice for individuals with severe PDs (Young, [<reflink idref="bib50" id="ref38">50</reflink>]). Functional schema modes, i.e. healthy ways of emotional expression, behaviour, and adaptation (Claassen & Pol, [<reflink idref="bib8" id="ref39">8</reflink>]; Wolterink & Westerhof, [<reflink idref="bib49" id="ref40">49</reflink>]) are especially important in inpatient settings, as they are related to changes in both pathology and well-being (Phagoe et al., [<reflink idref="bib32" id="ref41">32</reflink>]; Schaap et al., [<reflink idref="bib37" id="ref42">37</reflink>]; Wolterink & Westerhof, [<reflink idref="bib49" id="ref43">49</reflink>]). These studies also found a small but significant relapse six months after treatment. However, there is a lack of knowledge about how treatment results at the end of treatment can predict long-term mental health, especially in times of stress, such as during the COVID-19 pandemic.</p> <p>Several studies found that individuals with complex, chronic mental health problems, including personality disorders, experienced increased mental health issues during the COVID-19 pandemic (Castelein et al., [<reflink idref="bib6" id="ref44">6</reflink>]; De Lange et al., [<reflink idref="bib13" id="ref45">13</reflink>]; Heidari et al., [<reflink idref="bib19" id="ref46">19</reflink>]; Preti et al., [<reflink idref="bib33" id="ref47">33</reflink>]). The pandemic negatively impacted their lives due to missed social interactions, drastically altered daily routines and increased stress at home during lockdowns. However, some studies also reported positive effects of the COVID-19 pandemic, such as fewer external stimuli, reduced interactions with others, and more time for reflection (Castelein et al., [<reflink idref="bib6" id="ref48">6</reflink>]; De Lange et al., [<reflink idref="bib13" id="ref49">13</reflink>]; Heidari et al., [<reflink idref="bib19" id="ref50">19</reflink>]). A systematic review by Di Stefano et al. ([<reflink idref="bib14" id="ref51">14</reflink>]) found a negative impact on individuals with PDs due to the COVID-19 pandemic. Generally, dysfunctional and negative personality traits were found to be positively correlated with worse mental health during COVID-19, while functional personality traits were positively correlated with better mental health outcomes. This indicates that healthy and adaptive coping patterns may improve mental health during a significant stressor like a pandemic.</p> <hd id="AN0190648268-3">Objective</hd> <p>The current study examines the impact of the pandemic on individuals who have been in inpatient treatment for severe PDs years before COVID-19. The study can be considered a natural experiment as the pandemic coincided with a study on the long-term effects, 2–8 years after being in inpatient SFT. Part of the participants were assessed shortly before the pandemic, and others during its initial months. This enabled an evaluation of whether differences in psychopathology and well-being exist between these two groups. Furthermore, data on functional modes, psychopathology, and well-being were available to predict levels at the long-term follow-up. This facilitated an assessment of whether modes and well-being at the end of treatment relate to levels of well-being and psychopathology at long-term follow-up. The third and final research question pertains to how the pandemic affects the relation between the end of treatment and the follow-up two to eight years after treatment.</p> <hd id="AN0190648268-4">Method</hd> <p></p> <hd id="AN0190648268-5">Design</hd> <p>This study had a naturalistic, prospective within-subject design. Data collection spanned from 2012 and 2020 at five measurement points: pre-treatment, intermediate (after six months of treatment), post-treatment (after one year of treatment), 6-month follow-up, and long-term follow-up (LFU; 2–8 years after treatment completion). This study focused on the post-treatment and LFU data. Part of the data were previously utilised in earlier publications (Phagoe et al., [<reflink idref="bib32" id="ref52">32</reflink>]; Schaap et al., [<reflink idref="bib37" id="ref53">37</reflink>]; Wolterink & Westerhof, [<reflink idref="bib49" id="ref54">49</reflink>]). The current study raised the number of participants from 65 (Schaap et al., [<reflink idref="bib37" id="ref55">37</reflink>]) and 106 (Wolterink & Westerhof, [<reflink idref="bib49" id="ref56">49</reflink>]; Phagoe et al., [<reflink idref="bib32" id="ref57">32</reflink>]) to 148 and added a long-term follow-up. Lolkema ([<reflink idref="bib28" id="ref58">28</reflink>]) conducted an initial analysis of the long-term follow-up, without Covid-19 as the primary focus.</p> <p>The study received approval from the Ethics Committee of the Faculty of Behavioural Sciences at the University of Twente (request number 18883).</p> <hd id="AN0190648268-6">Participants</hd> <p>Participants in inpatient SFT were asked to participate in the study, with 148 clients agreeing to participate at the beginning of their treatment (pre-measurement, see Figure 1). They were subsequently invited to complete questionnaires at each following measurement point, even if they did not participate in one or more of the former measurement moments. At post-treatment, there were 121 participants. The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available.</p> <p>Graph: Figure 1. Flowchart of sample selection.</p> <p>An inclusion criterion for the LFU was a minimum of six months of treatment and at least 2 years post-treatment. Out of 122 eligible participants, 52 participated both at the end of treatment and at LFU two to eight years later. Among these 52 participants, 20 responded on the LFU before COVID-19, and 32 responded on the LFU during COVID-19. The demarcation between before and during COVID is set on March 1, 2020. The mean time of the LFU measurement was 5.13 (SD = 1.84) years after the end of treatment, with a minimum of 1.69 and a maximum of 7.85 years. Table 1 shows the sample characteristics at post-treatment between responders and non-responders of the LFU. There were no differences in gender, age, well-being, and functional modes at post-treatment.</p> <p>Table 1. Sample characteristics at post-treatment between responders and non-responders of the long-term follow-up (percentages and means (SD)).</p> <p> <ephtml> <table><thead valign="bottom"><tr><td /><td>Post-treatment only (<italic>N</italic> = 69)</td><td>Long-term follow-up (<italic>N</italic> = 52)</td></tr></thead><tbody><tr><td>Gender</td><td>21.7% men 78.3% women</td><td>28.8% men 71.2% women</td></tr><tr><td>Mean age</td><td>26.66 (6.6)</td><td>26.52 (6.9)</td></tr><tr><td>Mean duration of treatment</td><td>42.42 (16.8)</td><td>49.04 (13.89)</td></tr><tr><td>Completion of treatment</td><td>68.1%</td><td>86.5%</td></tr><tr><td>Emotional well-being post-treatment</td><td>2.73 (1.24)</td><td>2.86 (1.20)</td></tr><tr><td>Social well-being post-treatment</td><td>1.95 (1.01)</td><td>2.03 (1.15)</td></tr><tr><td>Psychological well-being post-treatment</td><td>2.88 (1.20)</td><td>3.03 (1.06)</td></tr><tr><td>Functional modes post-treatment</td><td>72.50 (14.72)</td><td>74.96 (15.01)</td></tr></tbody></table> </ephtml> </p> <hd id="AN0190648268-7">Materials</hd> <p></p> <hd id="AN0190648268-8">Mental health continuum – short form (MHC-SF)</hd> <p>The MHC-SF is a 14-item self-report questionnaire that measures mental well-being, divided into emotional, psychological, and social well-being (Keyes, [<reflink idref="bib23" id="ref59">23</reflink>]). The Dutch version of the MHC-SF has been validated by Lamers et al. ([<reflink idref="bib25" id="ref60">25</reflink>]) in the general population and by Franken et al. ([<reflink idref="bib16" id="ref61">16</reflink>]) in clinical samples. The MHC-SF has good convergent and discriminant validity, high internal reliability, and moderate test-retest reliability.</p> <p>Schema Mode Inventory (SMI).</p> <p>The SMI is a self-report questionnaire to measure the presence of schema modes in individuals with a personality disorder. This questionnaire is developed by Young et al. ([<reflink idref="bib51" id="ref62">51</reflink>]). The Dutch SMI was found to have acceptable internal consistencies of the 14 subscales (Cronbach's α's from.79 to.96), adequate test-retest reliability, and moderate construct validity (Lobbestael et al., [<reflink idref="bib27" id="ref63">27</reflink>]). In this study, merely the functional modes have been used, namely the Health Adult and the Happy Child modes. The sum of the scores on these modes is used to assess functional modes (see also Wolterink & Westerhof, [<reflink idref="bib49" id="ref64">49</reflink>]).</p> <hd id="AN0190648268-9">Brief symptom inventory (BSI)</hd> <p>The Brief Symptom Inventory (BSI; De Beurs, [<reflink idref="bib11" id="ref65">11</reflink>]) is a valid self-report questionnaire, measuring psychological symptoms across nine dimensions: somatisation, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. The internal consistency ranges from an alpha of.71 to.96. The test-retest reliability is between.71 and.90 (De Beurs & Zitman, [<reflink idref="bib12" id="ref66">12</reflink>]). The total number of complaints has been used in the current study.</p> <hd id="AN0190648268-10">Data analysis</hd> <p>For statistical analysis, IBM Statistical Program for Social Sciences (SPSS version 21) was used. A Kolmogorov–Smirnov test and a Shapiro–Wilk test showed that it can be assumed that the data is normally distributed. As a next step, the correlations between the measures at the end of treatment and at LFU were computed. To answer the research questions, hierarchical multivariate regression analyses were run. The first model included an independent variable indicating if participants were assessed before or during the pandemic. Well-being and psychopathology at LFU were the dependent variables. The second model added the functional modes and well-being at the end of treatment in a stepwise procedure. The third model added the interaction between the timing (before or during the pandemic) and the measures of functional modes and well-being at the end of treatment that were significant in the second step. To interpret significant interaction effects, separate regression analyses for those who filled out the questionnaires before and during the pandemic were planned.</p> <hd id="AN0190648268-11">Results</hd> <p>Before running the multiple linear regression analyses, the correlations between the independent variables at the end of treatment and the dependent variables at LFU were computed. All independent variables are significantly correlated with the dependent variables (<emph>r</emph> =.300 –.899) except from social well-being at the end of treatment and psychopathology at LFU (<emph>r</emph> = −.279). This indicates moderate relationships between the post-treatment measurement and the LFU.</p> <p>To answer the research questions, hierarchical regression analyses were run. In the first model, the variable before or during the pandemic was used as an independent variable and the scores on the three components of well-being and psychopathology at LFU were the dependent variables. Model 1 in Table 2 shows that there were significant differences in social well-being and psychological well-being. This means that participants who filled out the questionnaires during COVID-19 scored lower on social and psychological well-being, but not on emotional well-being and psychopathology compared to the participants before COVID-19. The pandemic seems to explain a small part of the variance (<emph>R</emph><sups>2 </sups>= 0.083 for social well-being and <emph>R</emph><sups>2</sups> = 0.072 for psychological well-being).</p> <p>Table 2. Hierarchical Linear Regression models for LFU measurement.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Variable</td><td>Model 1 Beta coefficients</td><td>Model 2 Beta coefficients</td><td>Model 3 Beta coefficients</td></tr></thead><tbody><tr><td>Emotional well-being LFU</td><td char="." /><td char="." /><td char="." /></tr><tr><td>During pandemic</td><td char=".">−.145</td><td char=".">−.069</td><td char=".">−.357</td></tr><tr><td>Social well-being end of treatment</td><td char="." /><td char=".">.380**</td><td char=".">.204</td></tr><tr><td>Interaction</td><td char="." /><td char="." /><td char=".">.346</td></tr><tr><td>Explained variance (adjusted <italic>R</italic><sup>2</sup>)</td><td char=".">−.002</td><td char=".">.118</td><td char=".">.124</td></tr><tr><td>Social well-being LFU</td><td char="." /><td char="." /><td char="." /></tr><tr><td>During pandemic</td><td char=".">−.323*</td><td char=".">−.235</td><td char=".">−.578*</td></tr><tr><td>Social well-being end of treatment</td><td char="." /><td char=".">.443**</td><td char=".">.234</td></tr><tr><td>Interaction</td><td char="." /><td char="." /><td char=".">.412</td></tr><tr><td>Explained variance (adjusted <italic>R</italic><sup>2</sup>)</td><td char=".">.083</td><td char=".">.258</td><td char=".">.279</td></tr><tr><td>Psychological well-being LFU</td><td char="." /><td char="." /><td char="." /></tr><tr><td>During pandemic</td><td char=".">−.306*</td><td char=".">−.193</td><td char=".">−.711</td></tr><tr><td>Functional modes end of treatment</td><td char="." /><td char=".">.433**</td><td char=".">.302</td></tr><tr><td>Interaction</td><td char="." /><td char="." /><td char=".">.510</td></tr><tr><td>Explained variance (adjusted <italic>R</italic><sup>2</sup>)</td><td char=".">.072</td><td char=".">.233</td><td char=".">.225</td></tr><tr><td>Psychopathology</td><td char="." /><td char="." /><td char="." /></tr><tr><td>During pandemic</td><td char=".">.154</td><td char=".">.033</td><td char=".">−.086</td></tr><tr><td>Functional modes end of treatment</td><td char="." /><td char=".">−.447**</td><td char=".">−.476*</td></tr><tr><td>Interaction</td><td char="." /><td char="." /><td char=".">.117</td></tr><tr><td>Explained variance (adjusted <italic>R</italic><sup>2</sup>)</td><td char=".">.002</td><td char=".">.173</td><td char=".">.154</td></tr></tbody></table> </ephtml> </p> <p>1 Note. Data in the table are standardised coefficients. *<emph>p</emph> <.05 **<emph>p</emph> <.01. <emph>N</emph> = 43 for Emotional, Social, and Psychological well-being, <emph>N</emph> = 46 for Psychopathology.</p> <p>In the second model, functional modes and the three dimensions for well-being at the end of treatment were added in a stepwise procedure. This model shows that higher scores on social well-being at the end of treatment are moderately related to higher scores on emotional well-being at LFU (<emph>R</emph><sups>2 </sups>=.258) as well as to higher scores on social well-being at LFU (<emph>R</emph><sups>2 </sups>=.233). Furthermore, functional modes were related to psychological well-being at LFU (<emph>R</emph><sups>2 </sups>=.233) and psychopathology at LFU (<emph>R</emph><sups>2 </sups>=.173). Social well-being at end of treatment could explain the effect of the variable before versus during the pandemic on social well-being at LFU, whereas functional modes could explain the effect of the variable before versus during the pandemic on psychological well-being at LFU.</p> <p>Finally, in model 3, the interaction effect between the end of treatment variables and the assessment before or during the pandemic was added. No significant interaction effects were found (Table 2).</p> <hd id="AN0190648268-12">Discussion</hd> <p>This study aimed to understand the impact of the COVID-19 pandemic on the mental well-being and psychopathology of individuals who had been in inpatient Schema-Focused Therapy (SFT) years before the pandemic. The findings indicate that participants who were assessed during the COVID-19 pandemic scored lower on social and psychological well-being than the participants of the before-COVID-19 group, while showing no significant difference in emotional well-being and psychopathology. However, accounting for the scores at the end of treatment revealed that differences in social and psychological well-being between the COVID-19 and pre-COVID-19 groups could be attributed to social well-being and functional modes at the end of treatment. Furthermore, higher scores on social well-being at the end of treatment were predictive of higher scores on emotional and social well-being in the long term. Similarly, higher scores on the functional modes at the end of treatment appear to be a predictor for higher scores on psychological well-being and lower scores on psychopathology in the long-term. The pandemic did not alter the relationship between well-being and functional modes at the end of treatment, and mental well-being and psychopathology in the long term.</p> <p>The study shows that experiencing a stressful period such as the pandemic did not affect long-term treatment outcomes, suggesting that individuals who received inpatient SFT for personality disorders enhanced their resilience. The lower levels of social and psychological well-being during the pandemic were explained by their social well-being and levels of functional modes at the end of treatment, highlighting the role of these factors in fostering resilience during stressful periods as a pandemic.</p> <p>Surprisingly, the presence or absence of a major crisis like the COVID-19 pandemic did not alter the impact of predictors measured at the end of treatment on long-term follow-up scores. This contrasts with findings from general population and inpatient studies that found mental health and well-being were affected by the pandemic. (Bell et al., [<reflink idref="bib2" id="ref67">2</reflink>]; Castelein et al., [<reflink idref="bib6" id="ref68">6</reflink>]; De Lange et al., [<reflink idref="bib13" id="ref69">13</reflink>]; Heidari et al., [<reflink idref="bib19" id="ref70">19</reflink>]; WHO, [<reflink idref="bib47" id="ref71">47</reflink>]). As outlined in the introduction, research emphasises the crucial role of mental well-being to fostering resilience. Individuals with PDs often experience low levels of well-being and have a high risk in developing psychopathology during times of stress (Franken et al., [<reflink idref="bib16" id="ref72">16</reflink>]). However, the findings of this study indicate that the inpatient SFT enhances participants' resilience, thus mitigating the impact of the pandemic on the mental health and wellbeing of those individuals after treatment.</p> <p>Few studies on mental health during COVID-19 had a longitudinal character, which often precluded assessments of whether impairments were related to earlier levels of functioning. Nonetheless, other research has demonstrated that aspects of social well-being, such as a belief in a just world or a feeling of belonging, were associated with reduced depression, fear, and stress during the COVID-19 pandemic (Besser et al., [<reflink idref="bib3" id="ref73">3</reflink>]; Nudelman et al., [<reflink idref="bib31" id="ref74">31</reflink>]; Snel et al., [<reflink idref="bib39" id="ref75">39</reflink>]). A study among students in South Africa found that social well-being, as well as psychological and physical well-being, was related to mental health during the pandemic (Visser & Law-van Wyk, [<reflink idref="bib44" id="ref76">44</reflink>]). This supports our finding that social well-being earlier in time seems to be a protector of well-being and mental health during the pandemic.</p> <p>Similarly, higher scores on the functional modes at the end of treatment were protective of psychological well-being and psychopathology both before and during the COVID-19 pandemic. This finding aligns with other research indicating that psychological adaptability, healthy coping strategies and personality traits are protective factors for well-being and mental health during the pandemic (Bell et al., [<reflink idref="bib2" id="ref77">2</reflink>]; Besser et al., [<reflink idref="bib3" id="ref78">3</reflink>]; Dawson & Golijani-Moghaddam, [<reflink idref="bib10" id="ref79">10</reflink>]; Di Stefano et al. ([<reflink idref="bib14" id="ref80">14</reflink>]); Visser & Law-van Wyk, [<reflink idref="bib44" id="ref81">44</reflink>]). On the other hand, functional modes and psychological well-being seem to overlap, as functional modes represent healthy adaptive behaviour and satisfaction of basic needs (Jacob & Arntz, [<reflink idref="bib22" id="ref82">22</reflink>]; Young et al., [<reflink idref="bib52" id="ref83">52</reflink>]), whereas psychological well-being refers to positive individual functioning in terms of self-realisation (Westerhof & Keyes, [<reflink idref="bib45" id="ref84">45</reflink>]). However, when individuals can utilise healthier forms of expression, behaviour, and adaptation at the end of treatment, their long-term psychopathology symptoms are reduced. This was also found in the research of Phagoe et al. ([<reflink idref="bib32" id="ref85">32</reflink>]) during treatment and at short-term follow-up, where changes in mental well-being and symptoms of psychopathology were associated with functional modes.</p> <p>To the best of our knowledge, this study is among the first to focus on the long-term effects of inpatient group SFT before and during the COVID-19 pandemic. It provided a unique opportunity to longitudinally examine how treatment outcomes influence long-term mental well-being and psychopathology during a major stressor like the pandemic. However, limitations of this study refer to the sample size. Although many participants did not fill out the questionnaires at long term, there were no systematic differences between those participants and the ones who did fill out the long-term measurement. This can have resulted in a loss of statistical power in the regression analyses, particularly for the interaction analyses, thereby increasing the chance of incorrectly rejecting the null hypothesis (Bush, [<reflink idref="bib5" id="ref86">5</reflink>]).</p> <p>This study underscores the necessity of continuing the research on the effects of functional modes and social well-being on long-term treatment outcomes. The results emphasise the importance to embed the functional modes and social well-being into the inpatient treatment of PDs. Further research is recommended to explore the working mechanisms through which treatment influences social well-being and the functional modes, as current treatment and research predominantly focus on reducing psychopathology. Additionally, more research is needed on the long-term effects of inpatient SFT for PDs, as this information is currently lacking in the literature, given the significant impairments caused bij these disorders and therefore the importance of effective, long-term treatment.</p> <p>Overall, this explorative study provides insight into the long-term positive effects of inpatient SFT for individuals with personality disorders on well-being and psychopathology. Interestingly, improvements in functional modes and social well-being appear to provide protection during challenging times, such as the COVID-19 pandemic, enhancing resilience and adaptive coping strategies.</p> <hd id="AN0190648268-13">Data availability statement</hd> <p>The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available.</p> <hd id="AN0190648268-14">Disclosure statement</hd> <p>No potential conflict of interest was reported by the author(s).</p> <ref id="AN0190648268-15"> <title> References </title> <blist> <bibl id="bib1" idref="ref7" type="bt">1</bibl> <bibtext> American Psychiatric Association. (2014). DSM-5 Handboek voor de classificatie van psychische stoornissen (1st ed.). Boom.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref67" type="bt">2</bibl> <bibtext> Bell, L. M., Smith, R., van de Venter, E. C., Shuttleworth, C., Wilson, K., & Lycett, D. 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Westerhof</p> <p>Reported by Author; Author; Author; Author; Author</p> <p></p> <p>Eline Lolkema (MSc) psychologist at PsyQ Apeldoorn, the Netherlands.</p> <p>Karin Timmerman (MSc) art therapist, psychologist, PhD student at Mediant, De Boerhaven, Expertise Centre for Personality Disorders, the Netherlands.</p> <p>Dr. Gert-Jan Prosman associate professor, Mental health psychologist at the faculty of Behavioural Management and Social Sciences (BMS), Department Positive Clinical Psychology and Technology (PCPT), University of Twente, The Netherlands</p> <p>Roel M. Pietersen (MSc), Mental health psychologist and clinical psychologist at Mediant, de Boerhaven.</p> <p>Prof. dr. Gerben J. Westerhof is the Supervising author, Professor Narrative Psychology and Technology, University of Twente, the Netherlands.</p> </aug> <nolink nlid="nl1" bibid="bib47" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib33" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib43" firstref="ref4"></nolink> <nolink nlid="nl4" bibid="bib36" firstref="ref6"></nolink> <nolink nlid="nl5" bibid="bib15" firstref="ref9"></nolink> <nolink nlid="nl6" bibid="bib20" firstref="ref10"></nolink> <nolink nlid="nl7" bibid="bib24" firstref="ref11"></nolink> <nolink nlid="nl8" bibid="bib26" firstref="ref12"></nolink> <nolink nlid="nl9" bibid="bib38" firstref="ref13"></nolink> <nolink nlid="nl10" bibid="bib46" firstref="ref14"></nolink> <nolink nlid="nl11" bibid="bib16" firstref="ref15"></nolink> <nolink nlid="nl12" bibid="bib18" firstref="ref16"></nolink> <nolink nlid="nl13" bibid="bib21" firstref="ref17"></nolink> <nolink nlid="nl14" bibid="bib29" firstref="ref18"></nolink> <nolink nlid="nl15" bibid="bib35" firstref="ref19"></nolink> <nolink nlid="nl16" bibid="bib40" firstref="ref20"></nolink> <nolink nlid="nl17" bibid="bib41" firstref="ref21"></nolink> <nolink nlid="nl18" bibid="bib48" firstref="ref22"></nolink> <nolink nlid="nl19" bibid="bib45" firstref="ref24"></nolink> <nolink nlid="nl20" bibid="bib42" firstref="ref26"></nolink> <nolink nlid="nl21" bibid="bib34" firstref="ref30"></nolink> <nolink nlid="nl22" bibid="bib37" firstref="ref31"></nolink> <nolink nlid="nl23" bibid="bib49" firstref="ref32"></nolink> <nolink nlid="nl24" bibid="bib30" firstref="ref33"></nolink> <nolink nlid="nl25" bibid="bib17" firstref="ref34"></nolink> <nolink nlid="nl26" bibid="bib22" firstref="ref35"></nolink> <nolink nlid="nl27" bibid="bib52" firstref="ref37"></nolink> <nolink nlid="nl28" bibid="bib50" firstref="ref38"></nolink> <nolink nlid="nl29" bibid="bib32" firstref="ref41"></nolink> <nolink nlid="nl30" bibid="bib13" firstref="ref45"></nolink> <nolink nlid="nl31" bibid="bib19" firstref="ref46"></nolink> <nolink nlid="nl32" bibid="bib14" firstref="ref51"></nolink> <nolink nlid="nl33" bibid="bib28" firstref="ref58"></nolink> <nolink nlid="nl34" bibid="bib23" firstref="ref59"></nolink> <nolink nlid="nl35" bibid="bib25" firstref="ref60"></nolink> <nolink nlid="nl36" bibid="bib51" firstref="ref62"></nolink> <nolink nlid="nl37" bibid="bib27" firstref="ref63"></nolink> <nolink nlid="nl38" bibid="bib11" firstref="ref65"></nolink> <nolink nlid="nl39" bibid="bib12" firstref="ref66"></nolink> <nolink nlid="nl40" bibid="bib31" firstref="ref74"></nolink> <nolink nlid="nl41" bibid="bib39" firstref="ref75"></nolink> <nolink nlid="nl42" bibid="bib44" firstref="ref76"></nolink> <nolink nlid="nl43" bibid="bib10" firstref="ref79"></nolink>
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  Data: <searchLink fieldCode="AR" term="%22Eline+Lolkema%22">Eline Lolkema</searchLink><br /><searchLink fieldCode="AR" term="%22Karin+Timmerman%22">Karin Timmerman</searchLink><br /><searchLink fieldCode="AR" term="%22Gert-Jan+Prosman%22">Gert-Jan Prosman</searchLink><br /><searchLink fieldCode="AR" term="%22Roel+Pietersen%22">Roel Pietersen</searchLink><br /><searchLink fieldCode="AR" term="%22Gerben+J%2E+Westerhof%22">Gerben J. Westerhof</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22British+Journal+of+Guidance+%26+Counselling%22"><i>British Journal of Guidance & Counselling</i></searchLink>. 2025 53(5):703-712.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 10
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Well+Being%22">Well Being</searchLink><br /><searchLink fieldCode="DE" term="%22Coping%22">Coping</searchLink><br /><searchLink fieldCode="DE" term="%22COVID-19%22">COVID-19</searchLink><br /><searchLink fieldCode="DE" term="%22Pandemics%22">Pandemics</searchLink><br /><searchLink fieldCode="DE" term="%22Personality+Problems%22">Personality Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Predictor+Variables%22">Predictor Variables</searchLink><br /><searchLink fieldCode="DE" term="%22Hospitals%22">Hospitals</searchLink><br /><searchLink fieldCode="DE" term="%22Patients%22">Patients</searchLink><br /><searchLink fieldCode="DE" term="%22Psychotherapy%22">Psychotherapy</searchLink><br /><searchLink fieldCode="DE" term="%22Schemata+%28Cognition%29%22">Schemata (Cognition)</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Resilience+%28Psychology%29%22">Resilience (Psychology)</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Netherlands%22">Netherlands</searchLink>
– Name: SubjectThesaurus
  Label: Assessment and Survey Identifiers
  Group: Su
  Data: <searchLink fieldCode="SU" term="%22Brief+Symptom+Inventory%22">Brief Symptom Inventory</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/03069885.2025.2460836
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0306-9885<br />1469-3534
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Objective: This study investigates how well-being and adaptive coping post-inpatient schema-focused therapy (SFT) predict mental health during COVID-19 in individuals with Personality Disorders (PD), 2-8 years after treatment. Method: Using a naturalistic, prospective within-subject design, 52 PD-diagnosed participants completed assessments post-treatment and at long-term follow-up, with 20 pre-COVID and 32 during COVID. Measures included Schema Mode Inventory, Mental Health Continuum Short Form, and Brief Symptom Inventory. Correlations and hierarchical multivariate regression were used. Results: COVID-19 was associated with lower social and psychological well-being. Social well-being at treatment completion and functional modes predicted changes. Conclusion: Inpatient SFT enhances long-term resilience by improving social well-being and functional modes, benefitting well-being during COVID-19. Clinical significance: COVID-19 has significantly impaired mental health, particularly for individuals with complex PD. This article seeks insight into factors that contribute to resilience in individuals with PD who underwent treatment 2-8 years prior, especially during stressful periods, like COVID-19.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2026
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1499289
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1499289
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  BibEntity:
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      – Type: doi
        Value: 10.1080/03069885.2025.2460836
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 10
        StartPage: 703
    Subjects:
      – SubjectFull: Well Being
        Type: general
      – SubjectFull: Coping
        Type: general
      – SubjectFull: COVID-19
        Type: general
      – SubjectFull: Pandemics
        Type: general
      – SubjectFull: Personality Problems
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      – SubjectFull: Predictor Variables
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      – SubjectFull: Hospitals
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      – SubjectFull: Patients
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      – SubjectFull: Psychotherapy
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      – SubjectFull: Schemata (Cognition)
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      – SubjectFull: Program Effectiveness
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      – SubjectFull: Resilience (Psychology)
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Netherlands
        Type: general
      – SubjectFull: Brief Symptom Inventory
        Type: general
    Titles:
      – TitleFull: Functional Modes and Social Well-Being as a Protector of Mental Health during COVID-19
        Type: main
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            NameFull: Eline Lolkema
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            NameFull: Karin Timmerman
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              Type: published
              Y: 2025
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            – Type: issn-print
              Value: 0306-9885
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              Value: 1469-3534
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              Value: 53
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