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A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder: A randomized controlled trial

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A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder: A randomized controlled trial

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This study tests the effectiveness of adding an eight-month, thirty-session schema-focused therapy (SFT) group to treatment-as-usual (TAU) individual psychotherapy for borderline personality disorder (BPD). Patients (N=32) were randomly assigned to SFT-TAU and TAU alone. Dropout was 0% SFT, 25% TAU. Significant reductions in BPD symptoms and global severity of psychiatric symptoms, and improved global functioning with large treatment effect sizes were found in the SFT-TAU group. At the end of treatment, 94% of SFT-TAU compared to 16% of TAU no longer met BPD diagnosis criteria (p<.001). This study supports group SFT as an effective treatment for BPD that leads to recovery and improved overall functioning.
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A schema-focused approach to group psychotherapy
for outpatients with borderline personality disorder:
A randomized controlled trial
Joan M. Farrell
a
,
*
, Ida A. Shaw
b
, Michael A. Webber
a
a
Indiana University School of Medicine, Department of Psychiatry, Center for Borderline Personality Disorder Treatment & Research,
Larue D. Carter Memorial Hospital, 2601 Cold Spring Road, Indianapolis, IN 46222, USA
b
BASE Consulting Group, LLC, 6551 Carrollton Avenue, Indianapolis, IN 46220, USA
article info
Article history:
Received 2 December 2008
Received in revised form 30 December 2008
Accepted 4 January 2009
Keywords:
Borderline personality disorder
Schema-focused therapy
Schema therapy
Cognitive behavioral therapy
Group psychotherapy
abstract
This study tests the effectiveness of adding an eight-month, thirty-
session schema-focused therapy (SFT) group to treatment-as-usual
(TAU) individual psychotherapy for borderline personality disorder
(BPD). Patients (N¼32) were randomly assigned to SFT-TAU and
TAU alone. Dropout was 0% SFT, 25% TAU. Significant reductions in
BPD symptoms and global severity of psychiatric symptoms, and
improved global functioning with large treatment effect sizes were
found in the SFT-TAU group. At the end of treatment, 94% of SFT-
TAU compared to 16% of TAU no longer met BPD diagnosis criteria
(p<.001). This study supports group SFT as an effective treatment
for BPD that leads to recovery and improved overall functioning.
Ó2009 Elsevier Ltd. All rights reserved.
1. Introduction
Borderline personality disorder (BPD) is a disabling and prevalent psychiatric disorder, which is
characterized by substantial distress and disruptions in functioning. Patients with BPD experience
a chronic pervasive pattern of instability in areas of affect, behavior, interpersonal relationships,
identity, and cognition. It is a disorder with high prevalence – 1–2% in the general population and up to
25% or more in clinical populations, depending upon the study (Lieb, Zanarini, Schmahl, Linehan, &
Bohus, 2004). Prevalence appears to be increasing, as recently the Wave 2 National Epidemiologic
Survey on Alcohol and Related Conditions found a prevalence rate of 5.9% for BPD in the general
population (Grant, Chou, Goldstein, Huang, Stinson, Saha, et al., 2008). Although several medications
*Corresponding author. Tel.: þ1 317 941 4331.
E-mail address: joan.farrell@fssa.in.gov (J.M. Farrell).
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J. Behav. Ther. & Exp. Psychiat. xxx (2009) 1–12
Please cite this article in press as: Joan M. Farrell et al., A schema-focused approach to group psycho-
therapy for outpatients with borderline personality disorder: A randomized controlled trial, Journal of
Behavior Therapy and Experimental Psychiatry (2009), doi:10.1016/j.jbtep.2009.01.002
have shown efficacy for various symptoms in controlled trials, the Cochrane review indicates that there
is no convincing evidence that any medication is a treatment for BPD as awhole (Stoffers, Lieb, Voellm,
et al., in preparation). Thus, psychotherapy continues to be the necessary and primary treatment
modality for BPD (Webber & Farrell, 2008).
Specific structured psychotherapies have demonstrated efficacy for some BPD symptoms in
randomized controlled clinical trials. These include Dialectical Behavioral Therapy (Linehan, Comtois,
Murray, Brown, Gallop, Heard, et al., 2006), Schema-Focused Therapy (Schema Therapy; Giesen-Bloo,
van Dyck, Spinhoven, van Tilburg, Dirksen,van Asselt, et al., 2006), Cognitive Therapy (Davidson et al.,
2006); Transference-Focused Psychotherapy (Clarkin, Levy, Lenzenweger, & Kernberg, 2007; although
differences with comparison groups were N.S.), Mentalization-Based Therapy (Chiesa, Fonagy, &
Holmes, 2006), and Systems Training for Emotional Predictability and Problem Solving (Blum et al.,
2008). Two recent pilot studies targeted specifically toward reducing self-injury also look promising
(Gratz & Gunderson, 2006; Weinberg, Gunderson, Hennen, & Cutter, 2006). Comparability across
treatments, however, is limited by the use of different measures of BPD symptoms, their severity and
global adjustment (McMain & Pos, 2007; Moher, Schulz, & Altman, 2001).
Despite the positive findings of these treatments for some patients and some symptoms of the
disorder, comprehensiveBPD treatment continues to be a challenge. The BPD symptoms least impacted
by psychotherapeutic treatment are those more related to temperament and the ability to function
effectively in occupational and social roles (Binks et al., 2006). Consumers of BPD treatment express
dissatisfaction with psychotherapy that eliminates life-threatening symptoms, but leaves them
underemployed and still feeling dysphoric and empty (Alexander, 2006a, 2006b). Schema-Focused
Therapy (SFT) has shown particular promise as a comprehensive treatment for BPD with the goal of
complete recovery in a large, well-designed clinical trial of individual psychotherapy twice weekly for
three years or less in the Netherlands (Giesen-Bloo et al., 2006). In addition, cost-effectiveness for SFT
was demonstrated (Van Asselt et al., 2008). An independent small-scale Norwegian case series study
reported similar effectiveness of individual SFT (Nordahl & Nysaeter, 2005).
The consistency and duration of psychotherapy that may be needed for more comprehensive BPD
treatment, however, is difficult to obtain, particularly for individuals with severe symptoms who are
treated in public healthcare settings. There are compelling economic and service delivery reasons to
use a group psychotherapy modality. In addition, groups uniquely possess important curative factors
stemming from supported peer-to-peer interactions, such as universality, a sense of belonging,
vicarious learning, and opportunities for in vivo practice, among others. In light of the clinical and cost-
effectiveness of SFT and the potential advantages of the group format, we developed a schema therapy
group for outpatients with BPD and conducted a randomized controlled clinical trial of this group
treatment added to ongoing individual psychotherapy ‘‘as usual’’. This study tests the hypotheses that
the active treatment group participating in a thirty session, eight-month schema therapy group
program in addition to weekly individual psychotherapy will experience significant reductions in BPD
symptoms and global severity of psychiatric symptoms and improvement in global functioning
compared to the control group participating in individual treatment-as-usual (TAU) alone.
2. Method
2.1. Participants
Thirty-two women with a diagnosis of BPD, ages 22–52, were located by referral from individual
psychotherapists in the community. The study was advertised by flyers sent to all psychologists and
psychiatrists who were affiliated in anyway with the local medical school and posted in local community
mental health and university outpatient clinics. Potential subjects could inquire about the study
themselves but needed to be referred by their individual psychotherapist to participate in the study.
Patients who agreed to participate weretold that they would be randomly selected as to whether they
were assigned to the group treatment added totheir individual psychotherapy, or would remain in their
individual psychotherapy. The informed consent suggested that the time and effort involvedfor those in
the control group would contribute to our understanding of effective BPD treatment. In addition,
participants were informed that they would be offered the treatment found to be most effective after the
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study’s completion. If this were the group treatment, they would receive it free of charge as a kind of
compensation for their involvement. The likelihood that the treatment of patients continuing in TAU
alone would be negatively affected by not being assigned to the adjunctive, experimental SFT-group
treatment is thought to be low.At the time of the study SFT was not a known treatment in the community.
For inclusion, subjects had to be females between the ages of 18 and 65, who met criteria for a BPD
diagnosis confirmed by the Diagnostic Interview for Personality Disorders-Revised (Gunderson,
Frankenburg & Chauncey, 1990) and the Borderline Syndrome Index (Conte, Plutchik, Karasu, & Jerrett,
1980) and were in individual psychotherapy of at least six-months duration and would agree to
continue that treatment for the course of the study. Weekly individual psychotherapy, eclectic in
orientation and primarily supportive was ‘‘treatment as usual’’ in the community. Attendance at
weekly individual psychotherapy sessions was a condition of remaining in the study. Therapists were
MD psychiatrists, senior psychiatry residents with supervision, experienced master’s level Clinical
Social Workers and Ph.D. psychologists. Patients were followed in private practice, university outpa-
tient and community mental health center settings. Exclusion criteria were: an Axis I diagnosis of
a psychotic disorder or a below average IQ (89), as measured by the Shipley Institute of Living Scale. IQ
was made an exclusion criterion because of the cognitive and reading demands of the program. An
open clinical interview conducted by an experienced clinical psychologist was used to confirm the
absence of psychosis. Patients were randomly assigned using a random number table to the treatment
or control group after qualifying for the study. Control of psychopharmacological treatment was
beyond the scope of the study. Patients were stable on their psychotropic medications before
randomization, limiting the likelihood of a confounding effect from drug treatment. Pharmacotherapy
was limited to first generation antipsychotics, selective serotonin reuptake inhibitors, tricyclic anti-
depressants and/or benzodiazepines. All patients had a history of suicide attempts and self-injury in
the two-year period before the study began.
Fig. 1 shows the patient flow. There was no drop out from the SFT-group arm at any point, but 25% of
the TAU group were lost before first follow-up, leaving N¼12 in the control group. Table 1 presents the
main demographic characteristics of both groups. For the control group, only completers’ character-
istics are given.
2.2. Outcome measures
1. Borderline Syndrome Index (BSI) (Conte et al, 1980) a 52 item true or false self-report measure of
BPD symptoms that allows measurement of change by specifying a time period for the subject to
base answers on. The BSI asks for presence of 52 BPD symptoms during the last 2 weeks. The total
score has an internal consistency KR-20¼.92 (p<.001).
2. Symptom Check List-90 (SCL-90) (Derogatis, 1994) the global severity score (sum of all items
divided by the number answered) was used as a measure of subjective experience of general
symptoms. Internal consistency of this score is very high, Cronbach alpha ¼.79–.90.
3. Diagnostic Interview for Borderline Personality Disorders-Revised (DIB-R) (Zanarini et al.,
199 0) a structured interview that assesses four putative aspects of BPD psychopathology
(affect, cognition, impulse, interpersonal) and assigns scaled severity scores. This measure was
used to confirm diagnosis at baseline and to assess change by using a shorter time frame
(Zanarini, Vujanovic et al., 2003). The DIB-R structured interviews were conducted by two
Ph.D. Clinical Psychologists not involved in treatment delivery. Efforts were made to keep
them blind to treatment group membership, but for 10% of the subjects the blind was broken
due to patient report. Both raters were trained by the principal investigator and achieved an
ICC .98.
4. Global Assessment of Function Scale (GAFS) ratings by patients’ individual therapists was used as
a measure of global functioning since it includes symptom, social and occupational functioning.
Therapists were given a GAFS checklist to use so that the anchors for assigning scores were in front
of them when they recorded their ratings. They were chosen as raters since they were removed
from the hypotheses of the study, although not blind to their patient’s group membership and no
inter-rater reliability was possible.
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Outcome measures were repeated at baseline, post-treatment and at six-month follow-up.
2.3. Treatment
The group-SFT program consists of thirty weekly sessions, each lasting 90 min, over an eight-month
period. Group size was six members and two active therapists, which we based upon two years of
piloting BPD groups of different sizes to determine our sense of the optimal ratio of therapists to
patient. This manual-based treatment (Farrell & Shaw, 1990) combines four content components that
we view as central to psychotherapy for patients with BPD: emotional awareness training (described in
Farrell & Shaw, 1994), BPD psychoeducation, distress management training (Farrell, Shaw, Foreman, &
Fuller, 2005) and schema change work (Young, 1990; Young, Klosko, & Weishaar, 2003). This treatment
combination has four goals: 1) establishing a positive therapeutic alliance through therapist validation
and education that establishes the usefulness of the treatment 2) increasing emotional awareness, so
that patients can notice pre-crisis distress and have some understanding of their emotional experience,
8 Patients Excluded
1 declined participation
2 Did not meet Inclusion
criteria
Patients allocated to
SFT + TAU (N=16)
32 Randomized
Patients allocated to
TAU (N=16)
0 Lost
4 Lost in 0-8 month
period, before first
follow-up
Reasons: all either
moved with no
forwarding address
or did not answer
repeated phone
contact attempts
Completed
Group Treatment
Included in data
analyses (N= 16)
Completed
Control condition
Included in data
analyses (N= 12)
Patients Screened for
Eligibility (N=40)
Fig. 1. Consort diagram of patient flow in the randomized controlled trial.
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3) developing an effective individualized distress management plan and 4) helping patients become
free enough of maladaptive schemas to be able to use their healthy adult coping skills. Accomplishing
these goals is hypothesized to lead to decreases in the severity and frequency of BPD symptoms,
a decrease in the severity of global psychiatric symptoms and improved global function. The inclusion
of treatment components that provide education and target the behavioral skill deficits like distress
management and emotional awareness of people withBPD is compatible with the theoretical model of
SFT (Young et al., 2003). Adapting SFT to a group modality provides additional learning potential,
including opportunities for the emotional experiences that are critical for schema change.
2.3.1. Schema change component
The integral schema change component adapts the techniques of schema therapy for people with
BPD developed by Young (Young, 1990; Young et al., 2003) to a group modality and adds structured
homework assignments, group exercises and kinesthetic and experiential awareness exercises (Farrell
& Shaw, 1994). Schemas are psychological constructs that include beliefs that we have about ourselves,
the world and other people, which are the product of how our basic childhood needs were dealt with.
They are comprised of memories, bodily sensations, emotions and cognitions that develop during
childhood and are elaborated through a person’s lifetime. Schemas may be extremely inaccurate,
dysfunctional and limiting, but they are strongly held and frequently not in the person’s conscious
awareness. Schema therapy draws from learning theory principles, developmental psychology and
a variety of experiential therapies. The focus is on identifying and changing maladaptive schemas and
their associated ineffective coping strategies. The schema change component employed in this group
treatment program focuses on decreasing the hold of negative schemas at least enough to allow
patients to use the skills they learn in treatment to keep them alive and improve their functioning in
the world. The major schemas focused on include: defectiveness/shame, social isolation and unde-
sirability, mistrust/abuse, dependence/incompetence, unrelenting standards and subjugation.
Schema change requires both cognitive and experiential work. Cognitive schema change work
employs basic cognitive behavioral techniques to identify and change automatic thoughts, identify
cognitive distortions, and conduct empirical tests of the person’s maladaptive rules about how to
survive in the world that have developed from schemas. Experiential work includes work with visual
imagery, gestalt techniques like the ‘‘empty chair’’, creative work to symbolize positive experiences,
limited re-parenting and the healing experiences of a validating psychotherapist. Behavioral pattern
breaking work is employed as well, to ensure that therapeutic changes generalize to behavior outside
of the therapy setting.
2.3.2. Therapist style
Therapist style models that of individual schema therapy by establishing an active, supportive and
genuine relationship that provides a safe environment for the patient to be vulnerable and express
Table 1
Patient demographics by group.
Treatment group Control group
a
Age, mean (SD) 35.3 (9.30) 35.9 (8.08)
Education
College graduate 5 (31%) 5(42%)
Some college 9 (56%) 3 (25%)
High school graduate 2 (13%) 4 (33%)
Employment status
Housewife 2 (12.5%) 2 (17%)
Student 1 (6%) 2(17%)
Employed 11 (69%) 6 (50%)
Disability 2 (12.5%) 1 (8%)
SSI
b
0 1 (8%)
Psychotropic medication at baseline 16 (100%) 12 (100%)
Recent suicide planning, steps, or attempts 16 (100%) 12 (100%)
Recent non-suicidal self-injury 16 (100%) 12 (100%)
a
Completers only (N¼12).
b
SSI, Supplemental security income for people with disabilities that prevent employment.
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emotions. The theory is that patients did not have core emotional needs met by caregivers, and this led
to the development of coping strategies that continue in adulthood and limit healthyadult functioning.
The therapist’s provision of limited, or adaptive, re-parenting allows the patient with BPD to fill in
critical early gaps in emotional learning like attachment and autonomy and to feel valued and worthy.
Initially, the therapist tries to compensate for these deficits within the limits of appropriate profes-
sional boundaries and ultimately fosters the patient learning to care for her or his own needs in an
effective manner and attain autonomy and healthy interpersonal functioning. Limited re-parenting is
accomplished in part by the experience of acceptance, validation, and support from psychotherapists.
This experience is healing to a patient’s damaged sense of self, self-hatred and hopelessness. Some
adaptations of individual therapist style are necessary when conducting group treatment. These
include: the need to focus on and balance the collective need of the group as a parent would for a group
of siblings. Group re-parenting may be a closer approximation to patients’ developmental experience
unless they were only children. This closer match with the early environment has the potential to
provide additional schema healing experiences.
The manual for the treatment provides structure in a format for sessions that consists of: discussion
of homework from the previous session, presentation of newinformation, discussion with opportunity
for questions and answers, experiential or cognitive work, and assignment of homework. The format
also allows for individualization based upon the composition and schema issues of each unique group.
A treatment manual aids adherence and facilitates replication at other sites. To insure treatment
integrity, co-therapist teams were used. Two of the three groups had the two program developers as
therapists and the third had one developer and one clinical psychologist trained by observing a full
group cycle. Weekly supervision meetings took place during the course of the study and random
videotapes of sessions were reviewed for fidelity by the program developers. The manual developed for
the study acted as an additional fidelity check.
3. Results
Of the 32 patients who began treatment, four subjects in the control group completed pre-test
assessments but were lost to follow-up (Fig. 1). This left 16 treatment group members and 12 control
group members. There was a 100% retention rate over 14 months in the treatment group, and there was
a 75% retention rate for the control group. The difference failed to reach significance, p¼.10, Fisher-
exact test, two-tailed. Overall, the retention rate for the study was 88%.
Fig. 2 shows the means of the four outcome measures for the two groups at the three assessment
points. At baseline, differences between the groups were N.S. (Table 2). As hypothesized, at the end of
the SFT-group treatment, ANCOVA with baseline as covariate demonstrated that there was a significant
difference between the groups in favor of the SFT-group condition (Table 2). Specifically, the treatment
group had significantly lower scores at the end of thirty sessions of SFT-group psychotherapy on both
measures of BPD symptoms (BSI and DIB-R) and on global severity of psychiatric symptoms (SCL-90);
and had higher scores on global functioning (GAFS from individual psychotherapists). On all measures,
this positive treatment effect was maintained or even increased at the six-month follow-up (Table 2).
An additional ANCOVA was conducted to examine the subscale scores of the DIB-R. Table 3 presents
the subscale results at baseline, posttest and six-month follow-up. There were no significant differ-
ences between the SFT and TAU groups on any subscale at baseline. At both posttest and follow-up
points, the SFT-group had significant improvement on all subscales compared to the TAU group.
When baseline scores were compared to post-treatment scores, the improvement on all measures
was significant for the SFT-group, but not for the TAU control group (Table 4). This improvement was
maintained or strengthened from post to six-month follow-up for the treatment group. The lack of
significant improvement in the control group was also maintained at six-month follow-up. The TAU
group showed little improvement, or even some deterioration, over the fourteen months of the study.
Table 5 presents the within-group effect sizes, which are very large for SFT, and virtually zero for TAU.
The improvements in the treatment group were clinically significant as well. The mean score post-
treatment on the BSI was below the threshold on that measure for the presence of BPD, indicating
remission, while the control group mean remained well above the threshold. After treatment,15 of the
16 (94%) active arm subjects no longer met BSI criteria for BPD while 11 out of 12 (92%) of control group
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subjects still met criteria for a BPD diagnosis, a highly significant difference,
c
2
(1, N¼28) ¼20.43,
p<.001, OR ¼165 (95%CI ¼9.27, 2936). Furthermore, on the DIB-R, the treatment group mean was
below the threshold for being given a BPD diagnosis, and the same 15 (94%) subjects would no longer
be diagnosed with BPD, while the control group mean remained above threshold, and 75% of the
control subjects would still be diagnosed with BPD,
c
2
(1, N¼28) ¼14.12, p<.0 01, OR ¼45
(95%CI ¼4.04, 501). At six-month follow-up, no treatment group patient met criteria for a BPD
DIB
0
1
2
3
4
5
6
7
8
9
10
baseline posttest follow-up
ST
TAU
SCL-90
0
0.5
1
1.5
2
2.5
baseline posttest follow-up
BSI
0
5
10
15
20
25
30
35
40
baseline posttest follow-up
GAF
30
35
40
45
50
55
60
65
70
75
80
baseline posttest follow-up
ST
TAU
ST
TAU
ST
TAU
Fig. 2. Means of the outcome measures by group and time.
Table 2
Means and SDs of the outcome measures by group and time, and analysis of (co)variance results.
Measure Baseline Posttest 6-m follow-up Baseline Posttest
a
6-m follow-up
a
Mean SD Mean SD Mean SD F(1, 26) pd
b
F(1, 25) pd
b
F(1, 25) pd
b
BSI
SFT&TAU 34.75 (7.67) 18.81 (9.47) 15.75 (9.10) .32 .58 .22 23.78 <.001 1.97 48.20 <.000 2.81
TAU 33.33 (4.77) 32.75 (5.90) 33.08 (4.56)
DIB-R
SFT&TAU 8.63 (1.41) 3.44 (2.76) 3.25 (2.79) 1.33 .26 .46 30.18 <.001 2.22 35.86 <.000 2.42
TAU 9.17 (.94) 8.58 (1.51) 8.75 (1.29)
SCL-90
SFT&TAU 1.75 (.54) 1.26 (.60) .96 (.47) .11 .75 .13 11.21 .001 1.35 29.71 <.000 2.20
TAU 1.84 (.86) 2.01 (.79) 1.93 (.72)
GAF
SFT&TAU 48.81 (7.04) 60.50 (10.17) 66.19 (7.51) .02 .89 .06 11.85 .002 1.39 60.00 <.000 3.13
TAU 49.17 (5.78) 50.08 (5.07) 48.25 (5.29)
a
Analysis of covariance with baseline as covariate. All group by covariate interactions were N.S. (F’s <1.0; p’s >.39) and were
therefore left out of the model.
b
Cohen’s d(between-group effect size of the F-test), with positive dindicating superior effects of SFT&TAU compared toTAU.
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diagnosis on the DIB-R, while the number in the control group meeting BPD criteria increased to 83%,
c
2
(1, N¼28) ¼17.08, p<.001, OR ¼75 (95%CI ¼5.97, 941).
The mean improvement in global functioning for the treatment group was 12 points post-treatment
and 16 points at six-month follow-up. Increases in GAF scores of this magnitude reflect a clinically
meaningful enhancement of global functioning. The mean score for the treatment group changed from
serious symptoms to mild symptoms while the control group moved only one point up at post and one
point down at six-month follow-up, thus remaining in the serious symptoms range.
4. Discussion
Thirty sessions of group-SFT added to weekly individual psychotherapy produced statistically and
clinically significant improvements on all outcome measures in female outpatient with BPD. No
significant differences were present initially between the treatment and control groups on any
symptom measure. Meaningful reductions in impulsive and self-injurious behavior and decreased self-
hatred, loneliness and emptiness were reported by many treatment group subjects 2–3 months into
the eight months of treatment. Significant decreases in symptoms and improved function were
apparent at the end of treatment and a trend toward further improvement from post-treatment to six-
month follow-up was present.
Whereas the improvements in the SFT condition were impressive and clinically meaningful, no
significant changes were observed in the TAU control group receiving only continuing weekly indi-
vidual psychotherapy ‘‘as usual’’ in the community. This lack of positive effect may be the result, inpart,
of the absence of BPD specialization in the individual psychotherapy available at the time in the
community. It also indicates that our sample was severely and chronically disturbed, with no evidence
Table 3
Means and SDs of the DIB-R subscales by group and time, and between-group analysis of (co)variance results.
DIB-R Subscale Baseline Posttest 6-m follow-up Baseline Posttest
a
6-m follow-up
a
Mean SD Mean SD Mean SD F(1, 26) pF(1, 25) pF(1, 25) p
Affect
SFT&TAU 9.88 .34 5.88 3.44 5.75 3.55 .06 .81 15.22 .001 11.70 .002
TAU 9.83 .58 9.83 1.12 9.25 .87
Cognition
SFT&TAU 3.19 1.94 1.69 2.02 1.50 1.97 2.27 .14 11.73 .002 14.47 .001
TAU 4.25 1.71 4.25 1.49 4.33 1.61
Impulses
SFT&TAU 5.94 1.48 1.56 1.37 1.56 2.07 1.65 .21 24.69 <.001 22.36 <.0 01
TAU 6.75 1.87 5.58 2.68 6.0 0 2.52
Interpersonal
SFT&TAU 11.38 3.01 4.88 4.02 5.13 3.48 .56 .46 28.59 <.0 01 23.95 <.0 01
TAU 12.17 2.44 12.00 2.80 11.33 2.87
a
Analysis of covariance with baseline as covariate.
Table 4
Within-group t-tests of changes with respect to baseline (positive signs indicate improvement).
Measure Posttest 6-m follow-up
t(15 or 11) pt(15 or 11) p
BSI SFT 6.11 <.001 8.13 <.001
TAU .44 .67 .31 .76
DIB-R SFT 7.58 <.001 6.76 <.001
TAU 1.40 .19 1.24 .24
SCL-90 SFT 3.36 .004 6.41 <.001
TAU .97 .35 .56 .59
GAF SFT 4.71 <.001 8.49 <.001
TAU .48 .64 .64 .54
J.M. Farrell et al. / J. Behav. Ther. & Exp. Psychiat. xxx (2009) 1–128
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of spontaneous recovery or recovery by nonspecific attention, in contrast to other findings (Zanarini,
Frankenburg, Hennen, & Silk, 2003). We only analyzed the data of patients that completed the posttest.
However, a last observation carried forward procedure to estimate the missing values of the four
patients in the control group that dropped out would not lead to different conclusions given the lack of
meaningful change in the control group.
Although much progress has been made in the development and availability of treatments for BPD
in the last fifteen years, available approaches have demonstrated differential effectiveness for various
symptoms. Self-injurious behavior, suicidal behavior, and impulsivity are the symptoms treated most
effectively and by the largest number of treatments. However, mood, quality of life issues, and global
functioning are treated less successfully by most treatments. The DIB-R yields subscale score in the four
areas of BPD psychopathology – affect features, cognitive features, impulsive features and interper-
sonal features. The specific symptoms assessed for each subscale are as follows:
1. Affect: the chronic experience of – major depression, hopelessness/helplessness/worthlessness
/guilt, anger/frequent angry acts, anxiety, loneliness/emptiness.
2. Cognition: odd thoughts/unusual perceptual experiences, nondelusional paranoia, quasi-psychotic
experiences.
3. Impulse: substance abuse/dependence, sexual deviance, self-mutilation, manipulative suicide
attempts, other impulsive patterns.
4. Interpersonal: intolerance of aloneness, abandonment/engulfment/annihilation concerns,
counter-dependency/serious conflict over help/care, stormy relationships, dependency
/masochism, devaluation/manipulation/sadism, demandingness/entitlement, serious treatment
regression.
The finding that significant improvement took place in all four of the subscale/symptom areas
provides support for the assertion that group-SFT impacts all areas of BPD psychopathology. We chose
the DIB-R because our treatment targets included affective experience and interpersonal function as
well as injurious and potentially injurious impulsivity and suicidal behavior.
The clinical trial evidence presented here provides strong preliminary support for the contention
that SFT-group treatment, in addition to decreasing all of the major areas of BPD symptoms and global
severity of psychiatric symptoms, improves global functioning. The lack of change in the TAU control
group receiving individual psychotherapy supports the assumption that the group treatment accounts
for most positive changes in the treatment group.
The remarkable 100% retention rate in the SFT-group in this trial is quite notable for this clinical
population and may be attributable to a number of factors. First, the treatment was designed specif-
ically to meet the needs of BPD patients, aiming to be very validating. Second, the therapists had
considerable experience with patients with BPD and likely conveyed a broad sense of hope and
optimism about the treatment program. Third, the effectiveness of the treatment reinforced patients’
continuing participation. Indeed, it was apparent from anonymous post-treatment evaluations that
patients did experience the group therapy approach as validating and supportive. The sense of
belonging derived from a homogeneous diagnostic group was felt to be rewarding. The 75% retention
rate for the control group is also quite high, given that they were not compensated financially for
completing assessments. The medical school setting is highly rated by the community, which added
motivation to participate. It has been our experience that patients with BPD are motivated to partic-
ipate in research to add to knowledge about BPD in order to help others like them.
Table 5
Effect sizes using pooled SDs at baseline and mean change scores per condition (a positive sign indicates improvement).
Treatment group BSI DIB-R SCL-90 GAF
SFT TAU SFT TAU SFT TAU SFT TAU
Posttest 2.48 .09 4.29 .49 .72 .25 1.80 .14
Follow-up 2.96 .04 4.45 .35 1.17 .13 2.67 .14
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The SFT-group program evaluated here attempts to supply needed foundation skills in emotional
awareness and distress management, combined with the essential schema change work that allows
application of these skills. The schema change component of this treatment and the adaptive re-
parenting therapist interventions that run through all components of the treatment are what distin-
guish this approach to BPD psychotherapy from other cognitive behavioral approaches, such as
dialectical behavioral therapy. We see schema change as an essential part of treatment for people with
BPD that will allow them to be free from the internal barriers that prevent them from using their
improved coping or interpersonal skills to improve their quality of life. An individual must have some
belief in her own basic worth and agency to take action that is in her best interest. We think that
teaching skills to this group of patients without addressing these barriers to applicationwill prove to be
of limited effectiveness in producing improved function. Lack of improved function is something that
has plagued the outcome studies of many current skills-based treatments.
Currently, there is a largely consumer-driven movement to find treatment that can move patients
with BPD beyond symptomatic remission to the next phase of recovery – a meaningful life, with
a positive sense of identity, healthy relationships, and employment that matches ability level. Freedom
from life-threatening behavior is a necessary, but not sufficient, goal of successful psychotherapeutic
treatment. These goals are consistent with those of SFT, which goes beyond teaching coping skills to
address the emotional learning deficits of BPD patients at the experiential, affective level as well as the
cognitive level. This comprehensive approach helps patients build autonomous, healthy adult func-
tioning and can lead to remission from BPD. While the DIB-R does measure all areas of BPD psycho-
pathology, admittedly, we did not assess healthy adult functioning with validated instruments.
However, this effect of SFT was assessed and confirmed in other studies (Giesen-Bloo et al., 2006; Van
Asselt et al., 2008). Future studies of group-SFT should include explicit assessment of healthy
functioning.
We found that using a group modality presented some advantages with regards to the SFT
mechanism of action and the particular schema issues of BPD patients. The limited re-parenting of SFT
is accomplished, in large part, by the experience of acceptance, validation, and support from
psychotherapists. This experience is healing to a patient’s damaged sense of self, self-hatred, and
hopelessness. A psychotherapy group that provides acceptance and validation can amplify the schema
healing process. Patients sometimes accept peer responses as ‘‘more genuine’’ than the responses of
professionals who they may believe ‘‘have to respond positively’’. Another benefit of the group format
for SFT is the addition of ‘‘siblings’’ to the re-parenting work, creating a whole family unit dynamic. In
addition, the group curative factors of universality, belonging, and acceptance are harnessed. These
aspects of group are all of particular significance for the schema issues of patients with BPD, including
defectiveness/shame, abandonment, and mistrust/abuse. At the end of this treatment, when asked
‘‘What was most helpful about the group therapy program?’’, the most frequent answer was ‘‘being in
a group of people like me’’. They reported that this was the ‘‘first time (they) felt a sense of belonging
or acceptance’’, that they were ‘‘not alone’’ and ‘‘not crazy’’ (i.e. defective). The group itself can play an
important curative role in the treatment of patients with BPD if it is structured to avoid the invalid-
ating, schema perpetuating experiences of the family of origin and offers opportunities for bonding,
learning, healing, developing autonomy and practicing healthy adult skills. This time-limited group
can give BPD patients literally a base, or foundation, for the additional treatment they need to have
a good quality of life.
A recent development in SFT is the use of schema modes in the therapy (Kellogg & Young, 2006;
Arntz, 2004; Young et al., 2003). Whereas this concept has already been tested outside treatment
(e.g., Arntz, Klokman, & Sieswerda, 2005; Lobbestael, Arntz, & Sieswerda, 2005; Lobbestael, van
Vreeswijk, & Arntz, 2008) and as part of individual therapy (Giesen-Bloo et al., 2006), a formal test of
mode-based group-SFT is needed. Our clinical impression is that schema-mode based SFT for BPD can
be successfully applied in a group format.
The results of this study suggest that SFT can be effectively adapted to the group modality. SFT in
groups is still in an early stage of demonstratingefficacy, but the large and significant treatment effects
demonstrated in this trial suggest that this could be a cost effective treatment option that can be made
available for those suffering from BPD across public health and private settings. The results of this study
add to the growing evidence base supporting SFTas an effective treatment for BPD that can lead to both
J.M. Farrell et al. / J. Behav. Ther. & Exp. Psychiat. xxx (2009) 1–1210
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symptom reduction and improved global functioning and qualityof life. The favorable cost-effectiveness
evaluation of SFT adds another dimension to its value (Van Asselt et al., 2008). Further evaluation of
this group model with a larger sample size at various sites and with strict monitoring of medication
usage is warranted.
Acknowledgements
This study was conducted through the support of an NIMH RO3 grant to the first author.
We thank Arnoud Arntz, Ph.D. for his invaluable editorial and statistical consultation and Frank
Lawhead, MA for editorial and data analysis assistance. We acknowledge the work of Finlay Grier, PhD
in conducting structured interviews for the study.
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... The aforementioned studies delivered ImR individually, but ImR has also been successfully incorporated into Group Schema Therapy treatment of borderline personality disorder and eating disorder (28)(29)(30)(31)(32). The application of Group Schema Therapy has been described in the work by Farrel et al. (32). ...
... The aforementioned studies delivered ImR individually, but ImR has also been successfully incorporated into Group Schema Therapy treatment of borderline personality disorder and eating disorder (28)(29)(30)(31)(32). The application of Group Schema Therapy has been described in the work by Farrel et al. (32). ...
... Different ways of conducting the study of ImR have been proposed, but, in this study, we employed the three-stage one proposed by Arntz and Weertman (40), adapting it to the group setting which is in line with the work by Farrell et al. (32). ...
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Schema group therapy is an effective treatment for personality disorders, but its focus on cognitive techniques may be a limitation for older adults. This article describes the rationale and initial evaluation of a group schema therapy protocol enriched with psychomotor therapy (GST+PMT) for older adults in geriatric mental health care. We concluded that group schema therapy enriched with PMT is feasible in later life and its effect might be mediated by targeting schema modes. The (cost-)effectiveness of the presented treatment protocol is currently being evaluated in a randomized controlled design (van Dijk et al., 2019)”
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The use of schema therapy to treat personality disorders in older adults is gaining scientific attention. Personality disorders are prevalent in one out of ten older adults and have a detrimental effect on quality of life. Although 24% or more of nursing home residents may have personality disorders, psychotherapeutic treatment options in the case of comorbid cognitive impairment have not yet been studied. This study concerns a 63-year-old care-dependent male nursing home resident with a personality disorder, a substance use disorder, and several cognitive impairments due to cerebrovascular disease, who presented with complaints of loneliness, low self-esteem, sleeping problems and anger outbursts. Schema therapy was delivered based on the schema mode model for a period of 27 months. Post-treatment assessment demonstrated a decrease in early maladaptive schemas and dysfunctional schema modes and improved personality functioning overall. Although situational psychological distress fluctuated throughout treatment, quality of life improved after 7 months and remained stable onwards. Presented complaints either remitted or strongly diminished. Substance use was also addressed and was in remission for the last 20 months of therapy. This case study suggests that schema therapy is a viable treatment for older adults with personality disorders who present with cognitive impairments in nursing homes.
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This paper describes a new approach to increasing emotional stability in patients with borderline personality disorder (BPD) through experiential exercises designed to increase their level of emotional awareness. This approach, called Emotional Awareness Training, is hypothesized to provide the groundwork for emotional stability in BPD patients and to be an important prerequisite to the effective use of cognitive and behavioral interventions with these patients. A comprehensive model for the treatment of BPD is described, which begins with emotional awareness training, followed by training in distress reduction and emotional regulation skills, and work on identifying and challenging early maladaptive cognitive schemas. A treatment manual for Emotional Awareness Training is available from the authors. The models for BPD treatment of Dialectical Behavior Therapy and Cognitive Therapy are reviewed and the issue of research to evaluate the effectiveness of cognitive-behavioral treatment is discussed.
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Patients with borderline personality disorder (BPD) have problems constantly changing moods, their relationships with others, unclear identities, and impulsive behaviors. Prevalence in the general population is estimated at 1.1–2.5% and varies in clinical populations depending on the setting, from 10% of the outpatients up to 20–50% of inpatients. The comorbidity in this group of patients is high and diverse. The majority of BPD patients have experienced sexual, physical, and/or emotional abuse, and emotional neglect in their childhood; sexual abuse in particular between the ages of 6 and 12. These traumatic experiences in combination with temperament, insecure attachment, developmental stage of the child, as well as the social situation in which things took place, result in the development of dysfunctional interpretations of the patient's self and others.Treating BPD patients with schema therapy makes it relatively easy to comprehend the patient's dysfunctional behavior and it gives the therapist many tools to treat the patient.
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Drug treatment of patients with borderline personality disorder (BPD) is common but mostly not supported by evidence from high-quality research. This review summarises the current evidence up to August 2014 and also aims to identify research trends in terms of ongoing randomised controlled trials (RCTs) as well as research gaps. There is some evidence for beneficial effects by second-generation antipsychotics, mood stabilisers and omega-3 fatty acids, while the overall evidence base is still unsatisfying. The dominating role SSRI antidepressants usually play within the medical treatment of BPD patients is neither reflected nor supported by corresponding evidence. Any drug treatment of BPD patients should be planned and regularly evaluated against this background of evidence. Research trends indicate increasing attention to alternative treatments such as dietary supplementation by omega-3 fatty acids or oxytocin.
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This book discusses schema-focused therapy, an integrative approach . . . to treat characterological patients including borderline, narcissistic, avoidant, dependent, obsessive-compulsive, passive-aggressive, and histrionic personality disorders. . . . [This] model is [an] integration of cognitive behavior therapy with gestalt, object relations, and psychoanalytic approaches. It expands on conventional cognitive behavior therapy by placing more emphasis on the therapeutic relationship, affective experience, and the discussion of early life experiences. In addition to presenting the rationale, theory, and practical techniques of schema-focused therapy, this book includes an extended case example, and revised editions of the Schema Questionnaire, Client's Guide, and schema listings. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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This article presents the Schema Therapy (Young, Klosko, & Weishaar, 2003) approach to the treatment of borderline personality disorder. Schema therapy draws on the cognitive-behavioral, attachment, psychodynamic, and emotion-focused traditions and conceptualizes patients who have borderline personality disorder as being under the sway of five modes or aspects of the self. The goal of the therapy is to reorganize this inner structure. To this end, there are four core mechanisms of change that are used in this therapy: (1) limited reparenting, (2) experiential imagery and dialogue work, (3) cognitive restructuring and education, and (4) behavioral pattern breaking. These interventions are used during the three phases of treatment: (1) bonding and emotional regulation, (2) schema mode change, and (3) development of autonomy.