Background and Objectives
Schema Therapy (ST) is a highly effective treatment for Borderline Personality Disorder (BPD). In a group format, delivery costs could be reduced and recovery processes catalyzed by specific use of group processes. As patients may also need individual attention, we piloted the combination of individual and group-ST.
Methods
Two cohorts of BPD patients (N = 8, N = 10) received a combination of weekly group-ST and individual ST for 2 years, with 6 months extra individual ST if indicated. Therapists were experienced in individual ST but not in group-ST. The second cohort of therapists was trained in group-ST by specialists. This made it possible to explore the training effects. Assessments of BPD manifestations and secondary measures took place every 6 months up to 2.5 years. Change over time and differences between cohorts were analyzed with mixed regression.
Results
Dropout from treatment was 33.3% in Year 1, and 5.6% in Year 2, without cohort differences. BPD manifestations reduced significantly, with large effect sizes, and 77% recovery at 30 months. Large improvements were also found on general psychopathological symptoms, schema (mode) measures, quality of life, and happiness. Cohort-2 tended to improve faster, but there were no differences between cohorts in the long term.
Limitations
The study was uncontrolled, training effects might have been non-specific, and the sample size was relatively small.
Conclusions
Combined group–individual ST can be an effective treatment, but dropout might be higher than from individual ST. Addition of specialized group-ST seems to speed up recovery compared to only individual ST.
Borderline personality disorder (BPD) is a severe mental condition, characterized by a pervasive pattern of instability in moods, interpersonal relationships, self-image and behavior. The prevalence is estimated to be 1–2% of the general population and ranges from 10 to 20% among outpatient and inpatient individuals treated in mental health clinics (American Psychiatric Association, 2005). Specific structured therapies have demonstrated efficacy in reducing BPD-symptoms in randomized controlled trials, such as dialectical behavior therapy (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991) and cognitive therapy (Davidson et al., 2006). In the last decade more comprehensive treatments which aim at full recovery have been tested. Various treatments seem promising. Among them is Schema Therapy (ST; Arntz and van Genderen, 2009 and Young et al., 2003). In a multicenter trial in which ST was compared to Transference Focused Psychotherapy (TFP; Yeomans, Clarkin, & Kernberg, 2002) ST turned out to have better treatment retention and to be more effective on various measures (Giesen-Bloo et al., 2006). ST was also more cost-effective than TFP with lower societal costs and stronger effects (van Asselt et al., 2008). A second study demonstrated that ST can be successfully implemented in regular practice, and that telephone availability outside office hours is not necessary (Nadort et al., 2009).
The duration of ST makes the therapy expensive, and problematic to deliver to all patients requesting it. These are compelling reasons to use a group therapy format. Other advantages of group therapy relate to the curative factors as described by Yalom and Leszcz (2005). Among these are universality, getting and giving emotional support, modeling, sense of belonging, practicing interpersonal skills and bonding. Patients can experience the satisfaction of being helpful to others and by doing so bolster their self-confidence. An important assumption in working with patients with BPD in groups is that they recognize each other's problems faster and easier than their own problems, and as a consequence patients can validate, support, confront and advise one another. Moreover, patients often experience such responses by other patients as more genuine than when made by a therapist. For these reasons, it has been argued that group-ST might “catalyze” the change processes of ST, thus leading to faster and deeper changes than individual ST (Farrell and Shaw, 2012 and Farrell et al., 2009).
We developed a protocol for outpatient treatment, in which ST in group was combined with individual ST. We assumed that individual treatment was essential for a number of reasons. We considered individual attention and attachment a basic need of the BPD patient, and it was our opinion that trauma processing is preferably offered in individual sessions, where specific techniques can be used to process painful and disturbing memories, that might be too confronting for other group members. An additional argument is that the combination mimics natural development of attachment with different persons (parent and peers).
During the study, we learned that Farrell and Shaw (2012) had developed a specialized group-ST model, of which a first RCT indicated very strong effects (Farrell et al., 2009). The group process is handled in a very specific way, which demands specific behavior and collaboration of the therapist pair. Our therapists were trained in their method; but the first cohort was already halfway through treatment and the second hadn't started when the training took place. This offered us the possibility to explore whether there were any differences between the two cohorts associated with the use of the Farrell and Shaw model.
