Preliminary evidence supports the use of group schema therapy for Borderline Personality Disorder (BPD); however, evidence supporting the use of group schema therapy with other personality disorders or indeed those with mixed personality disorders is sparse. However, in most clinical settings, it is often more common at any given point in time to encounter patients with a range of personality disorders than to have a caseload or waiting list consisting of any one specific personality disorder.

We conducted a pilot study using short-term group schema therapy (ST-g) in a case series of eight patients with Cluster A, B, and C personality disorders and high levels of comorbidity. Treatment comprised 20 sessions that included cognitive, behavioral, interpersonal, and experiential techniques.

Six participants attended until end of treatment and two dropped-out before mid-treatment. All outcome measures showed changes in treatment completers with large effect sizes in depression, anxiety, and avoidant personality disorder symptom severity levels between pre-therapy and follow-up. Four participants no longer met criteria for personality disorder diagnosis at the end of therapy. By follow-up, five participants had achieved a loss of diagnosis, suggesting that participants derived ongoing benefits from the group even after treatment ended. All six completers no longer met criteria for depression at the end of treatment; this was maintained for all participants at 6-month follow-up. At follow-up, the majority of participants showed clinically significant change on the Global Symptom Index (GSI). The majority of participants showed a reduction in maladaptive modes on the Schema Mode Inventory (SMI) at follow-up. Additionally, 40% of participants showed clinically significant change on the SMI adaptive modes at follow-up. Qualitative feedback indicated that the group helped to normalize participants' emotional experiences and difficulties and promoted self-expression and self-disclosure, while reducing inhibition.

Although there are limitations to our pilot study such as the small sample size and lack of control group, this naturalistic pilot study allowed a rich and detailed exploration of the level of change possible over a 20 week schema therapy group with a mixed personality disorder sample. Naturalistic designs are clinically useful and have high ecological validity, which can allow results to be generalized to patients generally seen in typical clinical settings (i.e., community mental health teams, hospital wards).

What could this research mean?  

This study may have implications for the significant number of patients with personality disorders who may not respond to conventional treatments offered within many health service settings. In particular, those with Cluster C personality disorders can remain ‘stuck’ in long-term individual therapy frequently avoiding behavioural and interpersonal changes. Their avoidant and rigid coping mechanisms can be difficult to challenge in individual work, even with relentless empathic confrontation and behavioural task setting.  However, group therapy can provide a natural (but safe) environment whereby participants can learn to challenge and actively encourage each other to make changes. Indeed, schemas are regularly triggered within the group setting through interpersonal group dynamics, thereby providing an ideal setting for addressing schema perpetuation processes as they are occurring.

In particular, the mixed nature of the personality disorder group included in our study facilitates active participation amongst group members. We find that there are usually enough schemas and modes in common amongst group members to enable participants to feel understood and bonded to the group, whilst the differences enable them to react differently and to challenge each other more intensely. Unsurprisingly, those with BPD tend to be able to be more emotionally expressive, and can empower those with Cluster C personality disorders to begin to gradually explore the possibility of reducing avoidance and connecting with their own vulnerability. The discussions generated around underlying schemas and modes can also enable participants to learn as a group how to generate feelings of safety around their vulnerability, as well as how to be compassionate toward their own and others’ Vulnerable Child modes.

This study contributes to a growing body of literature that suggests that ST-g shows promise as an intervention which may stimulate avoidant coping patterns through experiential, cognitive and behavioral group processes, many of which appear to be unique to working in a group setting.

For further reading:

Skewes, S.A., Samson, R.A., Simpson, S.G. & van Vreeswijk, M. (2015). Short-term group schema therapy for mixed personality disorders: a pilot study. Frontiers in Psychology, 5:1592. doi:10.3389/fpsyg.2014.01592

Simpson, S. G., Skewes, S. A., van Vreeswijk, M., and Samson, R. (2015). Commentary: Short-term group schema therapy: an introduction to the treatment protocol. Frontiers in Psychology, 6:609. doi: 10.3389/fpsyg.2015.00609