In this blog post, Veronique Dickhaut and Arnoud Arntz describe the development of a combined group and individual Schema Therapy (ST) protocol for the treatment of patients suffering from Borderline Personality Disorder, and the results of a pilot study based on that protocol. Patients who received combined group/individual ST showed greater improvement in comparison with those who received solely individual ST. Notably, these patients reached happiness levels almost equivalent those found in the general population. The blog concludes with an outline of the currently-running group ST international RCT. 

Even before the ISST welcomed Joan Farrell and Ida Shaw at the 2008 Coimbra conference, ST therapists had been developing all kinds of group forms of schema therapy (ST). One such development took place in Maastricht, where the young trainee Veronique Dickhaut wanted to develop and test a form of group-ST for borderline personality disorder (BPD). Although I was initially reluctant, we agreed to try it out. To develop a protocol, we organized a small invitational conference where we discovered that the participants “agreed to disagree” on a range of issues. So we had to make decisions that might have been a bit arbitrary, including the decision that we would test a combination of individual and group ST. We reached this decision with the reasoning that each format meets a different kind of need (for individual attention and for being a member of a group of peers, etc.). We planned to study two cohorts of about 8-9 BPD patients each, in an uncontrolled design with 2 years of treatment, where we used a closed group format and where some patients were seen individually by the group therapists and others by other schema therapists (with collective peer supervision). Individual ST was allowed to be continued for an additional 6 months, gradually reducing the frequency of sessions.

About 6 months after starting the first cohrt, as our therapists were struggling with questions of how to handle the group dynamics and how to apply ST techniques in the group setting, we met Joan and Ida at the Coimbra conference, and learned that they had developed a very effective model based on more than 20 years of experience in delivering ST in groups. Following this meeting, our therapists received additional training from Joan and Ida - , before the 2^nd cohort started, and around 1 year of treatment of the 1^st cohort.

The results of our pilot study showed some interesting things. First, there was a clear indication that the 2^nd cohort improved faster than the 1^st cohort, whereas the 1^st cohort – being a bit stuck at year 1 – started to catch up after the therapists changed to using the approach developed by Joan and Ida (see Figure 1). Second, the effects were large and seemed to be larger than in the individual ST study (Giesen-Bloo et al., 2006; see Figure 2). This indicates that the hypothesis that group-ST might catalyze change when delivered in the correct way, might be true (Farrell et al., 2009). Third, when we looked at the final mean level of happiness reached, participants reported a similar level as that of the general Dutch population (Figure 3). This indicates that the treatment not only reduced psychopathology, but also helped patients develop more fulfilling lives. Lastly, dropout was higher than that typical of individual ST – but note that dropout is generally higher in group than in individual treatments, e.g. because of scheduling problems.

The question of whether group-ST is effective for BPD when delivered as single or main treatment, or should be combined with individual ST, cannot be answered on theoretical grounds or on the basis of opinions of clinicians. And though the findings of our open trial described above are suggestive, they do not yet prove things… This is the main reason we embarked on the (currently-running) international RCT of group-ST for BPD (Wetzelaer et al., 2014), which examines this question empirically by comparing group ST in two formats (combined with individual therapy vs. intensive group therapy alone) to treatment-as-usual. We hope this ongoing study will help determine which modality is more effective and preferred by participants (both patients and therapists; see Wetzelaer et al., 2014).

References.

Dickhaut, V. & Arntz, A. (2014). Combined Group and Individual Schema Therapy for Borderline Personality Disorder: a Pilot Study. Journal of Behavior Therapy and Experimental Psychiatry, 45, 242-251.

Farrell, J., Shaw, I., & Webber, M. (2009). A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder: A randomized controlled trial. Journal of Behavior Therapy and Experimental Psychiatry, 40, 317-328. doi:10.1016/j.jbtep.2009.01.002

Giesen-Bloo, J., Dyck van, R., Spinhoven, P., Tilburg van, W., Dirksen, C., Asselt van, T., Kremers, I., Nadort, M. & Arntz, A. (2006). Outpatient psychotherapy for Borderline Personality Disorder: a randomized controlled trial of schema-focused therapy versus transference focused psychotherapy. Archives of General Psychiatry, 63, 649-658.

Wetzelaer, P., Farrell, J., Evers, S.M.M.A., Jacob, G., Lee, C.W., Brand, O., van Breukelen, G., Fassbinder, E., Fretwell, H., Harper, R.P., Lavender, A., Lockwood, G., Malogiannis, I.A., Schweiger, U., Startup, H., Stevenson, T., Zarbock, G., &  Arntz, A. (2014). Design of an international multicentre RCT on group schema therapy for borderline personality disorder. BMC Psychiatry, 14:319. DOI: 10.1186/s12888-014-0319-3