Major Outcome Study

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Summary of Results of a Major Outcome Study:

Schema Therapy for Borderline Personality Disorder

New Hope for an “Untreatable” Mental Illness:

Schema Therapy Fosters Full Recovery

For Many Patients with Borderline Personality Disorder

For the first time, a major outcome study has shown that a high percentage of patients with Borderline Personality Disorder can achieve full recovery across the complete range of symptoms. The controlled study, appearing in the Archives of General Psychiatry published by the American Medical Association, shows that a new approach -- Schema Therapy -- is more than twice as effective as a more traditional psychodynamic approach, Transference Focused Psychotherapy (TFP). Borderline Personality Disorder (BPD) has, until recent years, been considered untreatable, with little scientific justification for longer-term therapy.

This study demonstrates that schema therapy leads to complete recovery in about 50% of the patients, and to significant improvement in two-thirds. The success of the therapy is strongly related to its duration and intensity (two sessions a week for 3 years). The results clearly contradict the prevailing opinion that therapy for BPD cannot lead to full recovery, and that longer-term psychotherapy is ineffective.

According to the National Institute of Mental Health, Borderline Personality Disorder is found in about 2 percent of the general population - about 5.8 to 8.7 million Americans, most of whom are young women. Patients with the disorder live life on the edge: they're typically impulsive, unstable, exquisitely sensitive to rejection, have regular outbursts of anger, and live daily with extreme emotional pain. They often self-mutilate and make repeated suicide attempts. Identity problems, low stress tolerance, and fears of abandonment also make the disorder difficult for patients and for those who live with them. Many with BPD either cannot work or do not function at levels that could be expected in light of their intellectual capacities. As a result, the disorder carries high medical and societal costs, accounting for more than one in every five inpatient psychiatric admissions.

Until recently, psychotherapy offered help for only some of the symptoms of BPD. The best available alternatives, such as Dialectical Behavioral Therapy, relieve many of the self-destructive behavioral symptoms of the disorder but have not been able to reduce many of the other core symptoms, especially those related to deeper personality change.

New York-based psychologist Jeffrey Young, Ph.D. (on the faculty in the Dept. of Psychiatry at Columbia University) began to develop Schema Focused Therapy in the mid-1980s. Encouraged by its success, he established the first Schema Therapy Institute in the mid-1990s in Manhattan. Adopted by many clinicians in the United States, Europe, and Asia, the therapy came to the attention of researchers in The Netherlands who were developing a large-scale study of treatments for Borderline Personality Disorder. The clearly articulated approach of Schema Therapy lent itself well to a controlled outcome study.

In this study, Dutch investigators, including Dr. Josephine Giesen-Bloo and Dr. Arnoud Arntz (the project leader), compared Schema Therapy (also known as Schema Focused Therapy or SFT) with Transference Focused Psychotherapy (TFP) in the treatment of Borderline Personality Disorder. 86 patients were recruited from 4 mental health institutes in the Netherlands. Patients in the study received two sessions per week of SFT or TFP for 3 years. After three years, full recovery was achieved in 45% of the patients in the SFT condition, and in 24% of those receiving TFP. One year later, the percentage fully recovered increased to 52% in the SFT condition and 29% in the TFP condition, with 70% of the patients in the SFT group achieving “clinically significant and relevant improvement”. Moreover, the dropout rate was only 27% for SFT, compared with 50% for TFP, indicating that Schema Therapy instilled a greater sense of allegiance among patients.

Patients began to feel and function significantly better after the first year, with improvement occurring more rapidly in the SFT group. There was continuing improvement in subsequent years. Thus investigators concluded that both treatments had positive effects, with Schema Therapy clearly more successful.

Schema Therapy is an integrative approach, founded on the principles of cognitive-behavioral therapy and then expanded to include techniques and concepts from other psychotherapies. Schema therapists help patients to change their entrenched, self-defeating life patterns - or schemas -- using cognitive, behavioral, and emotion-focused techniques. The treatment focuses on the relationship with the therapist, daily life outside of therapy, and the traumatic childhood experiences that are common in this disorder. Dr. Young believes that Schema Therapy's greater effectiveness arises in part from its use of “limited reparenting,” which is not part of other approaches to BPD.

Both Schema Therapy and Transference Focused Psychotherapy focus on deeper personality change, in comparison to other recent treatments that have been limited to the reduction of specific behavioral symptoms of the disorder, such as self-mutilation. According to Dr. Young: "With Schema Therapy, patients with BPD are now breaking free from lives of chaos and misery. Not only are they learning skills to stop self-harming behaviors (as they have with Dialectical Behavior Therapy), but a high percentage of BPD patients are finally making deeper personality changes that have not been possible until now.”

Although the treatment involves many sessions over three years, schema therapy is nevertheless cost-effective. An economic analysis conducted by the authors of the study (not included in the Archives article) indicated that, for each year schema therapy patients were in the study, Dutch society benefited from a net gain of 4,500 Euros per patient (the equivalent of about 5,700 US dollars), despite the cost-intensive treatment. The savings over the course of several years after the completion of treatment could actually prove to be higher.

Schema therapists and researchers are hoping that this validation of the effectiveness of Schema Therapy for patients with Borderline Personality Disorder -- that for so many years has been considered intractable - will lead to more research studies and will encourage more clinicians to learn Schema Therapy. They also hope that this study will convince healthcare insurers to reimburse for the costs of effective longer-term psychotherapy for this painful and costly illness.

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Journal Citation: Josephine Giesen-Bloo, MSc; Richard van Dyck, MD, PhD; Philip Spinhoven PhD; Willem van Tilburg MD, PhD; Carmen Dirksen, PhD; Thea van Asselt, Msc; Ismay Kremers, PhD; Marjon Nadort, MSc; and Arnoud Arntz, PhD. (2006): Outpatient Psychotherapy for Borderline Personality Disorder: a randomized trial of Schema focused therapy versus Transference focused therapy. Archives of General Psychiatry, Vol. 63, No. 6, pp. 649-658.