Responding to the treatment challenge of patients with severe BPD: results of three pilot studies of inpatient schema therapy.

BACKGROUND: Schema Therapy (ST), a psychotherapy model integrating cognitive, experiential and behavioural interventions, was initially developed and evaluated as an outpatient treatment for patients with severe and chronic disorders, among them Borderline Personality Disorder (BPD). Two randomized controlled trials have demonstrated the effectiveness of ST for BPD, delivered in an individual or group format, in the outpatient setting. However, the most severely impaired BPD patients are referred to inpatient treatment due to suicidality and severe self-harm. Specialized inpatient treatment programs are limited, with little evaluative research. AIMS: The pilot studies are designed to be first steps in naturalistic clinical settings to evaluate the effects of an intensive inpatient ST treatment program. METHOD: This report presents the results of three independent uncontrolled pilot studies with a total of 92 BPD patients. The programs combine individual and group modalities and are consistent theoretically with the ST model for BPD patients. RESULTS: RESULTS show that inpatient ST can significantly reduce symptoms of severe BPD and global severity of psychopathology with effect sizes ranging from Cohen's d = 2.84 to Cohen's d = .43. CONCLUSIONS: Differences in the effect sizes across the three pilot studies could be explained by length of treatment, number of group psychotherapists and their training. Although there are limitations to the presented pilot studies such as differences in the samples, treatment settings, variations in the treatment itself and the use of different measures, which may have influenced outcome, they are a starting point for describing and evaluating inpatient treatment for BPD in naturalistic settings.

Effectiveness of Predominantly Group Schema Therapy and Combined Individual and Group Schema Therapy for Borderline Personality Disorder: A Randomized Clinical Trial.

IMPORTANCE: Schema therapy (ST), delivered either in an individual or group format, has been compared with other active treatments for borderline personality disorder (BPD). To our knowledge, the 2 formats have not been compared with treatment as usual (TAU) or with each other. Such comparisons help determine best treatment practices. OBJECTIVE: To evaluate whether ST is more effectively delivered in a predominantly group or combined individual and group format and whether ST is more effective than optimal TAU for BPD. DESIGN, SETTING, AND PARTICIPANTS: In this multicenter, 3-arm randomized clinical trial conducted at 15 sites in 5 countries (Australia, Germany, Greece, the Netherlands, and the UK), outpatients aged 18 to 65 years who had BPD were recruited between June 29, 2010, and May 18, 2016, to receive either predominantly group ST (PGST), combined individual and group ST (IGST), or optimal TAU. Data were analyzed from June 4, 2019, to December 29, 2021. INTERVENTIONS: At each site, cohorts of 16 to 18 participants were randomized 1:1 to PGST vs TAU or IGST vs TAU. Both ST formats were delivered over 2 years, with 2 sessions per week in year 1 and the frequency gradually decreasing during year 2. Assessments were collected by blinded assessors. MAIN OUTCOMES AND MEASURES: The primary outcome was the change in BPD severity over time, assessed with the Borderline Personality Disorder Severity Index (BPDSI) total score. Treatment retention was analyzed as a secondary outcome using generalized linear mixed model survival analysis. RESULTS: Of 495 participants (mean [SD] age, 33.6 [9.4] years; 426 [86.2%] female), 246 (49.7%) received TAU, 125 (25.2%) received PGST, and 124 (25.0%) received IGST (1 of whom later withdrew consent). PGST and IGST combined were superior to TAU with regard to reduced BPD severity (Cohen d, 0.73; 95% CI, 0.29-1.18; P < .001). For this outcome, IGST was superior to TAU (Cohen d, 1.14; 95% CI, 0.57-1.71; P < .001) and PGST (Cohen d, 0.84; 95% CI, 0.09-1.59; P = .03), whereas PGST did not differ significantly from TAU (Cohen d, 0.30; 95% CI, -0.29 to 0.89; P = .32). Treatment retention was greater in the IGST arm than in the PGST (1 year: 0.82 vs 0.72; 2 years: 0.74 vs. 0.62) and TAU (1 year: 0.82 vs 0.73; 2 years: 0.74 vs 0.64) arms, and there was no significant difference between the TAU and PGST arms (1 year: 0.73 vs 0.72; 2 years: 0.64 vs 0.62). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, IGST was more effective and had greater treatment retention compared with TAU and PGST. These findings suggest that IGST is the preferred ST format, with high retention and continuation of improvement in BPD severity after the completion of treatment. TRIAL REGISTRATION: trialregister.nl Identifier: NTR2392.

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

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.