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.

Schema therapy for borderline personality disorder: A qualitative study of patients' perceptions.

Schema therapy (ST) has been found to be effective in the treatment of borderline personality disorder (BPD). However very little is known about how the therapy is experienced by individuals with BPD including which specific elements of ST are helpful or unhelpful from their perspectives. The aim of this study is to explore BPD patients' experiences of receiving ST, in intensive group or combined group-individual format. Qualitative data were collected through semi-structured interviews with 36 individuals with a primary diagnosis of BPD (78% females) who received ST for at least 12 months. Participants were recruited as part of an international, multicenter randomized controlled trial (RCT). Interview data (11 Australian, 12 Dutch, 13 German) were analyzed following the procedures of qualitative content analysis. Patients' perceptions of the benefits gained in ST included improved self-understanding, and better awareness and management of their own emotional processes. While some aspects of ST, such as experiential techniques were perceived as emotionally confronting, patient narratives informed that this was necessary. Some recommendations for improved implementation of ST include the necessary adjunct of individual sessions to group ST and early discussion of therapy termination. Implications of the findings are also discussed, in particular the avenues for assessing the suitability of patients for group ST; management of group conflict and the optimal format for delivering treatment in the intensive group versus combined group-individual formats.

The Development and Psychometric Evaluation of the Group Schema Therapy Rating Scale - Revised.

BACKGROUND: Recent research has supported the efficacy of schema therapy as a treatment for personality disorders. A group format has been developed (group schema therapy; GST), which has been suggested to improve both the clinical and cost-effectiveness of the treatment. AIMS: Efficacy studies of GST need to assess treatment fidelity. The aims of the present study were to improve, describe and evaluate a fidelity measure for GST, the Group Schema Therapy Rating Scale - Revised (GSTRS-R). METHOD: Following a pilot study on an initial version of the scale (GSTRS), items were revised and guidelines were modified in order to improve the reliability of the scale. Students highly experienced with the scale rated recorded GST therapy sessions using the GSTRS-R in addition to a group cohesion measure, the Harvard Community Health Plan Group Cohesiveness Scale - II (GCS-II). The scores were used to assess internal consistency and inter-rater reliability. Discriminant validity was assessed by comparing the scores on the GSTRS-R with the GCS-II. RESULTS: The GSTRS-R displayed substantial internal consistency and inter-rater reliability, and adequate discriminate validity, evidenced by a weak positive correlation with the GCS-II. CONCLUSIONS: Overall, the GSTRS-R is a reliable tool that may be useful for evaluating therapist fidelity to GST model, and assisting GST training and supervision. Initial validity was supported by a weak association with GCS-II, indicating that although associated with cohesiveness, the instrument also assesses factors specific to GST. Limitations are discussed.

Design of an international multicentre RCT on group schema therapy for borderline personality disorder.

BACKGROUND: Borderline personality disorder (BPD) is a severe and highly prevalent mental disorder. Schema therapy (ST) has been found effective in the treatment of BPD and is commonly delivered through an individual format. A group format (group schema therapy, GST) has also been developed. GST has been found to speed up and amplify the treatment effects found for individual ST. Delivery in a group format may lead to improved cost-effectiveness. An important question is how GST compares to treatment as usual (TAU) and what format for delivery of schema therapy (format A; intensive group therapy only, or format B; a combination of group and individual therapy) produces the best outcomes. METHODS/DESIGN: An international, multicentre randomized controlled trial (RCT) will be conducted with a minimum of fourteen participating centres. Each centre will recruit multiple cohorts of at least sixteen patients. GST formats as well as the orders in which they are delivered to successive cohorts will be balanced. Within countries that contribute an uneven number of sites, the orders of GST formats will be balanced within a difference of one. The RCT is designed to include a minimum of 448 patients with BPD. The primary clinical outcome measure will be BPD severity. Secondary clinical outcome measures will include measures of BPD and general psychiatric symptoms, schemas and schema modes, social functioning and quality of life. Furthermore, an economic evaluation that consists of cost-effectiveness and cost-utility analyses will be performed using a societal perspective. Lastly, additional investigations will be carried out that include an assessment of the integrity of GST, a qualitative study on patients' and therapists' experiences with GST, and studies on variables that might influence the effectiveness of GST. DISCUSSION: This trial will compare GST to TAU for patients with BPD as well as two different formats for the delivery of GST. By combining an evaluation of clinical effectiveness, an economic evaluation and additional investigations, it will contribute to an evidence-based understanding of which treatment should be offered to patients with BPD from clinical, economic, and stakeholders' perspectives. TRIAL REGISTRATION: Netherlands Trial Register NTR2392. Registered 25 June 2010.

The evaluation of supervision: construction of brief questionnaires for the supervisor and the supervisee.

This study evaluated the psychometric properties of two parallel questionnaires (for the supervisor and supervisee, respectively). Ninety supervisees and 37 supervisors from different parts of Germany took part in the study. The three dimensions of clarifying, problem solving, and relationship were confirmed, but for both supervisor and supervisee versions of the scale medium intercorrelations also allowed a combined scale to be formed. In exploratory regression analysis, the relationship dimension related to both perspectives (i.e., supervisor and supervisee) served as the best predictor for overall supervision satisfaction. Despite the fact that general session satisfaction correlated in the medium range between supervisor and supervisee, there was no correlation between the perspectives as measured by the questionnaires. Possible reasons for this unexpected correlational pattern are discussed.