A large scale randomized control trial, just released in the American Journal of Psychiatry (the official journal of the American Psychiatric Association) shows Schema Therapy to be significantly more effective than two major alternative approaches to the treatment of a broad range of personality disorders (avoidant, obsessive compulsive, dependent, paranoid, histrionic, and narcissistic). Schema Therapy resulted in a higher rate of recovery, greater declines in depression, greater increases in general and social functioning and had a lower drop out rate. The results also suggest Schema Therapy is more cost-effective, achieving these results in a total of 50 sessions, and that it can be readily implemented in regular clinical settings.
This is an important extension of Schema Therapy's unprecedented outcomes in the treatment of borderline personality disorder. Three major outcome studies (Farrell et al., 2009; Nadort et al., 2009; Giesn-Bloo et al., 2006) have shown that many patients with Borderline Personality Disorder can achieve full recovery across the complete range of symptoms and that it is twice as effective as a popular alternative, Transference Focused Psychotherapy. This study extends these impressive findings by including a broad range of understudied personality disorders and suggests that Schema Therapy is the most effective means currently available to alleviate the high societal and personal costs of these prevalent disorders. While rapidly gaining popularity in Europe, Schema Therapy is virtually unknown in the United States.
What sets Schema Therapy apart from all the other major treatments for personality disorders, including treatments like Dialectical Behavioral Therapy, is its use of limited reparenting. This involves the therapist doing more to directly meet the early core emotional needs of the patient. Limited reparenting is organized around modes, or parts of the self. The therapist works to get past modes like the Detached Protector and Punitive Parent Mode to reach the Vulnerable Child Mode. Direct access to the Vulnerable Child is the key to the therapist being able to meet these needs and is the cornerstone of treatment. All the major alternatives involve the therapist talking to the adult patient about their vulnerabilities and thus are more focused on adult to adult interactions. Schema therapy focuses on direct contact between the therapist and this vulnerable or child part of the self. This sets a very different tone to the treatment; one that patients respond readily to and that is believed to be the reason for the unusually low drop out rate. The adult side of the patient is gradually brought in as it becomes healthy enough to take over for the therapist.
Personality disorders are common (3-15% of the general population) and are associated with high personal suffering for those with the disorder and for those in their life. They also result in high societal costs. Psychotherapy is considered the primary treatment for personality disorders however research into its effectiveness with this population is still in its infancy.
In this study Schema Therapy was compared with Clarification-Oriented Psychotherapy (a variation on client-centered therapy developed specifically for personality disorders) and "treatment as usual" (TAU). TAU consisted of the typical treatment provided for these patients and consisted primarily of insight-oriented psychotherapy by highly experienced psychotherapists. Patients receiving Schema Therapy showed statistically significant greater improvement in recovery from personality disorders. Based on the primary outcome measure, roughly 80% recovered in Schema Therapy, 60% in Clarification-Oriented Psychotherapy and 50% in TAU. The dropout rate was also lowest among the patients receiving Schema Therapy, suggesting that Schema Therapy is more readily accepted by patients. All measures were made three years after treatment started. The study design is noteworthy in that it compares two specialized treatments (Schema Therapy and Clarification-Oriented Psychotherapy) and treatment as usual, thus pointing out differences in therapies and perhaps providing suggestions about their "active ingredients." This was a large, multi-site study (323 patients in 12 Dutch mental health institutes).
Schema Therapy was delivered weekly for 40 sessions in the first year and then with 10 booster sessions in the second year. Clarification-Oriented Psychotherapy and TAU were weekly with an open ended number of sessions.
Schema Therapy is a relatively new approach developed by Dr. Jeffrey Young of New York City and Columbia University in large part explicitly to treat personality disorders. It is an integrative psychotherapy drawing on CBT, Gestalt, and psychoanalytic psychotherapies to create a unique, structured therapy with a cohesive model of etiology and treatment.
This present study investigated typical treatment settings rather than rare expert, highly structured, specialized situations. The therapists using Schema Therapy in the study were not experts in Schema Therapy. In fact, they were therapists already employed in Dutch community mental health centers who expressed interest in Schema Therapy, received four days of training, and then peer supervision throughout the study (as well as yearly expert supervision). This study suggests that Schema Therapy can realistically be implemented effectively in typical therapy settings.
An important additional finding of this study is that therapists trained in Schema Therapy by actively practicing techniques in their training sessions and receiving immediate feedback did significantly better than therapists trained in Schema Therapy primarily by readings, lecture and video examples of techniques. This is rare and important data in the literature. Being able to compare treatment outcomes based on style of therapist training can guide future training in Schema Therapy and perhaps psychotherapy more generally.
Some of the primary investigators conducting this study will be presenting and discussing this research in detail at the bi-annual international Schema Therapy conference this June in Istanbul.
One of the most recent developments is a group version of Schema Therapy developed by Farrell & Shaw (2012) in the Midwest USA. Outcome studies on group demonstrate even larger effect sizes than individual for BPD (Farrell, et al, 2009; Reiss, Lieb, Arntz, Shaw & Farrell (2012). An international randomized controlled trial led by Arntz and Farrell is underway at 14 sites in six countries comparing varying doses of combined group and individual schema therapy to the usual community treatment provided for patients with BPD. The group model (Farrell, Reiss & Shaw, 2014) is also being tested for other personality disorders in ongoing studies in Europe.
Schema Therapy has spread quickly around the world spurred, in part, by the impressive series of findings in recent outcome studies. Since its adoption in the United States lags far behind the rest of the world, the investigators are especially interested in disseminating this information to the many patients and professionals who would benefit from this important advance.