Schema therapy is an innovative psychotherapy developed by Dr. Jeffrey Young for personality disorders, chronic depression, and other difficult individual and couples problems.

Schema therapy integrates elements of cognitive therapy, behavior therapy, object relations, and gestalt therapy into one unified, systematic approach to treatment.   Schema therapy has recently been blended with mindfulness meditation for clients who want to add a spiritual dimension to their lives.      © Copyright 2004 Schema Therapy Institute
 

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And one year after the therapy ended, 70 percent of the schema therapy patients had achieved "clinically significant and relevant improvement" in symptom reduction-working, attending school, thinking less frequently about suicide and more successfully regulating their emotions.

The study demonstrates for the first time that schema therapy can help people with BPD live more stable lives and make deep personality changes, says Jeffrey Young, PhD, a New York City-based psychologist who developed the therapy in the mid-1980s.

Young says he developed schema therapy because other therapies weren't serving his most difficult patients, particularly their need to develop a deep bond of trust with a therapist.

Drawing from cognitive-behavioral therapy, attachment theory and Gestalt techniques, the schema approach helps a therapist and client confront severe emotional damage, usually stemming from abuse in childhood, using an approach Young describes as "limited re-parenting."

Within firm limits, an attachment between therapist and client is allowed to develop-an approach different from other therapies' more neutral stances, Young says.

For the study, Dutch researchers divided 86 BPD patients from four mental health treatment centers into two groups. The first received schema therapy, and the second transference-focused psychotherapy, which seeks to help a client change from seeing themselves, and other people, in split-off extremes of "good" and "bad" to a more integrated mix of good qualities and bad qualities. Both groups received 50-minute, twice-weekly sessions of therapy for three years.

One year after completing treatment, 52 percent of the schema therapy participants reached full recovery-evaluated as such if their Borderline Personality Disorder Severity Index score fell below a cutoff point for a BPD diagnosis, and if other quality-of-life measures, such as improved social relationships and fewer incidents of self-mutilation, demonstrated a fundamental shift in how they viewed themselves and other people, says project leader Arnoud Arntz, PhD, a Maastricht University psychology professor.

By comparison, 29 percent of the transference-focused psychotherapy participants reached full recovery.

The schema therapy dropout rate was 27 percent, while half the transference group dropped out.

In fact, schema therapy limits societal costs as well as bolsters quality of life, Arntz says. The researchers estimated that per BPD participant who received schema therapy, Dutch society saved an average of $5,700 per year in medical costs and more stable employment, Arntz says.

Arntz hopes follow-up studies replicate the results and determine if group therapy based on schema therapy is possible.

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Schema Therapy Builds on CBT  by Mark Moran

Schema therapy, the newest of the psychotherapies for BPD, appears to synthesize elements of several successful therapies. Paris has described it as“ CBT with a psychodynamic component.”

Schema therapy founder Jeffrey Young, Ph.D., who is on the faculty of the Department of Psychiatry at Columbia University College of Physicians and Surgeons, was one of the first students of Aaron Beck, M.D., the founder of cognitive therapy.

“I found that cognitive therapy was extremely effective with many Axis I disorders, as research has since substantiated, but was much less effective by itself with Axis II personality disorders,” he told Psychiatric News. “I began to look for ways to expand cognitive-behavior therapy to work with Axis II issues by integrating elements drawn from other approaches as well as CBT, including psychodynamic therapies such as object relations, emotion-focused/gestalt therapies, and attachment theory.”

Young described schema therapy as an active, structured therapy for assessing and changing deep-rooted psychological problems by looking at repetitive life patterns and core life themes, called “schemas.” Schema therapists use an inventory to assess the schemas that cause persistent problems in a patient's life.

“Once we have determined what schemas a patient has, we use a range of techniques for changing these schemas,” Young said. “These include cognitive restructuring, limited re-parenting, changing schemas as they arise in the therapy relationship, intensive imagery work to access and change the source of schemas, and creating dialogues between the `schema,' or dysfunctional, side of patients and the healthy side.”

He added that systematic behavioral techniques are also employed to change dysfunctional coping styles, especially maladaptive behaviors in intimate relationships.

In a randomized trial of schema therapy versus transference-focused therapy published in the Archives in June 2006, statistically and clinically significant improvements were found for both treatments on all measures after one, two, and three-year treatment periods. Data on 44 schema therapy patients and 42 transference-focused therapy patients were available.

Main outcome measures included scores on the Borderline Personality Disorder Severity Index, quality of life, and general psychopat hologic dysf unction. Patient assessments were made before randomization and then every three months for three years.

Significantly more schema therapy patients fully recovered (46 percent versus 26 percent) or showed reliable clinical improvement (66 percent versus 33 percent) on the Borderline Personality Disorder Severity Index than patients receiving transference-focused therapy. They also improved more in general psychopathologic dysfunction and showed greater increases in quality of life.

Statistical analysis also revealed a higher dropout risk among transference-focused therapy (52 percent) patients than among patients receiving schema therapy (29 percent), according to the study report.

The authors also stated that, in a separate analysis, schema therapy was found to be highly cost-effective for society, despite the length and intensity of the treatment.

Young, who was not involved in the study, said it is the first to demonstrate “deep personality change” in a high percentage of patients long considered untreatable.

“Up until now, existing therapies for BPD have proven to lead to only partial recovery or have only been able to reduce self-harming behaviors,” he said. “This should be of great interest to psychiatrists because patients with BPD are usually considered the most difficult, frustrating, and risky patients within most therapists' practices.

“The second important implication for psychiatrists is that the use of a neutral stance toward the BPD patient, which is advocated in most psychodynamic approaches to BPD, is clearly much less effective than the more engaged, warm, and nurturing stance of schema therapy,” Young said.“ This was demonstrated by the dramatic differences in dropout rates between the two treatments.”

Despite their proven effectiveness, all of the psychotherapies for BPD are time and labor intensive.

“All suffer from the need for highly trained therapists, specialized settings, human resources, and time,” Paris told Psychiatric News. “There are many barriers to psychotherapy for BPD. Most involve money, since only a small number of these patients can pay, and few have adequate insurance. Another barrier is the failure of psychiatrists and other professionals to recognize and diagnose BPD. Still another is the current tendency to treat BPD with medication alone.”

Paris said in an address at APA's annual meeting last year in Toronto that drugs were vastly overused in treatment of all the personality disorders (Psychiatric News, July 7, 2006).

“The problem is that there is no science to support poly-pharmacy, and it's probably bad for patients,” he said at the meeting. “When you give patients with classical depression an antidepressant, they may be cured in a few weeks. But you never see that in patients with borderline personality. It might take the edge off, but patients never go into remission.”

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