Combining individual schema and group schema therapy together appears to be the best approach for reducing symptoms of borderline personality disorder (BPD), new research suggests.
Schema is a form of psychotherapy that focuses on experiential approaches rather than on behavior change.
The findings from an international randomized controlled trial underscore the importance of offering both individual and group approaches to patients with BPD, study investigator Arnoud Arntz, PhD, professor, Department of Clinical Psychology, University of Amsterdam, the Netherlands, told Medscape Medical News.
“In the Netherlands, there’s a big push from mental health institutes to deliver treatments in group therapy [only] because people think it’s more cost-effective; but these findings question that idea,” Arntz said.
The findings were published online March 2 in JAMA Psychiatry.
Early Childhood Experiences
Patients with BPD exhibit extreme sensitivity to interpersonal slights, intense and volatile emotions, and impulsive behaviors. Many abuse drugs, self-harm, or attempt suicide.
Evidence-based guidelines recommend psychotherapy as the primary treatment for BPD.
Schema therapy uses techniques from traditional psychotherapy but focuses on an experiential strategy. It also delves into early childhood experiences, which is relevant because patients with BPD often experienced abuse or neglect early in life.
As well, with this approach, therapists take on a sort of parenting role with patients to try to meet needs “that were frustrated in childhood,” said Arntz.
Previous research has suggested both individual and group schema therapy help reduce BPD symptoms, but the effectiveness of combining these two approaches has been unclear.
The current study included 495 adult patients (mean age, 33.6 years; 86.2% women) enrolled at 15 sites in five countries: the Netherlands, England, Greece, Germany, and Australia. All participants had a Borderline Personality Disorder Severity Index IV (BPDSI-IV) score of more than 20.
The BPDSI-IV score ranges from 0–90, with a score of 15 being the cutoff for a BPD diagnosis.
Investigators randomly assigned participants to one of three arms: predominantly group schema therapy, combined individual and group schema therapy, and treatment as usual — which was the optimal psychological treatment available at the site.
The two schema therapy arms, whether group or individual, involved a similar number of sessions each week. However, the frequency was gradually reduced over the course of the study.
The primary outcome was change in BPD severity as assessed at baseline, 6 months, 12 months, 18 months, 24 months, and 36 months with the BPDSI-IV total score.
Researchers first compared both the group therapy and the combination therapy with treatment as usual and found that together, the two schema arms were superior for reducing total BPDSI-IV score, with a medium to large effect size (Cohen d, 0.73; 95% CI, .29 – 1.18; P = .001).
The difference was significant at 1.5 years (mean difference, 2.38; 95% CI, .27 – 4.49; P = .03).
When the treatment arms were compared separately, the combination therapy was superior to both the group therapy (Cohen d, 0.84; 95% CI, .09 – 1.59; P = .03) and to treatment as usual (Cohen d, 1.14; 95% CI, .57 – 1.71; P < .001).
The effectiveness of the predominantly group therapy did not differ significantly from that of treatment as usual.
The difference in effectiveness of combined therapy compared with treatment as usual became significant at 1 year. It became significant at 2.5 years compared with predominantly group therapy.
In both schema arms, session frequency was tapered to only once a month; and in year 3, no further treatment was offered. However, symptom improvement continued during years 2 and 3.
Arntz explained this could be because patients realized they could apply what they learned after therapy was discontinued, which boosted their self-confidence.
Treatment retention was greater with combined therapy compared to the other options.
There was also improvement in several secondary outcomes, including happiness and quality of life, in most patients. However, patterns of outcomes for societal and work functioning improved more for those in either arm that received schema therapy.
“Group therapy seems to offer something that is important for learning to cooperate with other people. At work, you often have to collaborate with people who are not necessarily your friends,” Arntz noted.
The number of suicide attempts declined over time, with the combination arm being significantly superior to treatment as usual. During the study period, three patients died from suicide: one from each treatment arm. Another death had an unknown cause.
Overall, the results suggest that group and individual sessions address different needs of patients, the investigators note.
While patients may learn to get along with others in a group setting, they may be more comfortable discussing severe trauma or suicidal thoughts in one-on-one sessions with a therapist, they add.
Commenting for Medscape Medical News, John M. Oldham, MD, Distinguished Emeritus Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, said the study had a number of strengths, including its size and “good, solid” methodology.
“This is another big study that demonstrates a well-established form of psychotherapy leads to effective improvement in patients with borderline,” said Oldham, who was not involved in the research.
However, he also noted a number of study limitations. First, training for therapists to deliver schema therapy is not always readily available, said Oldham. In addition, schema therapists in the study “were pretty junior,” with some appearing to be “trained on the job,” he said.
Oldham noted that cost may be another deterrent to implementing this therapeutic approach. Only those with substantial financial resources could afford once-a-week group therapy and once-a-week individual therapy for 2 years, at least in the United States, he said.
Because patients had to be willing to undergo therapy for 2 years to be enrolled in the study, the results may not be generalizable to the entire BPD population, Oldham added. “Many borderline patients would turn around and walk out the door if asked to commit to that,” he said.
So the study population may be “better attuned and receptive to therapy” and less impaired compared to many patients with this condition, Oldham said.
He also said the study did not compare individual schema therapy alone with group schema alone.
Study sites were supported by the Netherlands Organization for Health Research and Development and the Netherlands Foundation for Mental Health Study; Else Kröner-Fresenius-Stiftung; Australian Rotary Health; Greek Society of Schema Therapy, First Department of Psychiatry of the Medical School of the University of Athens, and Institut für Verhaltenstherapie Ausbildung Hamburg; South London and Maudsley NHS Foundation Trust and the Research Center Experimental Psychopathology, Maastricht University and Bradford District Care NHS Foundation Trust. Arntz has received grants from the Netherlands Organization for Health Research and Development and the Netherlands Foundation for Mental Health. Oldham reported no relevant financial relationships.
JAMA Psychiatry. Published online March 2, 2022. Abstract