a systematic review of the evidence base for schema therapy

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A Systematic Review of the EvidenceBase for Schema TherapySamantha A. Masley a , David T. Gillanders b , Susan G. Simpson c &Morag A. Taylor aa

NHS Grampian, Adult Mental Health, Royal Cornhill Hospital,Aberdeen, United Kingdomb School of Health in Social Science, University of Edinburgh,Edinburgh, United Kingdomc School of Psychology, Social Work & Socia l Policy University of South Australia, Adelaide, Australia

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To cite this article: Samantha A. Masley, David T. Gillanders, Susan G. Simpson & Morag A. Taylor(2011): A Systematic Review of the Evidence Base for Schema Therapy, Cognitive Behaviour Therapy,DOI:10.1080/16506073.2011.614274

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A Systematic Review of the Evidence Base for SchemaTherapy

Samantha A. Masley 1 , David T. Gillanders 2 , Susan G. Simpson 3 andMorag A. Taylor 1

1 NHS Grampian, Adult Mental Health, Royal Cornhill Hospital, Aberdeen, United Kingdom;2 School of Health in Social Science, University of Edinburgh, Edinburgh, United Kingdom;

3 School of Psychology, Social Work & Social Policy University of South Australia, Adelaide,Australia

Abstract. Schema Therapy is becoming an increasingly popular psychological model for working withindividuals who have a variety of mental health and personality difculties. The aim of this review is tolook at the current evidence base for Schema Therapy and highlight directions for further research. Asystematic search of the literature was conducted up until January 2011. All studies that had clinicallytested the efcacy of Schema Therapy as described by Jeffrey Young (1994 and 2003) were considered.These studies underwent detailed quality assessments based on Scottish Intercollegiate GuidelinesNetwork (SIGN-50) culminating in 12 studies being included in the review. The culminative message(both from the popularity of this model and the medium-to-large effect sizes) is of a theory that hasalready demonstrated clinically effective outcomes in a small number of studies and that would benetfrom ongoing research and development with complex client groups. It is imperative that psychologicalpractice be guided by high-quality research that demonstrates efcacious, evidence-based interventions.It is therefore recommended that researchers and clinicians working with Schema Therapy seek to buildon these positive outcomes and further demonstrate the clinical effectiveness of this model throughongoing research. Key words: Schema Therapy; ST/SFT; empirical evidence; schema-focused therapy

Received 24 April, 2011; Accepted 10 August, 2011

Correspondence address: Samantha A. Masley, Department of Clinical and Counseling Psychology,Block A, Royal Cornhill Hospital, Aberdeen, Ab25 2ZH United Kingdom. Tel: 07929480298. E-mail:[email protected]

IntroductionWithin public health care organizations,mental health professionals are continuallystriving to provide the best interventions andtreatments available. Until recently there was adearth of research that supported the effec-tiveness of psychological therapies for person-ality disorders (Fonagy & Bateman, 2006;Binks et al., 2009). These client groups wereconsidered ‘untreatable’ by many because of the lack of treatment models with adequatesophistication and depth to address the needsof these more complex client groups (Young,Klosko, & Weishaar, 2003). With new psycho-logical theories constantly evolving, it is

essential to ensure that clinical practice keepspace with research evidence. In such dynamicenvironments, systematic reviews are starting

to play an increasingly important role inassessing the existing evidence for psychologi-cal interventions (SIGN, 2008).

The aim of this review is to collate thecurrent evidence base for one of the morerecent models of psychological therapySchema Therapy (Young, 1994; Young et al.,2003). Schema Therapy (ST) was developed byJeffery Young in the 1980s with the goal of improving interventions for individuals whohad personality disorders and more complex,chronic and characterological difculties.

q 2011 Swedish Association for Behaviour Therapy ISSN 1650-6073http://dx.doi.org/10.1080/16506073.2011.614274

Cognitive Behaviour Therapy iFirst article, pp. 1–18, 2011

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Such individuals are often considered ‘difcultto treat’ using traditional cognitive therapyand are frequently described as ‘treatmentfailures’ (Young et al., 2003). From extensiveclinical experience, Young identied that suchindividuals appeared to benet from someadaptations to traditional cognitive therapy.Over time these adaptations evolved into ST— a broad integrative model that overlaps withother models of psychopathology includingCognitive Behavioural Therapy and psycho-dynamic models (Young et al., 2003).

Over recent years, this model has becomeincreasingly popular with clinicians andacademicians who have started to test boththe theoretical assumptions and the clinical

effectiveness of this model. However, due tothe recency of both the model and research inthis area, no other review has been conductedin this eld to our knowledge.

What is Schema Therapy? There are four main concepts that are central toST: early maladaptive schemas, coping styles,schema domains and schema modes (Younget al., 2003). Early maladaptive schemas(EMS)are at the heart of model. Currently, there are18 EMS and these are described as

extremely stable and enduring themes,comprised of memories, emotions, cognitions,and bodily sensations regarding oneself andone’s relationship with others, that developduring childhood and are elaborated onthroughout the individual’s lifetime, and thatare dysfunctional to a signicant degree (Younget al., 2003, p. 7).

Young states that schemas are present inevery human being but are manifested in amore rigid and extreme way in cases of psychopathology.

EMS commonly develop in children wholive in an environment that fails to meet theircore emotional needs or in an environmentwhere they experience repeated episodes of abuse, neglect, hostility and criticism (Younget al., 2003). Depending on the child’s earlyenvironment, the development of schemas canbe grouped into ve domains: (1) disconnec-tion and rejection, (2) impaired autonomy and

performance, (3) impaired limits, (4) otherdirectedness and (5) over vigilance andinhibition. Each domain represents an import-ant component of a child’s core needs, for

example, schemas in the disconnection andrejection domain typically originate indetached, cold, rejecting, withholding, lonely,explosive, unpredictable, or abusive families(Young et al., 2003).

Coping styles refer to the ways a child adaptsto these environments and experiences. Thereare three main coping strategies that thesechildren adopt: (1) overcompensation (ghtingthe schema and acting as though the oppositewere true), (2) surrendering (or giving in to theschema) and (3) avoidance (trying to avoidschema activation) (Young et al., 2003).Although these coping styles initially develop tohelp a child survive toxic environments, overtime and in different environments such

strategies can serve to maintain the dysfunc-tional schemas and cease to serve an adaptivefunction for the individual (Young et al., 2003).

Schema modes are the most recent additionto the ST model. Modes reect the moment-to-moment emotional and behavioural stateof a person at a given time. Modes comprise of clusters of schemas, for example, defectiveness(the belief that one is awed or defective) andemotional deprivation (the belief that you willnever be understood and that your needs willnever be met by others) are both part of theVulnerable Child mode. ST and schema modetherapy do not reect two separate entities,rather schema mode work is seen as anadvanced component of ST, which is particu-larly benecial when working with individualswho have borderline personality disorder(BPD) or other complex presentations. Suchindividuals often present with a number of schemas being simultaneously activated,which can make individual schema workmore complex (Young et al., 2003). Byallowing therapists to work with groups of schemas simultaneously, schema modetherapy can simplify therapeutic interventionsfor some individuals.

The goal of Schema TherapyYoung et al. (2003) explain that healthypersons can adaptively meet their own coreneeds through self-care and close adaptiverelationships with others. The goal of ST is tohelp those who are currently unable to do this.

This may involve identifying and reducingmaladaptive coping behaviours, which func-tion to perpetuate schemas and reduce thelikelihood of schema change, whilst developing

2 Masley, Gillanders, Simpson and Taylor COGNITIVE BEHAVIOUR THERAPY

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healthier, more adaptive alternatives andhealing unhelpful schemas. This can be a longprocess that requires the individual to confrontand modify schemas that may have previouslyserved a protective and adaptive function.

In ST, the therapeutic relationship is seen asthe foundation for these changes to occur. AsEMS and modes arise when core needs are notmet, schema therapists aim to identify andmeet these previously unmet needs in a limitedway within the therapy relationship by usinga variety of techniques including empathicconfrontation and experiential, cognitive andbehavioural strategies. This may then progressto mobilizing other supportive relationships.By helping the individual identify missed

experiences or unmet needs in early childhoodand providing opportunities to address thesewithin a therapeutic relationship, ST serves asan antidote to the early damaging experiencesthat led to the formation of maladaptiveschemas and modes. In ST this is referred to as‘limited reparenting’ (Young et al., 2003).

Why conduct this review? Over the last 20 years, ST has evolved into amodel that is both simple to understand and

also deep and complex in nature. Thecombination of these factors has resulted inST being a popular model with clinicians andresearchers. The aim of this systematic reviewis to identify and consolidate the currentclinical evidence base for ST and suggest areasin need of future development.

MethodReview objectiveTo review the treatment evidence for ST asdescribed by Jeffrey Young (Young, 1994;Young et al., 2003).

ParticipantsYoung suggests that ST is not appropriate forall individuals. Indications that ST may not beappropriate in the short term are

1. current major crises,2. psychosis,3. acute, untreated Axis I disorder,

4. current chronic substance misuse,5. when the presenting problem is situationaland not related to a schema or life patternand

6. when the individual is under 18 years, aspersonality variables in younger peoplemay still be forming.

All study participants were considered in

relation to these recommendations. The onlyxed exclusion criteria was age. No study withparticipants under 18 years was included inthis review.

PsychopathologyAlthough ST was originally developed toimprove treatment outcomes for individualswith personality disorders and chronic char-acterological difculties, it is not restricted tothis group. ST is recommended to be used with

a variety of psychopathology. When individ-uals present with co-morbid Axis I and Axis IIdisorders, it is recommended that Axis Idisorders are prioritized before addressingAxis II psychopathology. To ensure that thisreview represents a broad range of individuals,all forms of intervention (e.g., group andindividual formats) and psychopathologywere considered. Because of the high preva-lence of co-morbidity of mental healthconditions, it was considered clinically usefulto include studies with participants who mayhave more than one mental health diagnosis.

SettingThe aim of this review is to evaluate ST in abroad range of mental health settings tooptimize its clinical utility and therefore bothinpatient and outpatient settings wereconsidered.

InterventionsBecause of the limited number of outcomestudies in this area, all studies that applied STto individuals with a mental health conditionwere considered. Although it was anticipatedthat the number of sessions would vary, onlythose studies that evaluated the efcacy of aST intervention and exceeded 10 sessions wereincluded in the review. This is due to STaiming to achieve deep schema change, whichis unlikely to occur in very short interventions.

OutcomesAs ST may have a variety of differentoutcomes depending on an individual’s uniqueneeds, all outcomes were considered.

VOL 00, NO 0, 2011 Evidence Base for Schema Therapy 3

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LanguageOnly English language studies were includedbecause of lack of translation resources.

Study DesignIdeally, systematic reviews consider evidenceonly from high-quality randomized controlledtrials(RCTs). However, there are many whofeelthat this may not be the best way of evaluatingthe true value of psychological treatments forpersonality disorders (Emmelkamp & Vedel,2009). This is due to the inherent problems inrunning research with such complex clientgroups. Additionally, RCTs do not tell usmuch about implementing psychological treat-ments in real public health service settings. This

is due to their strict guidelines and inclusioncriteria, which are often unrepresentative of routine clinical practice. As research intopsychological therapies is ultimately aboutinforming clinical practice, this review includesRCTs, controlled trials (CT) and uncontrolledtrials (UT). Single case studies or studies withless than ve participants have been excludedowing to the higher potential for bias in thesestudy designs. Finally, economic evaluationsand studies using duplicate data have not been

included.

Search StrategyThe following search terms were used in thisstudy: ‘schema therapy’ or ‘schema-focusedtherapy’. However, for the purposes of thisstudy, these would be referred to as ‘schematherapy’, which is now the most commonlyused description. The following electronicdatabases were searched until 10 January 2011:

. MEDLINE (from 1950)

. EMBASE (from 1980)

. CINAHL (from 1982)

. The Cochrane Central Register of Con-trolled Trials (CENTRAL) (TheCochrane Library 2009, issue 3)

. PsycINFO (from 1872)

Searching other resourcesThe reference lists of included and excludedstudies were searched for additional studiesand prominent researchers were contacted to

enquire about other sources of information,including ongoing research or unpublisheddata. Finally, two prominent ST websites (theInternational Society for Schema Therapy’s

website (http://www.isst-online.com/) andSchema Therapy’s website’ (http://www.schematherapy.com)) were also searched.

Study selectionAll titles and abstracts were initially screenedand irrelevant studies or purely theoreticalstudies were excluded, and the full text of allthe remaining studies were obtained and read.Those studies that utilized data previouslyreported were removed to prevent duplication.A owchart of the selection process can beseen in Figure 1.

ResultsFollowing this selection procedure, 12 studiesmet all the study requirements (see Table 1). Intotal, four of the studies were considered to beassessing the effectiveness of ST in thetreatment of BPD (Farrell, Shaw, & Webber,2009; Giesen-Bloo et al., 2006; Nadort et al.,2009; Nordahl & Nysaeter, 2005), one focusedon the effectiveness of ST techniques in thetreatment of childhoodmemories (Weertman&Arntz, 2007), two targeted substance misuseand concurrent personality disorders (Ball,

2007; Ball, Cobb-Richardson, Connolly,Bujosa, & O’neall, 2005), one looked at ST forposttraumatic stress disorder (PTSD) (Cock-ram, Drummond, & Lee, 2010), one evaluatedgroup ST in an eating disorder population(Simpson, Morrow, van Vreeswijk, & Reid,2010) and three focused on individuals withagoraphobia and cluster C personality dis-orders (Gude & Hoffart, 2008; Gude, Monsen,& Hoffart, 2001; Hoffart & Sexton, 2002).

Quality AssessmentIn order to differentiate between strong andweak evidence, quality assessments werecarried out on all studies. To assist withthese assessments, the Scottish IntercollegiateGuidelines Network (SIGN 50) were used.These checklists provided a framework to ratethe methodological quality of each study.Based on these ratings, each study was givenone of the following overall quality ratings:

. ‘A’ was awarded to those high-quality

RCTs that met all or most of the qualitycriteria and when they did not fullthem, the conclusions in the study weredeemed very unlikely to alter.


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. ‘B’ was awarded to those RCTs andcontrolled trials that met most of thequality criteria and when the con-clusions in the study were deemedunlikely to alter.

. ‘C’ was awarded to those RCTs orcontrolled trials when few or none of thequality criteria had been fullled and theconclusions of the study were deemedlikely or very likely to alter.

. ‘D’ was awarded to single-group designsand uncontrolled studies.

To try and minimize bias in ratings, twostudies were rated again by an independent

rater and compared to the existing assessment.No differences were found between theresearcher’s assessment and the independentresearcher’s assessment on either study.Table 2 summarizes the quality criteria ratingsfor this study.

DiscussionSchema Therapy for BPDIn total, four studies looked at the effective-ness of ST in treating BPD. Of these, onecompared treatment as usual (TAU) to TAUwith group ST (Farrell et al., 2009), one

Titles and abstractsscreened n = 130

Full copies obtainedand assessed foreligibility n =103

Publications to berevewed n = 12

Studies identifiedthrough contact with

experts n = 1

Excluded n = 27(Not related to ST )

Excluded n = 93

Theoretical articles n = 73• Non-English language n = 8• Not 'Schema Therapy' n = 3• Unable to obtain n = 1• No outcome data n = 2• Duplicate data n = 1• Less than 5 participants n = 3• Less than 10 sessions n = 1

Figure 1 . Flow chart of the study selection process.


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T a b l e 1 . S u m m a r y o f i n c l u d e d s t u d i e s

S t u d y

A i m

D e s i g n

I n t e r v e n t i o n

O u t c o m e m e a s u r e s

C o n c l u s i o n s

E f f e c t s i z e s

B a l l ( 2 0 0 7 ) .

T o c o m p a r e D u a l

F o c u s S c h e m a

T h e r a p y ( D F S T ) t o a

1 2 - S t e p F a c i l i t a t i o n

T h e r a p y ( 1 2 F T ) i n 3 0

p a r t i c i p a n t s ( 1 5 m a l e s

a n d 1 5 f e m a l e s ) w i t h a

d i a g n o s e d p e r s o n a l i t y

d i s o r d e r a n d c o n c u r -

r e n t s u b s t a n c e m i s u s e

R C T

6 m o n t h s o f e i t h e r

D F S T o r 1 2 F T

S u b s t a n c e u s e t i m e l i n e

c a l e n d a r ; A d d i c t i o n

S e v e r i t y I n d e x ; B r i e f

S y m p t o m I n d e x ; M u l -

t i p l e A f f e c t A d j e c t i v e

C h e c k l i s t - R e v i s e d ;

W o r k i n g A l l i a n c e

I n d e x

B o t h g r o u p s d e m o n -

s t r a t e d a r e d u c t i o n i n

s u b s t a n c e m i s u s e , a

n d

t h i s w a s m o r e r a p i d i n

t h e D F S T c o n d i t i o n .

P a r t i c i p a n t s r e p o r t e d a

s t r o n g e r t h e r a p e u t i c

a l l i a n c e i n t h e D F S T

c o n d i t i o n .

R e d u c t i o n i n d y s p h o -

r i c

a f f e c t d i d n o t o c c u r

i n t h e D F S T b b u t i n

t h e 1 2 F T g r o u p .

U n a b l e t o c o m p u t e

B a l l , C o b b -

R i c h a r d s o n ,

C o n n o l l y

,

B u j o s a , &

O ’ N e a l l

( 2 0 0 5 )

T o c o m p a r e D u a l

F o c u s S c h e m a

T h e r a p y ( D F S T ) t o

s t a n d a r d

g r o u p s u b s t a n c e a b u s e

c o u n s e l l i n g ( S A C ) i n

5 2 h o m e l e s s , m a l e c l i -

e n t s w i t h a d i a g n o s e d

p e r s o n a l i t y d i s o r d e r

a n d c o n c u r r e n t s u b -

s t a n c e m i s u s e

R C T

2 4 w e e k s o f e i t h e r

D F S T o r S A C

D u e t o l o w r e t e n t i o n o f

p a r t i c i p a n t s w a s a b l e

t o p r o v i d e o n l y o u t -

c o m e d a t a o n u t i l i z a -

t i o n o f t h e r a p y

G r e a t e r u t i l i z a t i o n o f

D F S T

. O v e r a l l , h o w -

e v e r , i

n d i v i d u a l s w i t h

m o r e s e v e r e p e r s o n a l -

i t y

d i s o r d e r s u t i l i z e d

S A C m o r e t h a n D F S T

. U n a b l e t o c o m p u t e

C o c k r a m ,

D r u m m o n d ,

& L e e ( 2 0 1 0 )

T o c o m p a r e S c h e m a

T h e r a p y ( S T ) w i t h t r a -

d i t i o n a l C B T ( T C B T )

f o r t h e t r e a t m e n t o f

P T S D i n w a r v e t e r a n s ;

T C B T w a s d e l i v e r e d t o

1 2 7 i n d i v i d u a l s

b e t w e e n 1 9 9 6 a n d

2 0 0 2 ;

S T w a s d e l i v e r e d t o 5 4

v e t e r a n s b e t w e e n 2 0 0 7

a n d 2 0 0 8

C T

1 9 0 h o u r s o f e i t h e r

S T o r T C B T

P T S D C h e c k l i s t

M i l i t a r y ;

Y o u n g S c h e m a Q u e s -

t i o n n a i r e - L

3 ; H o s p i t a l

A n x i e t y a n d

D e p r e s s i o n S c a l e

P T S D s y m p t o m s ,

a n x i e t y , d e p r e s s i o n

a n d E M S d e c r e a s e d

s i g n i c a n t l y f o l l o w i n g

S T . W

h e n c o m p a r e d t o

T C

B T , t

h e S T

g r o u p s h o w e d s i g n i -

c a n t l y g r e a t e r

r e d u c t i o n s i n P T S D

a n d a n x i e t y s y m p t o m s .

B e t w e e n i n t a k e a n d

f o l l o w - u p , e f f e c t s i z e s

w e r e m e d i u m t o l a r g e

i n t h e S T

g r o u p ( C o h e n ’ s d

b e t w e e n 0 . 6 1 a n d 0 . 8 2 )

a n d s m a l l t o m e d i u m

i n t h e C B T c o m p a r i -

s o n g r o u p ( b e t w e e n 0 . 3

a n d 0 . 5 3 )


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F a r r e l l ,

S h a w , &

W e b b e r

( 2 0 0 9 )

T h i s s t u d y t e s t s t h e

e f f e c t i v e n e s s o f a d d i n g

a n 8 m o n t h , 3

0 s e s s i o n

s c h e m a - f o c u s e d

t h e r a p y ( S T ) g r o u p t o

t r e a t m e n t a s u s u a l

( T A U ) f o r 3 2 w o m e n

w i t h a d i a g n o s i s o f

b o r d e r l i n e p e r s o n a l i t y

d i s o r d e r ( B P D )

R C T

E i t h e r 8 m o n t h s ( 3 0

s e s s i o n s ) o f

g r o u p S T a n d T A U

o r j u s t T A U

B o r d e r l i n e S y n d r o m e

I n d e x ; S C L - 9 0 R

,

D i a g n o s t i c I n t e r v i e w

f o r B o r d e r l i n e P e r s o n -

a l i t y D i s o r d e r s -

R e v i s e d ; G l o b a l

A s s e s s m e n t o f F u n c -

t i o n i n g S c a l e ;

T h e s e w e r e a d m i n i s -

t e r e d p r e - t r e a t m e n t ,

p o s t - t r e a t m e n t a n d a t

6 - m o n t h f o l l o w - u p

A t t h e e n d o f t h e

t r e a t m e n t , 9 4 % o f

S T

þ T A U g r o u p n o

l o n g e r m e t t h e c r i -

t e r i o n f o r B P D

, w h i l s t

o n l y 1 6 % o f T A U n o

l o n g e r m e t t h e c r i -

t e r i o n . S i g n i c a n t l y

l o w e r s c o r e s o n B S I ,

D I B - R a n d S C L - 9 0 R

a n d h i g h e r s c o r e s o n

t h e G A F . T h e s e e f f e c t s

w e r e m a i n t a i n e d a t 6 -

m o n t h f o l l o w - u p .

A t f o l l o w

- u p , e f f e c t

s i z e s u s i n g p o o l e d

s t a n d a r d d e v i a t i o n s

w e r e a l l l a r g e i n t h e S T

g r o u p ( b e t w e e n 4 . 4 5

a n d 1

. 1 7 ) a n d a l l s m a l l

i n t r e a t m e n t a s u s u a l

( b e t w e e n

0 . 1 4 a n d

0 . 3 5 )

G i e s e n - B l o o

e t a l . (

2 0 0 6 )

T o c o m p a r e t h e e f f e c -

t i v e n e s s o f S c h e m a

T h e r a p y ( S T ) a n d

t r a n s f e r e n c e f o c u s e d

t h e r a p y ( T F T ) i n 8 8

p a t i e n t s w i t h a d i a g -

n o s e d b o r d e r l i n e p e r -

s o n a l i t y d i s o r d e r

( B P D ) i n d e x s c o r e

a b o v e 2 0

R C T

T w o s e s s i o n s p e r

w e e k f o r 3 y e a r s o f

e i t h e r S T o r T F T

B o r d e r l i n e P e r s o n a l i t y

D i s o r d e r S e v e r i t y

I n d e x s c o r e ( 4 t h v e r -

s i o n ) ; Q u a l i t y o f l i f e ;

g e n e r a l p s y c h o p a t h o -

l o g i c a l d y s f u n c t i o n ;

m e a s u r e s o f S c h e m a

T h e r a p y / t r a n s f e r e n c e

f o c u s e d p s y c h o t h e r a p y

p e r s o n a l i t y c o n c e p t s

T h r e e y e a r s o f S c h e m a

T h e r a p y o r T r a n s f e r -

e n c e - F o c u s e d P s y -

c h o t h e r a p y r e d u c e d

B P D s p e c i c ( a n d g e n -

e r a l ) p s y c h o p a t h o l o g i c

d y s f u n c t i o n , i m p r o v e d

q u a l i t y o f l i f e a n d

i n c r e a s e d m o d e l -

s p e c i c c o n c e p t s .

T h e B P D S I - I

V

d e m o n s t r a t e d S T t o b e

m o r e e f f e c t i v e t h a n

T F T o n t h e f o l l o w i n g

s u b - s c a l e s : a b a n d o n -

m e n t f e a r s ( p ¼ . 0

4 ) ,

r e l a t i o n s h i p s

( p ¼ . 0

3 ) ; i d e n t i t y d i s -

t u r b a n c e ( p ¼ . 0

2 ) ;

i m p u l s i v i t y ( p ¼ . 0

3 ,

p a r a - s u i c i d a l b e h a -

v i o u r ( p ¼ . 0

4 ) ;

W i t h r e s p e c t t o t h e

s t u d y ’ s m

a i n o u t c o m e

m e a s u r e s , 1 y e a r o f S T

r e s u l t e d i n C o h e n ’ s d

r a n g i n g b e t w e e n 0 . 4 3

a n d 1 . 0 3 a n d i n T F P

b e t w e e n 0 . 0 9 a n d 0 . 9 9

.

( C o n t i n u e d )


Downoa

yUnv

yoE

nug

Dav

G

an

a

Novm


9/19

T a b l e 1 . C o n t i n u e d

S t u d y

A i m

D e s i g n





d i s s o c i a t i v e a n d

p a r a n o i d i d e a t i o n

( p ¼ . 0

2 ) . N

o s i g n i -

c a n t d i f f e r e n c e s w e r e

f o u n d o n t h e o t h e r

s u b - s c a l e s ; h o w e v e r ;

t h e r e w e r e s i g n i c a n t l y

s t r o n g e r l i n e a r t r e n d s

f o r S T i n c r e a s i n g

q u a l i t y o f l i f e .

G u d e &

H o f f a r t

( 2 0 0 8 )

W i l l S T i n c r e a s e i n t e r -

p e r s o n a l f u n c t i o n i n g

m o r e t h a n T A U i n

p a t i e n t s w i t h p a n i c

d i s o r d e r , a

g o r a p h o b i a

a n d c o - o c c u r r i n g c l u s -

t e r C t r a i t s ?

C T

1 2 w e e k s o f e i t h e r

g r o u p T A U o r

g r o u p S T

I I P , S y m p t o m C h e c k

L i s t - 9

0 ; M o b i l i t y

I n d e x f o r A g o r a p h o b i a

T h e s e w e r e a d m i n i s -

t e r e d a t p r e - t r e a t m e n t ,

d i s c h a r g e a n d a t f o l -

l o w - u p

P a t i e n t s i n t h e S T

g r o u p s h o w e d g r e a t e r

i m p r o v e m e n t i n i n t e r -

p e r s o n a l f u n c t i o n t h a n

t r e a t m e n t a s u s u a l .

E f f e c t s i z e s f r o m p r e -

t r e a t m e n t t o f o l l o w -

u p o n t h e I I P a n d S C L -

9 0 p h o b i c a n x i e t y s u b -

d i m e n s i o n w e r e l a r g e

i n t h e g r o u p o f t h o s e

h a v i n g c o m p l e t e d S T

( 0 . 8

8 a n d 1 . 8 2 ) ,

w h e r e a s t h e T A U

g r o u p e x h i b i t e d l o w -

t o - m o d e r a t e e f f e c t

s i z e s ( 0 . 5 5 a n d 0 . 0 1 )

G u d e , M o n -

s e n , & H o f -

f a r t ( 2 0 0 1 )

T o d e t e r m i n e w h e t h e r

a l o w l e v e l o f a f f e c t

c o n s c i o u s n e s s w i l l b e

r e l a t e d t o a h i g h l e v e l

o f c l u s t e r C p a t h o l o g y

a t p r e - t r e a t m e n t ;

w h e t h e r c h a n g e i n

c l u s t e r C p a t h o l o g y i s

i n u e n c e d b y c h a n g e i n

a f f e c t c o n s c i o u s n e s s ;

w e t h e r a f f e c t c o n -

s c i o u s n e s s w i l l s h o w

a n y c h a n g e d u r i n g

s c h e m a f o c u s e d p h a s e

O n e

g r o u p ( p r e -

p o s t

d e s i g n )

1 1 - w e e k i n p a t i e n t

g r o u p ; 5 w e e k s

c o g n i t i v e t r e a t m e n t

o f p a n i c / a g o r a p h o -

b i a a n d 6 w e e k s S T

T h e A f f e c t C o n s c i o u s -

n e s s I n t e r v i e w ; M o b i -

l i t y I n v e n t o r y a n d t h e

S t r u c t u r e d C l i n i c a l

I n t e r v i e w f o r D S M I V

P r e - t r e a t m e n t l e v e l o f

a f f e c t c o n s c i o u s n e s s d i d

n o t c o r r e l a t e w i t h c l u s -

t e r C p e r s o n a l i t y

i n d e x e s b u t t h e a v o i -

d a n t i n d e x d i d a t p o s t -

t r e a t m e n t . A f f e c t c o n -

s c i o u s n e s s c h a n g e d

d u r i n g t h e S T p h a s e b u t

n o t d u r i n g t h e C T

p h a s e . T h e s e r e s u l t s

i n d i c a t e t h a t S T m a y

i n c r e a s e a f f e c t c o n s c i -

o u s n e s s m o r e t h a n C T .

T h e o v e r a l l c h a n g e

b e t w e e n p r e - t r e a t m e n t

a n d f o l l o w - u p o n t h e

m e a s u r e s o f p e r s o n a l -

i t y c h a n g e r a n g e d

b e t w e e n 0 . 2 0 a n d 0 . 5


Downoa

yUnv

yoE

nug

Dav

G

an

a

Novm


10/19

H o f f a r t &

S e x t o n

( 2 0 0 2 )

T o e x a m i n e t h e r o l e o f

o p t i m i s m i n t h e p r o -

c e s s o f S T i n 3 5

p a t i e n t s w i t h p a n i c

d i s o r d e r a n d o r a g o r -

a p h o b i a a n d D S M - I

V

c l u s t e r C p e r s o n a l i t y

t r a i t s

O n e g r o u p

( p r e - p o s t

d e s i g n )

1 1 - w e e k i n p a t i e n t

g r o u p ; 5 w e e k s

c o g n i t i v e t r e a t m e n t

o f p a n i c / a g o r a p h o -

b i a a n d 6 w e e k s S T

T h e A f f e c t C o n s c i o u s -

n e s s I n t e r v i e w ; M o b i -

l i t y I n v e n t o r y ; t h e

S t r u c t u r e d C l i n i c a l

I n t e r v i e w f o r D S M I V ;

P a n i c R a t i n g S c a l e ; t h e

S t a t e - T r a i t A n x i e t y

I n v e n t o r y ; S c h e m a

Q u e s t i o n n a i r e ; t h e

I n v e n t o r y o f I n t e r p e r -

s o n a l P r o b l e m s

P o s i t i v e a s s o c i a t i o n

b e t w e e n o p t i m i s m a n d

s c h e m a p r o c e s s e s a n d

b e t w e e n E M S a n d l e v e l

o f d i s t r e s s , e

m p a t h y ,

i n s i g h t a n d t h e r a p i s t s

o p t i m i s m

.

E f f e c t s i z e s f r o m p r e -

t r e a t m e n t t o f o l l o w -

u p o n t h e M I - A A L

w a s 0 . 5 2

, t h e S T A I w a s

0 . 3 2 a n d t h e P e r s o n a l -

i t y D i s o r d e r c l u s t e r C

i n d e x w a s 0 . 3 9

N a d o r t e t a l .

( 2 0 0 9 )

Q u e s t i o n 1 : T o e v a l u -

a t e t h e s u c c e s s o f

i m p l e m e n t i n g o u t p a t i -

e n t s c h e m a f o c u s e d

t h e r a p y f o r 6 2 i n d i v i d -

u a l s w i t h a d i a g n o s i s o f

B P D a n d t o d e t e r m i n e

t h e a d d e d v a l u e o f

t h e r a p i s t t e l e p h o n e

a v a i l a b i l i t y o u t s i d e

o f c e h o u r s i n c a s e o f

c r i s i s

R C T

T w o 4 5 - m

i n s e s -

s i o n s p e r w e e k f o r

1 8 m o n t h s e i t h e r

w i t h o r w i t h o u t

t h e r a p i s t c r i s i s s u p -

p o r t

N a d o r t e t a l . ’ s

s t u d y : t w o 4 5 - m

i n

s e s s i o n s p e r w e e k

f o r 1 8 m o n t h s

B o r d e r l i n e P e r s o n a l i t y

D i s o r d e r S e v e r i t y

I n d e x s c o r e ( f o u r t h

v e r s i o n ) ; E u r o Q o l ;

W H O Q o l ; B P D - 4

7 ;

S C L - 9

0

S a m e a s a b o v e

N o a d d i t i o n a l e f f e c t s

o f e x t r a c r i s i s s u p p o r t

w i t h t e l e p h o n e a v a i l -

a b i l i t y w e r e f o u n d .

S T

c a n b e s u c c e s s f u l l y

i m p l e m e n t e d i n r e g u l a r

m e n t a l h e a l t h c a r e .

T r e a t m e n t r e s u l t s a n d

d r o p o u t w e r e c o m p a r -

a b l e t o a p r e v i o u s

c l i n i c a l t r i a l .

S i g n i c a n t e f f e c t s a t

1 . 5 y e a r s

o f S T f o r t h e

w h o l e g r o u p e m e r g e d

f o r p a t i e n t s ’ r e d u c t i o n

o f B P D S I s c o r e s

( d ¼

1 . 5 5 ) , r e d u c t i o n

o n t h e B P D - 4

7 s c o r e s

( d ¼

0 . 8 0 ) , S C L - 9 0

s c o r e s ( d ¼

0 . 5 7 ) a n d

t h e Y o u n g S c h e m a

Q u e s t i o n n a i r e

( d ¼

0 . 6 9 )

Q u e s t i o n 2 : A s e c o n d

a i m w a s t o c o m p a r e

t h e o u t c o m e s o f t h i s

s t u d y w i t h t h e p r e v i o u s

R C T c o n d u c t e d b y

G i e s e n - B l o o e t a l .

( 2 0 0 6 ) t o d e t e r m i n e

w h e t h e r s i m i l a r o u t -

c o m e s w o u l d b e f o u n d

i n r e g u l a r p r a c t i c e

C T

I n t h e R C T ( G i e s e n -

B l o o e t a l . , 2 0 0 6 ) , a

p r e - t o p o s t - t r e a t m e n t

e f f e c t s i z e d i f f e r e n c e o f

d ¼

1 . 2 4 w a s f o u n d o n

t h e B P D S I

I n t h e p r e s e n t s t u d y t h e

p r e - a n d p o s t - d

i f f e r -

e n c e w a s d ¼

1 . 5 5

( C o n t i n u e d )


Downoa

yUnv

yoE

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Dav

G

an

a

Novm


11/19


S t u d y

A i m

D e s i g n





N o r d a h l &

N y s a e t e r

( 2 0 0 5 )

T o t e s t t h e e f f e c t i v e -

n e s s o f S T f o r 6 f e m a l e

p a t i e n t s w i t h B P D i n a

s i n g l e c a s e s e r i e s d e s i g n

C a s e s e r i e s

d e s i g n

B e t w e e n 1 8 a n d 3 6

m o n t h s o f w e e k l y

S T s e s s i o n s

T h e s y m p t o m c h e c k l i s t

9 0 , r

e v i s e d ; B e c k

d e p r e s s i o n i n v e n t o r y ;

B e c k a n x i e t y i n v e n -

t o r y ; i n v e n t o r y o f

i n t e r p e r s o n a l p r o -

b l e m s ; t h e Y o u n g

s c h e m a q u e s t i o n n a i r e

F r o m b a s e l i n e t o f o l -

l o w - u p , i m p r o v e m e n t

w a s c l i n i c a l l y m e a n -

i n g f u l f o r 5 o f t h e 6

p a t i e n t s . T h r e e o f t h e

s i x

p a t i e n t s d i d n o t

m e e t t h e c r i t e r i a f o r

B P D b y t h e e n d o f

t h e r a p y .

C o h e n ’ s d f o r t h e

g r o u p o f 6 p a t i e n t s a s a

w h o l e s h o w e d t h a t t h e

p r e - t r e a t m e n t t o f o l -

l o w - u p e f f e c t s w e r e

l a r g e , w i t h e f f e c t s i z e

r a n g i n g f r o m 1 . 8 t o 2 . 9

S i m p s o n ,

M o r r o w ,

v a n V r e e s -

w i j k

, & R e i d

( 2 0 1 0 )

T o e v a l u a t e t h e e f f e c -

t i v e n e s s o f

g r o u p S c h e m a

T h e r a p y f o r 8 i n d i v i d -

u a l s w i t h a d i a g n o s e d

e a t i n g d i s o r d e r a n d c o -

m o r b i d A x i s I a n d I I

c o n d i t i o n s

P r e - p o s t

t e s t c a s e

s e r i e s

d e s i g n

2 0 g r o u p S c h e m a

T h e r a p y s e s s i o n s

E D E - Q ; Y S I - L

2 ;

H A D S ; E Q 5 - D ;

E x p e r i e n c e o f s h a m e

s c a l e

R e s u l t s i n d i c a t e d t h a t

4 o f t h e 6 c o m p l e t e r s

h a d c l i n i c a l l y s i g n i -

c a n t i m p r o v e m e n t i n

e a t i n g . B y f o l l o w - u p a l l

c o m p l e t e r s h a d

a c h i e v e d o v e r 6 0 %

i m p r o v e m e n t i n

s c h e m a s e v e r i t y .

C o h e n ’ s d s h o w e d t h a t

t h e p r e - t r e a t m e n t t o

f o l l o w - u p e f f e c t s w e r e

a l l m e d i u m o r l a r g e

e x c e p t o n t h e m e a s u r e

o f d e p r e s s i o n

T h e e f f e c t s i z e s r a n g e d

f r o m 0 . 9 1 – 1 . 7 0

W e e r t m a n

&

A r n t z ( 2 0 0 7 )

T o t e s t t h e h y p o t h e s i s

t h a t t h e t r e a t m e n t o f

c h i l d h o o d m e m o r i e s i s

a n e f f e c t i v e w a y t o

c h a n g e p e r s o n a l i t y

d i s o r d e r - r e l a t e d s c h e -

m a s a n d p s y c h o -

p a t h o l o g y i n

p e r s o n a l i t y d i s o r d e r s

i n a s a m p l e o f 2 1

p a r t i c i p a n t s

C r o s s o v e r

d e s i g n

6 1 w e e k l y S T s e s -

s i o n s w i t h t h r e e

f o l l o w -

u p a s s e s s m e n t s a t

3 , 6 , a n d 1 2 m o n t h s

R o s e n b e r g S e l f -

E s t e e m - S c a l e ; 9 0 - i t e m

S y m p t o m C h e c k l i s t ;

D u t c h P e r s o n a l i t y

Q u e s t i o n n a i r e ; S c h e m a

Q u e s t i o n n a i r e ; P e r s o n -

a l i t y D i s o r d e r B e l i e f

Q u e s t i o n n a i r e ; M i s k i -

m i n s s e l f - g o a l o t h e r

d i s c r e p a n c y s c a l e

S T

f o r p e r s o n a l i t y d i s -

o r d e r w a s a s s o c i a t e d

w i t h g o o d o v e r a l l

i m p r o v e m e n t s t h a t

w e r e m a i n t a i n e d .

G i v e n t h e a b s e n c e o f

i m p r o v e m e n t d u r i n g

t h e e x p l o r a t i o n p e r i o d ,

t h e s e e f f e c t s i z e s c o u l d

n o t b e a t t r i b u t e d t o

a t t e n t i o n e f f e c t s .

E x p e r i e n c e o f t h e r a p i s t

i n S T f o r p e r s o n a l i t y

d i s o r d e r w a s r e l a t e d t o

b e t t e r o u t c o m e s .

T h e e f f e c t s o f t o t a l

t r e a t m e n t a t p o s t - t e s t ,

3 , 6 a n d 1 2 m o n t h

f o l l o w - u p w e r e l a r g e

( d ¼

0 . 9 7 – 1 . 9

7 )


Downoa

yUnv

yoE

nug

Dav

G

an

a

Novm


12/19

T a b l e 2 . Q u a l i t y a s s e s s m e n t c r i t e r i a b a s e d o n S I G N - 5

0 g u i d e l i n e s .

S t u d y

C l a r i t y o f

q u e s t i o n

C o n t r o l

c o n d i t i o n

u s e d ?

T r e a t m e n t a n d

c o n t r o l r u n

s i m u l t a n e o u s l y ?

S i m i l a r c o n -

t r o l c o n d i t i o n

i n r e l a t i o n t o

i n t e n s i t y

,

d u r a t i o n , e t c ?

R a n d o m i z a t i o n

u s e d ?

S i m

i l a r i t y

o f g r o u p s

a t s t a r t

T r e a t m e n t

i n t e g r i t y

a s s e s s e d ?

O u t c o m e

m e a s u r e s ?

M e a s u r e m e n t

o f s c h e m

a

c h a n g e ?

R e t e n t i o n

I n t e n t i o n

t o t r e a t

a n a l y s i s D e s i g n F

o l l o w -

u p ?

Q u a l i t y

r a t i n g

B a l l , 2 0 0 7

W e l l

c o v e r e d

Y e s

( 1 2 F T )

Y e s

U n k n o w n -

p o o r d e s c r i p -

t i o n

Y e s b u t l a c k s

d e s c r i p t i o n

N o t

k n o w n

Y e s

A d e q u a t e N o

P o o r

N o t

r e p o r t e d

R C T N

o

C

B a l l e t a l . , 2 0 0 5 W e l l

c o v e r e d

Y e s

( S A C )

Y e s

P o o r

Y e s b u t l a c k s

d e s c r i p t i o n

N o t

k n o w n

Y e s

A d e q u a t e N o

V e r y p o o r N o

R C T N

o

C

C o c k r a m e t a l . ,

2 0 1 0

W e l l

c o v e r e d

T A U

N o

W e l l c o v e r e d N o

N o t

k n o w n

N o t

k n o w n

W e l l c o v -

e r e d

O n l y i n S F T 1 0 0 % i n

S F T

u n k n o w n

f o r c o m -

p a r i s o n

c o n d i t i o n

N o

C T 3

m o n t h s B

F a r r e l l e t a l . ,

2 0 0 9

W e l l

c o v e r e d

T A U

Y e s

P o o r

R a n d o m n u m -

b e r t a b l e

W e l l

c o v e r e d

Y e s

W e l l

c o v e r e d

N o

1 0 0 % i n

S F T , 7 5 %

i n T A U

N o

R C T 6

m o n t h s B


e t a l . ,

2 0 0 6

W e l l

c o v e r e d

T F T

Y e s

Y e s

A d a p t i v e

b i a s e d U r n

p r o c e d u r e

W e l l c o v -

e r e d

Y e s

W e l l

c o v e r e d

N o

7 3 % S F T ,

4 9 % o f

T F T

Y e s

R C T N

o t o f -

c i a l l y b u t

s t u d y

w

a s o v e r

3

y e a r s

A

G u d e &

H o f f a r t , 2 0

0 8 W e l l

c o v e r e d

T A U

N o

P o o r

N o

W e l l

c o v e r e d

N o t

k n o w n

W e l l

c o v e r e d

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compared ST to Transference-FocusedTherapy (TFT) (Giesen-Bloo et al., 2006),another one compared ST with therapisttelephone support to ST without therapisttelephone support in a health service setting(Nadort et al., 2009) and the last looked at STfor BPD in a case series design (Nordahl &Nysaeter, 2005).

Overall, of the four studies reviewed, themost compelling evidence for the effectivenessof ST in treating BPD comes from Giesen-Bloo et al.’s (2006) study. This study directlycompared the effectiveness of ST to TFT in 88participants with a diagnosis of BPD. Therigorous assessment procedures, regular qual-ity checks, standardized outcome measures

and randomization are particular strengths of this research. The main outcomes of this studywere reductions in general and BPD specicpsychopathological dysfunction, increasedquality of life and signicant improvementson BPDSI-IV subscales in the ST groupcompared to the TFT group (see Table 1 fordetails). Overall the study’s main outcomemeasures resulted in medium to large effects inthe ST group (between 0.43 and 1.03) ascompared to small to large effects (between0.09 and 0.99) in the TFT group.

In addition to these strengths, this studyalso benets from its choice of controlcondition. TFT has previously demonstratedefcacy in reducing BPD symptoms in a RCT(Clarkin, Levy, Lenzenweger, & Kernberg,2007). It also shares some characteristicswith ST. For example, both aim to changepersonality structure, reduce self-destructivebehaviours and increase quality of life(Giesen-Bloo et al., 2006). Finally, boththerapies can be offered in equal frequencyand duration, making it highly unlikely thatthe positive ST outcomes displayed could beattributed to other factors. TFT was thereforea good choice as a control group for Giesen-Bloo et al.’s (2006) study.

One consideration when attempting togeneralize these ndings to other settings isthe intensity and duration of the intervention.Although personality disorders typicallyrequire greater intensity and duration of therapeutic input, planning sessions twice a

week for up to 3 years may be beyond theresources of some health care organizations.The study by Nadort et al. (2009) was set

up as an ‘implementation study’ to determine

whether the results found in Giesen-Blooet al.’s (2006) RCT could be replicated in apublic health service outpatient setting. Forthis reason they did not use a differenttreatment control, rather results were directlycompared with those of the Giesen-Bloo et al.’s(2006) study. After the intervention phase,results and dropout rates were comparablebetween the two studies. This suggests that STcould be successfully implemented in regularpractice. This type of study is important, as itattempts to demonstrate efcacy in real healthsettings (rather than the controlled conditionsfound in a RCT). As such these ndings maybe more generalizable to public health careorganizations.

However, interpretation of these resultsmay be limited to some extent by someinherent differences between comparisongroups. At pre-treatment, the participants inthe implementation study displayed lowerBPDSI scores, less medication use and higherreported quality of life (Nadort et al., 2009).They were also recruited in different timeframes. Therefore, this group may have beensomewhat less severe than those in the earlierclinical trial by Giesen-Bloo et al. (2006).Nevertheless, all participants did meet fullcriteria for BPD in both the studies. Ideally,future research attempting to demonstrateefcacy in general practice should use asimultaneous active treatment control allow-ing randomization to either ST or the controlgroup. This design would better control fornon-therapeutic factors that may inuence theoutcomes. However, practically this designmight be difcult to achieve in regular clinicalpractice. Under such circumstances, a well-conducted quasi-experimental design control-ling for baseline differences may be moreachievable (Emmelkamp & Vedel, 2009).

Overall, the study by Nadort et al. (2009)provides additional clinically useful infor-mation, which would not be easily obtainablewithin a pure RCT. One of the main aims of this research study was to determine the addedbenet of out-of-hours therapist telephonesupport to the treatment outcomes. Telephonesupport has been one of the more controver-sial aspects of ST within some health care

settings and potentially may deter therapistsfrom using this model. Interestingly, this studysuggested that there was no added benet of telephone support. The implications of these


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ndings may make ST more accessible and lessonerous for therapists working in settings notset up to support this level of out-of-hourssupport.

The study by Nadort & Nysaeter (2005)used a case series design and as suchparticipants in this study acted as their owncontrols. Although small in size, the largeeffect sizes of the main outcome measuresbetween pre-treatment and follow-up werecomparable to those in much larger studies.Additionally, the outcome measures wereadministered at regular intervals in a con-trolled way. These ndings therefore contrib-ute to the positive outcomes of ST.

The nal study looking at ST for the

treatment of BPD was conducted by Farrellet al. (2009). This study appears to show thelargest benets in reducing BPD symptomssuggesting that 94% of participants attendinga ST group (in addition to TAU) no longermet criteria for BPD at end of treatment.However, other factors could account forsome of these benets, making it difcult togeneralize the ndings of this as a stand-alonestudy. Firstly, the ST condition receivedgreater frequency of therapeutic input, withan additional 90 minutes structured clinicalcontact per week, which was specicallytargeted towards reducing BPD symptoms. Itis possible that the structured group environ-ment with targeted content and additionaltime may account for some of the perceiveddifferences rather than the ST component. Aseach treatment is likely to have its ownstructure, it can be difcult to match one typeof therapy with another. This is a more generaldifculty when investigating psychologicaltherapies. Ideally, in order to establish if STis the primary change factor, future researchshould compare group ST to a controltreatment that is as equally structured,targeted and intense as possible. Additionally,the group ST treatment was run by itsdevelopers (suggesting high treatment delity)so it remains to be seen how effective othertherapists are in delivering this intervention.Possible challenges to research in this area .Ideally, it is recommended that future researchof similar quality to Giesen-Bloo et al.’s (2006)

study is conducted, comparing ST to a suitablecontrol treatment (such as TFT or DialecticalBehaviour Therapy (DBT), for example,Linehan et al. (2006)). Such controlled

comparisons are needed in order to enhancethe evidence base for ST in general clinicalpractice. However, realistically it is acknowl-edged that there may be some difculties indoing this type of research within health careorganizations with resource pressures. Clin-icians working within health care organiz-ations need to have managerial support forboth their clinical time and resources. ST isstill relatively new and under-researched.Within the current economic climate, it maybe challenging to get managerial support forST research within health care departments,which might be under pressure to providetime-limited evidenced-based treatments. Itmight be helpful for clinicians seeking funding

for such research to read the economicevaluation by van Asselt et al. (2008). Thisevaluation looks at the overall costs of BPDand compares this with the treatment costs.Although it is beyond the scope of thisevaluation to review this paper in moredepth, van Asselt et al. (2008) providecompelling evidence that ST is a cost effectivetreatment in comparison to the considerablecosts incurred by health care organisations,and wider society, in supporting people withBPD. Overall, these difculties may explainthe scarcity of research in ST.Research recommendations . Despite thesepotential challenges, the research conductedto date suggests that ST displays mainly largeeffect sizes and positive outcomes in decreas-ing BPD symptoms. Although clinicians whowork in this eld may be under pressure toprovide succinct, cost-effective treatments, thecomplex nature of personality disorders meansthat at face value ST may initially appear anexpensive intervention but may in reality bemore cost-effective than other treatments (vanAsselt et al., 2008). Another way to make thistherapy more accessible could be to look atgroup ST rather than individual sessions. Thisis supported by Farrell et al.’s (2009) study,which suggests that group processes mayimprove the effectiveness of ST whilst alsoreducing the length of treatment required.

Finally, although difcult to perfectlymatch psychological therapies in terms of intensity, duration, structure and treatment

goals, future research should aim to usecontrol conditions that are as much as possiblesimilar to ST. If control conditions vary interms of intensity, frequency, duration and


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goals, it becomes difcult to determinewhether the observed effects are due to thepsychological treatment or differences in otherfactors such as design and methodology.

Schema Therapy for personalitydisorderThe study by Weertman & Arntz (2007)explored whether treatment of childhoodmemories is an effective way to changepersonality disorder-related schemas andpsychopathology. This study used a crossoverdesign and therefore did not have a simul-taneous active treatment control. Overall, STwas associated with good overall outcomesand large effect sizes. Interestingly, this studyalso looked at the impact therapist experiencehad on outcomes. ST for BPD (and person-ality disorder in general) requires therapisttraining and supervision (Young et al., 2003).This study demonstrates the positive clinicalimpact of increased therapist experience ontherapeutic outcomes. Such ndings suggestthat therapist experience may be an importantinuence on the outcomes of ST.

Schema Therapy for PTSDThe study by Cockram et al. (2010) aimed todetermine whether group ST would reducePTSD symptoms in war veterans compared toa comparison CBT group that was previouslyrun in the clinic. The main difference betweenthe ST group and the CBT group was thecontent of six cognitive restructuring sessions.In the ST group, these six sessions focusedexclusively on schema work and includedtrauma imagery, which allowed reprocessingof childhood experiences. There was alsoreference to how early experiences could havemade some individuals more vulnerable toPTSD, which was absent in the CBT group.Overall, this study suggests that the STgroup had signicantly better outcomes thanthe CBT group in reducing PTSD symptomsand anxiety. There was no signicant differ-ence between the ST and CBT group indepressive symptoms.

This study benets from having a controlcondition that was simila

a systematic review of the evidence base for schema therapy

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