Researchers believe schema therapy, a technique popular in Europe, is cost-effective and delivers better outcomes for a wide range of personality disorders including avoidant, obsessive-compulsive, dependent, paranoid, histrionic, and narcissistic conditions.
A large scale randomized control trial demonstrating the value of the intervention has been recently published in the American Journal of Psychiatry.
Schema therapy resulted in a higher rate of recovery, greater declines in depression, and greater increases in general and social functioning and had a lower dropout 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.
Traditionally, schema therapy has been used for the treatment of borderline personality disorder.
Three major outcome studies have shown that use of this technique on patients with Borderline Personality Disorder can aid full recovery across the complete range of symptoms.
In these studies, researchers found the technique to be twice as effective as a popular alternative, Transference Focused Psychotherapy.
The current study extends these 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.
How Schema Therapy Works
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 dropout 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 percent 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 though research into its effectiveness with this population is still in its infancy.
A Compared Study
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 percent recovered in schema therapy, 60 percent in Clarification-Oriented Psychotherapy, and 50 percent in TAU.
The dropout rate was also lowest among the patients receiving schema therapy, suggesting it 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 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 the technique.
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.
Schema therapy has spread quickly around the world, yet its adoption in the United States lags far behind other countries. Researchers believe the new study will inform patients and professionals on the benefits of the new technique.