Schema Therapy and the treatment of personality disorders

Arntz, A. (2018). Schematherapie en de behandeling van persoonlijkheidsstoornissen. Bloom.

Summary by: Gijs Hoentjen

Introduction

Schema Therapy (ST) is developed by Jeffrey Young from the perspectives of cognitive (behavior)therapy (C(G)T). He integrated techniques from the gestalt therapy and other experiential therapies with the CT, with the focus on improving personality disorders. Besides Young, also David Edwards en David M. Clark were involved with the integration of experiential therapies in CT. The terminology schema focused therapy clarifies the therapy’s focus on the underlying level of schemas, and not on the surface phenomena (e.g. automatic thoughts and reasoning errors). Because the name was involved with other models, the name changed to schema therapy. Young claims that (personality)psychopathology arises from the activation of maladaptive (or dysfunctional) schema’s, and that they have their origins in the early development. Young expanded the model with: Emotional needs; The nature of the schema; Core beliefs for each DSM-disorder versus. Early maladaptive schemas; Coping; Modi; Experienced as a mechanism of change; the therapeutical alliance and the terminology limited reparenting; attention for experiences in childhood.

 

Research

ST is specifically used in the treatment of personality disorders, chronic depression and (other) treatment-resistant syndrome disorders (eating disorders, OCD and complex PTSD).  Research found different insights towards the ST. For instance, differences between research seemed to have a high correlation with the length of the treatment. Another insight gave information about the superiority of ST when you compare it with the transference focused psychotherapy (TFP) when recovering from BPS. Also, the drop-out was significant lower in ST. Lastly, ST was superior when compared to TFP in costs effectivity, as the ST was cheaper on society level and more effective.

When looking at the recovery of personality disorders, ST seemed to be superior compared to the normally used treatments. Moreover, the treatment drop-out seemed to be lower in ST than in the usual treatments (but not lower than in COP). Lastly, ST seemed to be superior when looking at costs effectivity: less costs on society level, while the clinical effects were bigger.

If you’re looking at chronical depression, there is no evidence yet found to prefer ST over existing treatments like CBT. This result is comparable to the results found in studies comparing ST and CBT when focused on eating disorders. There’s no significant difference found.

In contrast, good effects have been reported when using ST in OCD treatment. A possible explanation can be the admissibility of participants for exposure.

 

Ongoing research

As good results were found by previous studies, but most of them were leaded by the ST developers, questions are asked regarding the replication of those results. Different current studies look at the replication of previous found results.

Currently the effect of group-ST for the comorbid diagnose of social anxiety disorder and avoidant personality disorder.

Forms of ST focused on children and minors are currently being developed, and the first pilot studies are on their way. Most of them focus on personality problematic in the development of children and minors.

Lastly, current pilot studies focus on extreme problematic disorders, such as dissociative identity disorder (DIS), and comorbid diagnose of personality disorders and for instance autism, addiction, psychose.

 

Conclusion

While ST got developed from CGT, there are significant differences: like the focus on the developing history of the client, the therapeutical alliance and the expanded use of experiential techniques. With those changes, ST became an integrative treatment, while still being based on the cognitive model. In a short period of time, ST became popular in the Netherlands and provides the needs of clients and therapeutics regarding the treatment for complex personality disorders. While empirical reasoning provides insight in the (costs)effectiveness and acceptation of ST, the development of ST and research into it has a long way to go. Replication research is needed to expand the evidence-based evidence.

Besides the popularity of ST, also concerns regarding the treatment are rising. Sometimes ST is used for complex clients in forms or doses that have not been tested before, and sometimes this treatment is given by barely schooled therapeutics. There is no mandatory registry for therapists and there is no juristic protection from ST. Another problematic point is the number of schooled therapists (thousands) compared to the limited offered ST treatments for persons with complex personality disorders. This can possibly be explained due to the way therapists get hired, and therapists avoiding the ST even if they are schooled in this domain.