November 19, 2009
Full Recovery Now Possible For An ‘Untreatable’ Mental Illness
Innovative therapy that offers new hope
Patients coping with the chaos and misery of Borderline Personality Disorder now have reason for strong confidence in making major life changes through a new treatment, Schema Therapy. For the first time, three major outcome studies have shown that many patients with Borderline Personality Disorder can achieve full recovery across the complete range of symptoms. In one study Schema Therapy was shown to be more than twice as effective in bringing about full recovery as a widely-practiced traditional treatment (Transference Focused Psychotherapy). Schema Therapy was also found to be more cost-effective and to have a much lower dropout rate. In a second study group schema therapy led to even stronger outcomes than those in the previous investigation over a briefer period with a 0% drop out rate and a recovery rate of 94% over an 8 month period. A third study, now in press, shows that individual Schema Therapy can be successfully implemented in regular mental health care settings with no loss of effectiveness.
While other specialized treatments for BPD have demonstrated empirical support, all but Schema Therapy have serious limitations in their impact on patients' functioning and quality of life and only Schema Therapy has demonstrated cost effectiveness. Schema Therapy is also associated with higher levels of patient and therapist satisfaction with the treatment.
The first of these large scale studies was reported in the Archives of General Psychiatry, published by the American Medical Association, the second published in the Journal of Behavioral Therapy and Experimental Psychiatry and the third will soon be appearing in Behavior Research and Therapy. Schema Therapy is an integrative approach that expands on the principles of cognitive-behavioral therapy.
According to the National Institute of Mental Health, Borderline Personality Disorder is found in about 1 to 2.5 percent of the general population although a recent large-scale epidemiological study reported a much higher estimate of 5.9%. This latter study indicates that BPD is potentially five to six times as prevalent as either schizophrenia or bipolar disorder.
Patients with the disorder live life on the edge: they're typically impulsive, unstable, exquisitely sensitive to rejection, have regular outbursts of anger, and live daily with extreme emotional pain. They often self-mutilate and make repeated suicide attempts. Identity problems, low stress tolerance, and fears of abandonment also make the disorder difficult for patients and for those who live with them. Many with BPD either cannot work or do not function at levels that could be expected in light of their intellectual capacities. As a result, the disorder carries high medical and societal costs, accounting for more than one in every five inpatient psychiatric admissions.
Until recently, psychotherapy offered help for only some of the symptoms of BPD. The best available alternatives, such as Dialectical Behavioral Therapy, relieve many of the self-destructive behavioral symptoms of the disorder, but have not been able to reduce many of the other core symptoms, especially those related to deeper personality change. New York-based psychologist Jeffrey Young, Ph.D. (on the faculty in the Dept. of Psychiatry at Columbia University) began to develop Schema Focused Therapy in the mid-1980s. Encouraged by its success, he established the first Schema Therapy Institute in the mid-1990s in Manhattan. Adopted by many clinicians in the United States, Europe, and Asia, the therapy came to the attention of researchers in the Netherlands who were developing a large-scale study of treatments for Borderline Personality Disorder. The clearly articulated approach of Schema Therapy lent itself well to a controlled outcome study.
In the first study, Dutch investigators, including Dr. Josephine Giesen-Bloo and Dr. Arnoud Arntz (the project leader), compared Schema Therapy (also known as Schema Focused Therapy or SFT) with Transference Focused Psychotherapy (TFP) in the treatment of Borderline Personality Disorder. 86 patients were recruited from 4 mental health institutes in the Netherlands. Patients in the study received two sessions per week of SFT or TFP for 3 years. After three years, full recovery was achieved in 45% of the patients in the SFT condition, and in 24% of those receiving TFP. One year later, the percentage fully recovered increased to 52% in the SFT condition and 29% in the TFP condition, with 70% of the patients in the SFT group achieving "clinically significant and relevant improvement". Moreover, the dropout rate was only 27% for SFT, compared with 50% for TFP, indicating that Schema Therapy instilled a greater sense of allegiance among patients.
Patients began to feel and function significantly better after the first year, with improvement occurring more rapidly in the SFT group. There was continuing improvement in subsequent years. Thus investigators concluded that both treatments had positive effects, with Schema Therapy clearly more successful. In the third study mentioned above, Dutch investigators including Dr. Marjon Nadort and Dr. Arnoud Arntz assessed the effectiveness of schema therapy in the treatment of BPD when utilized in regular mental health care settings. A total of 62 patients were treated in 8 mental health centers located in the Netherlands. The treatment was less intensive along a number of dimensions including a shift from twice weekly to once weekly sessions during the second year. Despite this, there was no lessening of effectiveness with recovery rates that were at least as high and similarly low drop out rates. In the second study mentioned above investigators DR. Joan Farrell, Ida Shaw and Dr. Michael Webber at the Indiana University School of Medicine Center for BPD Treatment & Research tested the effectiveness of adding an eight-month, thirty-session schema therapy group to treatment-as-usual (TAU) for BPD with 32 patients. The drop out rate was 0% for those patients who received group schema therapy in addition to TAU and 25% for those who received TAU alone. At the end of treatment, 94% of the patients who received group schema therapy in addition to TAU compared to 16% of the patients receiving TAU alone no longer met BPD diagnostic criteria. The schema therapy group treatment led to significant reductions in symptoms and global improvement in functioning. The large positive treatment effects found in the group schema therapy study suggest that the group modality may augment or catalyze the active ingredients of the treatment for BPD patients. A collaborative randomized controlled trial with 14 sites in six countries is in development to further explore this productive interaction between groups and schema therapy.
Schema Therapy is an integrative approach, founded on the principles of cognitive-behavioral therapy, then expanded to include techniques and concepts from other psychotherapies. Schema therapists help patients to change their entrenched, self-defeating life patterns "“ or schemas -- using cognitive, behavioral, and emotion-focused techniques. The treatment focuses on the relationship with the therapist, daily life outside of therapy, and the traumatic childhood experiences that are common in this disorder. Dr. Young believes that Schema Therapy's greater effectiveness arises in part from its use of "limited reparenting," which is not part of other approaches to BPD.
Both Schema Therapy and Transference Focused Psychotherapy focus on deeper personality change, in comparison to other recent treatments that have been limited to the reduction of specific behavioral symptoms of the disorder, such as self-mutilation. According to Dr. Young: "Other treatments for BPD, such as Dialectical Behavior Therapy, have also led to more effective coping skills and a significant reduction in self-harm. With Schema Therapy patients are, in addition, breaking free of lives of pain, self-hatred, and emptiness, making deeper personality changes, and significantly improving the quality of their lives."
Even the most intensive version of Schema Therapy mentioned in the first study was found to be cost effective. An economic analysis conducted by the authors of the study indicated that, for each year Schema Therapy patients were in the study, Dutch society benefited from a net gain of 4,500 Euros per patient (the equivalent of about 5,700 US dollars), despite the cost-intensive treatment. The savings over the course of several years after the completion of treatment could actually prove to be higher. The newest innovation, group schema therapy, is likely to be even more cost effective.
Schema therapists and researchers are hoping that these repeated validations of the effectiveness of Schema Therapy for patients with Borderline Personality Disorder -- that for so many years has been considered intractable"”will lead to more research studies and will encourage more clinicians to learn Schema Therapy. They also hope that this study will convince healthcare insurers to reimburse the costs of effective longer-term psychotherapy for this painful and costly illness.
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