SUMMARY:

Schema therapy (ST) is effective in promoting clinically meaningful gains that ameliorate symptomatology for personality disorders, in particular borderline personality disorder (BPD). However very little is known about how the therapy is experienced by patients or therapists. In addition, implementation of ST requires proper training, supervision and quality control. Insight from therapists can inform future delivery of ST. This symposium aims to explore patients’ experiences of receiving Group ST and Combination ST and therapists’ experiences of delivering ST including their perspectives of the ST training. Qualitative approaches using focus groups and in-depth semi-structured interviews were employed and emerging data were analysed following the procedures of inductive content analysis. Participants in all three studies were recruited as part of an international, multicentre randomised controlled trial. Reported gains made by BPD patients in the first study included increased insight and better connection with one’s emotions. In the second study, both patient and therapist groups were concordant on the therapeutic value of several components of the ST model including the therapeutic alliance and utility of experiential techniques. However, therapists reflected on the challenge of managing therapeutic boundaries. Finally therapists’ evaluations of ST training in the third study indicated the utility of experiential learning in promoting self-reflection and recognising one’s resistances. Recommendations for more effective implementation of ST are discussed, together with issues for other specialist treatment approaches to personality disorders including BPD. Study implications also outline the need to address concerns with applying different modalities of ST within public mental health settings.

Chairperson: Prof. Arnoud Arntz

1. Schema Therapy for Borderline Personality Disorder: Patients’ Perceptions by Yeow May Tan

Background Schema therapy (ST) is effective in promoting clinically meaningful gains that ameliorate symptomatology for borderline personality disorder (BPD) and improving quality of life. However very little is known about how the therapy is experienced by individuals with BPD including the specific elements of ST are effective from their perspectives. The aim of this study is to explore BPD patients’ experiences of receiving ST. Method Qualitative data were collected through semi-structured interviews with 38 individuals with a primary diagnosis of BPD (eight males, 30 females) who had received ST for at least 12 months. Participants were recruited as part of an international, multicentre randomised controlled trial (RCT) and interview data (14 Dutch, 13 German, 11 Australian) were analysed following the procedures of inductive, content analysis. Results Patients’ broad perceptions of ST included, but not limited to the experience of greater self-understanding, better awareness of, access to and management of their own emotional processes. While the process of ST was perceived as emotionally confronting, patient narratives highlighted that this was perceived as necessary. Conclusions Recommendations for more effective implementation of schema therapy are discussed as well as issues for other specialist treatment approaches to BPD particularly concerning dynamics within the group, termination of therapy and definitions of recovery from BPD. Finally implications of the findings are discussed in terms of assessing the suitability of members for group ST and management of group conflict.

2. A Qualitative Study of Patients’ and Therapists’ Perspectives on Schema Therapy by Noor de Klerk

Background: Several studies have evaluated the (cost) effectiveness of schema therapy for personality disorders, but little research has been done on the perspectives of patients and therapists. The present study aims to explore patients’ and therapists’ perspectives on schema therapy. Method Qualitative data were collected through indepth semi-structured interviews with 15 patients and a focus group of eight therapists. A thematic analysis was performed.

Results: Most patients and therapists agreed that helpful aspects in schema therapy were the highly committed therapeutic relationship, the transparent and clear theoretical model and the specific schema therapy techniques. Furthermore, some but not all shared the opinion that 50 sessions was not enough for some patients. Patients’ and therapists’ perspectives on the unhelpful aspects of the therapy differed. Patients lacked clear advance information about the possibility that they might temporarily experience stronger emotions and the possibility of having telephone contact outside session hours. They missed practical goals in the later stage of therapy, and enough time and a proper link between the past and the present with regard to imagery. For therapists, it was hard to manage the therapeutic relation, to get used to a new kind of therapy and to keep the treatment focused on personality problems.

Conclusions: The schema therapy protocol included helpful elements for patients and therapists, but some elements were not sufficiently included in the protocol. Perspectives and recommendations from patients and therapists need to be taken into consideration when adjusting the protocol and implementing schema therapy.

3. Therapists’ Experiences of Schema Therapy Training by Marieke C. ten Napel-Schutz

Background: Implementation of new effective treatments involves training, supervision and quality control of therapists, who are used to utilize other methods. Not much is known about therapists’ views on how new psychotherapy methods should be taught. The purpose of this study is to get insight in how experienced therapists experience the training in a new method so that training methods for experienced therapists can be improved.

Method: Qualitative research using focus groups. For an RCT on the effectiveness of Schema Therapy (ST) for six personality disorders more than 80 therapists were trained in ST. They applied the ST-protocol after 4-day training, with peer supervision and limited expert supervision. Sixteen of these trained ST-therapists from seven health institutions participated in the focus groups. The transcripts and records of the focus groups were analyzed on repeating themes and subthemes and in terms of higher order categories.

Results: Therapists appreciated didactical learning methods, but particularly valued experiential learning. Especially, novice ST-therapists missed role-plays, feedback to learn required skills and attitudes, and attention to their resistance to new techniques (e.g., empathic confrontation; imagery). Peer supervision gave emotional recognition, but therapists lacked regular advice from an ST-expert.

Conclusions: In teaching a new therapeutic method didactic teaching is necessary, but experiential learning is decisive. Experiential learning includes practicing the new therapy and reflecting on one’s experiences, including resistance against new methods. Emphatic confrontation, case conceptualization, roleplay, peer supervision and opportunities to ask an expert supervisor during peer supervision are found to be helpful.