Effectiveness of brief schema group therapy for borderline personality disorder symptoms: a randomized pilot study

Figures & data

Figure 1. Flow chart of the study design.

Table 1. Program of the schema group therapy.

Appointment 1. Welcoming all patients to the group. Presentation of schema group therapy and general mode chart. Discussion of group rules. Working with group adherence: an exercise on group connection with a ball of yarn demonstration. Relaxation exercise.

Appointment 2. Discussion of group communication. Therapists’ demonstration of critical communication, how it affects others, and how to communicate by expressing one’s own emotions without criticizing others. Presentation of vulnerable child mode. Discussion with emotion cards on experiences of vulnerable child mode. Working with group adherence by giving all patients wristbands as a symbol of being part of the group. Homework: gentle talk to the vulnerable child on a schema therapy internet page.

Appointment 3. Discussion of previous homework. Presentation of angry child mode. Discussion with emotion cards on experiences of angry child mode. Couple exercise on discussing a frustrating experience. Homework: an audible angry child mode exercise on a schema therapy internet page.

Appointment 4. Discussion of previous homework. Presentation of punitive and demanding parent mode. Discussion with emotion cards on experiences of punishing parent mode. Discussion in couples of a situation where punishing parent mode is apparent. Homework: arguments against the punishing parent talk on a schema therapy internet page.

Appointment 5. Discussion of previous homework. Presentation of compliant surrender and over-compensator modes. Discussion of compliant surrender and over-compensator modes. Therapists’ demonstration of these modes in an imaginary job interview situation. Discussion of mode benefits and disadvantages and what the patients would like to say to the compliant surrenderer and over-compensator. Homework: audible compliant surrender and over-compensator exercises on a schema therapy internet page.

Appointment 6. Discussion of previous homework. Presentation of detached protector mode. Discussion of detached protector mode. Therapists’ demonstration of detached protector mode in an imaginary job interview situation. Discussion of mode benefits and disadvantages and what the patients would like to say to the detached protector. Homework: audible detached protector exercise on a schema therapy internet page.

Appointment 7. Discussion of previous homework. Presentation of happy child mode. Discussing happy childhood memories and looking at the patients’ childhood photos. Making a card for oneself as a child. Homework: cheering oneself in ways listed on a schema therapy internet page.

Appointment 8. Discussion of previous homework. Imagery exercise in group concerning vulnerable child mode. Discussing how patients react to their own vulnerability. Couples exercise of talking the other’s vulnerable child mode.

Appointment 9. Discussion of punitive or demanding parent mode. Patients and therapists write down their punitive or demanding parent mode talk on a bedsheet. Discussion of own and others’ sentences on the bedsheet. Tearing the bedsheet together.

Appointment 10. Discussion of angry child mode. Physical exercises of anger expression in group.

Appointment 11. Therapists have written letters for each patient’s vulnerable child and read the letters aloud in group. Discussing how this feels.

Appointment 12. Demonstration of imagery rescripting by therapists. Two imagery rescripting sessions with patients.

Appointment 13. Discussing how patients have felt during imagery rescripting. Continuing imagery rescripting with patients.

Appointment 14. Continuing imagery rescripting with patients.

Appointment 15. Continuing imagery rescripting with patients.

Appointment 16. Continuing imagery rescripting with patients.

Appointment 17. Listening to patients’ current problems and working with chair work.

Appointment 18. Continuing with chair work.

Appointment 19. Discussion of normal day mode changes and chair work.

Appointment 20. Patients and therapists write positive reminders and wishes on patients’ cards. Discussion about group ending.

Clarification of terms:

Imagery rescripting is an experiential technique in which the therapist aids the patient to visualize a meaningful and traumatic past experience and they work together to rewrite a new solution that answers to the patient’s unmet needs.

Chair work is an experiential technique in which the patient is encouraged to give voice to his or her different modes situated in different chairs, to enact or re-enact scenes from the past, the present, or the future, whereas the therapist respond to the speech of the patient's modes a healing way or by correcting talk.

Table 2. Sociodemographic and clinical characteristics of intervention and control group patients.

	Schema therapy	TAU
	N (%)	N (%)
Women	23 (92)	12 (100)
Education
University	2 (8)	1 (8)
College	2 (8)	0
Vocational school	9 (36)	4 (33)
No occupation	12 (48)	7 (58)
Patients working or studying	14 (56.0)	4 (33.3)
	Mean baseline scores (SD)
BSL-23 total	39.0 (±15.1)	55.7 (±14.9)
BSL-23 behavior	3.2 (±2.8)	3.5 (±3.5)
OASIS	11.3 (±3.8)	13.2 (±2.6)
Mean PHQ-9	14.0 (±5.7)	16.3 (±4.1)
Mean AUDIT	6.4 (±4.8)	8.4 (±5.6)
Sheehan work/study	6.0 (±3.1)	6.8 (±2.3)
Sheehan social life	5.2 (±2.8)	6.7 (±1.6)
Sheehan family life	5.2 (±2.8)	6.7 (±1.6)
	Mean follow-up scores (SD)
BSL-23 total	32.0 (±16.4)	42.6 (±18.8)
BSL-23 behavior	1.5 (±1.7)	1.9 (±1.8)
OASIS	10.3 (±3.9)	11.4 (±3.5)
Mean AUDIT	5.7 (±5.5)	9.2 (±8.2)
Mean PHQ-9	11.9 (±5.2)	14.3 (±5.9)
Sheehan work/study	5.2 (±3.3)	6.9 (±2.4)
Sheehan social life	5.6 (±2.6)	5.9 (±2.7)
Sheehan family life	4.9 (±2.9)	6.3 (±2.1)

BSL-23 total: Short Borderline Symptom List total symptom scale; BSL-23 behavior: Short Borderline Symptom List behavior scale; Overall Anxiety Severity and Impairment scale; PHQ-9: Patient Health Questionnaire 9 scale; AUDIT: Alcohol Use Disorders Identification Test scale; Sheehan work/study: Sheehan Disability Scale work or study; Sheehan social life: Sheehan Disability Scale social life or leisure activities; Sheehan family life: Sheehan Disability Scale family life or home responsibilities.

Figure 2. Average BSL score (left panel) and BSL behavior score (right panel) in the TAU and Schema therapy groups at both baseline and follow-up. The whiskers denote 95% Wald’s confidence intervals.

Table 3. Treatment effects with multiple imputation of missing data.

Change variable	β0 (TAU)	SE (β0)	p-value	β1 (treatment effect)	SE(β1)	p Value
BSL average	−12.550	4.852	0.010	5.604	5.909	0.343
BSL behavior	0.364	0.793	0.647	−2.059	0.964	0.033
OASIS	−1.750	1.116	0.117	0.633	1.381	0.646
PHQ-9	−2.083	1.696	0.219	−0.093	2.680	0.964
AUDIT	0.750	1.254	0.550	−1.025	1.580	0.516
SDS work/study	0.090	1.042	0.931	−1.014	1.285	0.430
SDS social life	−0.667	0.904	0.461	0.340	1.108	0.759
SDS family life	−0.417	0.653	0.523	0.080	0.814	0.922
SMI vc	−2.667	2.122	0.209	0.406	2.680	0.880
SMI ac	−0.357	2.150	0.868	−0.247	2.659	0.926
SMI dp	0.417	1.808	0.818	−0.489	2.229	0.826
SMI pp	−1.640	1.759	0.351	−1.082	2.207	0.624

Note: A linear model intercept (β_0, TAU column) and slope (β_1,Treatment effect) were fit to observed change scores of the outcome variables (rows) from baseline to follow-up. The treatment effect corresponds to a difference in change scores between the Schema therapy and TAU groups. That is,

TAU + Treatment effect is the average change in the treatment group.

SE: Standard error; BSL average: Sort Borderline Symptom List scale, average part; BSL behavior: Short Borderline Symptom List scale, behavior part; Overall Anxiety Severity and Impairment scale; PHQ-9 = Patient Health Questionnaire 9 scale; AUDIT: Alcohol Use Disorders Identification Test scale; SDS/study: Sheehan Disability Scale work or study. SDS social life: Sheehan Disability Scale social life or leisure activities; SDS family life: Sheehan Disability Scale family life or home responsibilities; SMI vc: Schema Mode Inventory vulnerable child mode; SMI ac: Schema Mode Inventory angry child mode; SMI dp: Schema Mode Inventory detached protector mode; SMI pp: Schema Mode Inventory punishing parent mode.