Introduction
Borderline personality disorder (BPD) is one of the most common (Maier, Lichtermann, Klingler, Heun, & Hallmayer, 1992) serious and challenging psychiatric disorders for both patient and therapist. BPD's core features, including impulsivity, negative affect, problematic relationships, incapacity of controlling intense, fluctuating emotions and lacking sense of self, cause major psychosocial impairment (American Psychiatric Association, 2000). The symptoms of BPD are clustered in two groups: the acute symptoms, including impulsivity, self-injurious and reckless behavior; and the temperamental symptoms, such as poor self esteem, fear of abandonment, distrust, and anger (Zanarini et al., 2007). Patients with BPD often experience crisis episodes, characterized by depression, anxiety, and (para) suicidal and self-injurious behavior, sometimes leading to hospitalization (Van Asselt, Dirksen, Arntz, & Severens, 2007). Substance abuse and other types of self-destructive behavior, like delinquency, unsafe sex and reckless driving might also be salient characteristics (Trull, Sher, Minks-Brown, Durbin, & Burr, 2000), resulting in high rates of (non-)health related costs (American Psychiatric Association, 2001, Van Asselt et al., 2007).
The effectiveness of pharmacotherapy to treat BPD has shown to be limited and mostly based on single study effects (Lieb et al., 2010, Stoffers et al., 2010, Zanarini, 2004). Antidepressants and first-generation antipsychotics seem to have some beneficial effects on comorbid psychopathology, whereas second-generation antipsychotics and mood-stabilizers seem to contribute to reduction of affective dysregulation symptoms, and omega-3 fatty acids to reduction of suicidality. Yet none of the afore-mentioned drugs have shown to affect overall BPD severity nor the core symptoms, such as identity disturbance or feeling of emptiness (Stoffers et al., 2010). For this reason, psychotherapy is still the preferred treatment approach (APA, 2001); however, not without great difficulties. For instance, patients with BPD tend to instigate therapists' counter-transference reactions during sessions (Maltsberger & Buie, 1974); they often show retrocession in treatment (Gunderson & Kolb, 1978) and therapy dropout is high (67%; Gunderson et al., 1989). Furthermore, studies examining the efficacy of psychotherapy for BPD are still scarce to allow drawing strong conclusions (Stoffers et al., 2012).
Dialectical Behavior Therapy (DBT) is currently the most extensively studied and used approach to treat BPD (Heard and Linehan, 2005, Lieb et al., 2004, Linehan, 1993, Linehan et al., 2001, Zanarini, 2009). This type of cognitive-behavior therapy enhances adaptive behavior skills to cope with emotions, distress and interrelationship difficulties (Linehan, 1993). Dialectical Behavior Therapy has shown to be effective in randomized controlled trials (see Lynch, Trost, Salsman, & Linehan, 2007). The treatment has been shown in the past to be beneficial for anger, general mental health (Stoffers et al., 2012), suicidal and self-destructive behavior (Harned et al., 2006, Linehan et al., 1991, Linehan et al., 1993, Linehan et al., 1999, Stoffers et al., 2012) and, as a consequence, the number of hospitalizations (Harned et al., 2006, Linehan et al., 1991, Linehan et al., 1993, Linehan et al., 1999). Yet, according to recent (meta-)analyses, the effects of DBT on global symptoms as well as the effects on specific symptoms are moderate (Cohen's d ≈ 0.50; Kliem et al., 2010, Stoffers et al., 2012).
Other two relatively well-studied psychological treatments for BPD are the Mentalization-Based Treatment (MBT) and the Transference Focused Psychotherapy (TFP), both psychodynamic approaches (Zanarini, 2009). MBT derives from the attachment and cognitive theory and hypothesizes that early attachment difficulties have led to impairments in the capacity of BPD patients to mentalize, in other words, to be aware of and understand their own and others' mental states. The therapy focuses on increasing mentalizing capacities to achieve stability of affect and impulses (Bateman & Fonagy, 2010). MBT has been found to be superior to Treatment as Usual (TAU) in two trials conducted by the developers of MBT (Bateman and Fonagy, 1999, Bateman and Fonagy, 2009), where suicidality, parasuicidality, interpersonal problems and depression were significantly reduced with very large effects (Stoffers et al., 2010). A recent RCT, conducted by an independent team, found no evidence for superiority of MBT above a less intensive control treatment, supportive group therapy offered once every two weeks (Jørgensen et al., 2012). TFP aims to address the extreme, rigid and split off BPD internal representations of the self and others by focusing the attention of the treatment on analyzing and reframing the transference brought by the patient to the therapeutic relationship (Yeomans & Delaney, 2008). TFP has been found in a RCT superior to TAU (community treatment by experts) on overall BPD severity and attrition (Doering et al., 2010), but TFP did not lead to a complete improvement of the impulsivity features of BPD (Clarkin et al., 2007) nor general psychopathology and global functioning (Stoffers et al., 2012).
The aim to find a treatment that leads to strong positive changes in all facets of the disorder and related elements, like quality of life and social functioning, motivates the interest in finding alternatives for the treatment of BPD. One of the emerging alternatives is schema therapy (ST; Young and Klosko, 1993, Young et al., 2003). This treatment has evolved greatly over the last 20 years (Kellog & Young, 2006) and has lately received a lot of attention from the scientific community, particularly in The Netherlands, Scandinavia, and United Kingdom (Nordahl & Nysæter, 2005). Its increasing popularity is mainly due to the results of a RCT, where ST was found to have greater positive effects on a broader range of symptoms compared to TFP (Giesen-Bloo et al., 2006).
Theoretical principles of ST have recently been described with respect to BPD (Nysaeter & Nordahl, 2008). However, review publications on both effectiveness and empirical evidence for the theoretical background of the therapy are lacking. At this point, it is important to evaluate the theoretical and empirical basis of ST before it can be considered as a well-established approach. Therefore, the current paper will address two questions. First, to what extent can an empirical foundation be found for the theoretical background of the schema model? Second, how effective and feasible is ST for the treatment of BPD? To answer these questions, this paper will first describe the theoretical elements and techniques that are part of ST. Then, the empirical evidence concerning the theoretical model of ST will be presented together with findings about the effectiveness and implementation possibilities of ST. Finally, conclusions in terms of effectiveness and implementation possibilities will be drawn, and recommendations for future research will be presented.
Section snippets
Method
The description of the elements and techniques of ST, with focus on BPD, was based on extant and well-known therapy manuals and papers written on the subject. To provide empirical evidence on the theoretical model and the effectiveness of ST for BPD, we performed a comprehensive review of the literature. We used the search engines PsycInfo, Science Direct, PubMed, Web of Science, Eric, SpringerLink and the Cochrane Library to find relevant papers. The search language was English and papers from
Development of schema therapy: Differentiating from pure cognitive therapy
ST has been developed as an extension of Beck's cognitive therapy to enable the treatment of more pervasive, enduring psychological disorders in which cognitive therapy was less successful (McGinn and Young, 1996, Young, 1994). These characterological problems (as Young named them in 1994) differed importantly from the standard depressions on which Beck's model of cognitive therapy was based (McGinn & Young, 1996). First, Young noticed that the patients' complaints were often vague, and
Discussion
The overall aim of the present paper was to make a comprehensive evaluation of ST for the treatment of BPD. Therefore, we analyzed the cohesiveness and validity of Young's theoretical framework behind the proposed mechanisms of change, and we reviewed the clinical results obtained until now with ST. Two specific objectives were established. First, we wanted to examine if ST, specifically in the frame of BPD, can be empirically founded. Second, we studied how effective and feasible this therapy
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