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BABCP spring meeting: Arnoud Arntz on schema therapy for personality disorders (3rd post)

I wrote yesterday giving the official description of Arnoud Arntz's workshop in Belfast and explaining that getting an update on his work was the major reason I travelled to the BABCP Spring Conference & Workshops.  So how was it actually being there?  It was definitely worthwhile.  When I walked into the workshop, Arnoud greeted me saying something like "Why are you here, you already know all this stuff!"  Far from it.  Although I have done several days of training with Arnoud in the past, there is still lots for me to learn.  And it was very interesting to get an update on how his work has progressed. 

I guess the biggest take home message for me from hearing Arnoud present over the two days in Belfast was from his lecture at the main conference the next day.  Here he gave pre-publication details of a big new research study where Schema Therapy (which has been so successful with Borderline Personality Disorder) was used to treat several other Personality Disorders.  What I now write is taken from my jotted down notes during his lecture, so I may not have all the details precisely right.  So as I understood it, this as yet unpublished study involved 320 personality disorder sufferers who were each given 50 sessions of Schema Therapy (ST).  This involved 40 sessions in the first year and 10 booster sessions in the second year.  The Personality Disorders involved were primarily, I think, Cluster C (anxious or fearful disorders) - Dependent, Obsessive-Compulsive, and (most numerous) Avoidant.  I think there were also some sufferers from non-Borderline Cluster B (dramatic, emotional or erratic disorders) - for example Narcissistic and Histrionic.  There was a matched control group who had treatment as usual (TAU) and some form of supportive therapy.

The key finding was that about 50% of the control group no longer qualified for a Personality Disorder diagnosis by the end of treatment, whereas over 80% of the Schema Therapy treated group had recovered to this level.  Note that not qualifying for a PD diagnosis doesn't mean that the people involved were totally better, but the improvement is likely to have been well worthwhile emotionally, interpersonally, and functionally.  The main study is in revision with the American Journal of Psychiatry.  I believe there is a further paper, in revision with the British Journal of Psychiatry, showing that Schema Therapy was considerably more cost-effective than treatment as usual, for example in successfully helping people return to work. 

A further fascinating finding seems to give important information about the training of Schema Therapists ... and possibly therapists more generally.  In this large trial involving 320 patients treated over two years, therapists were trained in two cohorts.  This was done for the first therapist cohort by using primarily lectures & video demonstrations.  For the second cohort, training involved considerably more actual practice with lots of work in role plays.  Now here's the fairly startling take home message.  Although overall recovery rate for patients treated with Schema Therapy was 81% compared with about 51% for treatment as usual plus supportive therapy ... this general 81% figure was made up of a 65% recovery rate achieved by the first cohort of therapists and a much more impressive 96% recovery rate achieved by the second cohort of therapists.  OK, there were no doubt other factors, besides variation in training methods, contributing to this pretty huge difference in effectiveness.  It certainly though underlines the importance of considering therapist training methods carefully and probably leaning more than we often do to making more time for actual practice. 

In his lecture at the main conference, Arnoud also mentioned the work of his colleague David Bernstein who has been running a trial of Schema Therapy for 112 high security forensic patients with a variety of personality disorders.  The excellent (and recently updated) Wikipedia article on Bernstein's work comments: "Because of a great need for better treatment for forensic patients (who often suffer from personality disorders, e.g., Antisocial Personality Disorder), David Bernstein and his colleagues adapted the ST approach to meet the challenges posed by this population (e.g., aggression and callousness). Subsequently, David Bernstein initiated a large randomized clinical trial (RCT) testing the effectiveness of ST in comparison to regular treatment (‘treatment as usual') for forensic patients with cluster B personality disorders in seven ‘TBS' institutions in the Netherlands ... (In Dutch, TBS stands for ‘TerBeschikkingStelling,' which may be translated as ‘placed at the disposal' of the government in one of the specialized institutions for forensic psychiatric care).  Over the past years, over 100 patients have been participating in this RCT. Preliminary findings in the first 30 patients to complete the 3-year study suggest that ST is outperforming treatment as usual with respect to lowering recidivism risk (i.e. the risk of recommitting crimes), and facilitating resocialization into the community. These findings are not yet statistically significant, and need to be confirmed after all patients have finished three years of therapy. However, they suggest that ST is a promising treatment for forensic patients with cluster B personality disorders.  As results seem to show that ST is also beneficial for individuals with high levels of psychopathy, David Bernstein's research challenges the view that psychopathic people are untreatable."    

Exciting times ... and this broadening research on Schema Therapy's applicability to a variety of personality disorders (and other long-standing conditions like chronic depression) is well described in Arnoud Arntz's new book that came out last autumn - "Schema therapy in practice: an introductory guide to the schema mode approach".  I have written four posts on this book so far - "Arntz & Jacob's new book "Schema therapy in practice": some introductory comments", "Arntz & Jacob's new book ... links with attachment theory and with therapies for self-compassion", "Arntz & Jacob's new book "Schema therapy in practice": links with trauma-focused CBT and Marylene Cloitre's work on complex PTSD" and "Arntz & Jacob's new book "Schema therapy in practice": rescripting traumatic memories".  The post "Imagery, associative networks, embodied cognition and the transformation of meaning" also looks at this territory, and there are a bunch of relevant handouts & questionnaires available from this website's "Good knowledge" page "Emotions, schema & personality".  

 

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