Download Changes in schemas of patients with severe borderline personality

Scandinavian Journal of Psychology, 2014
DOI: 10.1111/sjop.12172
Personality and Social Psychology
Changes in schemas of patients with severe borderline personality
disorder: The Oulu BPD study
1,2
1
€
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€ HAKKO6
VIRPI LEPPANEN,
ANNA KARKI,
TOM SAARIAHO,3 SARI LINDEMAN4,5 and HELINA
1
Institute of Clinical Medicine, Psychiatry, University of Oulu, Finland
City of Oulu, Social and Health Services, Mental Health Services, Finland
3
Pain Clinic, Oulu University Hospital, Finland
4
Department of Clinical Medicine, University of Eastern Finland, Finland
5
Central Finland Health Care District, Jyv€askyl€a Central Hospital, Finland
6
Department of Psychiatry, Oulu University Hospital, Finland
2
Lepp€anen, V., K€arki, A., Saariaho, T., Lindeman, S. & Hakko, H. (2014). Changes in schemas of patients with severe borderline personality disorder:
The Oulu BPD study. Scandinavian Journal of Psychology.
Borderline personality disorder (BPD) is a relatively common and severe psychiatric disorder that can impair quality of life in many ways. The aim of
this study was to determine whether a combined treatment model for BPD patients, utilising major principles from schema-focused therapy (SFT) and
dialectical behavioral therapy (DBT), could be more effective in relieving early maladaptive schemas of BPD patients, compared to treatment as usual
(TAU). This study is a part of the Oulu BPD study conducted at mental health care services run by Oulu city social and health care services. The study
is a multisite, randomized controlled trial conducted over a one year period, involving two groups of patients with severe BPD: (1) Community Treatment By Experts (CTBE) patients (n = 18) receiving the combined treatment model, and 2) TAU patients (n = 27). The patients’ schemas were
assessed using the Young Schema Questionnaire (YSQ-L3a) before and after one year of treatment. The results reveal that CTBE patients who attended
the combined treatment model showed a statistically significant reduction in eight out of 18 early maladaptive schemas, while patients receiving treatment as usual did not demonstrate any significant changes in schemas. The cognitive therapeutic treatment model can be applied for clinical use in public mental health settings using existing professionals, and appears to produce positive changes in patients with BPD.
Key words: Early maladaptive schema, borderline personality disorder, cognitive therapy, public mental health services.
Virpi Lepp€anen, Institute of Clinical Medicine, Psychiatry, University of Oulu, P.O. Box 5000, 90014 Oulu, Finland. Tel: +358 447035915;
fax: +358 8336169; e-mail: virpi.leppanen@fimnet.fi
INTRODUCTION
Borderline personality disorder (BPD) is a common personality
disorder characterized by affective instability, unstable interpersonal relationships, impulsivity, identity problems, and transient
cognitive distortion (American Psychiatric Association, 1994).
The etiology of the disorder consists of both genetic and environmental factors (Kendler, Myers & Reichborn-Kjennerud,
2011). According to the definition of personality disorders in the
diagnostic and statistical manual of mental disorders IV (DSMIV), personality disorder is stable (American Psychiatric Association, 2012). The prevalence of BPD in the general population is
0.7% (Coid, Yang, Tyrer, Roberts & Ullrich, 2006).
The debate continues about the best strategies for the management of BPD. Recent years have seen increasingly rapid
advances in the field of cognitive behavioral therapies. Various
randomized trials and pilot studies have been performed to
assess new therapies such as schema therapy (Young, 1990) and
dialectical behavioral therapy (Linehan, 1993). The effectiveness
of several “third wave therapies” has been proved, although
relatively few RCTs have been conducted. The new therapy
techniques offer more optimistic outcomes to patient groups,
including BPD (Kahl, Winter & Schweiger, 2012).
Dialectical behavioral therapy (DBT) was first developed by
Professor Marsha M. Linehan (1993) at the University of
Washington, to help severely suicidal patients with borderline
personality. It draws its principles from behavioral science,
© 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
dialectical philosophy and Zen-Buddhism and consists, in
practice, both of individual and group therapy in addition to
telephone contact with the therapist and a consultation team for
the therapist. In DBT it is crucial to validate the patient’s affects
but at the same time encourage the patient to make changes.
DBT reportedly decreases self-harm, suicide attempts and the
need for hospital treatment (Linehan, Armstrong, Suarez, Allmon
& Heard, 1991; Linehan, Comtois, Murray et al., 2006; Linehan,
Tutek, Heard & Armstrong, 1994).
Schema-focused psychotherapy (SFT) developed by an American psychologist Jeffrey Young and colleagues (Young, Klosko
& Weishaar, 2003), is an integrative approach for longer-term
disorders and for treatment-resistant patients. The treatment
model combines elements from cognitive-behavioral, attachment
theory, Gestalt theory, object relations theory, constructivism,
and psychoanalytic schools. According to Young et al.’s definition, early maladaptive schemas are persistent dysfunctional
patterns that have developed during childhood or adolescence,
and comprise of memories, emotions, cognitions, and bodily
sensations. They influence personal view of oneself and one’s
relationships with others, and prevent one from developing normally in the emotional-interpersonal field. They repeat themselves throughout life and cause maladaptive behaviors to
develop. In SFT, a patient’s dysfunctional life patterns and the
schemas underlying them are identified and then addressed using
specific therapeutic methods. Crucial to SFT is an understanding
of the origins of schemas in childhood and adolescence and the
2 V. Lepp€anen et al.
identification of both healthy and unhealthy coping styles and
responses. Following this, cognitive and experiential strategies
are used to help the patient to create a healthy voice to address
the maladaptive schemas and to reparent the patient in order to
heal the patient’s traumas underlying the schemas. In the phase
of behavioral pattern-breaking, the patient’s final aim is to
replace their schema-driven behavioral patterns with healthier
coping styles. The relationship between the patient and the therapist is crucial during the healing process. Empathic confrontation
and limited reparenting are two characteristic features of the
therapy relationship in SFT.
Nadort, Arntz, Smit et al. (2009) studied the effectiveness of
SFT for BPD patients in regular mental health care. In their
study, therapists were given 50 hours of training in SFT supported by DVDs outlining the various different techniques used
in SFT. Most therapists had minimal experience with SFT but
the majority (25 out of 31 therapists) had experience of treating
patients with BPD. The therapists were also provided with expert
and peer supervision. Individual therapy was provided to patients
twice a week in the first year and once a week in the second
year, the total study time being 18 months. The results showed
significant improvement in Borderline Personality Disorder
Severity Index IV (BPDSI-IV) scores, Young Schema Questionnaire and on all BPD criteria in DSM-IV. Results were compared with another Dutch study (Giesen-Bloo, van Dyck,
Spinhoven et al., 2006) of SFT for BPD patients, where therapists were trained and supervised by the developer of SFT,
Jeffrey Young. However, no difference was found in the effectiveness of SFT for BPD patients between these two studies.
The study suggests it is possible to treat BPD patients successfully using SFT in regular mental health care. In the same study,
Nadort et al. (2009) found that the additional option of crisis
support by telephone outside office hours did not have any additional value on any measure 1.5 years after SFT.
Farrell, Shaw and Webber (2009) studied the effectiveness of
adding SFT in the form of group therapy sessions to the standard individual therapy used in the treatment of BPD patients.
Patients in the control group were treated by individual BPD
therapy alone. In this case, it was primarily supportive and eclectic in orientation. Weekly attendance at individual therapy was
required for participation in the study. In the study group, 30
group sessions were given over 8 months and each session
lasted 90 minutes. The themes of the sessions included emotional awareness training, BPD psychoeducation, distress management training and schema change work. The results of the
study showed a significant reduction in BPD symptomatology
and psychiatric symptoms overall. At its conclusion, 15 out of
16 of the patients in the study group no longer fulfilled the criteria for BPD, whereas 11 out of 12 patients in the control group
still met the criteria. Patients in the study group reported positive
experiences of working with the group, and researchers suggest
that working in a group of other BPD patients could itself be an
important curative aspect of the treatment.
There is little research comparing the effectiveness of SFT to
other therapies used in the treatment of BPD. In their study,
Giesen-Bloo et al. (2006) stated that SFT was significantly more
efficient than transference-focused psychotherapy (TFP) in treating BPD patients. Clinical improvement, reduction in psycho© 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Scand J Psychol (2014)
pathologic dysfunction and measures of personality concepts
showed a difference, indicating SFT to be superior to TFP,
though both therapy concepts were found to be beneficial.
SFT in a group format has been proved to be effective in
the treatment of other conditions. Van Vreeswijk, Spinhoven,
Eurelings-Bontekoe and Broersen (2014) studied short-term
schema cognitive-behavioral group therapy among heterogenous
psychiatric patients with a DSM-IV axis I disorder that had been
previously treated by evidence-based or best practice-based
therapy. Group therapy consisted of 20 sessions and significantly
improved symptoms and Young Schema Questionnaire ratings
among patients. The study also reported a strong correlation
between schema ratings and patients’ symptoms. Schema change
from pre-treatment to mid-treatment and from mid- to endtreatment predicted symptom relief. Cockram, Drummond and
Lee (2010) found schema-focused group therapy supplemented
by individual sessions to be more effective than traditional
cognitive-behavioral group and individual therapy in treating
early maladaptive schemas in Vietnam veterans suffering from
post-traumatic stress disorder (PTSD).
In a recent Dutch review of SFT in BPD, Sempertegui,
Karreman, Arntz and Bekker (2013) conclude that SFT seems to
be a promising treatment regarding both efficiency and costeffectiveness. SFT has, until now, been successfully implemented in regular mental health care settings in the Netherlands
and might therefore be easily implementable in other WestEuropean countries. The review indicates that SFT could be
developed further to become more cost-effective. The authors
call for further studies of SFT in BPD.
Aims
In the Oulu BPD study, our objective was to combine therapeutic patterns from two different psychotherapies (SFT and
DBT) to create a practical, easily implemented and effective
therapy that would not require years of training for the therapists. Patients in Finland have to attend a minimum number of
therapy sessions to be entitled for monetary compensation by
the Finnish health and social security system, but patients with
severe symptoms of BPD often fail to attend enough therapy
sessions to qualify (The Finnish social security institution/
Kansanel€akelaitos, 2012). Private psychotherapies are often not
an option for BPD patients. The Oulu BPD study aimed to
examine whether a therapy based on our manual and performed
by a public mental health care professional, with relatively
short additional education required, could be effective in treating patients suffering from BPD. In this part of the study, we
used the Young Schema Questionnaire long form (YSQ-L3a)
scores (Young & Brown, 2003) as an indicator of the effectiveness of the therapy before and after the trial. Knowledge of the
association of the changes in individual schemas to the changes
in BPD symptoms is sparse. As far we know there are no studies investigating the correlation of specific schemas to BPD criteria. There are suggestions that changes in schema domains
and BPD symptomatology mutually reinforce each other (Van
Vreeswijk et al., 2014) which may indicate that positive
changes in schemas may also predict positive changes in BPD
symptoms.
The Oulu BPD study 3
Scand J Psychol (2014)
This study is a part of a multisite randomized controlled Oulu
BPD trial. It was conducted in mental health care services of
Oulu city social and health care over a one-year period, and
involved two groups of patients with severe BPD. The aim was
to evaluate whether a combined treatment model for BPD
patients, including the principles of schema-focused therapy
(SFT) and dialectical behavioral therapy (DBT), had greater
impact on early maladaptive schemas of BPD than treatment as
usual (TAU).
MATERIAL AND METHODS
Participants in the Oulu BPD study
BPD patients. Participants in this randomized controlled trial (RCT) had
a diagnosis of borderline personality disorder (ICD-10: F60.3) (World
Health Organization, 2011) and were patients at mental health care services run by Oulu city social and health care departments. The Structured
Clinical Interview for DSM-IV Personality Disorders (SCID-II) (First,
Spitzer, Gibbon, Williams & Benjamin, 1994) was used to survey symptoms listed in the diagnostic criteria, with experienced psychiatrists conducting the interviews. In addition to a diagnosis of BPD, the inclusion
criteria were: age of at least 20 years, severe symptoms or previous
unsuccessful attempts at treatment. Symptoms considered severe included
parasuicidal behavior, such as cutting or impulsive overdose of medicines or considerable emotional instability affecting social or professional
life. In cases of previous unsuccessful treatment, treatment may have
ended because the patient withdrew from treatment, or because the
patient was still suffering from severe symptoms despite undergoing
treatment. The exclusion criteria were diagnoses of schizophrenia spectrum diseases, psychoses, type 1 bipolar disease, neuropsychiatric disorder and severe substance abuse having a negative effect on the
commitment to treatment. The Structured Clinical Interview for the
DSM-IV Axis I Disorders (SCID-I) (First, Spitzer, Gibbon & Williams,
1997) was conducted comprising schizophrenia spectrum diseases/
psychoses and type 1 bipolar disorder. Neuropsychiatric disorder and
substance abuse was assessed by a clinician.
Randomization. 112 patients were screened, 71 of which were randomized. Before randomization, patients were matched for age and severity
of symptoms assessed using the Borderline Personality Severity Index
(BPDSI-IV). According to a recent evaluation by Lepp€anen, Lindeman,
Arntz and Hakko (2013), psychometric properties of BPDSI-IV appear to
be suitable for assessing the severity of symptoms in Finnish BPD
patients. Randomization was conducted according to a 1:2 ratio, and was
completed by a person with no patient contact. Twenty-four patients
were randomized to the Community Treatment By Experts (hereafter
CTBE) group, and 47 patients to the Treatment As Usual (hereafter
TAU) group. A detailed description of the patient flow, explaining reasons for patient exclusion and attrition during the trial can be found in
the previous article. After one year intervention there were 20 patients
(83.3%) in the CTBE group and 33 patients (70.2%) in the TAU group.
Approval for the study was granted by the Ethics Committee of Oulu
University Hospital on June 18, 2009 (no.41/2009).
Community Treatment By Experts (CTBE)
In our clinical trial, volunteer professionals from the mental health care
service of the City of Oulu attended open lectures on borderline personality, schema-focused psychotherapy, dialectical behavioral therapy and
attachment theory. Lectures were given during the year preceding the
study (spring 2009–spring 2010) and provided information on the clinical
study, based on the manual for psychoeducational groups done by
Lepp€anen et al. (2013). The specification criteria for Community Treatment by Experts (hereafter CTBE) therapists did not include formal
© 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
psychotherapy training resulting in a professional title or experience of
treating BPD patients. Instead, the criteria included a willingness to work
with severely symptomatic BPD patients, a commitment to providing
patients with weekly 45–60-minute individual therapy sessions during
12 months and a commitment to participation in a joint consultation
group for 2 hours every two weeks, with the purpose of experts sharing
experiences and consulting each other. The psychoeducative group leaders (one occupational psychotherapist and two psychiatric nurses) did not
work as individual therapists in this study. The inclusion criteria for
work as a group leader were similar to those of the experts, but previous
group leadership experience was also required.
CTBE consisted of weekly individual therapy and psychoeducative
group sessions with telephone contact with a personal therapist available
during office hours. Telephone contact outside office hours was provided
by a City of Oulu psychiatric ward, where staff had been trained in
answering calls from the Oulu BPD study patients. Individual therapy
was provided over 12 months with each session lasting 45–60 minutes.
The content of each individual therapy sessions was decided individually
between the therapist and the patient and was not planned precisely in
advance. However, the therapists had the opportunity to use the psychoeducational group’s manual and most of the patients completed some of
their homework during their individual therapy sessions. In the consultation groups, the therapists learned to conceptualize patients’ problems
and symptoms using schema modes, and they were advised to use limited parenting and empathic confrontation. A key aim of the therapy was
the dialectic of acceptance and change.
Psychoeducative group meetings were divided into themes as follows:
rules and orientation (sessions 1–2), mode identifying (sessions 3–11),
affect regulation (sessions 12–19), interpersonal skills training (sessions
20–29), distress standing (sessions 30–36) and repetitions (sessions 37–
40). At the start of each group session, patients were given exercises and
material about the theme discussed. Each group meeting lasted 90 minutes. The design of the psychoeducative group meetings was based on
the Skills training manual for treating borderline personality disorder by
Linehan (1993), the first part of which (consciousness skills) was
replaced by mode identifying skills described in “Schema therapy” by
Young et al. (2003). Overall, the terms and principles of schema therapy
were more predominant in our model than those of dialectical behavioral
therapy, even if the latter gave our model its structure.
Treatment as Usual (TAU)
The control group consisted of BPD patients who received the treatment
that would normally be provided, according to the usual treatment practice of Oulu city mental health care services. The social and health services of city of Oulu represent a typical Finnish public health care
system, in which the services are organized regionally within the city.
Regional workgroups are responsible for treatment of all types of psychiatric patients. Practically, this means that each mental health care professional treats various types of patients, and workgroups cannot choose to
specialize and only treat a specific group of psychiatric patients. The
content of a health care professional’s mental health care education, the
length of their clinical career and their level of interest in BPD are not
consistent between regional workgroups. Therefore, there is heterogeneity
in the content of treatment received by patients with BPD, varying
widely from supportive weekly psychotherapy sessions to visits every
few weeks, occasional doctor’s appointments for drug control or home
rehabilitation. A more detailed description of the material and methods
are provided earlier (Lepp€anen et al., 2013).
Measures
Early maladaptive schemas. Young and Brown (2003) developed the
Young Schema Questionnaire (YSQ-L3a) which is a questionnaire surveying 18 early maladaptive schemas with 232 items: emotional deprivation (9 items), abandonment/instability (17 items), mistrust/abuse
(17 items), social isolation/alienation (10 items), defectiveness/shame
4 V. Lepp€anen et al.
(15 items), failure (9 items), dependence/incompetence (15 items), vulnerability to harm or illness (12 items), enmeshment/undeveloped self
(11 items), subjugation (10 items), self-sacrifice (17 items), emotional
inhibition (9 items), unrelenting standards/hypercriticalness (16 items),
entitlement/grandiosity (11 items), insufficient self-control/self-discipline
(15 items), approval-seeking/recognition-seeking (14 items), negativity/
pessimism (11 items) and punitiveness (14 items). Each schema is
surveyed in YSQ-L3a using a variable number of questions to which the
answer is given in a numeric scale from 1–6, 1 meaning “not true of
me” and 6 meaning “describes me perfectly.” The stability of the YSQ
has proved to be adequate and the YSQ has shown strong sensitivity in
predicting the presence or absence of psychopathology (Rijkeboer, van
den Bergh & van den Bout, 2005). In our study, according to the scoring
principle of Young and Brown (2003), only answers reporting 4–6 points
were taken into account, lower points being considered non-pathologic
and insignificant in assessing maladaptive schemas in BPD patients.
Scores for each schema were calculated by adding the scores reporting 4,
5 or 6 points together and then dividing the sum by the maximum rating
of the schema and multiplying the result by 100.
Participants in both the CTBE and TAU groups completed the Young
Schema Questionnaire (YSQ-L3a) at baseline and after one year of treatment. A total of 20 patients in the CTBE group and 32 patients in the
TAU group completed the one-year assessment but, because of missing
information for some YSQ-L3a items, only 18 patients in the CTBE
group and 27 patients in the TAU group were included in this study’s
final analyses. The final data (n = 43) used in this study did not differ
statistically significant for the original study sample (n = 26) in relation
to gender (current data vs. attrition; females, 91% vs. 77%, p = 0.155),
age at baseline (mean age, 32.1 vs. 33.1 years, p = 0.653) and BPDSIIV score at baseline (mean score, 28.5 vs. 31.1, p = 0.277), while a significant difference was observed in marital status (unmarried, 51.1%
vs. 23.1%; married/cohabiting, 26.7% vs. 53.8%; divorced, 22.2% vs.
23.1%, p = 0.039).
General population sample
The YSQ scores of the BPD patients were compared with the sex- and
age-matched general Finnish population, based on a sample of municipal
employees of Raahe town administration (Saariaho, Saariaho, Karila &
Joukamaa,2009). The average age was 32 years in the matched BPD
patient sample and 34 years in the matched control sample.
In the general Finnish population sample, the Young Schema Questionnaire – short form Finnish version (YSQ-S2 extended) with 90 items
was used (Saariaho, Saariaho, Karila & Joukamaa, 2012). In the YSQ-S2
the 18 maladaptive schemas, each containing five items, are assessed and
answers are given using a numeric scale of 1–6. In the Finnish general
population sample, the average schema score in each schema of the
YSQ-S2 was calculated using the mean value (from 1 to 6) of the items.
In our study, the broader form of the YSQ instrument – the Young
Schema Questionnaire – L3a (YSQ-L3a) – was applied (Young &
Brown, 2003). It includes 232 items, scored on a scale of 1 to 6 and
categorized into 18 maladaptive schemas as in YSQ-S2.
In our study a re-calculation of average schema scores was required to
enable a comparison of the schema scores of the BPD patients with those
of the general Finnish population sample. The analogous items of YSQL3a and YSQ-S2 were searched, five items for each schema. The average
schema score was then calculated using the entire range of scale (1–6),
while in the original form of YSQ-L3a, only the highest scores (4–6) were
used to calculate average schema scores.
Statistical analysis
Statistical significance of group differences in categorical variables was
assessed using Pearson’s chi-square test of Fisher’s Exact test and in
continuous variables using Student’s t-test or Mann-Whitney U-test. The
changes in schemas between baseline and after one year of treatment
were assessed using paired t-test or Wilcoxon test. All tests were two-
© 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Scand J Psychol (2014)
tailed with the limit for statistical significance set at p < 0.05. All statistical analyses were performed using PASW Statistics, version 18.0 (SPSS
Inc, 2009).
RESULTS
Sample characteristics
The sociodemographics of 45 BPD-patients stratified to the
CTBE and TAU groups are presented in Table 1. The only statistically significant difference between the study groups at baseline was found in marital status, with a greater proportion of
patients married in the CTBE group (50.0% versus 11.1% in
TAU group) (Fisher’s exact test, p = 0.006).
Comparison of schemas between BPD patients and the general
population sample
Mean schema scores in the BPD patients and the general population sample are presented in Table 2. A statistically significant
difference was found in all schemas except for self-sacrifice and
approval-seeking. In these two schemas no differences were
found between the groups, whereas in the other schemas BPD
patients reported significantly higher schema scores than the
general population sample.
Changes in schemas in the CTBE and TAU groups
The results of changes in schemas in the CTBE and TAU groups
are presented in Table 3. The maximum schema score is counted
as 100%, according to YSQ-L3a instructions. Table 3 shows
that eight schemas out of 18 in the CTBE group had decreased
significantly between the baseline and after one year of treatment. The schemas showing this positive improvement were
abandonment/instability ( p < 0.001), mistrust/abuse ( p = 0.016),
social isolation/alienation ( p = 0.035), dependence/incompetence
( p = 0.008), vulnerability to harm or illness ( p = 0.013), entitlement/grandiosity ( p = 0.011), insufficient self-control/selfdiscipline (p = 0.005), and approval-seeking/recognition-seeking
( p = 0.013). In the TAU group, however, no schemas showed a
statistically significant decrease between the measurements.
DISCUSSION
Early maladaptive schemas (EMS) are persistent patterns in the
way those affected observe the world and interact with other
people. These schemas form a risk factor for various psychiatric
disorders (Nordahl, Holthe & Haugum, 2005). We compared our
BPD patients’ schemas with a general population sample sourced
from employees of Raahe town administration, and found a significant difference in all schemas except for self-sacrifice and
approval-seeking. This finding reinforces the hypothesis that
BPD patients suffer from EMS significantly more often than the
healthy population and supports the idea of identifying and intervening in EMS as a way of treating BPD.
In this randomized controlled trial we found that our structured treatment model, based mainly on SFT but applying the
structure from DBT, was more effective than the conventional
The Oulu BPD study 5
Scand J Psychol (2014)
Table 1. Socio-demographics of the 45 BPD patients, according to the Community Treatment By Experts (CTBE) and Treatment As Usual (TAU)
groups
Age (in years) at baseline, M (SD)
Marital status
Unmarried
Married/cohabiting
Divorced
Education
Basic education/high school
Vocational school/professional courses
Tertiary level education
Tertiary level education not finished
Professional status
Employee without vocational education
Employee with professional qualification
Clerical employee/enterpriser
Employment status
Part-/full-time work
Unemployed/student
Sick leave, temporary disability pension
Full disability pension
Total
(n = 45)
CTBE
(n = 18)
TAU
(n = 27)
Group difference,
p-value
32.1 (8.5)
30.8 (6.9)
32.9 (9.5)
0.380
23 (51.1%)
12 (26.7%)
10 (22.2%)
8 (44.4%)
9 (50.0%)
1 (5.6%)
15 (55.6%)
3 (11.1%)
9 (33.3%)
0.006
11
22
10
2
3
8
5
2
8
14
5
0
(29.6%)
(51.9%)
(18.5%)
(0.0%)
0.264
(24.4%)
48.9%)
(22.2%)
(4.4%)
(16.7%)
(44.4%)
(27.8%)
(11.1%)
16 (35.6%)
15 (33.3%)
14 (31.1%)
6 (33.3%)
7 (38.9%)
5 (27.8%)
10 (37.0%)
8 (29.6%)
9 (33.3%)
0.808
8
9
23
5
5
4
9
0
3
5
14
5
0.176
(17.8%)
(20.0%)
(51.1%)
(11.1%)
(27.8%)
(22.2%)
(50.0%)
(0.0%)
(11.1%)
(18.5%)
(51.9%)
(18.5%)
Note: Values are number and percentage (%) of subjects, if not stated otherwise.
Table 2. Comparison of early maladaptive schemas between BPD
patients from the Oulu BPD study and the sex- and age-matched general
Finnish population sample
Oulu BPD
study
(n = 65)
General
population
sample
(n = 65)
Early maladaptive schema
M (SD)
M (SD)
p
Emotional deprivation
Abandonment/instability
Mistrust/abuse
Social isolation/alienation
Defectiveness/shame
Failure
Dependence/incompetence
Vulnerability to harm or illness
Enmeshment/undeveloped self
Subjugation
Self-sacrifice
Emotional inhibition
Unrelenting standards/
hypercriticalness
Entitlement/grandiosity
Insufficient self-control/
self-discipline
Approval-seeking/
recognition-seeking
Negativity/pessimism
Punitiveness
3.8
3.7
3.4
4.1
3.6
3.4
2.7
2.9
2.3
2.9
3.3
3.0
3.6
1.5
1.5
1.6
1.5
1.3
1.6
1.2
1.5
1.3
1.4
3.1
1.6
3.0
<
<
<
<
<
<
<
<
<
<
(1.4)
(1.1)
(1.4)
(1.4)
(1.5)
(1.6)
(1.3)
(1.3)
(1.3)
(1.2)
(1.2)
(1.4)
(1.4)
(0.8)
(0.8)
(0.7)
(0.7)
(0.7)
(0.7)
(0.4)
(0.6)
(0.5)
(0.6)
(0.8)
(0.8)
(1.1)
0.001
0.001
0.001
0.001
0.001
0.001
0.001
0.001
0.001
0.001
0.36
< 0.001
0.008
2.6 (1.0)
3.6 (1.2)
1.5 (0.5)
1.8 (0.7)
< 0.001
< 0.001
3.5 (1.1)
3.2 (1.0)
0.12
4.1 (1.2)
3.4 (1.2)
2.2 (1.0)
2.2 (0.9)
< 0.001
< 0.001
Note: The schema questionnaire used here was YSQ-S2 (see methodssection). Schema scores of Oulu BPD study patients and general population sample are measured using a similar method.
treatment that BPD patients receive in the city of Oulu. Eight
schemas (abandonment/instability, mistrust/abuse, social isolation/alienation, dependence/incompetence, vulnerability to harm
© 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
or illness, entitlement/grandiosity, insufficient self-control/selfdiscipline, approval-seeking/recognition-seeking) out of the 18
described decreased significantly in the CTBE group during the
study year, whereas no schemas decreased in the TAU group.
The treatment received by the CTBE group was realized using
existing resources from the public mental health care services
provided by Oulu city social and health care departments.
Our findings suggest that psychotherapy interventions based on
SFT represent an exciting option in the treatment of patients
with BPD.
Our study supports the results of other recent SFT studies.
Nadort et al. (2009) suggest that SFT style therapy can be implemented in regular mental health care with good results. The inclusion criteria in Nadort et al.’s study were a diagnosis of BPD
according to DSM-IV, age between 18–60 years, BPDSI-IV
score over 20 and Dutch literacy, and exclusion criteria included
psychotic disorders, resulting in study populations very similar to
those used in our study. Participants in Nadort et al.’s study
received individual therapy twice a week during the first year and
once a week during the second year. After18 months, BPDSIscores had reduced by 13.65 (from 30.92 to 17.27) and YSQ-L2
scores by 113.96 (from 709.40 to 595.44). YSQ-L2 items were
not assessed separately so no comparison of the exact change of
separate EMSs can be made with the results of our study. As in
our study, therapists were trained relatively briefly using a
50 hour education program and they each received both peer and
expert supervision. Most of the therapists did not have experience
of SFT but they were familiar with BPD.
In Finland qualification as a psychotherapist requires a relevant university degree and the completion of at least 60 study
credits. Following a change of the Finnish law in 2010, it
became compulsory for psychotherapist training to be organized
by a university or by another training organization in conjunction with a university (The Finnish Ministry of Social Affairs
6 V. Lepp€anen et al.
Scand J Psychol (2014)
Table 3. Comparison of change in early maladaptive schemas during one year of treatment among CTBE and TAU patients with BPD
Community Treatment By Experts (CTBE) group
(n = 18)
Baseline
After one-year
treatment
Change between
measurements
Early maladaptive schema
M (SD)
M (SD)
M (SD)
Emotional deprivation
Abandonment/instability
Mistrust/abuse
Social isolation/alienation
Defectiveness/shame
Failure
Dependence/incompetence
Vulnerability to harm or illness
Enmeshment/undeveloped self
Subjugation
Self-sacrifice
Emotional inhibition
Unrelenting standards/
hypercriticalness
Entitlement/grandiosity
Insufficient self-control/
self-discipline
Approval-seeking/recognitionSeeking
Negativity/pessimism
Punitiveness
36.9
35.3
35.6
49.4
45.1
39.7
25.6
30.7
14.2
27.3
33.3
39.2
33.2
28.7
21.4
24.3
37.8
34.6
40.5
18.8
15.2
8.3
22.2
31.4
32.2
32.0
(29.4)
(19.4)
(24.8)
(28.3)
(31.7)
(33.7)
(21.5)
(24.8)
(12.4)
(23.4)
(21.3)
(27.5)
(29.9)
(32.2)
(19.9)
(23.8)
(32.3)
(27.2)
(32.9)
(22.5)
(18.0)
(13.8)
(19.1)
(24.4)
(30.2)
(28.4)
8.2
14.0
11.3
11.6
10.5
0.8
6.9
15.5
5.9
5.1
1.9
7.0
1.2
Treatment As Usual (TAU) group (n = 27)
Baseline
After one-year
treatment
Change between
measurements
p
M (SD)
M (SD)
M (SD)
(21.6)
(12.4)
(17.9)
(25.7)
(22.3)
(19.8)
(9.7)
(23.6)
(17.3)
(19.8)
(16.7)
(28.1)
(16.4)
0.124
0.000
0.016
0.035
0.062
0.862
0.008
0.013
0.167
0.292
0.635
0.306
0.768
53.0
43.2
38.5
51.5
34.2
39.2
23.3
27.9
15.2
27.8
41.4
38.5
35.0
45.9
40.2
34.9
46.0
37.8
34.9
23.5
24.1
13.9
24.5
39.9
33.0
34.9
(33.4)
(24.3)
(28.1)
(31.0)
(27.1)
(32.3)
(22.3)
(25.0)
(19.2)
(24.9)
(28.6)
(28.1)
(29.9)
(31.8)
(27.8)
(27.6)
(32.7)
(25.3)
(33.4)
(27.9)
(25.0)
(20.6)
(25.8)
(23.7)
(31.3)
(26.8)
p
7.1 (25.0)
3.1 (21.7)
3.6 (20.5)
5.5 (26.1)
3.6 (24.5)
4.3 (34.8)
0.13 (26.1)
3.9 (26.1)
1.3 (18.3)
3.3 (28.5)
1.5 (17.8)
5.6 (32.6)
0.1 (25.8)
0.150
0.471
0.372
0.284
0.455
0.532
0.980
0.459
0.725
0.556
0.669
0.403
0.981
25.8 (23.9)
40.2 (21.8)
17.5 (18.0)
25.8 (18.8)
8.2 (12.2)
14.4 (18.9)
0.011
0.005
19.5 (17.2)
41.5 (23.4)
17.8 (22.1)
42.9 (23.7)
1.6 (22.8)
1.5 (23.7)
0.719
0.750
45.6 (23.8)
32.7 (22.0)
12.9 (19.7)
0.013
31.7 (22.3)
34.8 (24.0)
3.1 (19.1)
0.413
43.5 (24.2)
39.4 (27.3)
33.3 (24.7)
30.1 (23.9)
10.2 (24.5)
9.3 (24.6)
0.096
0.126
42.6 (26.2)
35.5 (24.1)
45.0 (33.1)
32.5 (24.1)
2.4 (23.8)
3.0 (21.1)
0.624
0.487
and Health, 1994). Psychotherapy training is expensive and is
usually funded mainly by the students themselves. On completion of their training, many psychotherapists have large
student loans to pay off and the allure of higher wages in the
private sector is often very tempting. According to a report by
the Social Insurance Institution of Finland (Kela), in 2011, 47%
of psychotherapists worked in the public sector and the same
percentage worked in the private sector (Valkonen, Henriksson,
Tuulio-Henriksson & Autti-R€am€o, 2011). The high costs of
psychotherapy and the shortage of these highly trained professionals makes the development of new forms of treatment
(for example for patients with BPD) very challenging. Our
study, along with those by Nadort et al. (2009) and Farrell et al.
(2009) suggests that, when the treatment-model is efficient, BPD
patients can be successfully treated by therapists trained over a
shorter period.
During one year of intervention, the mean number of treatment appointments per patient was 72 in the CTBE group and
19 in the TAU group. In public mental health settings, treatment
of BPD patients is usually heterogeneous and tailored to both
the patients and mental health professionals involved. This
means that BPD patients who have difficulties in committing to
treatment get appointment times and only one or a few at a time.
If they do not attend the appointment, the health care professional will try to contact the patient or wait for the patient to
make contact her/himself. Because of the large number of
patients and busy workload of health care professionals, new
appointments may not be available for a few weeks. In this
study CTBE patients received structured treatment and CTBE
therapists had arranged 40 appointment times for their patients
© 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
per year (approximately once a week). Psychoeducational group
meetings were also arranged once a week. It seems that BPD
patients committed better to structured treatment and the health
care professionals involved also found they could arrange treatment more systematically within this treatment model. There
were notable differences in the mean number of appointments
between CTBE and TAU groups and this may have affected the
results of our study. However, in the Oulu BPD study we have
succeeded in creating a cognitive therapeutic treatment model
which can be applied for clinical use in public mental health settings using existing professionals.
Strengths and limitations
Patients participating in the Oulu BPD study fulfilled strict selection criteria, leading to a homogenous study population which
can be considered a strength in our study. A limitation of our
study was that the sample size was small, with only 45 patients
completing the assessment for YSQ-L3a. Another limitation is
that we used a single outcome measure (schema) and changes
in symptomatology were assessed using a numeric scale. This
approach risks presenting an overly standardized record of
patients’ symptoms. YSQ-L3a is not an instrument commonly
used in evaluations of treatment outcomes in BPD patients and
we are unable to make any conclusions regarding the clinical
relevance of YSQ-L3a based on our study findings. Not every
participant will interpret the YSQ-questionnaire items in the
same way, especially when answering at home alone without
any support. Alternative methods, such as using interviews,
might have provided a more accurate description of symptoms.
The Oulu BPD study 7
Scand J Psychol (2014)
When completing the questionnaire at home, some patients failed
to complete some parts of the questionnaire.
Patients were randomized by age, sex and severity of BPD
symptoms (BPDSI-IV scores), but not by other sociodemographics, such as marital status, occupation or disability pension status. After randomization, the only significant difference between
the CTBE- and TAU-groups in the sociodemographic variables
in the total data (n = 71) was shown to be marital status
(Lepp€anen et al., 2013), which may indicate that marital status
should have been one of the randomization criteria. Marital status may have an impact on findings such as treatment motivation
and adherence. It may also influence other research results and
even cause changes in schemas. This is one of the limitations of
our study.
The only information available on the normal reference sample included the mean scores of the schemas. In clinical practice
the calculation of scores emphasizes the highest values (4–6
points) while in the general population sample the whole range
of values (1–6 points) are considered. The comparison of posttreatment scores of BPD patients to normal reference sample
scores was, therefore, not possible.
Participants in both the CTBE and TAU groups completed the
Young Schema Questionnaire (YSQ-L3a) at baseline and after
one year of treatment. A total of 20 patients in the CTBE group
and 32 patients in the TAU group completed the one-year assessment but, because of missing information for some YSQ-L3a
items, only 18 patients in the CTBE group and 27 patients in the
TAU group were included in the final analyses of this study. The
final data (n = 43) used in this study did not differ statistically significant from the original study sample (n = 26) in relation to gender (current data vs. attrition; females, 91% vs. 77%, p = 0.155),
age at baseline (mean age, 32.1 vs. 33.1 years, p = 0.653)
and BPDSI-IV score at baseline (mean score, 28.5 vs. 31.1,
p = 0.277), while a significant difference was observed in marital
status (unmarried, 51.1% vs. 23.1%; married/cohabiting, 26.7%
vs. 53.8%; divorced, 22.2% vs. 23.1%, p = 0.039). Furthermore,
the experts in the CTBE group did not have previous experience
of the SFT or DBT therapies used. The study year was the first
time the experts had treated BPD patients according to this protocol. Some patients in the TAU group moved to treatment in the
private sector during the study and thus did not complete the
study. Our follow-up period was relatively short due to the mixing
of CTBE and TAU groups after the study period. A minority of
our patients were male which can raise question about the reliability of the results with regards to male patients.
CONCLUSIONS
Patients receiving treatment based on a model incorporating
major principles of schema-focused therapy and dialectical
behavioral therapy, showed a statistically significant reduction in
8 out of 18 early maladaptive schemas, while patients receiving
treatment as usual did not show any significant changes in schemas. The structured treatment model appears to represent an
effective intervention in changes of schemas of BPD patients in
public mental health care settings. Additional benefits of the
model are that it uses existing health care resources and does not
require large-scale economic investment in new psychotherapeu© 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
tic training. However, given this study’s small sample size, our
conclusions are made with caution. Our study can be considered
as a pilot study in its nature and the results are preliminary, with
more controlled studies required to confirm our findings. Future
studies, which overcome the limitations of the present study, are
required in order to develop a more solid knowledge base for
the CTBE treatment format and its effectiveness.
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Received 4 January 2014, accepted 1 September 2014