Three preparatory studies for promoting implementation of outpatient schema therapy for borderline personality disorder in general mental health care

doi:10.1016/j.brat.2009.07.004

Behaviour Research and Therapy

Volume 47, Issue 11, November 2009, Pages 938-945

https://doi.org/10.1016/j.brat.2009.07.004 Get rights and content

Abstract

Objective

Three studies were conducted to prepare for the implementation of Schema Therapy (ST) for Borderline Personality Disorder (BPD) in general mental healthcare settings. Two were surveys to detect promoting and hindering factors, one was a preliminary test of a training program in ST.

Methods

In 2004, a diagnostic analysis of factors promoting and hindering implementation of a new treatment for BPD was conducted among both managers (n = 23) and therapists (n = 49) of 29 Dutch mental healthcare institutes through a written survey (Study 1). Next, a training program, including a set of DVDs displaying the major therapeutic techniques, was developed and tested among eight therapists. The training program was evaluated by the participants. After the training, three independent raters evaluated therapists' adherence and competence, viewing videos of the therapists completing structured role-plays (Study 2). In 2008, a second written survey was conducted in 22 mental health institutes to study factors for future nationwide implementation of ST (Study 3).

Results

Both surveys indicated that the situation in most institutes was favorable for implementing a new effective treatment, as participants were not satisfied with the existing treatments, had suitable professional backgrounds, worked in settings with (B)PD-oriented care programs, and expressed a need for change. The surveys yielded clear results for promoting or hindering successful implementation of ST. Promoting factors included scientific evidence for the effectiveness of the treatment, structural changes in the patient's personality, rapidly noticeable effects for the patient, low drop-out rates and a favorable cost-effectiveness. Possible barriers included implementation mandated unilaterally by management, choosing ST based on financial or organizational needs, extending implementation over a lengthy period of time and providing telephone support by therapists beyond office hours. The eight-day training program received very positive ratings. After the training, therapists were rated as sufficiently adherent and competent applying ST to treat BPD patients, with peer supervision and supervision recommended as a supplement to the training.

Conclusion

This study showed that the situation in 2005 was advantageous to start implementation of ST. Evaluation of the training and the achieved competence scores of trainees concluded that the training program was a good basis for training therapists in ST. Outcome of the survey in 2008 demonstrated that there was a clear interest for implementation of ST for BPD patients in the future.

Section snippets

Implementation

For successful implementation, crucial elements and principles recur through most publications examining models and theories used in the field of planning the implementation of a new treatment (Grol and Grimshaw, 2003, Grol and Wensing, 2006, Weinmann et al., 2007). While the scientific basis of these principles is still limited, they provide a framework for setting up an implementation plan. According to Grol and Wensing (2006), these elements are: A systematic approach to, and good planning

Mental health care institutes

Most of the institutes provided a specialized program for BPD patients (71.1%) and were already using some form of ST for borderline patients (84.2%). Most patients were treated with outpatient therapy (92.1%). Managers rated their average satisfaction of current therapy programs for BPD patients 5.1 (SD 1.9) on a scale from 1 to 10, (1 = minimal satisfaction, 10 = maximum satisfaction), and the therapists satisfaction score was 5.5 (SD 2.1). 39.5% of the respondents worked in institutes where

Discussion

Based on the respondents' answers, the situation in 2008 seemed encouraging for future implementation of ST. Most of the institutes already had treatment programs for BPD (either as such or as part of broader defined PD treatment programs), but present treatments of BPD were not viewed as particularly effective, and a clear interest in new and better treatments was expressed. 84% of the respondents were already using some form of ST. It was unclear from the results whether the programs were

General discussion

The three preparatory studies followed the guidelines of Grol and Wensing (2006), using a ‘good planning and systematic approach,’ and both surveys offered ‘a diagnostic analysis of the target group and settings,’ an ‘analysis of the care as usual,’ and ‘deviation from the proposed behaviour’. The situation in 2004 seemed favorable to start implementation of ST as treatment of BPD in the regular mental health service. Many cognitive therapists were working in these institutes, with an excellent

Funding/Support

This research was funded by Grant application Doelmatigheid/deelprogramma Implementatie van ZonMw, aanvraagnummer 945-16-313, 2006.

Role of the sponsor

The sponsor played no role in the data collection and analysis, manuscript preparation, or authorization for publication.

Acknowledgements

Acknowledgements: We wish to acknowledge Hannie van Genderen en Remco van der Wijngaart for their contributions to the training program. We would like to express our gratitude to Travis Atkinson for his invaluable help in correcting the manuscript.

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Three preparatory studies for promoting implementation of outpatient schema therapy for borderline personality disorder in general mental health care

Abstract

Objective

Methods

Results

Conclusion

Section snippets

Implementation

Mental health care institutes

Discussion

General discussion

Funding/Support

Role of the sponsor

Acknowledgements

Lancet

Journal of Behaviour Therapy and Experimental Psychology

Behaviour Research and Therapy

Behaviour Research and Therapy

European Psychiatry

Schema therapy for borderline personality disorder

Outpatient psychotherapy for borderline personality disorder: a Randomized trial of schema-focused therapy vs. Transference-focused psychotherapy

Archives of General Psychiatry

Implementatie; effectieve verandering in de patiëntenzorg

Implementatie: effectieve verbetering van de patiëntenzorg