Implementation of outpatient schema therapy for borderline personality disorder with versus without crisis support by the therapist outside office hours: A randomized trial

Abstract

Objective

This study aimed to evaluate the success of implementing outpatient schema focused therapy (ST) for borderline patients in regular mental healthcare and to determine the added value of therapist telephone availability outside office hours in case of crisis (TTA).

Methods

To enhance the implementation, the following adaptations regarding the original ST protocol were applied: a reduction in the frequency and duration of the therapy; training therapists of eight regular healthcare centers in ST with a structured and piloted program supported by a set of films (DVDs) with examples of ST techniques; training and supervision given by Dutch experts. Telephone availability outside office hours was randomly allocated to 50% of the therapists of each treatment center. Patient's outcome measures were assessed with a semi-structured interview and self-report measures on BPD, quality of life, general psychopathology and an ST questionnaire, before, during and after treatment.

Results

Data on 62 DSM-IV defined BPD patients were available. Intention-to-treat analyses showed that after 1.5 years of ST 42% of the patients had recovered from BPD.

No added value of therapist telephone availability (TTA) was found on the BPDSI score nor on any other measure after 1.5 years of ST.

Conclusions

ST for BPD can be successfully implemented in regular mental healthcare. Treatment results and dropout were comparable to a previous clinical trail. No additional effect of extra crisis support with TTA outside office hours ST was found.

Introduction

Borderline Personality Disorder (BPD) has long been viewed as severe and difficult to treat. However, during recent years several promising treatment possibilities have been developed. Among them, Schema Therapy (ST) was found to be effective regarding all aspects of BPD. How well ST can be delivered in regular mental healthcare practice is unknown, but it was expected that its implementation poses challenges. BPD is marked by chronic instability in multiple areas (emotional dysregulation, self-harm, impulsivity and identity disturbance). The lifetime prevalence of BPD in the general population is 2%. In psychiatric outpatient settings 10% of the patients suffer from BPD, in psychiatric inpatients settings 20% (APA, 2005). The medical and societal costs for BPD are substantial (Ten Have et al., 1995, Van Asselt et al., 2008, Van Asselt et al., 2007). About 10% of the BPD patients die because of suicide (Paris, 1993, Paris, 2008).

However, recent years showed progress in the development of treatment options (Arntz and van Genderen, 2009, Bateman and Fonagy, 2004, Linehan, 1993a, Linehan, 1993b, van Genderen and Arntz, 2005, Yeomans et al., 2002, Young et al., 2003) that are supported by randomized controlled trials (Bateman and Fonagy, 1999, Giesen-Bloo et al., 2006, Linehan et al., 1991, Linehan et al., 2006, Paris, 2008, Verheul et al., 2003). These treatments demonstrated effectiveness on symptom level, as manifested by reduced suicide attempts, fewer acts of self-harm or hospitalizations. In an RCT which compared Schema therapy (ST; also called Schema Focused Therapy (SFT)) and Transference Focused Psychotherapy (TFP) (Giesen-Bloo et al., 2006) both therapies showed a significant change in personality that was maintained at 1-year follow up (Giesen-Bloo et al., 2009). This study showed that three years of ST and TFP proved to bring about a significant change in patient's personality, shown by reductions in all BPD symptoms and general psychopathologic dysfunction, increases in quality of life, and changes in associated personality features. While both treatment conditions showed positive results in the treatment of many aspects of BPD, ST was superior to TFP with respect to reduction in BPD manifestations, general psychopathologic dysfunction, and change in ST/TFP personality concepts. ST had a recovery rate of 45.5% and a reliable change rate of 65.9%. The dropout rate for ST was significantly lower than for TFP.

Based on these positive results, a study of the implementation of ST in regular mental healthcare practice was conducted. One of the premises in the therapeutic approach of ST (Arntz and van Genderen, 2009, van Genderen and Arntz, 2005, Young et al., 2003) and Dialectical Behavior Therapy (Linehan, 1993a, Linehan, 1993b, Linehan et al., 1991, Linehan et al., 2006, Verheul et al., 2003) is that borderline patients need extra support from the therapist between sessions when they are in crisis or in emotional need. For this reason patients are offered a special phone number where they can reach their therapist outside of office hours. This personal connection between sessions is suggested to help to refute the patient's beliefs that there is nobody who really cares and can help to prevent or overcome crisis. In a pilot study of ST crisis support in the form of therapist phone accessibility outside office hours was one of the most controversial topics (Giesen-Bloo, Arntz, Dyck, Spinhoven, & van Tilburg, 2001) and led some therapists to withdraw from the project. In general mental healthcare there is much discussion about this topic because of the financial consequences, the burden to and responsibility of the therapist, and the possible risk of violation of boundaries. Therefore, telephone accessibility outside office hours was perceived as an important barrier for the successful implementation of ST in regular practice. The RCT by Giesen-Bloo et al. (2006) demonstrated that ST is a successful treatment, but it remains unknown whether the crisis support by the therapist was crucial to outcomes. Since the issue of crisis support outside office hours by the therapist makes it difficult to implement ST in regular practice and its effect has never been examined, we decided to investigate the role of the crisis support outside office hours in the implementation study by randomly allocating the crisis support outside office hours to 50% of the therapists.

In sum, this study tested the implementation of ST for BPD in regular mental healthcare and compared two modalities: one with extra crisis support by the therapist outside office hours and one without such telephone support. The study had three aims. First, to assess whether patient outcomes after 1.5 years of ST would be the same when implemented in regular practice, compared to what was found in a clinical trial of this therapy. Since rigorous evaluations such as RCTs always imply controlled conditions, it is unclear to what extent their positive effects can be generalized to regular clinical practice. Treatment effects may be more modest outside RCTs because of different circumstances (Rothwell, 1995, Weersing, 2005, Wilson, 1995). The second aim was to assess the added value of therapist telephone availability outside office hours in case of crisis (TTA) during those 1.5 years of ST. The third aim was to assess the problems that arose during the implementation process.