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GROUP SCHEMA THERAPY FOR BORDERLINE
PERSONALITY DISORDER: THE EFFECTS OF
THERAPY SPECIFIC FACTORS VERSUS NON-
SPECIFIC FACTORS ON OUTCOME
Emily Bastick
Bachelor of Psychology (Honours)
School of Psychology and Exercise Science
Murdoch University, Western Australia
This thesis is presented in partial fulfilment of the requirements for the degree of
Doctor of Psychology (Clinical), November 2017.
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DECLARATION
I declare that this thesis contains no material which has been accepted for the
award of any other degree in any other university and, to the best of my
knowledge or belief, contains no material previously published or written by
another person, except when due reference is made in the text.
This DPsych dissertation is a ‘Thesis by Publication’ and contains six chapters,
with two of those chapters containing manuscripts for publication. The candidate
had the primary role in the research and was the principal contributor to each
paper, appearing as first author on each respectively.
Each of the other stated authors provided some input to the respective manuscript
to varying degrees. This included supervision, active contributions to the
conceptualisation and design of the research, and expertise in relation to the
analyses and reporting results. As stated within each manuscript, active
contributions to data collection was provided by Suili Bot and Simone Verhagen.
For Study One (Chapter 3), all authors were invited to suggest edits, and had
provided final approval prior to submission. For Study Two (Chapter Five),
authors four and five were invited to suggest edits.
The Thesis by Publication conforms to the guidelines published by Murdoch
University Graduate Research Office.
Emily Bastick
November 2017
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DEDICATION
I dedicate this thesis to my late grandparents, Brian Daniels (14/02/1934 –
05/10/2003) and Elsie Daniels (06/11/1934 – 26/08/2015). Your influence on my
life has been profound, and I only wish you were here to help me celebrate this
achievement. I know that you would both be so proud. I miss you both very much.
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ACKNOWLEDGEMENTS
First and foremost, I wish to sincerely thank my supervisors Doctor Christopher
Lee and Professor Arnoud Arntz for their unwavering guidance, patience and
kindness throughout this project. I truly appreciate your enthusiasm, deep passion
and expertise in this field of work. I will be forever grateful to you.
I wish to specially acknowledge Suili Bot and Simone Verhagen who spent many
days and nights watching and rating tapes with me. It was not an easy task but you
never once complained. Your support has been incredible.
I also extend this warm thank you to Joan Farrell, Gerhard Zarbock, and the many
others who contributed to this research. I have learnt a great deal from your
knowledge and I am extremely lucky to have worked with you all.
To all of the participants and therapists who made this project possible, I extend
my sincerest gratitude. I truly appreciate courage and effort it would have taken to
participate in this study. I hope that you all continue to grow and flourish.
To my loyal friends, thank you for all of your continued support over the years
despite me not being around as much as I would have liked. I have always
promised you that one day it will be over and you will have me back, and that
time is now. I will make it up to you all!
Last but certainly not least, thank you to my dearest husband, my wonderful
family, and my dog, Nico. Although I sure have taken my time getting this
finished, you never once doubted that I would get there in the end. I have been
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truly fortunate to have you all by my side throughout this journey (particularly
you Nico for keeping my feet warm). I hope I have made you all proud. Mum and
dad, there is no doubt that I owe this achievement to you. You have provided me
with everything I have ever wanted or needed in life and for that I will be forever
grateful.
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ABSTRACT
The conclusions from initial research on group schema therapy (GST) are that it is
a promising treatment for borderline personality disorder (BPD). The overarching
aim of this research was to identify whether the unique aspects (or specific
factors) of GST effect positive change for patients with BPD. It was hypothesised
that both treatment fidelity and group cohesion are important factors in
influencing and predicting outcomes in GST for BPD.
With the aim in mind, Study One sought refine and evaluate a fidelity measure for
GST, the Group Schema Therapy Rating Scale - Revised (GSTRS-R). Following
a pilot study on an initial version of the scale, items were revised and guidelines
were modified in order to improve the reliability of the scale. Participants
included four therapists and 16 patients across two Australian GST groups.
Students highly experienced with the scale rated 10 video recorded GST therapy
sessions using the GSTRS-R in addition to a group cohesion measure, the Harvard
Community Health Plan Group Cohesiveness Scale – II (GCS-II). The resulting
GSTRS-R was found to have excellent internal consistency, substantial inter-rater
reliability, and adequate discriminate validity, evidenced by a weak positive
correlation with the GCS-II.
Study Two utilised the GSTRS-R to examine the relative contributions of specific
treatment factors related to schema therapy and non-specific factors (group
cohesion) on the treatment outcome of GST for BPD. Participants included 30
therapists and 122 patients across 15 GST groups within three countries. Specific
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treatment factors were assessed using GSTRS-R and group cohesion via the GCS-
II. There was a significant, moderate positive correlation between treatment
fidelity (therapist competence) and group cohesion within the GST groups. Better
therapist competence was associated with higher participant retention, with one
therapy delivery format having significantly better treatment retention than the
other. Neither therapist competence nor group cohesion were found to account for
a significant amount of variance in change scores (reduction in BPD symptoms).
Thus there appears to be unique aspects of schema therapy that improves retention
above common therapy factors such as group cohesion. The limitations and
clinical implications of both studies are discussed.
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TABLE OF CONTENTS
DECLARATION i
DEDICATION ii
ACKNOWLEDGEMENTS iii
ABSTRACT v
TABLE OF CONTENTS vii
LIST OF TABLES xi
LIST OF FIGURES xiii
CHAPTER 1: GENERAL OVERVIEW 1
Epidemiology of Borderline Personality Disorder .................................................. 1
Prevalence ......................................................................................................... 1
Comorbidities .................................................................................................... 2
The Impact of Borderline Personality Disorder on Social Functioning .................. 3
Risk of suicide and self-harm ........................................................................... 3
Economic cost ................................................................................................... 4
Limitations of Existing Treatment Modalities ......................................................... 6
Pharmacological treatment ............................................................................... 6
Psychological interventions for BPD ................................................................ 7
Schema Therapy for BPD ........................................................................................ 9
The efficacy of schema therapy for BPD ........................................................ 15
Group Schema Therapy for BPD ........................................................................... 16
Non-Specific Factors in Group Therapy ................................................................ 18
Specific Factors in Therapy ................................................................................... 20
Interplay Between Specific and Non-Specific Factors .......................................... 23
CHAPTER 2: FIDELITY MEASURES FOR GST 25
The Group Schema Therapy Rating Scale (GSTRS) ............................................. 25
CHAPTER 3: STUDY ONE: REFINEMENT AND PSYCHOMETRIC
EVALUATION OF THE GSTRS-R 28
Abstract .................................................................................................................. 30
Introduction ............................................................................................................ 31
Group schema therapy for borderline personality disorder ............................ 31
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Aims and hypotheses ...................................................................................... 33
Method ................................................................................................................... 34
Participants ...................................................................................................... 34
Raters .............................................................................................................. 35
Procedure ........................................................................................................ 35
Development of the GSTRS .................................................................... 35
Tape selection .......................................................................................... 42
Companion measure ....................................................................................... 43
The GCS-II (Soldz et al., 1987) ............................................................... 43
Statistical analyses .......................................................................................... 44
Internal consistency. ................................................................................ 45
Inter-rater reliability of the GSTRS-R. .................................................... 45
Validity of the GSTRS-R. ........................................................................ 46
Results .................................................................................................................... 46
Reliability ........................................................................................................ 46
Internal consistency. ................................................................................ 46
Inter-rater reliability. ................................................................................ 48
Discriminant validity ...................................................................................... 49
Discussion .............................................................................................................. 49
Limitations ...................................................................................................... 51
Application of the GSTRS-R .......................................................................... 53
Conclusions ............................................................................................................ 54
Acknowledgements ................................................................................................ 54
Ethical Statements .................................................................................................. 55
Conflict of Interests ................................................................................................ 55
Financial Support ................................................................................................... 55
References .............................................................................................................. 56
CHAPTER 4: BRIDGE 61
CHAPTER 5: STUDY TWO: GROUP SCHEMA THERAPY FOR
BORDERLINE PERSONALITY DISORDER: THE EFFECTS OF THERAPY
SPECIFIC VERSUS NON-SPECIFIC FACTORS ON OUTCOME 63
Abstract .................................................................................................................. 64
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Introduction ............................................................................................................ 66
Method ................................................................................................................... 73
Participants ...................................................................................................... 73
Patients ..................................................................................................... 73
Therapists ................................................................................................. 73
Group schema therapy treatment .................................................................... 74
Measures ......................................................................................................... 75
Fidelity ..................................................................................................... 75
Group cohesion ........................................................................................ 76
Raters and procedures ..................................................................................... 78
Tape selection .......................................................................................... 78
Statistical analyses .......................................................................................... 79
Results .................................................................................................................... 81
Discussion .............................................................................................................. 88
Acknowledgements ................................................................................................ 92
Ethical Statements .................................................................................................. 92
Conflict of Interests ................................................................................................ 92
Financial Support ................................................................................................... 92
References .............................................................................................................. 93
CHAPTER 6: GENERAL DISCUSSION 102
REFERENCES 107
APPENDICES 129
Appendix A: The DSM-5 diagnostic criteria for BPD ........................................ 129
Appendix B: The GSTRS coding guidelines ....................................................... 132
Appendix C: The Group Schema Therapy Rating Scale (GSTRS) ..................... 142
Appendix D: Inclusion and exclusion criteria for the randomised control trial
Wetzelaer et al. (2014) ........................................................................................ 150
Appendix E: The Group Schema Therapy Rating Scale – Revised (GSTRS-R) 151
Appendix F: The GSTRS-R coding guidelines ................................................... 165
Appendix G: The GSTRS-R specific scale coding guidelines ............................ 175
Appendix H: The Harvard Community Health Plan Group Cohesiveness Scale -
Version II guidelines ............................................................................................ 180
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Appendix I: The Harvard Community Health Plan Group Cohesiveness Scale -
Version II scoresheet ............................................................................................ 189
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LIST OF TABLES
CHAPTER 1
Table 1. Early Maladaptive Schemas (EMS) with Associated Schema
Domains........................................................................................... 11
Table 2. Schema Modes................................................................................. 12
CHAPTER 3
Table 1. Revision of GSTRS General scale items........................................ 38
Table 2. Item-Total Statistics and Standard Deviations for the Competence
Ratings for the GSTRS-R General Subscale................................... 47
Table 3. Item-Total Statistics and Standard Deviations for the GCS-II........ 48
CHAPTER 5
Table 1. cBPDSI_C: Descriptive Statistics and Correlation Matrix.............. 82
Table 2. Estimates of Fixed Effects for GSTRS-R with Dependent
Variable ‘BPDSI Change Scores for Participants who Completed
Therapy (cBPDSI_C)’..................................................................... 83
Table 3. Estimates of Fixed Effects for GCS-II with Dependent Variable
‘BPDSI Change Scores for Participants who Completed Therapy
(cBPDSI_C)’................................................................................... 83
Table 4. cBPDSI_I: Descriptive Statistics and Correlation Matrix.............. 84
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Table 5. Estimates of Fixed Effects for GSTRS-R with Dependent
Variable ‘BPDSI Change Scores for Participants who Initiated
Therapy (cBPDSI_I)’..................................................................... 85
Table 6. Estimates of Fixed Effects for GCS-II with Dependent Variable
‘BPDSI Change Scores for Participants who Initiated Therapy
(cBPDSI_I)’..................................................................................... 85
Table 7. Retention: Descriptive Statistics and Correlation Matrix................ 86
Table 8. Estimates of Fixed Effects for GSTRS-R with Dependent
Variable ‘Participants Remaining in Therapy at 18 Months
(Retention)’......................................................................................
87
Table 9. Estimates of Fixed Effects for GCS-II with Dependent Variable
‘Participants Remaining in Therapy at 18 Months
(Retention)’..................................................................................... 87
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LIST OF FIGURES
CHAPTER 3
Figure 1. Example of a Guideline from the Specific Subscale............. 41
Figure 2. Example of General Subscale Guidelines for Item 1............ 42
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CHAPTER 1
GENERAL OVERVIEW
Borderline personality disorder (BPD) is a highly prevalent, disabling
psychological disorder, which is characterised by substantial distress and enduring
disruptions in functioning. Most patients with BPD experience chronic, pervasive
patterns of instability in interpersonal relationships, affect, behaviour, and self-
identity (American Psychiatric Association [APA], 2000). Clinical signs of the
disorder include chronic suicidal tendencies, repeated self-injury, addiction, and
episodes of depression, anxiety and impulsive aggression, which make these
patients frequent users of mental-health resources (Lieb, Zanarini, Schmahl,
Linehan, & Bohus, 2004). The diagnostic criteria for BPD in accordance with the
APA’s most recent psychiatric classification and diagnostic tool, the Diagnostic
and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5; APA, 2013)
is presented in Appendix A.
Epidemiology of Borderline Personality Disorder
Prevalence
Although BPD is equally prevalent among men and women, women present
to services more often than men (APA, 1994; Coid, 2003; National Institute for
Health and Clinical Excellence [NICE], 2009), with the average number of BPD
traits being higher in adolescents and young adults (Cohen, Crawford, Johnson, &
Kasen, 2005; Coid, Yang, Tyrer, Roberts, & Ullrich, 2006). Although there is
limited Australian epidemiological data available, the community prevalence of
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BPD in Australian adults is estimated at 1-2% (Jackson & Burgess, 2000).
National estimates of community prevalence rates range between 0.7% in a
British national community sample (Coid et al., 2006) and 5.9% in a US sample
(Grant et al., 2008). A mid-range of 2-3% may not seem much, but those with
BPD diagnoses make up about 20-30% of psychiatric inpatients and about 10% of
outpatients receiving services (Korzekwa, Dell, Links, Thabane, & Webb, 2008;
Torgersen, Kringlen, & Cramer, 2001; Widiger & Frances, 1989). Importantly 2-
3% is considerably higher than the average lifetime prevalence of 0.3-1.5% for
bipolar disorder (Weissman et al., 1996) and 0.4% for schizophrenia (Saha,
Chant, Welham, & McGrath, 2005).
Comorbidities
Up to 96% of patients with BPD meet the criteria for concurrent Axis-I or
Axis-II diagnoses (Grant et al., 2008; McGlashan et al., 2000; Zanarini et al.,
1998). Comorbidities in BPD reflect a connection with both internalising and
externalising disorder symptoms and are considered the most relevant risk factors
for suicide completion (Black, Blum, Pfohl, & Hale, 2004). Those with
comorbidities have an average of 4.1 lifetime Axis-I comorbidities, and 1.9
lifetime Axis-II comorbidities (McGlashan et al., 2000). In particular, in terms of
Axis-I disorders, between 71% to 96.9% of BPD patients report lifetime clinical
depression (McGlashan et al., 2000; Zanarini, Frandenburg, Hennen, & Silk,
2004). This combination of BPD with depression increases patients’ subjective
levels of distress and leads to a higher severity of suicide risk and a high
frequency of suicide attempts (Soloff, Lynch, Kelly, Malone, & Mann, 2000).
Moreover, comorbid anxiety disorders are extremely common with 88% of BPD
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patients having a diagnosable anxiety disorder; 47-56% meet criteria for post-
traumatic stress disorder, and 34-48% meet criteria for panic disorder. In addition,
alcohol and substance abuse or dependence has been reported by 50-66% of
patients, predominantly in men, and eating disorders affect 29-53%,
predominantly in women. In terms of Axis-II disorders, the most frequently
diagnosed comorbid conditions are avoidant (43-47%), dependent (16-51%), and
paranoid (14-30%) personality disorders (McGlashan et al., 2000; Zanarini et al.,
1998).
The Impact of Borderline Personality Disorder on Social Functioning
The self-destructive and impulsive behaviours of people with BPD often
disrupts family and work-life, social relationships, and long term planning (APA,
1994; Skodol et al., 2002). Whilst families and friends may struggle to provide
support and care to these patients (Bauer, Döring, Schmidt, & Spießl, 2012;
Dunne & Rogers, 2013), society bears the cost of more intensive utilisation of
health services (see Sansone, Songer, & Miller, 2005).
Risk of suicide and self-harm
BPD is the diagnosis most strongly associated with suicide among persons
with a history of inpatient psychiatric treatment (Tidemalm, Elofsson, Stefansson,
Waern, & Runeson, 2005). For this reason, BPD is often regarded as one of the
most lethal psychiatric disorders and the most severe personality disorder. In
several studies, the percentage of patients with BPD that eventually committed
suicide (even after psychiatric treatment) was found to be between 2% and 17%,
depending on the length of the follow-up (Oldham, 2006; Pompili, Girardi,
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Ruberto, & Tatarelli, 2005; Zanarini, Frankenburg, Hennen, Reich, & Silk, 2006).
In addition, more than 75% of individuals with BPD regularly engage in high
levels of non-suicidal self-injury (NSSI) including superficial cutting and burning
(Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Stanley & Brodsky, 2005).
Often BPD patients engage in NSSI for the purposes of distraction, anger
expression, and for reconnecting with their feelings (Brown, Comtois, & Linehan,
2002).
Economic cost
The economic impact of BPD is significant, amounting to considerable
financial costs to both the individual and the community. Frankenburg and
Zanarini (2004) showed that patients with active BPD have a higher risk of
suffering from chronic physical conditions, making poor health-related lifestyle
choices, and using costly forms of medical services than patients with remitted
BPD.
Sansone and colleagues (2005) found that, when compared with psychiatric
inpatients with other diagnoses, inpatients with a diagnosis of BPD utilised
significantly higher levels of mental healthcare services. This included the number
of courses of psychotherapeutic treatment, the number of psychiatrists ever seen,
the number of presentation times, and the length of hospital stay for mental health
problems and/or substance abuse.
An Australian preliminary cost benefit study of the effect of outpatient
psychotherapy in 30 patients with BPD concluded that there were net savings in
the year following treatment (Stevenson & Meares, 1999). The results indicated
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that the cost of hospital admissions for the 30 patients the year before treatment
was $684,346 (ranging between $0 and $143,756 per patient). On average, they
cost the system $22,811 each. The overall cost significantly decreased in the year
post therapy to $41,424 (ranging between $0 to $12,333 per patient), costing the
system less than $1,380 each; an average decrease of $21,431 per patient. Equally
high values were found in the UK by Rendu, Moran, Patel, Knapp, and Mann
(2002) who found that the average cost for primary care attenders with a
personality disorder diagnosis was estimated to be over £3094 in comparison to
£1633 to those without. The costs incurred included healthcare costs and
productivity losses. More recently, van Asselt, Dirksen, Arntz, and Severens
(2007) examined the societal cost of illness of BPD in the Netherlands and found
that the total annual cost was €2.2 billion based on 1.1% prevalence rate in a
population of approximately 12 million. It should be noted, however that only
22% of this cost figure is health-related, the remaining costs consisted of
productivity losses, costs to criminal justice, informal care and out-of-pocket costs
as a result of their lifestyles (e.g., cigarettes, phone bills).
As a consequence of their lifestyle, there tends to be many out-of-pocket
costs for BPD patients. Of the patients included in the trial by van Asselt and
colleagues (2007), almost 60% reported to have out-of-pocket costs associated
with their BPD issues, totalling an annual average of €1395 per patient. Of these
patients, 63% reported that the main costs were a result of extremely high phone
bills, and excessive smoking, shopping, and binge eating. Other costs frequently
mentioned included the costs of bandaging self-inflicted wounds and excessive
buying of presents for others.
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Furthermore, many patients with BPD tend to be chronically under-
employed. The reasons for underemployment include relationship problems in the
workplace, and struggles with their sense of identity and life goals, causing them
to drift from job to job. One Australian study by Stevenson, Meares, and
D'Angelo (2005) reported that patients with BPD took an average of 3.5 months
off work per year before treatment, which significantly reduced to approximately
one week off work per year post treatment. In the Netherlands, van Asselt and
colleagues (2007) found that BPD patients were absent from their jobs for an
average of 218 hours per year (roughly 29 days, or 5 working weeks). When
compared to actual wages, average costs to productivity due to absence from work
were €1320 per patient per year.
Limitations of Existing Treatment Modalities
Pharmacological treatment
Several medications have demonstrated their effectiveness in treating
different symptoms of BPD pathology, such as affective instability, dissociative
states, impulsivity, or cognitive perceptual symptoms (APA, 2001). Within the
Cochrane systematic review (Lieb, Völlm, Rücker, Timmer, & Stoffers, 2010), it
was recommended that mood stabilisers (such as valproate semisodium,
topiramate, lamotrigine) are effective for affect regulation, instability, and
aggressive/impulse-control symptoms. Also, the research suggests that atypical
antipsychotics (such as aripiprazole) have beneficial effects on the cognitive-
perceptual aspect of BPD while first generation antipsychotics such as haloperidol
and flupentixol reduces anger and suicidal behaviour respectively. These
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medications may also facilitate treatment compliance and modifications of
temperament (Siever & Davis, 1991).
At present, The Cochrane review suggests that there is no convincing
evidence that any medication is an effective treatment for the overall severity of
BPD (Lieb et al., 2010; Stoffers et al., 2012). Nor have they been effective in
altering the nature or the course of the disorder (NICE, 2009). Thus, although
certain medications may be beneficial for specific symptom management,
psychotherapy continues to be the primary, necessary method of treatment for
BPD.
Psychological interventions for BPD
Researchers and practitioners have made substantial progress in developing
effective short-term psychological treatments for Axis-I disorders such as mood,
anxiety, eating, somatoform, and substance use disorders (e.g., cognitive
behaviour therapy [CBT]). The primary focus of these treatments is to reduce
symptoms, and to teach the patient skills and problem solving techniques.
Although many patients are helped by these treatments, many others are not, for
example, those with underlying personality disorders such as BPD (Young,
Klosko, & Weishaar, 2003).
Although a many studies have reported CBT to be effective in treating
specific symptoms of BPD (e.g., Cottraux et al., 2009; Davidson et al., 2006),
others have considered patients with BPD ‘difficult to treat’ and they have not
responded well to traditional cognitive therapy techniques, or have relapsed (e.g.,
Beck, Freeman, & Associates, 1990; Davidson, Tyrer, Norrie, Palmer, & Tyrer,
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2010; Mennin & Heimberg, 2000; see Young et al., 2003). Specifically, BPD
patients often present with chronic, vague or diffuse problems, cognitive rigidity,
and poor emotional awareness, which are ill suited to the problem-focused,
structured nature of CBT (Beck et al., 1990; Young, 1999). In addition, traditional
CBT is based on the assumption that the patient will be compliant and motivated
through prodding and positive reinforcement from the therapist to reduce
symptoms, build skills and solve their current problems. This compliance is
obtained through the formation of a therapeutic alliance within the first few
sessions of therapy; however, patients with BPD tend to have interpersonal styles
that undermine this collaborative relationship (e.g., by mirroring difficulties in
relationships outside of therapy; Young et al., 2003). Instead, patients with BPD
have complicated motivations in therapy (such as obtaining consolation from the
therapist) and are often unable or unwilling to comply with CBT procedures, for
instance completing homework assignments (e.g., monitoring tasks), or learning
self-control strategies (Beck et al., 1990; Young et al., 2003).
Furthermore, patients with BPD tend to have dysfunctional belief systems,
distorted thoughts and frequently engage in self-defeating behaviours that are
extremely resistant to change solely through CBT techniques. These patients tend
to express hopelessness about changing and their self-destructive patterns and
problems seem to be central to their identity, so much so that they cannot imagine
changing them. For example, cognitive and affective avoidance whereby patients
repeatedly detach or block themselves from painful memories and distressing
feelings becomes a habitual strategy for coping with negative affect and, in turn,
are exceedingly difficult to change (Young et al., 2003).
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Other therapies which have demonstrated efficacy for some BPD symptoms
in randomised controlled clinical trials include dialectical behaviour therapy
(DBT; Linehan et al., 2006), mentalisation-based therapy (Chiesa, Fonagy, &
Holmes, 2006), transference-focused psychotherapy (Clarkin, Levy,
Lenzenweger, & Kernberg, 2007), and systems training for emotional
predictability and problem solving (Blum et al., 2008). Despite the evidence for
their efficacy, the complexity and nature of BPD poses difficulties for all of these
treatments. For example, patients frequently drop out within 3-6 months of
beginning therapy (Kelly et al., 1992), often arrive at appointments late, or do not
show up at all, attend appointments inconsistently, and do not complete
homework assignments (Stone, 2000).
Young and colleagues (2003) identified that patients with personality
disorders appeared to benefit from certain adaptations to traditional cognitive
therapy. These adaptations included lengthening the treatment time, placing a
much greater emphasis on exploring the childhood and adolescent origins of
psychological problems, incorporating emotion-focused techniques and putting an
emphasis on the strength and quality of the therapeutic relationship. Over time,
these adaptations have evolved into schema therapy.
Schema Therapy for BPD
Schema therapy was developed as a treatment for personality disorders and
other longstanding problems and is a broad, integrative form of psychotherapy
with a theoretical framework that overlaps with other models of psychopathology
including cognitive, behavioural, self-psychology, relational approaches,
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psychodynamic object relations, and humanistic/existential models (Young,
1999).
Schema therapy addresses the patient’s core psychological themes, also
known as early maladaptive schemas (EMS) thereby producing changes on a
structural, emotional level. Young defines 18 EMS, which are grouped into five
“schema domains” of unmet emotional needs (see Table 1; please refer to Young
et al., 2009 for more information on specific EMS). Young (1999) defined these
EMS as pervasive self-defeating and dysfunctional patterns of interactions in
one’s interpersonal relationships and within oneself that are developed during
childhood or adolescence and persist throughout adulthood. EMS are supposed to
define the core structures of personality pathology and were not developed to
correspond to any particular personality disorder (Young & Gluhoski, 1996).
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Table 1
Early Maladaptive Schemas (EMS) with Associated Schema Domains.
Disconnection and Rejection Impaired Autonomy and Performance
1. Abandonment/Instability 6. Dependence/Incompetence
2. Mistrust/Abuse 7. Vulnerability to Harm or Illness
3. Emotional Deprivation 8. Enmeshment/Underdeveloped Self
4. Defectiveness/Shame 9. Failure
5.
Social Isolation/Alienation
Impaired Limits Other Directedness
10. Entitlement/Grandiosity 12. Subjugation
11. Insufficient Self-Control
/Self-Discipline 13. Self-Sacrifice
14.
Approval-Seeking/Recognition
Seeking
Over-Vigilance and Inhibition 15. Negativity/Pessimism
16. Emotional Inhibition
17. Unrelenting
Standards/Hypercriticalness
18.
Punitiveness
When EMS are triggered, several intense emotional, behavioural or cognitive
states occur that are referred to in schema therapy as “schema modes”.
Dysfunctional modes (as commonly activated in BPD patients) most frequently
occur when multiple EMS are triggered. Young has identified 10 schema modes
that can be grouped into four broad categories as displayed in Table 2 (please
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refer to Young et al., 2003 for more information on the specific modes). Four of
these schema modes are most prominent in BPD: the Vulnerable
(Abandoned/Abused) Child mode; the Angry/Impulsive Child mode; the Punitive
Parent mode, and the Detached Protector mode (Arntz, Klokman, & Sieswerda,
2005; Lobbestael, Arntz, & Sieswerda, 2005; Young, 2005).
Table 2
Schema Modes
Child Modes Dysfunctional Coping Modes
1. Vulnerable Child 5. Compliant Surrender
2. Angry Child 6. Detached Protector
3. Impulsive/Undisciplined Child 7. Overcompensator
4. Happy Child
Dysfunctional Parent Modes 10. Healthy Adult Mode
8. Punitive Parent
9.
Demanding Parent
The Vulnerable Child mode denotes the state in which patients experience
abandonment fears, feelings of worthlessness, helplessness and sadness. The
Angry and Impulsive Child modes represent states of intense pent-up childish
rage or self-gratifying impulsiveness without regard to consequences. The
Punitive Parent mode signifies a severe self-punitive state whereby the patient
punishes the one of the child modes for being “bad” or “evil” (often in the form of
self-mutilation). The Detached Protector mode has been said to be the most
prominent state observed by therapists in BPD patients (Arntz, Klokman, &
Sieswerda, 2005). This mode operates to protect the Vulnerable Child and is a
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state of psychological withdrawal (either with emotional detachment, substance
abuse, self-stimulating, avoiding people, or utilising other forms of escape),
ranging from being “spacey” to briefly losing focus.
Typically, as a result of the activation of one or more dysfunctional schemas,
BPD patients shift rapidly or “flip” between these modes, accounting for some of
their emotional reactivity and consequently the instability in their interpersonal
relationships.
Therefore, the overarching goal of schema therapy for BPD is to “build up the
patients Healthy Adult mode in order to nurture and protect the Abandoned Child,
to teach the Angry and Impulsive Child more appropriate ways of expressing
anger and getting needs met, to defeat and expel the Punitive Parent, and to
gradually replace the Detached Protector” (Young et al., 2003, p. 308). In essence,
the therapist must provide ways of making up for what was lacking in the
patient’s childhood.
In order to address EMS to prevent the patient from entering into
dysfunctional modes, specific interventions are employed, such as limited re-
parenting combined with cognitive and experiential techniques on adverse
childhood experiences. In individual schema therapy, limited re-parenting requires
that the therapist serve as a transitional parental figure who, within the bounds of
a professional relationship, works to directly meet the core psychological needs of
the patient. In turn, patients internalise these “healthy adult” abilities and
eventually meets their own needs (Young et al., 2003). Limited re-parenting
emphasises the importance of a safe and trusting therapeutic environment and
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14
relationship between the therapist and the BPD patient. When necessary, after-
hours contact is made available to the patients in times of crises such as suicide
attempts (Kellogg & Young, 2006).
Cognitive techniques involve both psycho-education and cognitive
restructuring in order to strengthen the patients’ Healthy Adult mode by helping
them to articulate a healthy voice to challenge negative beliefs embedded within
the EMS (Young et al., 2003). The educational component teaches patients about
normal needs and normal emotions and also asserts patients’ rights to express
their emotions and have their needs met in appropriate situations. The cognitive
restructuring component utilises Socratic dialogue and different visual aids (e.g.,
pie charts and analogue scales) to help the patient to adopt a less “black and
white” way of thinking, particularly in relation to the interpretation of the
behaviour of others.
Experiential techniques include imagery re-scripting, dialogues (e.g., imagery
or the “empty chair” technique employed in gestalt therapy), and letter writing
and have two aims: one, to trigger the emotions connected to EMS and two, to re-
parent the patient in order to bring about emotional healing and partially meet the
patient’s unmet childhood needs (Arntz, 2011; Arntz & Weertman, 1999; Young
et al., 2003). Imagery re-scripting is one of the most used experiential techniques
in schema therapy and assists the patient to modify personal meanings associated
with upsetting and traumatic memories from childhood. Within the imagery,
therapists functioning as the healthy adult mode can enter into the patient’s
childhood scenes and protect and support the abandoned/abused child. Therapists
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use dialogue work to help patients develop and strengthen their Healthy Adult
mode by using role-play, modelling and coaching to nurture their
abandoned/abused child and to fight their Punitive Parent. Finally, patients use
letter writing to express their feelings and affirm their needs by writing to those
who have harmed them or who have behaved in critical and repressive ways.
The efficacy of schema therapy for BPD
In recent years, several empirical studies have examined the efficacy of
schema therapy (Farrell, Shaw, & Webber, 2009; Giesen-Bloo et al., 2006;
Nysæter & Nordahl, 2008). One of the most significant of these was a large, well-
designed clinical trial in the Netherlands by Giesen-Bloo and colleagues (2006),
which demonstrated that schema therapy might show particular promise as a
comprehensive treatment for BPD with the goal of complete recovery. In the
study, 88 BPD patients were randomised to either the schema therapy or
transference focused psychotherapy (TFP) conditions and each received biweekly
individual psychotherapy for up to three years. The results indicated that relative
to TFP, patients in the schema therapy condition showed greater improvement
across BPD symptom domains, including abandonment fears, relationships,
identity disturbance, dissociation and paranoia, impulsivity and para-suicidal
behaviour. Furthermore, the authors found that the dropout rate was significantly
lower in the schema therapy condition. Overall, 46% of the schema therapy
patients (versus 24% of the TFP patients) had met the BPD recovery criterion
suggesting that long-term individual schema therapy is an effective treatment for
BPD.
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An independent Norwegian single case series trial of six patients with BPD
by Nordahl and Nysaeter (2005) reported similar effectiveness of individual
schema therapy. They found a large improvement in BPD symptoms from
baseline to follow-up for five of the six patients included in the study.
Furthermore, three of the six patients no longer fulfilled the criteria for BPD at the
end of the treatment.
Group Schema Therapy for BPD
Although the limited research on individual schema therapy has been
promising, it has indicated that the most significant outcomes have arisen from
long-term treatment (1-4 years), which may not be feasible in most mental
healthcare settings. A promising adaptation of schema therapy that addresses this
concern is to deliver the treatment in a group context (GST; Farrell et al., 2009).
GST incorporates psycho-education about schema theory and BPD, skills training
for emotional awareness and distress tolerance, and schema change work. Initial
studies of GST for BPD have shown improvement on both symptom levels,
reduced drop-out rates, and the possibility of complete remission.
In an initial evaluation of this approach by Farrell and colleagues (2009), 32
women with BPD were randomised to receive either treatment as usual (TAU), or
eight months of group schema therapy (GST) in addition to TAU. The group
treatment consisted of psycho-education about BPD, skills training for emotional
awareness and distress tolerance, and schema change work. Like individual
schema therapy, in-session activities included experiential activities (e.g., chair
work), cognitive restructuring, and behavioural skills. In addition, the process was
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17
adapted to a group modality by adding structured homework assignments, group
exercises, and kinaesthetic and experiential awareness exercises. Patients were
assessed at baseline, post-treatment and six-month follow-up. Patients in the GST
group showed improvements in all BPD symptom domains and at the end of
treatment, 94% of the patients no longer met diagnostic criteria for BPD
(compared to 16% in the TAU group). Furthermore, there was a 100% retention
rate for the GST group in comparison to only 75% in the TAU group. A
subsequent study by Dickhaut and Arntz (2014) examined a combination of
weekly GST and individual schema therapy for two years, with an additional six
months of individual schema therapy if indicated. The results demonstrated that
the addition of GST appeared to speed up BPD recovery with significant
reductions in BPD manifestations and dysfunctional schemas, and higher rates of
recovery and patient satisfaction. Moreover, Nenadić, Lamberth, and Reiss (2017)
found significant reductions of BPD and Cluster C personality symptoms and
trend-level improvement for schema mode activation following a short-term GST
inpatient program. However, the results did not suggest that there was significant
improvement in EMS, with the authors noting that this was a likely product of the
short duration of treatment.
Overall, there are compelling and economic service delivery reasons to use a
group psychotherapy modality, including cheaper fees for patients and the
capacity for practitioners to see more patients. Furthermore, although the
following are still quite speculative and require further investigation, there
appears to be some advantages of group therapy in comparison to individual
schema therapy. According to Farrell and Shaw (2012), limited re-parenting is
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18
enhanced in GST as added to the transitional parental figure (the therapist) is a
transitional family (the group); a combination which seems to amplify the effects
that each component has on its own. Additionally, patients seem to accept peer
responses as “more genuine” than the responses of the professionals who they
may believe “have to respond positively” (Farrell et al., 2009, p. 10). Common to
reports from patients who attend group therapy of varying modalities, Farrell and
colleagues (2009) noted that their participants reported that the group was “the
first time (they) felt a sense of belonging and acceptance” and that they were “not
alone” and “not crazy” (p. 10).
Non-Specific Factors in Group Therapy
Numerous researchers have identified that the supportive relationships
created and maintained by group members working together toward similar goals
can have substantial positive influence over therapeutic outcome, retention rates,
and clients’ views toward the group (Burlingame, Fuhriman, & Johnson, 2001;
Castonguay, Pincus, Agras, & Hines, 1998; Holmes & Kivlighan, 2000). This
relationship cultivated by the group is often referred to as group cohesion and is
said to be the group therapy counterpart to the therapeutic relationship in
individual therapy (Budman, Soldz, Demby, Davis, & Merry, 1993; Marziali &
Alexander, 1991; Yalom, 1995).
Yalom (1995) noted that cohesiveness refers to “the condition of members
feeling warmth and comfort in the group, feeling they belong, valuing the group
and feeling, in turn, that they are valued and unconditionally accepted and
supported by the other members” (p. 48). Furthermore, Yalom described
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19
cohesiveness as the “necessary precondition for effective therapy” (p. 50) and
declared that cohesiveness is an agent of change in members’ lives through “the
interrelation of group self-esteem and [personal] self-esteem” (p. 107). Moreover,
Yalom believed that “if it is the group members who, in their interaction, set in
motion the many therapeutic factors, then it is the group therapist’s task to create
a culture maximally conducive to effective group interaction” (pp. 109‐110). This
suggests that group members have a direct influence on therapeutic outcome,
whereas the group’s therapist’s influence is indirect.
In line with Yalom’s (1995) writings, the importance of group cohesiveness
has been empirically supported in numerous studies (e.g., Budman et al., 1993;
Marmarosh, Holtz, & Schottenbauer, 2005; Marziali & Alexander, 1991). For
example, research has found that there is a positive relationship between group
cohesiveness and therapy outcome (Kivlighan & Lilly, 1997; Ogrodniczuk &
Piper, 2003; Soldz, Budman, Demby, & Feldstein, 1990), better group cohesion
leads to higher patient satisfaction (Shea & Sedlacek, 1997), more successful
groups tend to be more cohesive (MacKenzie, 1987), and that there is less client
dropout when group members perceive that there is good group cohesion
(Falloon, 1981).
Furthermore, Fuhriman and Burlingame (1990) conducted a comparative
analysis of individual and group process variables. They identified six factors as
unique to group therapy situations. These therapeutic factors involved: (1)
vicarious learning (client improvement in response to the observation of another
group member’s experience); (2) role flexibility (client as both help seeker and
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20
help provider); (3) universality (group member’s realisation that other members
are struggling with similar problems); (4) altruism (client’s offering of support
and encouragement to other group members); (5) family re-enactment
(resemblance of group to one’s family of origin); and (6) interpersonal learning
(learning from interaction with other clients). Furthermore, they noted that the
group setting allows patients the opportunity to work therapeutically through
transference (the unconscious redirection of feelings from one person to another).
Specific Factors in Therapy
In comparison to the effects of non-specific factors on treatment outcome, a
considerable number of studies have also looked at the relationship between
specific factors (treatment fidelity) and outcome (Miller & Binder, 2002;
Perepletchikova & Kazdin, 2005). Two components of treatment fidelity have
received the most research attention to date (see Barber et al., 2006; Waltz, Addis,
Koerner, & Jacobson, 1993): integrity (or adherence), which refers to the degree
to which a treatment condition is implemented as intended; and competence,
which refers to the skill or quality with which interventions are delivered.
The results from studies exploring the relationship between treatment fidelity
and outcome have been mixed (see Webb, DeRubeis, & Barber, 2010 for a meta-
analytic review). Some studies have concluded that greater treatment adherence
has resulted in a better outcome for participants (e.g., Frank, Kupfer, Wagner,
McEachran, & Cornes, 1991; Guydish et al., 2014; Hogue et al., 2008; Huey,
Henggeler, Brondino, & Pickrel, 2000; Martino, Ball, Nich, Frankforter, &
Carroll, 2008). For example, Hogue and colleagues (2008) found that treatment
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21
adherence predicted the treatment outcome of manualised CBT and
multidimensional family therapy (MDFT), and was linked to multiple positive
outcomes up to 6 months after discharge. Specifically, a stronger adherence
predicted greater reductions in externalising behaviours (with a linear effect), and
intermediate levels of adherence predicted the largest declines in internalising
behaviours (with a curvilinear effect). Comparatively, Guydish and colleagues
(2014) examined the relationship between treatment fidelity and treatment
outcomes in a 12-step facilitation (TSF) intervention for stimulant abuse. The
results demonstrated that while adherence was only associated with better
employment outcomes, the greater effects on outcome were found to be due to
therapist competence in the delivery of the TSF intervention, which was
associated with both decreased drug use and better employment outcomes. One
possibility for these mixed findings is that the relationship between fidelity and
outcome may be complex and not linear.
Within the schema therapy for BPD research, it appears that only two studies
to date have analysed the effects of treatment fidelity on outcome, and the results
were promising. Firstly, Hoffart, Sexton, Nordahl, and Stiles (2005) explored
whether therapist competence within the early stages of an 11-week inpatient
program influenced treatment outcome. Participants included 35 patients with
panic disorder and/or agoraphobia and DSM-IV Cluster C personality traits. They
received five-weeks of group panic disorder/agoraphobia-focused cognitive
treatment followed by six-weeks of schema therapy (group psychoeducation
followed by nine to ten individual schema therapy sessions). A cognitive therapy
expert rated videotapes of the third individual session for each patient using the
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22
Cognitive Therapy Scale (CTS; Vallis, Shaw, & Dobson, 1986). To assist in the
rating, the observer was provided a list of strategies of the schema therapy model
and a case formulation for each patient. The results indicated that observer-rated
competence was associated with long-term effects on the overall outcome level,
predicting a general reduction in EMS and the number of Cluster C personality
traits.
Secondly, Bamelis, Evers, Spinhoven, and Arntz (2014) compared the
effectiveness of 50 sessions of schema therapy with clarification-oriented
psychotherapy in a multicentre randomised controlled trial between 2006 and
2011. One hundred and forty-seven patients with Cluster C, paranoid, histrionic,
or narcissistic personality disorder were randomly allocated to the schema therapy
condition. Schema therapists were split into two cohorts, each trained with
different educational formats at different time points. The first cohort received
training comprising of 75% theory versus 25% practice via lectures (20 hours),
video demonstrations (4 hours), role-play exercises in groups of two or three (3
hours), and limited individual feedback. The second cohort received training
comprising of 25% theory and 75% practice via lectures (4 hours), video
demonstrations (1 hour), plenary role-play demonstrations (2 hours), role-play
exercises in groups of two or three with plenary discussion afterwards (20 hours),
and extensive individual feedback. Independent blind-raters scored randomly
selected audiotapes on a series of 7-point Likert scales which indicated the
amount of time specific schema therapy interventions were heard. The results
demonstrated that the therapists in the second cohort scored significantly higher
on the use of schema therapy-specific techniques. Furthermore, the results
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23
suggested that the type of therapist training significantly influenced dropout,
recovery, global functioning, and self-ideal discrepancy, with the second cohort
attaining superior effects. These results strongly suggest that treatment fidelity
might be an important factor in influencing and predicting outcomes in schema
therapy.
In contrast, other studies have been unable to find a link between treatment
fidelity and outcome (e.g., Elkin, 1999; Miller & Binder, 2002). Some have
concluded that strong adherence to manualised therapies reflects an over-reliance
on technique, which inhibits the therapists ability to be empathic, which
compromises the development of a strong therapeutic relationship (Castonguay,
Goldfried, Wiser, Raue, & Hayes, 1996; Henry, Strupp, Butler, Schacht, &
Binder, 1993).
The complex, inconsistent results of prior research may reflect
methodological issues, including the need for more reliable and valid fidelity
measures. Additionally, the lack of research into the relationship between fidelity
and treatment outcome in group therapies highlights the need for further research
in the area.
Interplay Between Specific and Non-Specific Factors
Importantly, the question of whether specific and non-specific factors interact
must be posed. Some specific therapies may enhance or detract from the effect of
non-specific factors. For instance, within CBT, a relatively impersonal CBT
intervention like systematic desensitisation, doing a cognitive restructuring
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24
worksheet, or exposure response prevention therapy may be less reliant on non-
specific factors than specific factors when it comes to positive outcome. In
comparison, it is central to schema therapy and GST approaches that a re-
parenting relationship is formed between therapists and each individual member,
as well as between group members. Therefore, methods for developing and
maintaining those relationships are inherently part of the treatment model. Given
this notion, it is of great importance to better understand the relationship between
outcome and specific and non-specific factors within GST in order to improve its
efficacy.
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CHAPTER 2
FIDELITY MEASURES FOR GST
As noted in Chapter 1, Bamelis and colleagues’ (2014) investigated the
effects of treatment fidelity (as indicated by the degree of therapist training) on
outcome in schema therapy. As the results suggested, treatment fidelity is likely
an important factor in influencing and predicting outcomes in schema therapy for
personality disorders. Despite the promising introduction into research on the
effects of fidelity on outcome in individual schema therapy, the relationship
between fidelity and outcome in GST is yet to be investigated.
Further to this, there are not currently any published fidelity scales available
to assess therapist adherence to either individual schema therapy or GST for BPD
models. In addition to assisting research into the relationship between treatment
fidelity and outcome in GST, the development of a fidelity measure would
provide an avenue for ensuring that therapists deliver GST interventions to the
required standard. They would also ensure that the guidelines are adhered to and
facilitate appropriate training and supervision.
The Group Schema Therapy Rating Scale (GSTRS)
The GSTRS was developed in 2012 by researchers certified in schema
therapy (Zarbock, G., Schikowski, A, Heimann, A., Farrell, J., Shaw, I., Reiss, N)
along with two student researchers (Verhagen, S., Bot, S.) at the IVAH Institute
for Behavioural Therapy Training in Hamburg, Germany.
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The items in the scale were based on the techniques and approaches described
in the protocol created by Farrell and Shaw (2012). The student researchers listed
above originally tested the usability of the scale, and certain items were revised.
In collaboration with A. Schikowski, the students created the original guidelines
for the scale displayed in Appendix B. Following its eighth draft (see Appendix
C), one of the students used the scale as part of their research, investigating the
preliminary inter-rater reliability of the scale (the pilot study; see Bot, 2013).
The eighth version of the GSTRS consists of 27 General scale items, which
were divided into 6 subsections: General Therapist Behaviour, Limited
Reparenting, Group Therapeutic Skills, Group Climate, Structure, and Co-
Therapist Team; and 27 Specific scale items, which were divided into four
subsections: Mode Awareness and Change Work, Cognitive Interventions,
Experiential Interventions, and Behavioural Pattern Breaking Interventions. For
each item, Adherence was rated first. If the described therapist behaviour was
observed a 1 was rated, and if it was not observed a 0 was rated. For those items
that were rated a 1 for Adherence, Competence was then rated. Competence was
rated on a 6-point scale (1 = poor, 2 = unsatisfactory, 3 = adequate, 4 = good, 5 =
very good, 6 = excellent).
For the purpose of the pilot study, three independent raters (two from the
Netherlands and one from Australia) rated a total of 59 GST session recordings
gathered from the ongoing multi-site randomised controlled trial (RCT) of GST
for patients with BPD (see Wetzelaer et al., 2014). 15 recordings were collected
from Australia, 19 from the Netherlands, and 25 from Germany. All raters were
fluent in the language spoken by the participants within the groups that they rated
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(English, German, or Dutch). The results from inter-rater reliability analyses
indicated that there was adequate consistency between the two Dutch raters on the
General scale with a significant average measures intraclass correlation
coefficient (ICC) of .78, yet poor consistency between the Dutch and Australian
raters with a non-significant average measures ICC of -.12. Similarly, for the
Specific scale, the two Dutch raters demonstrated adequate reliability with a
significant average measures ICC of .72, yet the Dutch and Australian raters did
not with a non-significant average measures ICC of -.03.
However, as the two Dutch raters had worked intensively together on the
pilot study and were contributors to the development of the GSTRS it is likely
that they had formed similar views on how to rate using the GSTRS. Furthermore,
it was suggested that cultural and language differences between raters influenced
the way in which raters used the scale. It was therefore possible that the non-
significant inter-rater reliability statistics obtained using the Australian’s and one
of the Dutch student’s data were more representative of individuals new to rating
with the scale, as would be the case for future use of the GSTRS. These findings
and conclusions indicate the need to continue to refine and improve the scale and
its guidelines in order to improve its reliability for future use.
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CHAPTER 3
STUDY ONE: REFINEMENT AND PSYCHOMETRIC EVALUATION OF
THE GSTRS-R
Accepted for publication with the Journal of Behavioural and Cognitive
Psychotherapy.
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The Development and Psychometric Evaluation of the
Group Schema Therapy Rating Scale – Revised
Emily Bastick Murdoch University, Murdoch, Western Australia
Suili Bot Maastricht University, Maastricht, The Netherlands
Simone Verhagen Maastricht University, Maastricht, The Netherlands
Gerhard Zarbock IVAH -Institut für Verhaltenstherapie-Ausbildung, Hamburg, Germany
Joan Farrell Indiana University-Purdue University, Indianapolis, Indiana, USA
Centre for Borderline Personality Disorder Treatment & Research, Indianapolis,
Indiana, USA
Odette Brand University of Amsterdam, Amsterdam, The Netherlands
De Viersprong, Halsteren, The Netherlands
Arnoud Arntz University of Amsterdam, Amsterdam, The Netherlands
Christopher William Lee University of Western Australia, Crawley, Western Australia
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Background: Recent research has supported the efficacy of schema therapy as a
treatment for personality disorders. A group format has been developed (group
schema therapy; GST), which has been suggested to improve both the clinical and
cost-effectiveness of the treatment. Aims: Efficacy studies of GST need to assess
treatment fidelity. The aims of the present study were to improve, describe, and
evaluate a fidelity measure for GST, the Group Schema Therapy Rating Scale –
Revised (GSTRS-R). Method: Following a pilot study on an initial version of the
scale (GSTRS), items were revised and guidelines were modified in order to
improve the reliability of the scale. Students highly experienced with the scale
rated recorded GST therapy sessions using the GSTRS-R in addition to a group
cohesion measure, the Harvard Community Health Plan Group Cohesiveness
Scale – II (GCS-II). The scores were used to assess internal consistency and inter-
rater reliability. Discriminant validity was assessed by comparing the scores on
the GSTRS-R with the GCS-II. Results: The GSTRS-R displayed substantial
internal consistency and inter-rater reliability, and adequate discriminate validity,
evidenced by a weak positive correlation with the GCS-II. Conclusions: Overall,
the GSTRS-R is a reliable tool which may be useful for evaluating therapist
fidelity to GST model, and assisting GST training and supervision. Initial validity
was supported by a weak association with GCS-II, indicating that though
associated with cohesiveness, the instrument also assesses factors specific to GST.
Limitations are discussed.
Keywords: group schema therapy, treatment adherence, treatment competence,
fidelity, reliability, psychometric.
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Introduction
Group schema therapy for borderline personality disorder
Research on schema therapy delivered in individual sessions has
demonstrated that it is a promising treatment for personality disorders (Bamelis,
Evers, Spinhoven, & Arntz, 2014; Giesen-Bloo et al., 2006). Recently, the model
has been adapted for use in a group format, group schema therapy (GST; Farrell,
Shaw, & Webber, 2009). GST incorporates psycho-education about schema
theory and borderline personality disorder (BPD), skills training for emotional
awareness and distress tolerance, and experiential techniques. Initial studies of
GST for BPD have shown improvement on both symptom levels, reduced dropout
rate in comparison to transference-focused psychotherapy, treatment as usual, and
clarification-oriented psychotherapy, and the possibility of complete remission.
In an initial evaluation of this approach (Farrell, Shaw, & Webber, 2009), 32
women with BPD who were receiving individual therapy were randomised to
receive either an extra eight months of GST, or no additional treatment. Patients
who received GST showed improvements in all BPD symptom domains and at the
end of treatment, 94% of the patients no longer met diagnostic criteria for BPD
(compared to 16% in the control group). A subsequent study by Dickhaut and
Arntz (2014) examined a combination of weekly GST and individual schema
therapy for two years, with an additional six months of individual schema therapy
if indicated. The results demonstrated that the combination of GST and individual
therapy resulted in significant reductions in symptoms associated with BPD
manifestations and dysfunctional schemas. The effect sizes of the improvement
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32
were large. Reiss, Lieb, Arntz, Shaw, and Farrell (2014) also took the first steps to
test GST in naturalistic clinical settings in a series of pilot studies into intensive
inpatient schema therapy treatment. In their studies, they combined both
individual and group schema therapy modalities. The results validated that
inpatient schema therapy can significantly reduce symptoms of severe BPD and
global severity of psychopathology. A number of more recent studies have also
demonstrated significant symptom reduction following GST whether in a short-
term GST inpatient program (Nenadić, Lamberth, and Reiss, 2017), in an
outpatient programme lasting a year (Fassbinder et al., 2016), or in an outpatient
programme of just 20 sessions (Skewes, Samson, Simpton, & van Vreeswijk,
2015). However, in all three of these studies, there was no allocation to a no
treatment control or other treatment comparison condition.
As demonstrated above, the GST format appears promising. It also has
several advantages over the individual schema therapy format. First, group
therapy is more cost-effective than individual therapy and mental health services
(both private and publicly funded) would benefit from interventions that are less
costly. Private patients have less out of pocket expenses as a group session would
cost less per person than an individual session and public funded services can treat
more patients or treat existing patients for longer if the cost per patient is reduced.
Secondly, GST therapy allows for social/psychological factors that are not present
in individual therapy. More specifically, Yalom (1995) empirically identified
eleven factors which open the pathway to therapeutic change, including
universality, group cohesiveness, and corrective recapitulation of the primary
family group. In this light, Farrell and Shaw (2012) noted that limited re-parenting
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33
is enhanced in GST as added to the transitional parental figure (the therapist) is a
transitional family (the group); a combination which seems to amplify the effects
that each has on their own. Common to reports from patients who attend group
therapy of varying modalities, Farrell and colleagues (2009) noted that their
participants reported that the group was “the first time (they) felt a sense of
belonging and acceptance” and that they were “not alone” and “not crazy” (p. 10).
An important research question is the extent to which these group therapy
factors are enhanced by the specific aspects of the schema therapy model, or the
extent to which the schema model accounts for change beyond these common
factors. In order to assess the relative contribution of the specific aspects of
schema therapy, it is important to reliably assess what constitutes schema therapy
and whether therapists are adhering to the model.
Aims and hypotheses
The aim of the present study was to construct and assess the reliability and
validity of a rating scale of fidelity for group schema therapy. It was hypothesised
that the scale would display substantial internal consistency as demonstrated by
Cronbach’s alpha coefficients of .61 or above (Landis & Koch, 1977) and
substantial inter-rater reliability when used by trained raters. Discriminant validity
would be assessed by comparing the scale with a group cohesion tool, the Harvard
Community Health Plan Group Cohesiveness Scale-II (GCS-II; Soldz et al.,
1987). Since group cohesion is only one component of GST, and only partially
accounts for the effects of specific factors in therapy such as the use of
experiential techniques, it is expected that the competence ratings of the GST
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fidelity scale would have a low correlation with the GCS-II. However, the size of
the correlation would be in the low range (between 0.21 and 0.60).
Method
Participants
For the present study, GST session recordings were taken from an ongoing
international multi-centre randomised controlled trial (Wetzelaer et al., 2014)
investigating the clinical effectiveness of GST for BPD. Participants involved in
the trial were aged between 18 and 65 years and had a primary diagnosis of BPD.
For further details of the inclusion and exclusion criteria see Wetzelaer and
colleagues (2014) [See Appendix D]. All participants and therapists, directly or
indirectly involved in the study had given informed consent to participate, and for
the therapy sessions to be recorded and used for the purposes of this study.
Each group was run by two schema therapists, at least one of which was a
senior (or advanced) schema therapist. These therapists received six days of
training in GST. During the broader trial, intensive supervision sessions were held
once to twice a year. In addition, weekly peer supervision was provided locally
and central supervision by the developers of the GST model was provided through
teleconferencing and viewing of video recordings weekly during the first year,
biweekly for the six months thereafter, and monthly in the last six months. The
final sample for the current study featured a total of four therapists and 14 patients
across two groups (named after their locations, Peel and Rockingham).
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Raters
All three raters involved in the pilot study (Bot, 2013) of the GSTRS were
involved in the revision process. Two of the raters (SV and SB) were Dutch
masters level psychology students, who had sufficient English language
capacities, and the third rater (EB) was an Australian psychology doctoral student.
The raters were not certified schema therapists, however all raters received
clinical training during their education, were required to study the book, ‘Group
Schema Therapy for Borderline Personality Disorder’ (Farrell & Shaw, 2012). In
addition, the raters were required to watch the video produced by the IVAH
institute of Hamburg (Zarbock, Rahn, Farrell, & Shaw, 2011) which has been
used to train therapists in GST.
Procedure
Development of the GSTRS-R. An initial version of a fidelity measure for
GST, the GSTRS, was originally developed by Zarbock and Farrell in 2012 based
on the techniques and approaches described in the GST protocol created by Farrell
and Shaw (2012). The GSTRS consisted of two subscales: General and Specific.
The 27 items on the General subscale reflected a range of behaviours present
throughout each session, such as “therapist has a positive presence” and were
divided into six sections: General Therapist Behaviour, Limited Reparenting,
Group Therapeutic Skills, Group Climate, Structure, and Co-Therapist Team. In
contrast, the 27 items on the Specific subscale reflected the use of particular
techniques or interventions, present at a particular point in time, such as a
“physical grounding exercise” and were divided into four sections: Mode
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Awareness and Change Work, Cognitive Interventions, Experiential Interventions,
and Behavioural Pattern Breaking Interventions. Each item was initially rated for
treatment integrity (or adherence), which refers to the degree to which techniques
and methods as described in the treatment protocol are implemented. If
implemented, the item was then rated for competence, which refers to the skill or
quality with which the intervention was delivered.
In a pilot test of the ratings the inter-rater reliability of adherence was poor on
both General and Specific subscales with non-significant average measures ICCs
of -.11 and -.03 respectively (Bot et al., 2013). In order to improve reliability, four
aspects of the pilot scale were changed. These were changes in item content,
improvements in when the therapists were rated, the addition of descriptors to
help with assessing adherence to the specific subscale items, and the addition of
descriptors to help with assessing competency ratings.
To improve item content, the three raters highlighted items on the General
subscale of the GSTRS that appeared unclear to them, lacked precision or were
too similar to other items. In collaboration with the raters, a group of international
researchers and practitioners met regularly via audio conferences. The researchers
and practitioners were all certified schema therapists involved in the ongoing
multi-site RCT of GST for BPD. This revision process was repeated several times
until the three raters were confident that they were interpreting the items and their
corresponding guidelines in a similar manner. Table 1 displays changes made to
specific items on the General subscale of the GSTRS. Following the changes in
item content, the structure of the subsections was altered. The original six General
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subsections were reduced to five, eliminating the subsection of Group
Therapeutic Skills. There was also the addition of a subsection to the Specific
subscale: Anticipatory Socialisation to the Group Modality and Schema Therapy
Education.
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Revision of GSTRS General Subscale Items
Original GSTRS item Problem with the item Revised GSTRS-R item
04
Therapist acts as a role model for healthy adult behavior (e.g., by accepting own imperfections, apologizing for mistakes, acknowledging and taking care of one's own needs).
It may be possible that the therapists were not making any mistakes and it was unclear how to recognize that a therapist has accepted his/her own imperfections. Too similar to item 6.
04
Therapist addresses and resolves alliance ruptures using schema therapy technique and terminology (e.g., apologizing for not seeing the VC, pointing out one's demanding parent, explaining the idea behind an intervention, apologizing for having been too quick, impatient or for not providing enough details before an intervention, or for overlooking an important patient response).
05
Therapist combines both rational and emotional behaviors (e.g., experiential activation, cognitive reflection).
Required more clarification and an example. 05
Therapist addresses both cognitive and emotional processes of the patient in an integrated manner. Integration means that both processes are included for the same issue or are present in the same intervention.
06
Therapist self-discloses in an appropriate manner (e.g., to reduce participants' shame, to show that nobody is perfect, to model being aware of and open about one's own schema driven reactions and therefore more in control and able to cope).
It was not clear what self-disclosure specifically referred to. More guidelines were needed. Raters had differing views on the definition of self-disclosure.
06
Therapist self-discloses in an appropriate manner that serves the therapy process (e.g., to reduce participants' shame, to show that nobody is perfect, to model how being aware of and open about one's own schema driven reactions leads to more control and more effective coping).
08
Therapist attends to the modes of participants (e.g., validating/protecting VC, limiting IC, allows venting AC's anger, reinforcing HA and HC, disempowering DeP/PP, addressing DP).
More detail and clarity was required
08
Therapist attends to the need that is present for a patient based upon the modes he or she is in (e.g., validating/protecting VC, limiting IC, allowing AC's to vent anger, reinforcing HA and HC, disempowering DeP/PP, addressing DP).
09
Therapist establishes and maintains boundaries of group interactions (i.e., time and task management, reminding of ground rules).
Item was too similar to items 10 and 18 and required clarification. It was unclear whether maintaining boundaries needed to be explicitly stated or could be implicit within the session.
09
Limit setting: Therapist limits dysfunctional and disruptive behavior (e.g., violation of ground rules, verbal attack of another member) immediately, firmly and directly. Empathic confrontation is a different intervention. (Note: maintaining boundaries was relocated to item 20)
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10
Therapist deals with dysfunctional behavior (e.g., violation of ground rules, verbal attack of another member) and confronts participants in an empathic way (e.g., by validating underlying needs).
Items 9, 10 and 18 were too similar and needed clarification.
10
Empathic confrontation: Therapist confrontation is done in firm but friendly manner; the patient's underlying need is addressed. (a) Name the problem behavior, (b) strengthen connection, (c) connect to history or underlying feelings, (d) point out the result of the action, (e) discuss more effective options to get the patient's needs met.
11
Therapist responds to the overall group needs and atmosphere of the group (e.g., addresses low energy level, responds to level of vulnerability).
Items 11, 12 and 16 are combined to form a new item.
11
Therapist uses schema and mode language to label, identify, comment on, or regulate participant's experiences and behavior (in session or in a reported event outside of group). If appropriate, the underlying needs of the individual and the group as a whole are also labeled and addressed, including individual modes (e.g., "Tough Tammy, Mean Mommy")
12
Therapist openly labels currently activated modes and identifies the needs of individuals and the group as a whole.
14
Therapist is an active leader, who allows enough room (silence) for participants' involvement, but not so much that anxiety builds up.
More detail added. 13
Therapist is an active leader, who allows enough room (silence) for participants' involvement, but not so much that anxiety builds up. Therapist uses direction and limit setting actively to keep the group in the "working window" of activation, preventing over activation (high tension, turmoil, verbal attacks) as well as under-activation (e.g., detachment, lethargy).
16
Therapist uses schema and mode language to identify, comment on, or regulate participant's experiences and behavior.
Items 11, 12 and 16 are combined to form a new item.
11
See item 11 above.
18
Therapist addresses and manages conflicts that occur (between members, between co-therapists and between members and co-therapists).
Items 9, 10 and 18 were too similar and needed clarification.
16
Therapist addresses and manages interpersonal tensions, irritations, quarrels and/or open conflicts that occur (between members, between co-therapists and between members and co-therapists) according to the stage of the group. Healthy conflict can occur without breaking ground rules.
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20
Therapist creates an atmosphere that encourages and engages the playful child mode of each member and the group as a whole.
Needed clarification. It was unclear whether the playful child mode could be facilitated with nonverbal behavior and attitudes (e.g., implicit behaviors).
18
Therapist creates an atmosphere that encourages and engages the playful child mode of each member and the group as a whole. This could be done explicitly by using an exercise or task, implicitly by smiling, laughing, nonverbal teasing, or by para-lingual tone.
21
Therapist fosters group cohesion and acceptance (e.g., by pointing out similarities and supporting the acceptance of differences)
More detail added. 19
Therapist fosters group cohesion and acceptance (e.g., by pointing out similarities among group members while also supporting the acceptance of differences; limiting any negative evaluations of other members, encouraging "I feel" language instead of judgments of the other).
22
Therapist negotiates session agenda and topics, or issues that need to be addressed with the group collaboratively.
It was unclear about whether the agenda/plan needed to be set explicitly.
20
Therapist establishes and maintains the working frame of a group by time and task management and reminders of ground rules. High level of competence is defined by: the balance of structure and flexibility, and the therapist setting the stage for the task or topic and guiding the group actively toward a goal while also adjusting to the group needs.
23
Therapist balances structure and flexibility (i.e., going in with a goal but being ready to change the plan as the group necessitates)
26
Therapist explains the (schema therapy) rationale behind techniques and approaches to provide transparency.
More detail was required.
23
Therapist explains the (schema therapy) rationale behind techniques and approaches to provide transparency. The point at which this is done may vary - sometimes before and sometimes coming after (e.g., following experiential exercises). Therapist chooses the most suitable point in time for this explanation, so that the emotional process is facilitated (and not disturbed or closed down etc.).
27
Therapist gives homework and either refers to it, works with it or collects it to provide comments during the group session.
It was unclear what was considered homework and whether it was required every session.
24
Therapist gives some assignment or task (could be a question to consider further). These assignments must be followed up on in some way in the next session - either used in the session or collected for therapist review and return with comments.
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The second aspect of the GSTRS that was changed was that instructions to
rate Therapist A in the first 30 minutes of the recording, and Therapist B in the
second 30 minutes of the recording. This rule was abolished and instead, in all
tapes both therapists were rated simultaneously throughout the entire recording.
Thirdly, in order to improve rater consistency, guidelines were created for
rating the subscales of the GSTRS-R. These guidelines included specific
examples rather than relying on raters’ interpretations based on information
contained in Farrell and Shaw (2012). Figure 1 displays an example of a guideline
developed for one of the items in the Specific subscale. The final guidelines for
the GSTRS-R General subscale included descriptors of what would warrant a
score of non-adherence or adherence. Figure 2 displays an example of a guideline
from the General subscale.
Figure 1. Example of a Guideline from the Specific subscale.
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Figure 2. Example of General subscale guidelines for item 1.
The final change to the pilot version of the scale was to change the
competency rating system. In the pilot version, competency ratings occurred over
a 6-point scale. To improve scoring discrimination this 6-point scale was changed
to a 7-point scale corresponding to descriptors such as: 0 = very poor, 1 = poor, 2
= unsatisfactory, 3 = adequate, 4 = good, 5 = very good, and 6 = excellent. In
addition, examples were provided of good or poor competence to improve
reliability. The most recent version of the GSTRS-R can be accessed at
http://dx.doi.org/10.4225/23/585a265e14ab8 [see Appendices E, F, and G].
Tape selection. The final analysis of the GSTRS-R utilised 10 randomly
selected video- recorded therapy sessions from two Australian mental healthcare
sites that were not used during any of the previous review processes. In order to
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select the GST recordings, recordings from each site were numbered in
chronological order. A random number generator was used to determine a
recording number for each stage of therapy (one recording for months 1-4, 5-9,
10-14, 15-19, and 20-24). Inclusion criteria for the tapes were as follows:
1.! Therapy sessions were complete (no more than 20 minutes
missing, nor the beginning or end missing);
2.! There were 3 or more participants, plus two (of the original)
therapists present in the group;
3.! The video recording was of sufficient quality that all group
members were clearly audible.
If one of the randomly selected sessions did not meet the sufficient criteria, the
following tape in the series was selected. This tape then underwent the same
review process.
Each video file was provided to the three raters (EB, SV and SB) who
watched and rated the recordings independently. The raters concurrently rated the
recordings using the GSTRS-R and the GCS-II for the purpose of determining the
discriminant validity of the GSTRS-R.
Companion measure
The GCS-II (Soldz et al., 1987). The GCS-II is a group cohesion tool, and
was selected to explore the discriminant validity of the GSTRS-R [see
Appendices H and I]. Prior research has indicated that group cohesion is
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44
positively correlated with favourable treatment outcome within group
psychotherapy (see Kivlighan & Lilly, 1997; Ogrodniczuk & Piper, 2003; Soldz,
Budman, Demby, & Feldstein, 1990).
The GCS-II is an observer-rated group cohesion measure that consists of nine
ratings on the following dimensions: focus, interest/involvement, trust, facilitative
behaviour, bonding, global cohesiveness, affective intensity, conflict, and global
quality. Each dimension is rated on a 1 (very slight) to 9 (very strong) scale.
Although currently there does not appear to have been any published evaluation of
the internal consistency of inter-rater reliability of the GCS-II, it was selected due
to its successful use in a range of observer-rated group cohesion studies. Raters
were provided with a full copy of the scale, the GCS-II manual, and a set of blank
score sheets.
Statistical analyses
Adherence and competence ratings for the General and Specific subscales of
the GSTRS-R were analysed separately. The ratings of the two therapists for each
tape were averaged to obtain one score per tape, per rater.
All data were analysed using SPSS (version 23). Ratings were added to the
data set and were initially scrutinised for outliers. This involved manually
examining all three raters’ scores for each item across the 10 recordings. No
scores were removed following this step.
Items 9 and 10 from the competence ratings of the GSTRS-R General
subscale were removed prior to analyses due to a particularly low frequency of
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45
endorsement of these items (3 (1%) and 7 (2.3%), respectively). The remaining
missing items (5%) were excluded from analysis.
Internal consistency. The internal consistency of the adherence ratings was
initially calculated using the Kuder-Richardson-20 formula (the equivalent to
Cronbach’s alpha when computed for binary items). Items with zero variance
were removed. This accounted for 20 of the 28 items in the General subscale, as
all raters had deemed these behaviours were present, and 15 out of 28 items for
the Specific subscale, as all raters had deemed these behaviours were not present.
Due to the significant reduction in data and the few remaining number of items, it
appeared meaningless to report internal consistency on the remaining items.
The internal consistency of the competence rating for the General subscale
was computed using Cronbach’s alpha coefficient (Cronbach, 1951) on the mean
raters’ item scores. The competence ratings for the Specific subscale was not
analysed for internal consistency due to the low frequency with which the items
were endorsed (mean number of items per tape 1.8).
Inter-rater reliability of the GSTRS-R. Two-way mixed intraclass
correlation coefficients with a 95% confidence interval (ICC; Shrout & Fleiss,
1979) were used to measure the absolute agreement between the three raters
across the 10 recordings on the adherence ratings from each subscale (General
and Specific), and the competence ratings for the General subscale. Inter-rater
reliability was not calculated for the competence ratings of the Specific subscale
due to the low frequency of endorsement of items.
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Validity of the GSTRS-R. Prior to any validity analysis, the internal
consistency and inter-rater reliability of the GCS-II were calculated using
Cronbach’s alpha and the intraclass correlation coefficient respectively. A
Pearson’s bivariate correlation was used to analyse the relationship between the
item scores for the competence ratings on the General subscale of the GSTRS-II
and the GCS-II.
The scores from all three tests; Cronbach’s alpha, ICC, and Pearson’s r were
interpreted as: < 0 = poor agreement/no linear relationship, 0 - .20 = slight
agreement/very weak relationship, .21 - .40 = fair agreement/weak relationship,
.41 - .60 = moderate agreement/moderate relationship, .61 - .80 = substantial
agreement/strong relationship, and .81 – 1 = almost perfect to perfect
agreement/relationship (Landis & Koch, 1977).
Results
Reliability
Internal consistency. Internal consistency of the competence ratings for the
General subscale was excellent, with a Cronbach’s alpha value of .90. Corrected
item-total correlations ranged from -.12 to .89 as indicated in Table 2.
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Table 2
Item-Total Statistics and Standard Deviations for the Competence Ratings for the GSTRS-R General Subscale
Item number Corrected item-total correlation Standard Deviation
1 .39 .57
2 .08 .63
3 .78 .72
4 .35 .59
5 .43 .63
6 .27 .70
7 .34 .57
8 .56 .70
11 .26 .76
12 .71 .65
13 .36 .81
14 .84 .66
15 .13 .71
16 -.12 .77
17 .76 .78
18 .71 .64
19 .89 .73
20 .76 .72
21 .70 .79
22 .66 1.11
23 .67 .61
24 .46 .77
25 .09 .74
26 .33 .63
27 .38 .66
28 .35 1.01
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Internal consistency for the GCS-II was substantial with a Cronbach’s alpha
value of .76. Corrected item-total correlations ranged from .01 to .81 as indicated
in Table 3. Removing the worst performing item, item 9 increased the internal
consistency to a Cronbach’s alpha value of .81.
Table 3
Item-Total Statistics and Standard Deviations for the GCS-II
Item number Corrected item-total correlation
Cronbach's alpha if item deleted
Standard Deviation
1 .36 .75 .90
2 .49 .74 .54
3 .66 .71 .78
4 .36 .75 .91
5 .53 .72 1.10
6 .81 .69 .76
7 .58 .72 .67
8 .51 .73 1.07
9 .01 .81 1.04
Inter-rater reliability. Scores from the three raters across the 10 recordings
showed that the inter-rater reliability of the adherence ratings for the General
subscale of the GSTRS-R was almost perfect, with an average measures ICC of
.91 (95% CI: .89 - .93; F(279,558) = 11.69, p < .001).
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The inter-rater reliability for the adherence ratings for the Specific subscale
was substantial, with an average measures ICC of .75 (95% CI: .70 - .80;
F(279,558) = 4.10, p < .001).
Therapist competence overall was excellent. The agreement between raters
was very high; 91% of the items were rated as 4, 5, or 6. Due to a lack of variance
across the three raters’ scores for the competence ratings of the General subscale,
the ICC could not be calculated. If, however the inter-rater reliability is computed
according to the definition of Finn (1970, p.73), the total possible range from 0 to
6 is taken into account, resulting in an inter-rater reliability of .98.
Finally, the inter-rater reliability for the GCS-II was almost perfect, with an
average measures ICC of .86 (95% CI: .80 - .91; F(89, 178 = 7.84, p < .001).
Reviewing the scale without item 9, resulted in an average measures ICC of .82
(95% CI: .74 - .88; F(79, 158 = 5.81, p < .001).
Discriminant validity
The competence ratings for the GSTRS-R General subscale item scores were
weakly and significantly correlated to the GCS-II item scores (r = .45, p < .001).
Discussion
By and large, the stated hypotheses were confirmed. The results identified
that the newly revised GSTRS-R is adequately reliable and valid for assessing
therapist adherence to the GST model.
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In terms of reliability, the Cronbach’s alpha coefficient for the competence
ratings of the General subscale was excellent (.90), indicating that the core
subscale within the GSTRS-R has considerable internal consistency as predicted,
and the items are operating as a cohesive construct measuring the same underlying
elements of the intervention.
Although inter-rater reliability analyses could not be performed for the
competence ratings for the Specific subscale, two out of the remaining three inter-
rater reliability hypotheses were supported as outlined. There was close to perfect
agreement between raters for both the adherence and competence ratings for the
General subscale (.91 and .98 respectively). Inter-rater reliability for adherence
ratings for the Specific subscale was good but lower than predicted with an ICC of
.75. The validity of the Specific subscale is questionable.
Again, the internal consistency of the GCS-II was substantial with a
Cronbach’s alpha value of .76, and would improve moderately if item 9 were
removed (.81). Furthermore, the inter-rater reliability of the GSC-II was excellent,
with an ICC of .86. These results add to the void in the literature by providing
evidence for the reliability of the GCS-II. Moreover, the results indicated that it
was acceptable to use the GCS-II for the purpose of discriminant analysis in the
current study.
In line with the stated hypothesis, there was a significant, positive weak
correlation between the item scores of the competence ratings for the GSTRS-R
General subscale and the GCS-II (.45). This result provides support for the notion
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that the GSTRS-R incorporates an element of group cohesion whilst still
measuring an independent construct (i.e., fidelity to the schema model).
Limitations
Despite the generally positive findings, there are several limitations of the
present study and further investigation of the psychometric properties of the
GSTRS-R is recommended. First, further replications of this study should involve
a larger sample of recordings from a broader range of sites and countries in order
to combat any cultural effects and idiosyncratic behaviour of particular therapists,
as the tapes rated only involved four therapists. More heterogeneity in the
behaviours of the therapists would help to reduce the lack of variance that was
currently observed in some items.
In addition, the therapy sessions rated in this investigation were taken from a
research trial evaluating the new delivery mode of GST. Therefore, it is likely that
the therapists had received more training and supervision in GST than therapists
outside of the trial would. This likely skewed the range of competence to the
upper end with rating primarily falling in the 4 to 6 range, with very few ratings
falling below 4. The scale should be re-evaluated using recordings of therapists
who are only moderately trained in GST in order to produce data that is more
generalisable to the community health care setting and produce a wider range of
variance in techniques and competencies.
Furthermore, when averaging the ratings of the two therapists prior to
statistical analyses, the authors made the assumption that if one therapist had poor
adherence, and one therapist had very high adherence, then the rating of the pair
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52
would between that of two non-adherent and two highly adherent therapists.
Alternatively, it might be the case that a very good therapist compensates the
effects of a poorly functioning therapist, or that a poorly functioning therapist
damages the effects of the good therapist. The GST model assumes good
collaboration between therapists, requiring that both therapists adhere to the GST
protocol. The possibility that differences in adherence within the pair might
influence the outcome deserves further study.
It must also be noted that there was a high degree of concordance between the
three raters. This may reflect the fact that the three raters worked very closely on
the development of the scale in addition to having a greater understanding of the
items in the scale than would someone new to the scale or relatively new to GST.
As the scale was developed with the intention of being rated by
psychology/mental health students who are not professionally trained in GST, it is
imperative that the scale be tested on a new selection of raters that are limited in
their knowledge and experiences of conducting GST.
Importantly, the reliability of the competency ratings for the items in Specific
subscale remains unknown. The Specific subscale items were seldom endorsed,
reflecting that each item, or schema therapy technique, is just one of a large set of
possible techniques that can be utilised within the schema therapy model. The
considerably low rate of endorsement was surprising in the present study, in that
typically only a couple of the techniques described by items in the Specific
subscale were utilised within any one session of GST. Therefore, in order to
determine the internal consistency and the inter-rater reliability of the competency
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ratings of the Specific subscale, future studies should include a sample size four
times larger than that of the present study.
Finally, there are other ways that the validity of the GSTRS-R could be
assessed, including identifying the factor structure of the scale, which can reduce
the number of items within the scale for ease of use. Another option is to explore
its predictive validity such as comparing competence ratings of the GSTRS-R
General subscale to BPD patient’s change scores on the Borderline Personality
Disorder Severity Index (BPDSI) following GST treatment. As widely noted in
literature (e.g., Guydish et al., 2014; Hogue et al., 2008), better treatment fidelity
likely predicts better treatment outcome. Therefore, the validity of the GSTRS-R
will be further supported if the ratings are positively correlated with change
scores.
Application of the GSTRS-R
There are a number of potential applications for the GSTRS-R, for clinical
practice, training and research. The GSTRS-R may be used within the clinical
environment to ensure that clients are receiving a high quality of therapy and
could provide clinicians with information on how well they are adhering to the
GST model, and highlight areas in need of improvement for future therapy
sessions. Additionally, as different approaches of providing GST to patients with
BPD are trialled internationally, a scale for assessing the fidelity of GST would be
invaluable for reducing the variance between different therapist’s adherence and
competence to the GST model. Furthermore, the GSTRS-R would be a useful tool
within training programmes to facilitate the supervision and progression of new
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GST therapists, and to assess their progress throughout their training and career.
In this sense, the scale could be used as a “checklist” to ensure that all
components are being adequately adhered to.
Conclusions
Overall, the results from this study have shown that the revised version of the
General subscale of the GSTRS is a practical, reliable and valid tool for
evaluating fidelity to GST for BPD. Reflective of the success of the scales
revision process, the reliability of the scale was good and the weak positive
correlation with the GCS-II (Soldz et al., 1987) supports the discriminant validity
of the scale. As a whole, the findings of this study indicate that the scale could
potentially be invaluable to GST research, supervision and training practices, and
provide clinicians with an important method for evaluating and improving their
GST therapeutic technique.
Acknowledgements
The authors would like to thank those who contributed to the development
and refinement of the GSTRS-R including Eelco Muste and Neele Reiss. A
special thank you also extends to all patients, research assistants, and therapists
for their involvement in the parent study, the ongoing international multi-centre
randomised controlled trial (Wetzelaer et al., 2014).
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Ethical Statements
The authors abided by the Ethical Principles of Psychologists and Code of
Conduct as set out by the APA. Ethical approval was approved by the Murdoch
University Human Research Ethics Committee.
Conflict of Interests
Emily Bastick, Suili Bot, Simone Verhagen, Gerhard Zarbock, Joan Farrell,
Odette Brand, Arnoud Arntz, and Christopher Lee have no conflict of interest
with respect to this publication.
Financial Support
This study was supported by grants from the Australian Rotary Health, the
Netherlands Organization for Health Research and Development (ZonMW; 80-
82310-97-12142), the Netherlands Foundation for Mental Health (2008 6350),
Maastricht University, the Netherlands, the Else Kröner-Fresenius-Stiftung, and
IVAH - Institut für Verhaltenstherapie-Ausbildung, Hamburg, Germany. Funding
bodies played no role in the design of the study, in the collection, analysis and
interpretation of data, in the writing of the manuscript and in the decision to
submit the manuscript for publication.
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CHAPTER 4
BRIDGE
The results from Study One were favourable, and indicated that the GSTRS-R
is an adequately reliable and valid tool used for assessing therapist adherence to
the GST model. The next important question to explore is to what extent is group
cohesion, a non-specific group factor, enhanced by the specific aspects of the GST
model? Or, in other words, what extent does the schema model account for
change beyond the common group factor, group cohesion? Study Two attempts to
address these questions.
Numerous studies have explored the effects of either specific or non-specific
factors on treatment outcome for various group treatment models; very few have
examined both. The results of previous studies have been quite mixed. For
example in terms of specific factors, Guydish and colleagues (2014)
demonstrated that the greatest effects on treatment outcome were due to therapist
competence in the delivery of the TSF intervention. In another study, treatment
adherence was found to predict the treatment outcome of manualised CBT and
MDFT and was linked to positive outcomes up to 6 months after patient discharge
(Hogue et al., 2008).
Given other studies have failed to find a link between treatment fidelity and
outcome (e.g., Miller & Binder, 2002; Elkin, 1999), it has been postulated that
strong adherence to manualised therapies inhibits the therapists’ ability to be
empathic and thus develop a strong therapeutic relationship with the patient. In
the same vein, many studies have explored the effects of various non-specific
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factors on outcome. Again, the results have been mixed but predominantly this
research has indicated that cohesiveness is related to group therapy outcome
(Kivlighan & Lilly, 1997; Ogrodniczuk & Piper, 2003; Soldz et al., 1990), patient
satisfaction (Shea & Sedlacek, 1997), and less client dropout (Falloon, 1981).
What we do know from the limited schema therapy literature is that recovery
has been shown to be relatively higher among BPD patients receiving schema
therapy from an intensively and interactively trained cohort of therapists in
comparison to a cohort who had been trained mainly by lectures and video
demonstrations. Within this study, the type of therapist training was also found to
have a beneficial association to participant dropout, global functioning, and self-
ideal discrepancy (Bamelis et al., 2014). We also know that better observer-rated
connection in the first session of individual schema therapy (between therapist
and patient) has predicted greater across-session reduction in the strength of belief
in the particular maladaptive schema addressed within the therapy (Hoffart et al.,
2005). What we are yet to discover is the relative contributions that each group
cohesion and treatment fidelity have on outcomes in GST for BPD. This will be
addressed in Study Two.
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CHAPTER 5
STUDY TWO: GROUP SCHEMA THERAPY FOR BORDERLINE
PERSONALITY DISORDER: THE EFFECTS OF THERAPY SPECIFIC
VERSUS NON-SPECIFIC FACTORS ON OUTCOME
Prepared as a manuscript for publication.
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Group Schema Therapy for Borderline Personality
Disorder: The Effects of Therapy Specific Factors Versus
Non-Specific Factors on Outcome
Emily Bastick Murdoch University, Murdoch, Western Australia
Suili Bot Maastricht University, Maastricht, The Netherlands
Simone Verhagen Maastricht University, Maastricht, The Netherlands
Arnoud Arntz University of Amsterdam, Amsterdam, The Netherlands
Christopher William Lee University of Western Australia, Crawley, Western Australia
Background: The present study examined the relative contributions of therapist
competence and group cohesion on treatment outcome in a controlled trial of
group schema therapy (GST) for borderline personality disorder (BPD). Aims: To
examine the relative contributions of specific factors (treatment fidelity, namely
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therapist competence) and non-specific factors (group cohesion) on the treatment
outcome of GST for BPD. Method: Participants included 30 therapists and 122
patients across 15 GST groups within three countries. Observational ratings of
therapist competence and group cohesion were collected across all phases of
treatment by using the Group Schema Therapy Rating Scale – Revised (GSTRS-
R), and the Harvard Community Health Plan Group Cohesiveness Scale – II
(GCS-II). Results: There was a significant, moderate positive correlation
between treatment fidelity (therapist competence) and group cohesion within the
GST groups. Higher therapist competence was found to be associated with higher
participant retention, with Format B having higher participant retention than
Format A. Group cohesion was not found to be associated with participant
retention. Neither therapist competence nor group cohesion were found to be
associated with changes to BPD symptom levels. The stage in which the GST
techniques were assessed were not found to have any influence on retention or
changes to BPD symptom levels. Thus overall there appears to be unique aspects
of schema therapy that improves retention above common therapy factors such as
group cohesion.
Keywords: group schema therapy, GSTRS-R, group cohesion, treatment fidelity.
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Introduction
Despite a general acceptance that most psychotherapies have some efficacy
for clients, there is an ongoing, controversial debate on whether specific or non-
specific factors are more influential in facilitating therapeutic change. In order to
add to the existing literature, this study focuses on testing this issue in the context
of a specific therapy and disorder: group schema therapy (GST) for borderline
personality disorder (BPD).
The efficacy of schema therapy has been well documented in recent years
(Farrell, Shaw, & Webber, 2009; Giesen-Bloo et al., 2006; Nysæter & Nordahl,
2008). The most significant of which was a large, well-designed clinical trial in
the Netherlands by Giesen-Bloo and colleagues (2006), which demonstrated that
schema therapy might show particular promise as a comprehensive treatment for
BPD with the goal of complete recovery. The results indicated that relative to
transference-focused psychotherapy, patients in the schema therapy condition
showed greater improvement across BPD symptom domains, including
abandonment fears, relationships, identity disturbance, dissociation and paranoia,
impulsivity and para-suicidal behaviour. Furthermore, the authors found that the
dropout rate was significantly lower in the schema therapy condition.
Although the research on individual schema therapy has been promising, it
has indicated that the most significant outcomes have arisen from long-term
treatment (1-4 years), which may not be feasible in most mental healthcare
settings. A promising adaptation of schema therapy which allows for cost-
effective long-term treatment is to deliver the treatment in a group context. In an
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initial evaluation of this approach by Farrell and colleagues (2009), 32 women
with BPD were randomised to either continue with their individual
psychotherapy, or to receive eight months of GST in addition to continuing their
individual psychotherapy. The group treatment consisted of psycho-education
about BPD, skills training for emotional awareness and distress tolerance, and
schema change work. In-session activities included experiential activities (e.g.,
chair work), cognitive restructuring, and behavioural skills. In addition, the
process was adapted to a group modality by adding structured homework
assignments, group exercises, and kinaesthetic and experiential awareness
exercises. Patients were assessed at baseline, post-treatment and six-month
follow-up. Patients in the GST group showed improvements in all BPD symptom
domains and at the end of treatment, 94% of the patients no longer met diagnostic
criteria for BPD (compared to 16% in the control group). Furthermore, there was
a 100% retention rate for the GST group in comparison to only 75% in the control
group. A subsequent study by Dickhaut and Arntz (2014) examined a
combination of weekly GST and individual schema therapy for two years, with an
additional six months of individual schema therapy if indicated. The results
demonstrated that the addition of GST appeared to speed up BPD recovery with
significant reductions in BPD manifestations and dysfunctional schemas, and
higher rates of recovery and patient satisfaction. Moreover, Nenadić, Lamberth,
and Reiss, 2017 found significant reductions of BPD and Cluster C personality
symptoms and trend-level improvement for schema mode activation following a
short-term GST inpatient program.
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There are both economic and outcome related advantages to using a group
psychotherapy modality. According to Farrell and Shaw (2012), limited re-
parenting is enhanced in GST as added to the transitional parental figure (the
therapist) is a transitional family (the group); a combination which seems to
amplify the effects that each has on their own. In addition, numerous researchers
have identified that the supportive relationships created and maintained by group
members working together toward similar goals can have substantial positive
influence over therapeutic outcome, retention rates, and clients’ views toward the
group (Burlingame, Fuhriman, & Joshnson, 2001; Castonguay, Pincus, Agras, &
Hines, 1998; Holmes & Kivlighan, 2000). This relationship cultivated by the
group has been referred to as group cohesion (Budman, Soldz, Demby, Davis, &
Merry, 1993; Yalom, 1995).
Yalom (1995) noted that cohesiveness refers to “the condition of members
feeling warmth and comfort in the group, feeling they belong, valuing the group
and feeling, in turn, that they are valued and unconditionally accepted and
supported by the other members” (p. 48). Furthermore, Yalom described
cohesiveness as the “necessary precondition for effective therapy” (p. 50) and
declared that cohesiveness is an agent of change in members’ lives through “the
interrelation of group self-esteem and [personal] self-esteem” (p. 107).
In line with Yalom’s (1995) writings, the importance of group cohesiveness
has been empirically supported in numerous studies (e.g., Budman et al., 1993;
Marmarosh, Holtz, & Schottenbauer, 2005). Researchers have found that
cohesiveness is related to group therapy outcome (Kivlighan & Lilly, 1997;
Ogrodniczuk & Piper, 2003; Soldz, Budman, Demby, & Feldstein, 1990); that
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there is a significant relationship between cohesiveness in therapy groups and
patient satisfaction (Shea & Sedlacek, 1997); that more successful groups were
more cohesive (MacKenzie, 1987); and that perceived cohesiveness is related to
less client dropout (Falloon, 1981).
In addition to emphasising group cohesion, the GST model assumes that the
therapists adhere to the GST model and are competent in performing both the
specific and non-specific skills of the model. Although the research in relation to
schema therapy and GST is limited, a considerable number of studies with other
therapeutic models have explored the relationship between the presence of
specific factors relevant to that treatment (treatment fidelity) and outcome. Two
components of treatment fidelity have received the most research attention to date
(see Barber et al., 2006; Waltz, Addis, Koerner, & Jacobson, 1993): integrity (or
adherence), which refers to the degree to which a treatment condition is
implemented as intended; and competence, which refers to the skill or quality with
which interventions are delivered.
The results from these studies have been mixed. Some researchers have been
unable to find a link between treatment fidelity and outcome (e.g., Elkin, 1999;
Miller & Binder, 2002), and have concluded that a strong adherence to
manualised therapies reflects an over-reliance on technique, inhibiting the
therapists ability to be empathic, and essentially compromising the development
of a strong therapeutic relationship (Castonguay, Goldfried, Wiser, Raue, &
Hayes, 1996; Henry, Strupp, Butler, Schacht, & Binder, 1993). In contrast, others
have found that greater treatment adherence has resulted in a better outcome for
participants (e.g., Barber et al., 2006; Frank, Kupfer, Wagner, McEachran, &
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Cornes, 1991; Guydish et al., 2014; Hogue et al., 2008; Martino, Ball, Nich,
Frankforter, & Carroll, 2008). One possibility for these mixed findings is that the
relationship between fidelity and outcome may be complex and not linear. For
instance, within CBT, a relatively impersonal CBT intervention like systematic
desensitisation, doing a cognitive restructuring worksheet, or exposure response
prevention therapy may be less reliant on non-specific factors than specific factors
when it comes to positive outcome. For example, Hogue and colleagues (2008)
found that treatment adherence predicted the treatment outcome of manualised
cognitive behaviour therapy and multidimensional family therapy and was linked
to multiple positive outcomes up to six months after discharge. Specifically, a
stronger adherence predicted greater reductions in externalising behaviours (with
a linear effect), and intermediate levels of adherence predicted the largest declines
in internalising behaviours (with a curvilinear effect).
In comparison, it is central to schema therapy and GST approaches that a re-
parenting relationship is formed between therapists and each individual member,
as well as between group members. Therefore, methods for developing and
maintaining those relationships are inherently part of the treatment model.
Within the schema therapy for BPD research, it appears that only two studies
to date have analysed the effects of treatment fidelity on outcome, and the results
were promising. The first of which examined whether the connection between
patient and therapist, therapist competence, and the interaction between
connection and competence influenced treatment outcome (Hoffart, Sexton,
Nordahl, & Stiles, 2005). Thirty-five patients with panic disorder and/or
agoraphobia and DSM-IV Cluster C personality traits participated in an 11-week
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inpatient program comprising of closed treatment groups, nine to ten individual
schema therapy sessions, and eight group sessions during which one patient was
the focus of each session. The results indicated that better observer-rated
connection in the first session predicted greater across-session reduction in the
strength of belief of addressed schemas. They found that connection was unrelated
to across-session symptomatic improvement and to overall change. Competence
did however predict a reduction in early maladaptive schemas and the number of
Cluster C personality traits from pre-treatment to the follow-up period but was
unrelated to across-session change. They did not find an interaction between
connection and competence.
The second study was a multi-centre randomised controlled trial on the
clinical effectiveness of schema therapy for personality disorders and was
conducted between 2006 and 2011 in Dutch mental health facilities (Bamelis,
Evers, Spinhoven, & Arntz, 2014). Therapists were trained in two waves or
cohorts. Cohort 1 received four days of expert-training in a foreign language
(English), consisting of mainly lectures and video demonstrations. Cohort 2
received much more structured training in their native language (Dutch). They
were trained by a trainer who provided live demonstrations, they actively
participated in role-play, and received individual feedback. These differences in
type of training might lead to higher competency levels. The results of the study
demonstrated that recovery was relatively higher among those receiving schema
therapy from the second cohort of therapists. Interestingly, higher treatment
fidelity scores were rated in the second cohort than in the first, further indicating
that it was the use of specific schema therapy techniques that attributed to
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favourable outcomes. Furthermore, the type of therapist training was found to
positively influence participant dropout, global functioning, and self-ideal
discrepancy (the discrepancy between actual and ideal self-perception). These
results strongly suggest that treatment fidelity is an important factor in influencing
and predicting outcomes in schema therapy.
The purpose for the current study was to examine the relative contributions of
specific factors and non-specific factors (group cohesion) on the treatment
outcome of GST for BPD. In particular, this study will seek to:
1.! Examine whether there is a positive relationship between level of
group cohesion and better therapist competence. It is hypothesised
that better protocol adherence will lead to higher group cohesion.
2.! Examine whether change scores (treatment outcome) is attributable to
better therapist competence, or group cohesion. It is expected that
both therapist competence and group cohesion play an important part
in affecting treatment outcome.
3.! Determine whether there is a higher participant retention rate with
better group cohesion and better therapist competence in GST for
BPD.
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Method
Participants
The sample for the present study featured a total of 30 therapists and 122
patients across 15 groups within three countries: Australia, Germany, and the
Netherlands.
Patients. GST session recordings were taken from an ongoing international
multi-centre randomised controlled trial (RCT) investigating the clinical
effectiveness of GST for BPD (see Wetzelaer et al., 2014). Participants involved
in the RCT were aged between 18 and 65 years of age and had a primary
diagnosis of BPD. Participant inclusion and exclusion criteria are displayed in
Appendix A [Appendix D]. All participants had given informed consent for the
therapy sessions to be recorded and used for the purposes of this study.
Therapists. Each group was run by two schema therapists, at least one of
which was a senior schema therapist. These therapists received six days of
training in schema therapy; three of these in GST. During the broader trial,
intensive supervision sessions were held one to two times per year. In addition,
weekly peer supervision was provided locally and central supervision by the
developers of the GST model was provided through teleconferencing and viewing
of video recordings weekly during the first year, biweekly for the six months
thereafter, and monthly in the last six months.
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Group schema therapy treatment
Participants involved in the RCT were allocated to one of two formats. One
format (combination) received a combination of weekly GST plus weekly
individual schema therapy for the first 12 months, which decreased to fortnightly
sessions in the next six months, followed by monthly sessions in the remaining six
months. The second format (intensive) received twice-weekly GST with an
optional bank of 12 individual schema therapy sessions in the first 12 months,
which decreased to weekly GST with an optional bank of individual schema
therapy in the next six months, followed by monthly GST in the remaining six
months. For additional details see Wetzelaer et al. (2014). From herein the two
formats of GST delivery will be named Format A and Format B. For the benefit
of the broader study, the formats were kept blind and therefore the authors are not
aware of whether Format A or Format B received intensive GST.
Treatment followed the GST protocol created by Farrell and Shaw (2012).
Three stages were applied in a flexible manner, allowing the therapists to respond
to the participant’s modes as they appeared. The first stage focused on bonding
and cohesiveness by establishing group safety and creating a sense of belonging
and connection. Participants were given psychoeducation on BPD and schema
therapy, including childhood needs, and information about the schema therapy
model and how it works. The second stage, also known as the “working group”
stage (beginning around week 12 depending on the frequency of sessions) focused
on schema mode change. In order to create this change, mode awareness work,
cognitive interventions, experiential interventions, and behavioural pattern
breaking work are utilised. The third and final stage occurred in the second year
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of therapy and focused on the application and strengthening of the changes made
in the first year through behavioural pattern breaking and autonomy work.
Measures
Fidelity. The Group Schema Therapy Rating Scale - Revised (Zarbock et al.,
2014) was used to evaluate the fidelity to the GST model. The GSTRS-R is an
observer-rated measure that consists of 56 items: 28 General subscale items and
28 Specific subscale items. The 28 items on the General subscale reflect a range
of behaviours present throughout each session, such as “therapist has a positive
presence” and are divided into six sections: General Therapist Behaviour, Limited
Reparenting, Group Therapeutic Skills, Group Climate, Structure, and Co-
Therapist Team. In contrast, the 28 items on the Specific subscale reflected the use
of particular techniques or interventions, present at a particular point in time, such
as a “physical grounding exercise” and are divided into four sections:
Anticipatory Socialization to the group modality and ST Education, Mode
Awareness and Change Work, Cognitive Interventions, Experiential
Interventions, and Behavioural Pattern Breaking Interventions.
Consistent with other inventories assessing treatment fidelity (e.g., Waltz et
al., 1993), each item is rated separately for treatment integrity (or adherence),
which refers to the degree to which a treatment intervention is implemented as
intended; and competence, which refers to the skill or quality with which the
intervention was delivered. For each item, adherence is rated first: (0) for
behaviour/intervention was not present, (1) behaviour/intervention was present.
For items that were rated (1) for adherence, competence was then rated.
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Therefore, adherence is implied if competence was rated. Competence was rated
on a 7-point scale (0 = very poor, 1 = poor, 2 = unsatisfactory, 3 = adequate, 4 =
good, 5 = very good, 6 = excellent). Guidelines were created to improve the
reliability and validity of the ratings and can be freely accessed at
http://dx.doi.org/10.4225/23/585a265e14ab8.
For the purpose of this study, only the competence ratings from the GSTRS-R
General subscale were used. Recent research has strongly supported the reliability
and discriminant validity of the General subscale of the GSTRS-R (Bastick et al.,
in press). Bastick and colleagues (in press) report high internal consistency of the
competence ratings for the General subscale, with a Cronbach’s alpha value of
.90. Inter-rater reliability was also reported to be excellent for both adherence and
competence ratings of the subscale with coefficients of .91 and .98 respectively.
Furthermore, the competence ratings of the General subscale were weakly and
significantly correlated to ratings of a group cohesion measure, supporting the
notion that whilst the GSTRS-R incorporates an element of group cohesion, it
measures an independent construct (i.e., fidelity to the schema model).
Group cohesion. The Harvard Community Health Plan Group Cohesiveness
Scale – Version II (GCS-II; Soldz et al., 1987; [see Appendices H and I]) was
used to evaluate overall group cohesion for each rated group session. Cohesion,
according to this scale, is defined as group connectedness as evidenced by
working together towards a common therapeutic goal, constructive engagement
around common themes, and openness to sharing personal material (Budman et
al., 1993).
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The CGS-II is an observer-rated measure that consists of nine ratings on the
following dimensions: focus, interest/involvement, trust, facilitative behaviour,
bonding, global cohesiveness, affective intensity, conflict, and global quality.
Each dimension is rated on a 1 (very slight) to 9 (very strong) scale. The GCS-II
was selected due to its successful use in a range of observer-rated group cohesion
studies (Colmant, Eason, Winterowd, Jacobs, & Cashel, 2005; Crits-Christoph et
al., 2011; Kipnes, Piper, & Joyce, 2002).
Recent research by Bastick and colleagues (in press) explored the scales
psychometric properties which indicated that it has both substantial internal
consistency (.76) and inter-rater reliability (.86).
For the present study, the following variables were utilised:
Outcome variables
1.! cBPDSI_C - Pre- to post-therapy change scores on the BPDSI for
participants who completed therapy (completers);
2.! cBPDSI_I - Pre-therapy to last measurement change scores on the BPDSI
for all participants who began therapy (intent to treat);
3.! Retention – The percentage of participants remaining in treatment at 18
months.
Given the broader trial was not yet complete, change scores were transformed by
the Central Data Manager to conceal the actual raw change.
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Predictor variables
1.! GSTRS-R_A - GSTRS-R average competence ratings for the General
subscale per tape;
2.! GCS-II_A - CGS-II scale averages per tape.
Raters and procedures
Two of the raters (SV and SB) were Dutch, masters level psychology students
and the third rater (EB) was an Australian psychology doctoral student. All raters
were fluent in the language spoken by the participants within the groups that they
rated (English, German, or Dutch). The raters were not certified schema
therapists, however all raters were required to study the book, ‘Group Schema
Therapy for Borderline Personality Disorder’ (Farrell & Shaw, 2012). In addition,
the raters were required to watch the video produced by the IVAH institute of
Hamburg (Zarbock, Rahn, Farrell, & Shaw, 2011) which has been used to train
therapists in GST.
Tape selection. 65 tapes of video recorded therapy sessions were randomly
selected from 15 groups across nine sites (mean of 4.33 recordings per group,
ranging between 2 and 5). In order to make the selection, tapes from each site
were numbered in chronological order. A random number generator was used to
determine a recording number for each stage of therapy (one recording for months
1-4, 5-9, 10-14, 15-19, and 20-24). Inclusion criteria for the tapes were as follows:
1.! Therapy sessions were complete (no more than 20 minutes
missing, nor the beginning or end missing);
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2.! There were three or more participants, plus two therapists
present in the group;
3.! The video recording was of sufficient quality that all group
members were clearly audible.
If one of the randomly selected sessions did not meet the sufficient criteria, the
following tape in the series was selected. This tape then underwent the same
review process. Unfortunately, some of the groups did not have five useable tapes
that met the required criteria and therefore fewer tapes for that group were
selected.
Each of the 10 Australian video files were provided to all three raters (EB,
SV and SB) who watched and rated the recordings independently. All 23 German
tapes were rated by SV, and all 32 Dutch tapes were rated by SB. All raters rated
the recording using the GSTRS-R and the GCS-II concurrently.
Statistical analyses
Again, for the purpose of this study, only the competence ratings from the
GSTRS-R General subscale were used. Ratings from the Specific subscale were
not used due to low frequency of endorsement (10.1%). Adherence is implied if
competence was rated. Item scores were averaged for each scale, leaving one
GSTRS-R score and one GCS-II score per tape. All data were analysed using
SPSS (version 24). Ratings were added to the data set and were initially
scrutinised for outliers. This involved manually examining all scores for each item
across the 65 recordings. No scores were removed following this step.
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Two sets of change scores were calculated. The first set included only the
participants who completed therapy (cBPDSI_C), and was computed by
averaging the difference between the Borderline Personality Disorder Severity
Index (BPDSI) baseline measurement and the measurement after two years (end
of therapy), per group. The second set included all participants who began therapy
irrespective of whether or not they dropped out before completion (intent to treat;
(cBPDSI_I) and was computed by averaging the difference between the BPDSI
baseline measurement and the last measurement taken per group. The change
score for each group was used for each tape taken from that group. Retention rates
were calculated by recording the percentage of participants remaining in therapy
at 18 months, per group (retention).
Mixed effects regression was used test for the relative contribution of specific
and non-specific factors in the reduction of BPD symptoms and retention rate
during GST. All predictors were centered. The random part contained a random
slope for either GSTRS-R or GCS-II. The fixed part contained GSTRS-R score,
GST format (A vs. B; centered), stage of GSTRS score, and their interactions (for
GCS-II the same model was used with GSTRS-R replaced by GCS-II).
Backwards selection of non-significant fixed predictors was applied, starting with
the 3-way interaction, next the two-way interactions, and lastly the non-significant
main effects were deleted from the model (but leaving in main effects of GSTRS-
R and GCS-II). The residuals were inspected as to distribution and outliers. Due
to slightly abnormal distributions, the dependent variables of cBPDSI_C for both
the GCS-II and the GSTRS-R, and retention for the GCS-II were transformed
using a log transformation prior to further analysis.
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Multilevel modelling was considered, however after statistical consultation it
was determined that 15 groups would not be powerful enough for this type of
analysis. The change in BPD symptom level, as determined by the BPDSI, was
used as the outcome variable. Averages of GSTRS-R and GCS-II items were used
as the predictor variables.
Results
The assumption of singularity was also met as predictor variables were not
perfectly correlated. For the problem of multi-collinearity to be encountered,
tolerance has to be close to zero while variance inflation factor (VIF) has to be
under 10 (Coakes, 2005). Calculated using normal regression data, it was
determined that the assumption of multicollinearity was deemed to have been met,
with both tolerance (.81) and VIF (1.23) values being within acceptable limits.
Residual and scatter plots indicated the assumptions of normality, linearity and
homoscedasticity were satisfied (Hair, Anderson, Tatham, & Black, 1998).
For the participants who completed treatment, descriptive statistics for, and
bivariate correlations between the mixed effects regression variables are reported
in Table 1.
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Table 1
cBPDSI_C: Descriptive Statistics and Correlation Matrix.
cBPDSI_C GSTRS-R_A GCS-II_A
cBPDSI_C 1.00 .02 .08
GSTRS-R_A .02 1.00 .43 ***
GCS-II_A .08 .43 *** 1.00
Mean 11492.50 4.68 5.60
Standard Deviation 3278.21 .58 .70
Note: Borderline Personality Disorder Severity Index change scores for
participants who completed therapy (cBPDSI_C).
N = 65; *p < .05, **p < .01, ***p < .001.
After backwards selection of non-significant fixed predictors, neither the
GSTRS-R nor GCS-II models showed significant effects of GSTRS-R (Table 2)
or GCS-II (Table 3), respectively. Similarly, all interactions involving the main
effects of Stage and Format were non-significant, with the exception of the final
GCS-II model showing a significant effect of format, whereby Format A had
larger change scores than Format B (Table 3).
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Table 2
Estimates of Fixed Effects for GSTRS-R with Dependent Variable ‘BPDSI
Change Scores for Participants who Completed Therapy (cBPDSI_C)’.
Parameter Estimate Std. Error t 95% CI Lower Upper
Intercept 4.07 .01 23.26 *** 4.05 4.10
Z_GSTRS-R .02 .03 .84 .05 .08
N = 65; *p < .05, **p < .01, ***p < .001.
Table 3
Estimates of Fixed Effects for GCS-II with Dependent Variable ‘BPDSI Change
Scores for Participants who Completed Therapy (cBPDSI_C)’.
Parameter Estimate Std. Error t 95% CI Lower Upper
Intercept 4.05 .02 268.77 *** 4.02 4.08
Format .07 .03 2.25 * .01 .13
Z_GCS-II .01 .02 .316 .04 .05
N = 65; *p < .05, **p < .01, ***p < .001.
For the participants who initiated treatment (intent to treat), descriptive
statistics for, and bivariate correlations between the mixed effects regression
variables are reported in Table 4.
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Table 4
cBPDSI_I: Descriptive Statistics and Correlation Matrix.
cBPDSI_I GSTRS-R_A GCS-II_A
cBPDSI_I 1.00 .12 .12
GSTRS-R_A .12 1.00 .43 ***
GCS-II_A .12 .43 *** 1.00
Mean
10622.76
4.68
5.60
Standard Deviation 3674.31 .58 .70
Note: Borderline Personality Disorder Severity Index change scores for
participants who initiated therapy (cBPDSI_I).
N = 65; *p < .05, **p < .01, ***p < .001.
After backwards selection of non-significant fixed predictors, neither the
GSTRS-R nor GCS-II models showed significant effects of GSTRS-R (Table 5)
or GCS-II (Table 6), respectively. Similarly, neither the stage in which the GST
techniques were assessed, nor the group format of the sessions had any influence
on change scores for the intent to treat group (all interactions involving the main
effect of Stage or Format were non-significant).
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Table 5
Estimates of Fixed Effects for GSTRS-R with Dependent Variable ‘BPDSI
Change Scores for Participants who Initiated Therapy (cBPDSI_I)’.
Parameter Estimate Std. Error t 95% CI Lower Upper
Intercept 11010.54 481.09 22.89 *** 10048.66 11972.42
Z_GSTRS-R 616.88 736.84 .84 1011.59 2245.36
N = 65; *p < .05, **p < .01, ***p < .001.
Table 6
Estimates of Fixed Effects for GCS-II with Dependent Variable ‘BPDSI Change
Scores for Participants who Initiated Therapy (cBPDSI_I)’.
Parameter Estimate Std. Error t 95% CI Lower Upper
Intercept 10651.92 457.83 23.27 *** 9737.01 11566.83
Z_GCS-II 495.43 590.68 .84 867.38 1858.23
N = 65; *p < .05, **p < .01, ***p < .001.
Lastly retention rate was explored. Descriptive statistics for, and bivariate
correlations between the mixed effects regression variables are reported in Table
7.
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Table 7
Retention: Descriptive Statistics and Correlation Matrix.
Retention GSTRS-R_A GCS-II_A
Retention 1.00 .54 .19
GSTRS-R_A .54 1.00 .43 ***
GCS-II_A .19 .43 *** 1.00
Mean
78.88
4.68
5.60
Standard Deviation 15.43 .58 .70
Note: Participant retention rate; retention.
N = 65; *p < .05, **p < .01, ***p < .001.
After backwards selection of non-significant fixed predictors, the final
GSTRS-R model showed significant effects of GSTRS-R and Format (Table 8).
Higher GSTRS-R scores were associated with higher treatment retention, and
Format B had a higher treatment retention than Format A. The final GCS-II model
showed a significant effect of Format, but no significant effect of GCS-II (Table
9).
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Table 8
Estimates of Fixed Effects for GSTRS-R with Dependent Variable ‘Percentage
of Participants Remaining in Therapy at 18 Months (Retention)’.
Parameter Estimate Std. Error t 95% CI Lower Upper
Intercept 80.05 1.27 63.14 *** 77.51 82.58
Format -18.94 2.53 -7.49 *** -24.00 -13.89
Z_GSTRS-R 8.58 1.97 4.36 ** 4.18 12.99
N = 65; *p < .05, **p < .01, ***p < .001.
Table 9
Estimates of Fixed Effects for GCS-II with Dependent Variable ‘Percentage of
Participants Remaining in Therapy at 18 Months (Retention)’.
Parameter Estimate Std. Error t 95% CI Lower Upper
Intercept 1.89 .01 203.66 *** 1.87 1.91
Format -.08 .02 -4.50 *** -.12 -.05
Z_GCS-II .01 .01 .58 -.02 .03
N = 65; *p < .05, **p < .01, ***p < .001.
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Discussion
The present study was one of the first efforts to examine the relative
contributions of specific and non-specific factors on improvements in BPD
symptoms for participants who completed two years of GST. Findings in the
present study provided support for two out of three of the stated hypotheses.
As predicted, the results indicated that there was a significant, moderate
positive correlation between treatment fidelity (therapist competence) and group
cohesion within the GST groups. This result could be interpreted in a number of
ways. For example, if the members of the group are working cohesively, the
therapists may have more time to spend focusing on the specific skills and
techniques used within GST. Alternatively, it could be implied that the better the
therapists are at adhering to the GST model, the better they may be at facilitating
the group members to work cohesively. For example, part of the therapists’ role
within GST is to limit any dysfunctional behaviour of group members and to
respond to the overall group needs and atmosphere of the group (such as
responding to any vulnerability or addressing low energy levels). Therefore, if the
therapist is competently adhering to the model, group cohesion should be
maintained or improved. It is possible that a combination of the above might be
correct, or other variables such as group composition, or personal attributes of
group members and therapists.
Importantly, as predicted, the results also suggested that better therapist
competence is related to higher participant retention rates in GST for BPD. This
implies that participants found the most value in either the GST model itself, or
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the therapist’s delivery of the model. Furthermore, the stage in which the GST
techniques were assessed had no influence on retention which suggests that
participant retention can be predicted from early observations of GST techniques.
It was interesting to find that group cohesion did not predict treatment
retention, as found past research, for example, in Falloon (1981). It is possible that
other third party variables were influencing the results, such as client
characteristics. For example, the dynamics of a group of BPD patients may
dramatically influence the development of cohesion. A core feature of BPD
includes having significant impairments in interpersonal functioning such as in
intimacy or empathy. Therefore, while some patients may require the life of the
group to form relationships, others might adhere to others too quickly. This
inconsistency may have resulted in higher cohesion scores at times and low
cohesion scores at others.
Interestingly, Format B was found to have significantly higher participant
retention than Format A. Although the authors were kept blind as to which format
was provided with more GST sessions, some inferences can still be made. If
Format B was the intensive group format, where participants were provided with
twice-weekly GST sessions, it may be that the frequency of the group and/or the
group dynamics (outside of what was measurable using the GCS-II) played some
part in retaining participants.
However, on the other hand, if Format B was the combination format,
whereby participants were provided with a combination of weekly GST sessions
in addition to weekly individual schema therapy sessions, the results may suggest
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that participants felt that the GST component was more manageable or more
beneficial due to the inclusion of individual schema therapy component. This
notion has been supported in a qualitative study of participants’ experiences of
receiving schema therapy as part of the broader study (Tan, 2015; Tan et al.,
under review). Many participants commented that the combination of individual
and group schema formats was very helpful. For example one participant
described that the individual schema therapy component allowed them to have
further discussions, expanding on group content and also provided them with
undivided attention to explore their unique past on a more personal level.
However, it was also noted that 14 out of 20 participants in the intensive group
format expressed their preference for more individual sessions whereas none of
the members of the combination format requested more group sessions (Tan et al.,
under review).
Contrary to hypotheses, neither treatment fidelity nor group cohesion
appeared to significantly influence the improvements in BPD symptomatology
within the current study. Similarly, neither the stage in which the GST techniques
were assessed, nor the format of the sessions had any influence on the reduction
of BPD symptoms. Although surprising, these results were consistent with other
studies which have examined fidelity-outcome relationships (Barber et al., 2006;
Hogue et al., 2008; Elkin, 1999; Miller & Binder, 2002) and group cohesion-
outcome relationships (Antonuccio, Davis, Lewinsohn, & Breckenridge, 1987,
Gillaspy, Wright, Campbell, & Stokes, 2002; Kipnes, Piper, & Joyce, 2002).
Interestingly, just as many studies have found positive fidelity-outcome
relationships (Barber, Crits-Christoph, & Luborsky, 1996; Huppert et al., 2001)
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and group cohesion-outcome relationships (Burlingame et al., 2001; Castonguay
et al., 1998; Holmes & Kivlighan, 2000).
There are a number of possible explanations for the current results. First and
foremost, a major limitation of the present study was it being underpowered with
only 15 GST groups; although these groups represented 122 participants. It is a
much larger undertaking when research is conducted on groups in comparison to
individual therapy. One way which may overcome this problem would be to
analyse individual participant change scores and compare them in relation to the
overall group cohesion and fidelity scores. A second solution would be to expand
on the present study by gathering new ratings from recent groups which have
participated in the broader RCT. Additionally, it may have been beneficial to
gather a combination of both observer-rated and participant rated change-scores.
Self-perceived personality change, perceptions of how much the participants felt
they learned from the group experience, improvements in perceived self-esteem,
and self-reports of the extent to which participants gained from the group may
have been more powerful indicators of change than measuring the change in
BPDSI scores.
Despite the limitations, this study identified important findings for future
GST work. Overall, there was evidence that both group cohesion and therapist
competence are associated with improving client retention rate. It is important that
GST therapists consider the balance between adhering strictly to the GST model
and maintaining the cohesion of the group. Further research is required to explore
the relative contributions of fidelity and group cohesion on outcome.
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Acknowledgements
The authors would like to thank all participants and therapists included in this
study.
Ethical Statements
The authors abided by the Ethical Principles of Psychologists and Code of
Conduct as set out by the APA. Ethical approval was approved by the Murdoch
University Human Research Ethics Committee.
Conflict of Interests
Emily Bastick, Suili Bot, Simone Verhagen, Arnoud Arntz, and Christopher Lee
have no conflict of interest with respect to this publication.
Financial Support
This work was supported by the Australian Rotary Health, the Netherlands
Organisation for Health Research and Development (ZonMW; 80-82310-97-
12142), the Netherlands Foundation for Mental Health (2008 6350), the (German)
Else Kröner-Fresenius-Stiftung, and the (German) IVAH Institut für
Verhaltenstherapie-Ausbildung Hamburg.
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CHAPTER 6
GENERAL DISCUSSION
Schema therapy, one of the more recent empirically based psychotherapeutic
interventions for BPD is a broad, integrative psychotherapy that draws heavily on
cognitive behavioural, psychodynamic, and existential techniques (Young, 1999).
Schema therapy addresses the patient’s core psychological themes, or EMS,
thereby producing changes on a structural, emotional level. When EMS are
triggered, intense emotional, behavioural or cognitive states occur that are
described in schema therapy as “schema modes”. In order to address EMS to
prevent the patient from entering into dysfunctional modes, specific interventions
are employed, such as limited re-parenting combined with cognitive and
experiential techniques on adverse childhood experiences.
An important development in the growth of schema therapy was the
adaptation of schema therapy to a group format (GST; Farrell & Shaw, 2012;
Farrell et al., 2009). Prior research has consistently demonstrated that regardless
of the treatment model, the supportive relationships created and maintained by
group members working together toward a similar goal can have considerable
positive influence over the therapeutic outcome (Burlingame et al., 2001;
Castonguay et al., 1998; Holmes & Kivlighan, 2000). GST capitalises on this
notion by providing opportunities to extend the traditional limited re-parenting
found in individual schema therapy to the group “family”. This allows for patients
to receive corrective emotional experiences, particularly in relation to missed
childhood attachment opportunities. Furthermore, Farrell and Shaw (2012) have
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suggested that the supportive relationships developed between GST group
members may enhance certain schema therapy interventions. For example, group
cohesiveness, or a sense of belonging in the group may directly impact upon the
abandonment schema, a common schema of BPD patients. This theory implies
that both therapy specific and non-specific factors play a part in influencing GST
treatment outcomes.
In order to improve the efficacy of GST, it is of great importance to better
understand this relationship between GST specific and non-specific factors and
treatment outcome. After all, if non-specific group factors such as group
cohesiveness have a significant influence over treatment outcome, are there added
benefits to investing in therapist training? If not, then why invest in the GST
model to begin with? Does fidelity to the schema therapy model improve
treatment outcomes above and beyond the effects of the non-specific factors? The
limited existing research implies that the answer is yes.
Although the research has been limited, treatment fidelity has been identified
as an important factor in influencing and predicting outcomes in schema therapy.
As noted previously, Hoffart and colleagues (2004) investigated whether therapist
competence within the early stages of an 11-week inpatient program influenced
treatment outcome. Given the absence of a reliable schema therapy fidelity
measure, a cognitive therapy expert rated videotapes of the third individual
session for each patient using the CTS (Vallis et al., 1986). The results indicated
that observer-rated competence appeared to have long-term effects on the overall
outcome level, predicting a general reduction in EMS and the number of Cluster
C personality traits. Comparably, Bamelis and colleagues (2014) conducted a
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multi-centre randomised controlled trial on the clinical effectiveness of schema
therapy for personality disorders between 2006 and 2011. Therapists in the
schema therapy condition were trained in two cohorts. The first cohort received
four days of expert training in a foreign language (English), consisting of mainly
lectures and video demonstrations. In contrast, the second cohort received four
days of far more active training in their native language (Dutch), consisting of
lectures, video demonstrations, live role-play demonstrations, extensive group
role-play, and individual feedback. The results of the study demonstrated that
recovery was relatively higher among those receiving schema therapy from the
second cohort of therapists. Furthermore, the type of therapist training was found
to positively influence participant dropout, global functioning, and self-ideal
discrepancy. These results are consistent with the literature that has identified that
better treatment outcomes arise from more active therapist training (see Beidas &
Kendall, 2010).
With this in mind, the overarching aim of the present study was to explore
whether the unique aspects, or specific factors of GST directly relate to a
reduction in patient BPD symptomatology over and above the well-documented
effects of non-specific group factors. It was hypothesised that both specific
(fidelity) and non-specific (group cohesion) factors are important in influencing
and predicting outcomes in GST for BPD.
In order to evaluate this claim, it was important to develop a reliable and
valid GST fidelity measure. Study One focused on developing and evaluating
such a measure, the GSTRS-R. First and foremost, it was important that this
measure captured a broad, international range of views on what constituted GST,
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enabling the measure to be utilised internationally and across contexts. Following
a pilot study on the initial version of the GSTRS-R, items were revised and
guidelines were modified in order to improve the reliability of the scale.
Participants included four therapists and 16 patients across two Australian GST
groups. Once there was common agreement regarding the items, three students,
highly experienced with rating the scale rated 10 Australian GST video recorded
sessions with the GSTRS-R and a group cohesion measure, the GCS-II.
Consistent with the hypotheses, and reflective of the comprehensive revision
process, the results indicated that the scale had substantial internal consistency
and inter-rater reliability, and adequate discriminate validity, evidenced by a weak
positive correlation with the GCS-II.
With possession of a reliable fidelity measure for GST, Study Two sought to
examine the relative contributions of treatment fidelity and group cohesion on the
treatment outcome of two years of GST for BPD. Participants included 30
therapists and 122 patients across 15 GST groups within three countries.
Observational ratings of therapist competence and group cohesion were collected
across all phases of treatment using the GSTRS-R and the GCS-II. The results
were promising, showing that there was a significant, moderate positive
correlation between therapist competence and group cohesion within the GST
groups. Furthermore, the results indicated that higher therapist competence was
associated participant retention rate, with one format having significantly better
treatment retention than the other. Unfortunately, likely due to the analyses being
underpowered, the results did not suggest that better therapist competence or
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group cohesion was associated with significant reductions in BPD
symptomatology.
However, whilst holding the results of prior research into the efficacy of
schema therapy in mind, in conjunction to the known limitations of both studies, it
is unlikely that the only benefit of adhering to the schema therapy model is
improved retention rate. In addition to the future research recommendations
previously stated in chapters three and five, future research should explore the
notion that there may be particular components of GST that prove to be more
potent in influencing outcome. For example, it may be possible that imagery
change work (e.g., imagery re-scripting) within GST sessions vastly improves
client outcomes. Through subsequent frequency analysis of the Specific scale
items of the GSTRS-R analysed within Study Two, it was identified that only one
out of 65 sessions incorporated any imagery change work. Therefore, although it
appeared as though therapists were largely adhering to the model, there were no
guidelines on how many specific interventions should be employed. This may be
the difference in improvements in retention rate versus improvements in overall
BPDSI change scores.
The ultimate goal is for clinicians to be able to utilise the GST model as it
was intended by its developers, with almost certainty that they will achieve
positive outcomes for all of their patients. It is envisaged that the knowledge
gained from this project will be a catalyst for further research into the specific and
non-specific factors which influence GST outcome.
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APPENDICES
Appendix A
The DSM-5 diagnostic criteria for BPD
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met:
A.! Significant impairments in personality functioning manifest by:
1.! Impairments in self-functioning (a or b):
a.! Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.
b.! Self-direction: Instability in goals, aspirations, values, or career plans.
AND 2.! Impairments in interpersonal functioning (a or b):
a.! Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.
b.! Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealisation and devaluation and alternating between over involvement and withdrawal.
B.! Pathological personality traits in the following domains:
1.! Negative Affectivity, characterised by:
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Appendix A continued
a.! Emotional liability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.
b.! Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears or falling apart or losing control.
c.! Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.
d.! Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feelings of inferior self-worth; thoughts of suicide and suicidal behaviour.
2.! Disinhibition, characterised by:
a.! Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behaviour under emotional distress.
b.! Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for ones limitations and denial of the reality of personal danger.
3.! Antagonism, characterised by:
a.! Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.
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Appendix A continued
C.! The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
D.! The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
E.! The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).
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Appendix B
The GSTRS coding guidelines
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Appendix C
The Group Schema Therapy Rating Scale (GSTRS)
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Appendix D
Inclusion and exclusion criteria for the randomised control trial Wetzelaer et
al. (2014)
Inclusion Criteria Exclusion Criteria
1. Aged 18 to 65 years of age Primary diagnosis of borderline personality disorder, as assessed by the SCID-II
1. Lifetime psychotic disorder (short stress-related episodes are allowed)
2. Cognitive impairment (IQ < 80)
2. Primary diagnosis of borderline personality disorder, as assessed by the SCID-II
3. A diagnosis of ADHD, Bipolar Disorder Type 1, Dissociative Identity Disorder (DID), full or sub-threshold narcissistic or antisocial personality disorders 3. BPD severity score of above 20
on the borderline personality disorder severity index (BPDSI)
4. Serious and/or unstable medical illness
4. Willingness and ability to participate for at least 3 years
5. Substance dependence needing clinical detox (after detox and 2 months sobriety can be included)
6. Previous schema therapy of more than 3 months
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Appendix E
The Group Schema Therapy Rating Scale – Revised (GSTRS-R)
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Appendix F
The GSTRS-R coding guidelines
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Appendix G
The GSTRS-R specific scale coding guidelines
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Appendix H
The Harvard Community Health Plan Group Cohesiveness Scale – Version
II guidelines
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Appendix I
The Harvard Community Health Plan Group Cohesiveness Scale – Version
II scoresheet
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