Commentary: Short-term group schema therapy for mixed personality disorders: an introduction to the treatment protocol.

Abstract

The evidence base for schema therapy (ST) has grown rapidly in recent years, as applied to a wide range of clinical groups (Masley et al., 2011); for ST with groups see Farrell et al. (2009), Simpson et al. (2010), Farrell and Shaw (2012), van Vreeswijk et al. (2012), Renner et al. (2013), Videler et al. (2014). Variations exist between group schema therapy protocols utilized across clinical settings and client groups. It is therefore imperative that researchers describe treatment protocols in detail. A recent pilot study was published on the outpatient treatment of mixed personality disorders (Skewes et al., 2015), which demonstrated low attrition and clinical improvement over 20 weekly 60-min sessions. In addition, up to 5 × 30-min individual sessions are provided through the duration of the group for those who require additional support, especially during crises. This also includes a session provided at mid-therapy in order to provide feedback on progress to date and to focus goals for the second half of therapy. The purpose of this paper is to describe the treatment protocol utilized in this trial. The group is led by two therapists who alternate the role of taking the lead in session exercises, with the other focused on maintaining connection between participants, mainly through the use of eye-contact and non-verbal gestures. Therapist couples are able to model connection and confrontation through the way in which they communicate with each other and with group members. Therapists must balance the need to be “genuine” and consistent with their own individual therapeutic “style,” with the need to collaborate as a cohesive “parent couple,” guiding the group according to schema therapy “limited reparenting” principles. The schema model is applied in a flexible manner that requires group leaders to respond to modes as they appear on a moment-to-moment basis. Whereas participants with BPD often experience frequent mode “flipping,” those with cluster C personality disorders, tend to be overly fused to an avoidant or overcompensatory coping mode (e.g., “Detached Protector”; “Perfectionistic Overcontroller”). Therapists are required to respond to the needs of clients flexibly, and to be guided by sophisticated case conceptualizations that facilitate recognition of the range of modes present in a mixed personality disordered group. In order to ensure treatment fidelity and to check that all four aspects of the schema model (cognitive, behavioral, experiential, and limited reparenting) are covered adequately, sessions are monitored regularly by an accredited group trainer using the Group Schema Therapy Competency Rating Scale (Zarbock et al., 2014). A condition of participation in the group is that contact with external mental health professionals is limited to medical or psychiatric monitoring only. Mode “check-in points” are used at regular intervals during sessions, which involves a 5 minute mindfulness exercise to facilitate moment-to-moment awareness of modes and associated feeling-states (van Vreeswijk et al., 2014). A summary of the material incorporated within sessions is summarized in Table ​Table1.1. Some exercises can be found in Farrell et al. (2014). Table 1 Summary of schema therapy group protocol for mixed personality disorders. This protocol forms the basis for ongoing research into short-term treatment of mixed personality disorder population.