New Hope for an ‘Untreatable’ Mental Illness

For the first time, a major study has shown that a high percentage of patients with Borderline Personality Disorder can achieve full recovery and emotional health. The disorder is found in 1–2.5 percent of the general population — about 5.8 to 8.7 million Americans, most of whom are young women, and until recent years has been considered untreatable…

The controlled study, appearing in a recent issue of the Archives of General Psychiatry published by the American Medical Association, shows that a new approach — Schema Therapy — leads to complete recovery in about 50 percent of the patients, and to significant improvement in two-thirds. The success of the therapy is strongly related to its duration and intensity (two sessions a week for three years). The results clearly provide the first scientific justification for longer-term therapy, which was, until now, considered to be ineffective.

According to the National Institute of Mental Health, patients with the disorder live life on the edge: they’re typically impulsive, unstable, exquisitely sensitive to rejection, have regular outbursts of anger, and live daily with extreme emotional pain. They often self-mutilate and make repeated suicide attempts. Identity problems, low stress tolerance, and fears of abandonment also make the disorder difficult for patients and for those who live with them. Many with BPD either cannot work or do not function at levels that could be expected in light of their intellectual capacities. As a result, the disorder carries high medical and societal costs, accounting for more than one in every five inpatient psychiatric admissions.

Until recently, psychotherapy offered help for only some of the symptoms of BPD. The best available alternatives, such as Dialectical Behavioral Therapy, relieve many of the self-destructive behavioral symptoms of the disorder but have not been able to reduce many of the other core symptoms, especially those related to deeper personality change.

New York-based psychologist Jeffrey Young, Ph.D. (on the faculty in the Dept. of Psychiatry at Columbia University) began to develop Schema Focused Therapy in the mid-1980s. Encouraged by its success, he established the first Schema Therapy Institute in the mid-1990s in Manhattan. Adopted by many clinicians in the United States, Europe, and Asia, the therapy came to the attention of researchers in the Netherlands who were developing a large-scale study of treatments for Borderline Personality Disorder. The clearly articulated approach of Schema Therapy lent itself well to a controlled outcome study.

In this study, Dutch investigators compared Schema Therapy (SFT) with Transference Focused Psychotherapy (TFP) in the treatment of 86 patients recruited from four mental health institutes in the Netherlands. Patients in the study received two sessions per week of SFT or TFP for three years. After three years, full recovery was achieved in 45 percent of the patients in the SFT condition, and in 24 percent of those receiving TFP. One year later, the percentage fully recovered increased to 52 percent in the SFT condition and 29 percent in the TFP condition, with 70 percent of the patients in the SFT group achieving "clinically significant and relevant improvement." Moreover, the dropout rate was only 27 percent for SFT, compared with 50 percent for TFP, indicating that Schema Therapy instilled a greater sense of allegiance among patients.

Patients began to feel and function significantly better after the first year, with improvement occurring more rapidly in the SFT group. There was continuing improvement in subsequent years.

Schema Therapy is an integrative approach, founded on the principles of cognitive-behavioral therapy, then expanded to include techniques and concepts from other psychotherapies. Schema therapists help patients to change their entrenched, self-defeating life patterns — or schemas — using cognitive, behavioral, and emotion-focused techniques. The treatment focuses on the relationship with the therapist, daily life outside of therapy, and the traumatic childhood experiences that are common in this disorder. Dr. Young believes that Schema Therapy’s greater effectiveness arises in part from its use of "limited reparenting," which is not part of other approaches to BPD.

Success with SFT is not limited to the reduction of specific symptoms, such as self-mutilation. According to Dr. Young: "In addition to creating effective coping skills and a significant reduction in self-harm, Schema Therapy patients are breaking free of lives of chaos and misery and making deeper personality changes."

Although the treatment involves many sessions over three years, Schema Therapy is nevertheless cost-effective. An economic analysis conducted by the authors of the study (not included in the Archives article) indicated that for each year Schema Therapy patients were in the study, Dutch society benefited from a net gain of 4,500 Euros per patient (the equivalent of about 5,700 US dollars), despite the cost-intensive treatment. The savings over the course of several years after the completion of treatment could actually prove to be higher.

Schema therapists and researchers are hoping that this validation of the effectiveness of Schema Therapy for patients with Borderline Personality Disorder — that for so many years has been considered intractable — will lead to more research studies and will encourage more clinicians to learn Schema Therapy. They also hope that this study will convince healthcare insurers to reimburse the costs of effective longer-term psychotherapy for this painful and costly illness.