1. Group Schema Therapy Borderline Personality Disorder
Joan Farrell, Ph.D.
Ida Shaw, M.A.
Indiana University School of Medicine
Center for BPD Treatment & Research
BASE Consulting Group
Schema Therapy Institute Midwest .

2. THE ALL BPD GROUP: ORDEAL OR OPPORTUNITY?
Prevalence is high
Few willing therapists
We like challenges & believed in the benefits of group therapy for trauma
Bpd patients tended to leave mixed groups unexpectedly & feel more odd afterward
Owever, the results of our first RCT influenced us on the opportunity side. We began with the group from hell and eventually found that the ST group produced very large statistically and clinically effective treatment effects.
!988 – THE GROUP FROM HELL

3. GOALS OF BASE: GROUP SCHEMA THERAPY 1
Positive, trusting therapeutic alliance with therapists & group
Increased awareness of feelings and needs
Increased ability to regulate emotion
Free enough of maladaptive schemas to take healthy action that matches present situation. environment

4. RCT OUTPATIENT GROUP SCHEMA THERAPY
32 women patients were randomly assigned to two conditions:
TAU Individual psychotherapy (not ST)
TAU plus weekly Schema Therapy group

5. STUDY DESIGN Inclusion Criteria Exclusion Criteria
Women >18 years old
Met cut-off for BPD diagnosis on DIB-R
IQ > 89
In individual TAU psychotherapy for at least 6 months and agree to continue that treatment
Able to commit to 14 month study period
Antisocial PD
Lifetime dx of schizophrenia, schizo-affective disorder, bipolar 1 DID
Referred by their individual psychotherapists
University Hospital /State Psychiatric hospital joint outpatient clinic

6. PATIENT DEMOGRAPHICS BY GROUP
Treatment group
Control Group
AGE MEAN (sd)
35.3 (9.3)
35.9 (8.1)
EDUCATION - HS
13%
33%
COLLEGE GRAD
31%
42%
EMPLOYMENT
69%
50%
STUDENT 6%
17%
HOUSEWIFE
12.5%
DISABILITY 8%
PSYCHOTROPIC MED AT BASELINE
100%
RECENT SUI
RECENT SIB

7. SCHEMA THERAPY GROUP Outpatient 30 sessions over 8 months
Sessions were 90 minutes long
1 session per week
6 patients, 2 therapists
No outside group therapeutic contact with group therapists – referred to individual therapist

8. OUTCOME MEASURES BORDERLINE SYMPTOMS
DIB-R – Structured interview (Gunderosn)
Borderline syndrome index – self report (Conte, Plutchik)
GLOBAL SEVERITY PSYCH.SYMPTOMS
SCL-90 GLOBAL SEVERITY SCORE (DEROGATIS)
GLOBAL ASSESSMENT FUNCTIONING
RATING BY INDIVIDUAL THERAPIST
BLIND ASSESSMENT PRE, POST, 6 MONTH FOLLOW-UP

9. RESULTS: Improved Global Functioning Decreased Global Symptom Severity
Symptom Checklist 90
Global Severity Score
GAF Scores
By individual therapists

10. RESULTS: Reductions in BPD Symptoms
Diagnostic Interview for
Borderlines - Revised
Borderline Syndrome Index

11. LARGE TREATMENT EFFECT SIZES
RESULTS:
LARGE TREATMENT EFFECT SIZES
BSI
DIB-R
SCL-90
GAF
Treatment Group ST
TAU
Post-test
2.48
.09
4.29
.49
.72
-.25
1.80
.14
Six Month Follow-up
2.96
.04
4.45
.35
1.17
-.13
2.67
-.14
Effect sizes using pooled SDs at baseline and mean change scores per condition (a positive sign indicates improvement).

12. RECOVERY FROM BPD IS POSSIBLE
Outpatient results
Schema Therapy
TAU
TIME
Post
6 month
Recovered based on
DIB-R score
94%
100%
25%
17%
GAF > 60
56%
88% 8%
 p< .001 2
PATIENT RETENTION: ST GROUP 100%, TAU 75%
Farrell, Shaw et al, J of Behavior therapy & Experimental Psychiatry, 2009

13. PATIENTS REPORT AS MOST HELPFUL:
“The feeling of belonging”
“I felt understood for the first time”
“There are people like me, so there is hope!”
“Therapists were patient & consistent”
“Therapists did not give up on me”
“Learning effective coping skills”
Yalom’s universality effect seems particularly meaningful for this group of people.
Nan learned about self through monitoring – learned that way that she wasn’t “wrong” just different from her family.
Being in a group of people like me
helped me feel not alone (most frequent)
I felt understood for the first time
Having patient staff
Being on a separate unit
The consistency of the BPD team
Learning effective coping skills 13

14. WHY SUCH LARGE EFFECT SIZES?
The Curative Factors of groups directly address the main schema issues of patients with BPD (and many PDs).
Group Catalyzes or Augments Schema Therapy’s active ingredients – attachment, emotional learning, schema mode change, generalization and transition to Healthy Adult function

15. Group Curative Factors Schemas of BPD
Universality
Group cohesiveness
Altruism
Installation of hope
Corrective recapitulation of the primary family
Development of
socializing techniques
Existential factors
Catharsis
Imitative behavior
Interpersonal learning
Imparting of information
Yalom, The Theory and Practice of Group Therapy
Abandonment
Mistrust /abuse
Emotional deprivation
Defectiveness/shame
Social Isolation/alienation
Undeveloped self
Emotional Inhibition
Unrelenting standards
Punitiveness

16. GROUP CATALYZES ST COMPONENTS
Limited Re-parenting
Experiences with peers feel more “real”.
Closer analogue of the family may intensify
Autonomy
Group can act as a tangible “bridge” to life outside therapy
Schema Mode Change
More options for experiential work
Vicarious learning gets around detachment
The experience of belonging to a peer group is powerfully healing
Multiple person mode role-play vs chair-work

17. IF THE GROUP CURATIVE FACTORS ARE ACTIVATED Don’t do Individual therapy while a group merely watches
Individual patient focus limited
Focus weaves between individual, common schemas and group
One therapist is always attending to group connections
Cognitive focus is suspended when opportunities for emotional learning occur

18. SCHEMA THERAPY MODEL of BPD
Schemas = Trait-like, ongoing, are triggered
Modes = Moment-to-Moment States
MODES of BPD hypothesized by Young, empirically validated by Arntz & Loebestal:
Child Modes=innate response to unmet needs
Maladaptive Coping Modes = overused survival responses to trauma or unmet core needs
Dysfunctional Parent modes = internalized critic
Under-developed Happy Joyful Child and Healthy Adult Modes

19. MODES ACCOUNT FOR CLINICAL PRESENTATION
& SYMPTOMS OF BPD
Vulnerable child
Angry Child
Impulsive Child
MODE FLIPPING
Abandonment Fears
EXPLAINS THE CLINICAL PRESENTATION OF PATIENTS WITH BPD
Emotional Reactivity
Unstable relationships
Unstable self
Intense anger poor control
THE MODE MODEL PROVIDES YOU WITH THE FOCI
OF TREATMENT TO
FOLLOW
Impulsive behavior
SIB, SI
Punitive or
Demanding
Parent
Reality connection -
Dissociation
Psychotic symptoms
Emptiness
Detached Protector

20. MODE CHANGE IN GROUP ST GOOD QUALITY OF LIFE THERAPIST
ANGRY – IMPULSIVE
CHILD MODES
MODE CHANGE IN GROUP ST
THERAPIST P A R E N T
PUNITIVE
DEMANDING M O D S
DETACHED PROTECTOR
ANGRY CHILD CHANNELED
VULNERABLE
CHILD
IMPULSIVE CHILD LIMITED
THE GROUP
GOOD QUALITY OF LIFE
PUNITIVE & DEMANDING
PARENTS BANISHED
THAT WAS FOR THE EXPERIENTIAL PEOPLE AND VISUAL LEARNERS
HAPPY
CHILD DEVELOPS
HEALTHY ADULT

21. MAIN COMPONENTS OF SCHEMA THERAPY
LIMITED REPARENTING
AN INTEGRATIVE MODEL
EXPERIENTIAL WORK
IMAGERY RESCRIPTING
MODE ROLE PLAYS
COGNITIVE PROCESSING
BEHAVIORAL PATTERN BREAKING
THE LAST TWO COMPONENTS DISTINGUISHES ST FROM EXPERIENTIAL THERAPY

22. Limited Re-parenting meets core unmet childhood needs
Safety
Stability, predictability
Validation
Guidance
Caring
Support for exploration
Needs being met allows the Vulnerable Child to be present and experiential work can be done Reaching and healing the VC is one of STs major goals

23. Step One: Secure Attachment Establish Therapist - Patient Bonds
Be genuine
Eye contact
Soft tones
Convey that they matter
Friendly facial expressions
Validation of feelings
Active listening
Meet needs -be nurturing and supportive
Bond first with the
Vulnerable Child Mode

24. TWO “PARENTS” FOR THE BPD GROUP
Alternate taking the lead or focusing on maintaining connections with the group
Equal partners share the tasks and attend to the “children”
Use signals – when you want help, another idea, etc.
Support each other
Point out therapist schema and mode activation
One can take a patient out of group when necessary

25. LIMITED RE-PARENTING FOR A GROUP
Build a healthy “family”, the optimal setting for treating PD
A closer analogue to family of origin and “real life”
Group has more options for positive connections that can extend to “real life”

26. BUILDING A HEALTHY “FAMILY” FACILITATE COHESIVENESS
Point out similarities – symptoms, problems, developmental history
Differences are OK too – acceptance
Respect
Validation ALL
Mutual support
Shared emotional experiences, group memory, language
Conflict managed by therapists at first

27. ONE PRIMARY NEED IS SAFETY
Therapist Tasks include:
Be in charge – like a
symphony conductor–
amplify, quiet or control as needed
Impart competence & confidence
Teach Safe-place imagery
Group support can add safety if a “healthy family” has been created
Use empathic confrontation & limit setting when needed
Group can feel more or less safe depending upon the culture that is developed by the therapist. Group ST is designed to be a particular kind of group experience – a healthy family.

28. GROUP ST IS INTEGRATIVE
Combines structure and flexibility – homework provides a shared focus, but may be collected rather than discussed, to “seize the experiential moment”.
Therapists direct & set limits at first and as the “family” forms, let the “kids” take over, while maintaining involvement and availability – “do what they cannot”

29. MODE CHANGE WORK Get through/around coping modes
Heal Vulnerable child mode
Eliminate Punitive/demanding modes
Channel Angry Child mode
Healthy limits for Impulsive/Undisciplined Child mode

30. To do experiential work BYPASS DETACHED PROTECTOR
Experiential Focusing Exercise
Awareness work
Vicarious learning
Observing consequences of remaining in DP in peers
Empathic confrontation has increased salience when peers confront, sometimes too scary & therapist must

31. HEALING THE VULNERABLE CHILD
Group provides the new experience of belonging
Opportunities for receiving nurturing & caring from a larger “family unit” group
Discovery that sadness does not destroy the self

32. GROUP IMAGERY WORK Safety Images Good Parent Images
Building Healthy Adult Strength Images
Imagery Re-scripting
Individual focus is broadened to the group
Whole group re-scripting
Individual to group can include the group in many different ways: e.g. Michael, group planned the re-scripting with him and supported him during it. Or KG

33. MODE ROLE PLAY: Group provides many options
Good parent for Vulnerable Child
Fight the Dysfunctional “Parent” Mode
Support the VC doing this comes later
Comfort and soothe the frightened VC
Self-soothing comes later
Good Parent for Angry or Impulsive Child
Listen and validate
Set limits and Guide

34. CONTAIN & CHANNEL ANGRY/ IMPULSIVE CHILD MODE
Containment & limits from therapists & group
Safety in numbers
Role play options with “good parent” or peers
Assertiveness
Negotiation
Conflict resolution
Learning that anger can be positive & channeled safely

35. GROUP CONFLICT RESOLUTION
Conflict is an important learning opportunity
Properly managed by therapists can increase group cohesiveness
Set limits on “Bully” mode
As last resort, leave
wēi and jī
“We got through it, resolved it and no one was hurt or kicked out”

36. BANISH the “PUNITIVE PARENT”
“Villains” are clear to peers
Group consensus on what is “reasonable” vs. “punitive”
Group as an “army of defenders” – role plays
Creepy PP anthem
Destroy in effigy
Role plays & psychodrama
Re-scripting with “Good Parent”, later Healthy Adult
HEALTHY ADULT - BANISHES PUNITIVE PARENT
THERAPIST BANISHES PUNITIVE PARENT
GROUP JOINS IN AND/OR ESCORTS PP OUT

37. MULTIPLE MODE ROLE-PLAYS POSSIBLE
Banish Punitive Parent: played by Therapist, peers, patient then reverse roles
Healthy Adult Mode of pt. - banishes Punitive Parent
Group joins in to help and/or escorts PP out
Therapist and group play all roles this allows vicarious learning, avoids further detachment

38. STRENGTHEN THE HEALTHY ADULT MODE
Identify strengths & accomplishments
Support for claiming their voices
Reinforce competence
Praise
Share celebrations
Peers can reframe “mistakes” effectively
Group provides a controlled experience of competence and value -- with therapists there to help assign meaning to the event and the cognitive anchor of a label.

39. In conclusion Group can be the place where:
The Abandoned Child: finds security and healing
The Punitive Parent: is banished
Angry/Impulsive Child/Teen: transformed into strong and competent Healthy Adult
The all BPD “group from Hell” became a powerful medium for effectively treating BPD symptoms and improving the quality of life of this troubled group of patients

40. FOR MORE INFORMATION: www.bpd-home-base.org
Joan Farrell, Ph.D. & Ida Shaw, MA (317) Indianapolis, IN USA Group Schema Therapy training, supervision and research