GROUP SCHEMA THERAPY FOR BORDERLINE PERSONALITY …

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.

GROUP SCHEMA THERAPY FOR BORDERLINE PERSONALITY DISORDER

i

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


viii

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


ix

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


xii


Variable ‘BPDSI Change Scores for Participants who Initiated

Therapy (cBPDSI_I)’..................................................................... 85


‘BPDSI Change Scores for Participants who Initiated Therapy

(cBPDSI_I)’..................................................................................... 85

Table 7. Retention: Descriptive Statistics and Correlation Matrix................ 86


Variable ‘Participants Remaining in Therapy at 18 Months

(Retention)’......................................................................................

87


‘Participants Remaining in Therapy at 18 Months

(Retention)’..................................................................................... 87


xiii

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,


4

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


5

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


7

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,


8

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).


9

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,


10

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).


11

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


12

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


13

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


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


15

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.


16

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


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


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


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


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


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


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


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


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.


25

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.


26

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


27

(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.


28

CHAPTER 3

STUDY ONE: REFINEMENT AND PSYCHOMETRIC EVALUATION OF

THE GSTRS-R

Accepted for publication with the Journal of Behavioural and Cognitive

Psychotherapy.


29

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


30

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.


31

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


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


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


34

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).


35

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


36

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


37

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.


38 Table 1

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)


39 Table 1 continued

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.


40 Table 1 continued

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.


41

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.


42

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


43

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


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


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.


46

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.


47

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


48

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).


49

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.


50

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


51

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


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


53

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


54

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).


55

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.


56

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Skewes, S. A., Samson, R. A., Simpson, S. G., & van Vreeswijk, M. (2015).

Short-term group schema therapy for mixed personality disorders: a pilot

study. Frontiers in Psychology, 5(1592). doi:10.3389/fpsyg.2014.01592

Soldz, S., Bernstein, E., Rothberg, P., Budman, S. H., Demby, A., Feldstein, M.,

... Davis, M. (1987). Harvard Community Health Plan Group Cohesiveness

Scale - Version II (GCS-II): Rater manual. Harvard Community Health Plan,

Mental Health Research Program, Boston, MA.

Soldz, S., Budman, S. H., Demby, A., & Feldstein, M. (1990).

Patient activity and outcome in group psychotherapy: New findings.

International Journal of Group Psychotherapy, 40, 53-62.

http://dx.doi.org/10.1080/00207284.1990.11490583

Wetzelaer, P., Farrell, J., Evers, S., Jacob, G. A., Lee, C. W., Brand, O., van

Breukelen, G., Fassbinder, E., Fretwell, H., Harper, R. P., Lavender, A.,

Lockwood, G., Malogiannis, I. A., Schweiger, U., Startup, H., Stevenson, T.,

Zarbock, G., & Arntz, A. (2014). Design of an international multicentre RCT

on group schema therapy for borderline personality disorder. BMC

Psychiatry, 14(1), 319. http://dx.doi.org/10.1186/s12888-014-0319-3

Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.).

New York: Basic Books.


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Zarbock, G., Rahn, V., Farrell, J. M., & Shaw, I. A. (2011). Group schema

therapy: An innovative approach to treating patients with personality disorder

[DVD]. Hamburg: IVAH.


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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


62

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.


64

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


65

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.


66

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


67

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.


68

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


69

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, &


70

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


71

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


72

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


75

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.


76

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).


77

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.


78

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);


79

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.


80

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.


81

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)’.


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.


84

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


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).


85

Table 5

Estimates of Fixed Effects for GSTRS-R with Dependent Variable ‘BPDSI

Change Scores for Participants who Initiated Therapy (cBPDSI_I)’.


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)’.


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.


86

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


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).


87

Table 8

Estimates of Fixed Effects for GSTRS-R with Dependent Variable ‘Percentage

of Participants Remaining in Therapy at 18 Months (Retention)’.


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)’.


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.


88

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


89

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


90

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)


91

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.


92

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.


93

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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


103

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


104

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,


105

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


106

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.


107

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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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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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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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