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Schema Therapy for Borderline Personality Disorder: Patients' and Therapists' Perceptions by Tan Yeow May, BA

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Schema Therapy for Borderline Personality Disorder: Patients' and Therapists' Perceptions by Tan Yeow May, BA Schema Therapy for Borderline Personality Disorder: Patients’ and Therapists’ Perceptions By Tan Yeow May, B.A. (Hons) This thesis is presented for the degree of Doctor of Clinical Psychology at Murdoch University 2015 I declare that this thesis is my own account of my research and contains as its main content work which has not previously been submitted for a degree at any tertiary education institution. …………………………………..... Tan Yeow May Schema Therapy for Borderline Personality Disorder: Patients’ and Therapists’ Perceptions Tan Yeow May Murdoch University PERTH, WESTERN AUSTRALIA ABSTRACT Schema therapy (ST) is effective in promoting clinically meaningful gains that ameliorate symptomatology for borderline personality disorder (BPD). However very little is known about how the therapy is experienced by patients or therapists including which elements of ST are effective from patients’ and therapists’ perspectives. The aim of this study is to explore BPD patients’ experiences of receiving ST and therapists’ experiences in delivering ST. Qualitative data were collected through semi-structured interviews with 11 patients who had a primary diagnosis of BPD and eight trained schema therapists. Interview data were analysed following the procedures of inductive, content analysis. Patients’ broad perceptions of ST included the experience of greater self-understanding, better awareness of their own emotional processes and better connections with their emotions. While the process of ST was perceived as emotionally confronting, patient narratives highlighted that this was perceived as necessary. Therapists generally regarded their experience as rewarding based on patients’ positive responses to treatment, and discussed changes made in their professional (e.g. incorporating more ST in their therapy) and personal (e.g. increased self-awareness) lives. However therapists also described being confronted with novel challenging situations despite having years of therapy experience. Patients and therapists were concordant on several therapeutic components of ST (e.g. ST provides insight, benefits of experiential techniques) and some therapeutic group factors not specific to ST (e.g. sense of connection among group members). On the other hand there exists a possible interplay between level of patient dysfunction within the group and therapists’ ability to manage group conflict. Recommendations for more effective implementation of schema therapy are discussed as well as issues for other specialist treatment approaches to BPD particularly concerning termination of therapy and definitions of recovery. Finally implications of the findings are discussed in terms of assessing the suitability of patients for group ST. ACKNOWLEDGEMENTS My principal supervisor Dr. Christopher Lee was whom I received the most advice and direction for this thesis. I am very thankful for his guidance throughout the entire process of refining the topic and scope of my research, recruitment of participants, analysis of data and the final write-up. I also wish to thank my secondary supervisor Prof. Arnoud Arntz who provided his expertise on qualitative research and constructive feedback for the thesis write-up. The paper has been written by myself and edited by Dr. Christopher Lee and Prof. Arnoud Arntz. All errors and mistakes are however mine alone. I could not have asked for more committed and knowledgeable supervisors, who were not only generous with their time but also have a strong passion for their field of work. I would like to extend my appreciation to staff members at Rockingham and Peel mental health facilities who have assisted me in one way or another (e.g. booking of rooms, signing of progress notes), most importantly all the patients and therapists who shared their very personal accounts, without whom this thesis would not have been possible. Additionally I am grateful for the help of two Dutch postgraduate students Desiree Martius (PhD candidate) and Sophie Wastiaux (MSc candidate) for the countless Skype meetings to discuss the interpretation and refining of interview data. Finally I sincerely thank my partner Nick, my family and friends who provided endless love, encouragement and laughter. Table of Contents 1. Introduction .................................................................................................... 1 1.1 Borderline Personality Disorder (BPD) .......................................................... 1 1.1.1 Epidemiology of BPD ................................................................................. 2 1.1.2 Impact of BPD ............................................................................................. 4 1.1.3 Aetiology of BPD ........................................................................................ 7 1.2 Limitations of Existing Treatment Modalities ............................................... 8 1.2.1 Pharmacological treatment .......................................................................... 8 1.2.2 Ineffectiveness of traditional Cognitive-Behavioural Therapy ................... 9 1.2.3 Specialist Psychological Interventions for BPD ........................................ 10 1.3 Development of Schema Therapy for BPD .................................................. 15 1.3.1 Mechanisms of Schema Therapy for BPD ................................................ 17 1.3.2 Limitations of published articles on Individual and Group Schema Therapy ............................................................................................................... 19 1.3.3 Group Schema Therapy ............................................................................. 21 1.3.4 Combined Group and Individual Schema Therapy ................................... 23 1.4 Therapists’ and Patients’ Perceptions of Therapy ........................................ 24 1.4.1 Patients’ Perspectives of Recovery from BPD .......................................... 24 1.4.2 Patients’ Perspectives of Imagery ............................................................. 25 1.4.3 Differing Perceptions of Therapy .............................................................. 26 1.5 Rationale for Present Study .......................................................................... 28 1.5.1 Research Aims and Implications ............................................................... 29 2. Method – Patient Participants ..................................................................... 31 2.1 Patient Profiles ............................................................................................. 31 2.2 Procedure ...................................................................................................... 32 2.3 Data Analysis ............................................................................................... 34 2.4 Inter-Coder Agreement ................................................................................. 34 2.5 Interview data specific to the Australian site ............................................... 37 3. Results – Patient Participants ..................................................................... 38 3.1 Part One: General experiences of Schema Therapy ..................................... 38 3.1.1 A. Therapeutic and challenging aspects of ST in general ......................... 39 3.1.2 B. Perceptions of ST as compared to previous therapies .......................... 46 3.1.3 C. Expectations, Feelings and Beliefs prior to and after starting ST ............................................................................................................................ 50 3.2 Part Two: Group and Individual components of Schema Therapy .............. 52 3.2.1 A. Group experience and dynamics among group members ..................... 54 3.2.2 B. Structure and Format of Group and Individual ST ............................... 62 3.2.3 C. Relationship with group and individual therapists ............................... 69 4. Discussion – Patient Participants ................................................................ 73 4.1 Therapeutic Gains attributed to Components of the Schema Model ............ 77 4.2 Group Factors that Contribute to Therapeutic Gains ................................... 81 4.3 Factors that Disrupt Group Climate ............................................................. 84 4.4 Termination of Schema Therapy .................................................................. 85 4.5 Study Strengths ............................................................................................. 86 4.6 Limitations .................................................................................................... 87 4.7 Clinical Implications and Conclusion .......................................................... 88 5. Method – Therapist Participants ................................................................ 92 5.1 Schema Therapist Profiles ............................................................................ 92 5.2 Schema Therapy Supervision ....................................................................... 93 5.3 Procedure ...................................................................................................... 93 5.4 Data Analysis ............................................................................................... 94 6. Results – Therapist Participants ................................................................. 95 6.1 Part One: Group and individual therapists’ broad experiences in providing schema therapy
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