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Randomized Trial of Schema-Focused Therapy vs Transference-Focused Psychotherapy

Josephine Giesen-Bloo, MSc; Richard van Dyck, MD, PhD; Philip Spinhoven, PhD; Willem van Tilburg, MD, PhD; Carmen Dirksen, PhD; Thea van Asselt, MSc; Ismay Kremers, PhD; Marjon Nadort, MSc; Arnoud Arntz, PhD

Arch Gen Psychiatry. 2006;63:649-658.

Context  Borderline personality disorder is a severe and chronic psychiatric condition, prevalent throughout health care settings. Only limited effects of current treatments have been documented.

Objective  To compare the effectiveness of schema-focused therapy (SFT) and psychodynamically based transference-focused psychotherapy (TFP) in patients with borderline personality disorder.

Design  A multicenter, randomized, 2-group design.

Setting  Four general community mental health centers.

Participants  Eighty-eight patients with a Borderline Personality Disorder Severity Index, fourth version, score greater than a predetermined cutoff score.

Intervention  Three years of either SFT or TFP with sessions twice a week.

Main Outcome Measures  Borderline Personality Disorder Severity Index, fourth version, score; quality of life; general psychopathologic dysfunction; and measures of SFT/TFP personality concepts. Patient assessments were made before randomization and then every 3 months for 3 years.

Results  Data on 44 SFT patients and 42 TFP patients were available. The sociodemographic and clinical characteristics of the groups were similar at baseline. Survival analyses revealed a higher dropout risk for TFP patients than for SFT patients (P = .01). Using an intention-to-treat approach, statistically and clinically significant improvements were found for both treatments on all measures after 1-, 2-, and 3-year treatment periods. After 3 years of treatment, survival analyses demonstrated that significantly more SFT patients recovered (relative risk = 2.18; P = .04) or showed reliable clinical improvement (relative risk = 2.33; P = .009) on the Borderline Personality Disorder Severity Index, fourth version. Robust analysis of covariance (ANCOVA) showed that they also improved more in general psychopathologic dysfunction and measures of SFT/TFP personality concepts (P<.001). Finally, SFT patients showed greater increases in quality of life than TFP patients (robust ANCOVAs, P=.03 and P<.001).

Conclusions  Three years of SFT or TFP proved to be effective in reducing borderline personality disorder–specific and general psychopathologic dysfunction and measures of SFT/TFP concepts and in improving quality of life; SFT is more effective than TFP for all measures.

Author Affiliations: Department of Medical Psychology (Ms Giesen-Bloo) and Department of Clinical Epidemiology and Medical Technology Assessment (Dr Dirksen and Ms van Asselt), Academic Hospital Maastricht, Maastricht; Department of Medical, Clinical, and Experimental Psychology, University Maastricht, Maastricht (Ms Giesen-Bloo and Dr Arntz); Department of Psychiatry, Vrije Universiteit University Medical Center/Geestelijke Gezondheidszorg Buitenamstel, Amsterdam (Drs van Dyck and van Tilburg and Ms Nadort); and Department of Clinical and Health Psychology, Leiden University, Leiden (Drs Spinhoven and Kremers), the Netherlands.

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