Transcript Stichting Borderline – Stichting Borderline

Behaviour Research and Therapy 47 (2009) 938–945
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Behaviour Research and Therapy
journal homepage: www.elsevier.com/locate/brat
Three preparatory studies for promoting implementation of outpatient schema
therapy for borderline personality disorder in general mental health care
Marjon Nadort a, *, Richard van Dyck a, Johannes H. Smit a, Josephine Giesen-Bloo b,
Merijn Eikelenboom a, Michel Wensing c, Philip Spinhoven d, Carmen Dirksen e,
Jeroen Bleecke b, Bianca van Milligen a, Michiel van Vreeswijk f, Arnoud Arntz b
a
GGZ inGeest, Department of Psychiatry and EMGO Institute, VU University Medical Center Amsterdam, A.J. Ernststraat 887, 1081 HL Amsterdam, The Netherlands
Maastricht University, Department of Clinical Psychological Science, The Netherlands
Radboud University Nijmegen Medical Centre, Scientific Institute for Quality of Healthcare, The Netherlands
d
Leiden University, Department of Psychology, The Netherlands
e
Department KEMTA Academic Hospital Maastricht, The Netherlands
f
G-kracht, private mental health care outdoor clinic, Delft, The Netherlands
b
c
a b s t r a c t
Keywords:
Borderline personality disorder
Outpatient therapy
Schema therapy
Pilot- implementation
Process evaluation
Objective: Three studies were conducted to prepare for the implementation of Schema Therapy (ST) for
Borderline Personality Disorder (BPD) in general mental healthcare settings. Two were surveys to detect
promoting and hindering factors, one was a preliminary test of a training program in ST.
Methods: In 2004, a diagnostic analysis of factors promoting and hindering implementation of a new
treatment for BPD was conducted among both managers (n ¼ 23) and therapists (n ¼ 49) of 29 Dutch
mental healthcare institutes through a written survey (Study 1). Next, a training program, including a set
of DVDs displaying the major therapeutic techniques, was developed and tested among eight therapists.
The training program was evaluated by the participants. After the training, three independent raters
evaluated therapists’ adherence and competence, viewing videos of the therapists completing structured
role-plays (Study 2). In 2008, a second written survey was conducted in 22 mental health institutes to
study factors for future nationwide implementation of ST (Study 3).
Results: Both surveys indicated that the situation in most institutes was favorable for implementing
a new effective treatment, as participants were not satisfied with the existing treatments, had suitable
professional backgrounds, worked in settings with (B)PD-oriented care programs, and expressed a need
for change. The surveys yielded clear results for promoting or hindering successful implementation of ST.
Promoting factors included scientific evidence for the effectiveness of the treatment, structural changes
in the patient’s personality, rapidly noticeable effects for the patient, low drop-out rates and a favorable
cost-effectiveness. Possible barriers included implementation mandated unilaterally by management,
choosing ST based on financial or organizational needs, extending implementation over a lengthy period
of time and providing telephone support by therapists beyond office hours. The eight-day training
program received very positive ratings. After the training, therapists were rated as sufficiently adherent
and competent applying ST to treat BPD patients, with peer supervision and supervision recommended
as a supplement to the training.
Conclusion: This study showed that the situation in 2005 was advantageous to start implementation of
ST. Evaluation of the training and the achieved competence scores of trainees concluded that the training
program was a good basis for training therapists in ST. Outcome of the survey in 2008 demonstrated that
there was a clear interest for implementation of ST for BPD patients in the future.
Ó 2009 Elsevier Ltd. All rights reserved.
Background
Implementation
* Corresponding author.
E-mail address: [email protected] (M. Nadort).
0005-7967/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.brat.2009.07.004
For successful implementation, crucial elements and principles
recur through most publications examining models and theories
M. Nadort et al. / Behaviour Research and Therapy 47 (2009) 938–945
used in the field of planning the implementation of a new treatment (Grol & Grimshaw, 2003; Grol & Wensing, 2006; Weinmann,
Koesters, & Becker, 2007). While the scientific basis of these principles is still limited, they provide a framework for setting up an
implementation plan. According to Grol and Wensing (2006), these
elements are: A systematic approach to, and good planning of,
implementation activities. A diagnostic analysis of the target group
and settings should take place before the start of the implementation. An analysis of the care as usual and deviation from the
proposed behaviour is necessary and the choice of implementation
activities should link with the results of the diagnostic analysis.
Usually, a single method of measure is insufficient and it is better to
look for a cost-effective mix of methods tailored to the identified
obstacles and incentives to change. The target group should be
involved in the development and adaptation of the innovation, as
well as in planning the implementation. Focusing on organizational
and practical issues is important. Continuous evaluation of both the
implementation process and its results is necessary as is feedback
to the target group. Implementation should become an integral part
of the existing structures and long-term effects should be the aim.
According to Grol and Wensing’s principles, the present authors
conducted three studies to prepare the implementation of schema
therapy for borderline personality disorder in general mental
healthcare settings in the Netherlands.
Borderline personality disorder and schema therapy
Borderline Personality Disorder (BPD) is a severe and chronic
psychiatric disorder. It is marked by chronic instability in multiple
areas (emotional dysregulation, self-harm, impulsivity, and identity
disturbance). The life-time prevalence of BPD in the general population is about 2%. In psychiatric outpatient settings, 10% of the
patients suffer from BPD. The medical and other societal costs for
BPD are substantial (Ten Have, Lorsheyd, Van Bijl, & Osterthun
1995; van Asselt, Dirksen, Arntz, & Severens, 2007).
In a randomised controlled trial (RCT) comparing Schema Therapy
(ST) and Transference Focused Psychotherapy (TFP) (Giesen-Bloo
et al., 2006), ST was found to be a superior treatment to TFP. ST had
a recovery rate of 45.5% and a reliable change rate of 65.9%. The dropout rate for ST was significantly lower than for TFP. The positive
results regarding the effectiveness of ST were substantiated by an
economic evaluation showing that ST is also more cost-effective than
TFP (Van Asselt et al., 2008). Because these results were promising, an
implementation study for ST was conducted. The article on the
implementation study conducted between December 2005 and
February 2009 can be found separately in this special issue on
implementation (Nadort et al., 2009).
This implementation study was prepared using three smaller
studies: two surveys to help identify barriers and factors promoting
successful implementation of ST in regular mental healthcare
settings in the Netherlands, and one small test of an ST-training
program for therapists developed to use in an implementation
study of ST in the Netherlands. The results of these studies follow.
Part of the project that tested the efficacy and cost-effectiveness
of ST versus TFP for BPD included a set of dissemination and implementation activities. The first two studies presented in this paper
were part of these activities, while the third was part of a follow-up
project studying actual implementation of ST in regular practice.
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identified. Before data of the Giesen-Bloo et al. (2006) trial were
analysed, preparations were made to implement the most effective
treatment of the RCT. Preparations included conducting a survey
among some of the most important stakeholders for implementation: therapists and managers of mental health institutes in the
Netherlands. The survey’s goals were to assess whether the situation in these institutes was ripe for implementation of a highly
specialized psychological treatment for BPD, and to identify the
major factors promoting and hindering implementation, according
to these stakeholders. The survey was based on the theories by Grol
and Wensing (2006), which stress that different levels should be
addressed to detect obstacles and to identify supportive factors,
such as the individual care provider (competence, attitude, motivation for change and personal characteristics), the social setting
and network (opinions of colleagues, opinion leaders and professional network), and the management level (structural conditions,
interests and resources).
Method
To prepare for implementation of the most (cost-) effective
treatment of the RCT (Giesen-Bloo et al., 2006), in 2004 a survey was
conducted in Dutch mental healthcare institutes (Arntz, Dirksen, &
Bleecke, 2005). The goal of this survey was to identify factors
promoting or interfering with successful implementation of a new
psychotherapeutic treatment of Borderline Personality Disorder
(BPD). Based on Grol and Wensing’s recommendations (2001), both
managers and therapists of Dutch mental healthcare institutes were
sampled. Successful implementation entails managers supporting
the introduction of a new treatment, and therapists effectively
executing the new treatment. Using Grol’s framework, first trial
interviews with both managers and therapists were conducted,
addressing issues related to individual, social and contextual levels.
On the basis of these pilots, a survey was developed that would be
mailed to the sample. According to the levels listed by Grol and
Wensing, several items were written and included in the survey.
Participants and procedures
Conducted in 2004, data were collected from 29 mental health
institutes, distributed to nine Dutch provinces. The institutes were
randomly selected from Dutch mental healthcare institutes that
provided outpatient treatment for BPD patients. Before actual
sampling of the institutes, a list of Dutch mental healthcare institutes was created. Next, sampling was stratified over region (North,
East, Mid, West and South Netherlands). In each of the sampled
institutes, one or more managers and one or more therapists
involved with the treatment of BPD patients were mailed surveys,
and asked to complete and return them.
The number of respondents was 72. They were distributed
as follows: 49 therapists (28 psychotherapists, 11 psychiatrists,
9 psychiatric nurses and 1 assistant physician); 23 managers
(6 managerial psychiatrists, 6 treatment program heads, 6 policy
managers and 5 heads of treatment teams).
Analysis
For the survey data, descriptive statistics were calculated.
Study I: 2004 survey
Results of the 2004 survey
Introduction
In the mental health institutes, cognitive therapy appeared to be
the most prevalent psychotherapeutic treatment (72%). Among
therapists and managers, 67.3% of the therapists said they provided
cognitive treatment, and 82.6% of the managers reported cognitive
To prepare implementation activities, potential factors
hindering and promoting implementation of the treatment are
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M. Nadort et al. / Behaviour Research and Therapy 47 (2009) 938–945
therapy was provided in their departments. The other forms of
psychotherapy, including client centered psychotherapy, psychodynamic psychotherapy, and behavioral therapy, were each
provided in 20–40% of the departments. Approximately 20% of the
therapists applied at least one of the non-cognitive therapies. In
77.8% of the institutes a program for the treatment of BPD was used,
and most of these institutes had a specific BPD program (55.6% of
the total). In 22.2% of the institutes, a program for the treatment of
Personality Disorders (PD) was used. In 19.4% of the institutes, no
program was employed to treat BPD patients. On average, 9.75
therapists were involved in the treatment of BPD patients. In two
thirds of the departments, more than seven therapists were
involved in treating patients with BPD.
For the respondents, the most important sources of information
about new treatments were: 1.Written specialized resources
(69.4%); 2. Conferences (56.9%); 3. Contacts with colleagues at the
institute (50.0%); 4. Contacts with specialist colleagues outside the
institute (44.4%); 5. Courses (41.7%).None of the responders, therapists or managers reported to be unwilling to change their existing
treatment possibilities for BPD.
Of the therapists, 24.5% reported to be interested in new treatments for BPD, but were not yet willing to change the treatments
they delivered. 75.5% of the therapists claimed to be willing to change
the treatments they delivered for BPD, in the short or long-term.
For managers, 39.1% were interested in new treatments for BPD,
but were not yet willing to change the treatments their departments delivered. 60.9% of managers were interested in new treatment possibilities and would be willing to implement them when
a new, suitable treatment was available.
Both managers and therapists rated the present treatment
satisfaction for BPD patients with a median satisfaction score of 4.9
on a 0-10 scale. More than 50% of both groups rated the present
treatment for BPD as unsatisfactory.
For therapists, 77.6% rated the satisfaction of treatments they
used for BPD less than 7 on a 0-10 scale, with only 22.4% moderately
to highly-satisfied. For managers, 69.6% rated their present treatment satisfaction for BPD less than 7 on the 0-10 scale, with 30.4%
moderately to highly-satisfied.
Factors that may promote or hinder a successful implementation of a new psychotherapeutic treatment were described in 25
propositions. The following factors were rated most often as
moderately or highly supportive (percentage is proportion of
respondents rating the proposition as moderately or highly supportive):Table 1
The following factors were reported to be highest to hinder or
interfere with implementation (moderately or highly):Table 2
Factors that could be considered as either important or unimportant with respect to implementation of a new psychotherapy
were described in 25 propositions. The following factors were rated
as moderately to highly important by the indicated percentage of
respondents. Table 3
Table 1
Promoting factors for implementation.
93.0%
87.3%
87.2%
84.5%
83.1%
74.6%
74.3%
72.8%
Scientific foundation of the new treatment
The therapists that have to execute the new treatment have an
important say in the choice of the new treatment.
An important opinion leader in the organization supports the new
treatment.
The new treatment is supported by BPD patient organizations.
The possibility to first try out the new treatment before it is decided to
deliver it.
The implementation is executed under the direction of a project group
of the own institute.
The patient’s personality is structurally changed by the new treatment.
There are weekly peer supervisions for the new treatment.
Table 2
Hindering factors for implementation.
80.2%
69.0%
64.8%
The choice for the new treatment is based on financial or
organizational arguments, not on the basis of its effectiveness.
The implementation process takes more than a year.
The choice for the new treatment is imposed by the management.
Discussion
Considering the answers of the respondents, it could be
concluded that in 2004 the environment was favorable to start
implementation of ST for treatment of BPD in regular mental
healthcare settings. Many cognitive therapists were working in
these institutes, with an excellent background for further training
in ST and they had the support of their managers. In general,
enough cognitive therapists existed in mental health institutes to
create peer supervision groups, a necessity for optimal implementation of ST. Since most of the institutes already had treatment
programs for BPD (either specifically or as part of a broader defined
PD treatment program), existing programs would facilitate the
implementation of ST. With present treatments of BPD not particularly satisfying, and a clear interest in new and better treatments
noted, a second study to prepare the implementation of ST for BPD
was created to develop and test a training program for therapists.
The training was supplemented with a set of DVDs displaying the
major therapeutic techniques.
Study 2: training program and audiovisual training material
Introduction
The next implementation steps consisted of several elements:
production of a set of DVD’s showing the basic techniques and
methods of ST (Nadort, 2005), the development of a training
program and creation of a website1 (www.schematherapie.nl
(2005)).
Study 2 tested the structured training in ST for BPD developed to
disseminate ST among therapists and to implement ST in mental
healthcare institutes.
Method
DVDs with ST techniques demonstrations
In 2004 a six-hour DVD set of schema therapy techniques was
produced, consisting of 34 segments averaging 10 min in length
(Nadort, 2005). Key elements were chosen from Young, Klosko and
Weishaar’s work (2003), and from the protocol tested in the RCT
(Arntz & Van Genderen, 2009; Van Genderen & Arntz, 2005). In
addition to the specific techniques, the therapeutic approach was of
primary importance in the sample segments. On the DVDs,
professional actors played the borderline patients, and actual
therapists who had participated in the main ST BPD outcome study
played the therapists. Produced in Dutch, the DVDs were later
subtitled in English. The DVD segments include: introduction,
making contact and explanation of rationale of therapy, schema
1
The website offers information to the lay public about ST and offers a list of ST
therapists that are member of the Dutch Registry of Schema Therapists. The website
offers a link to order the DVD box, and provides the manual for the use of the DVDs.
In addition, all (homework) forms, questionnaires and other forms that can be used
in ST are available on the website for downloading. All of the continuing education
links in the field of schema therapy can be found on the website, as well as links to
recent research literature.
M. Nadort et al. / Behaviour Research and Therapy 47 (2009) 938–945
Table 3
Important factors for implementation.
98.6%
95.8%
95.8%
94.4%
94.3%
91.5%
91.5%
88.7%
85.9%
85.9%
84.9%
80.3%
78.9%
78.9%
78.8%
74.7%
74.6%
The new treatment is a clearly identifiable part of the total package of
treatments.
The new treatment has a clearly defined crisis management policy.
Peer supervision and supervision are important parts of the learning
phase of the new treatment.
The employer financially stimulates participation in training in the new
treatment.
Immediate colleagues are positive about the new treatment.
The new treatment fits in the existing structure of and collaboration
between treatment programs.
The government admits the new therapy in the treatment package.
The new treatment has a promptly noticeable effect for the patient.
BPD patients have difficulties to fulfill the minimal conditions of the
treatment.
The new treatment incorporates a specialized crisis facility.
The new treatment is ‘‘evidence-based’’.
The new treatment has a relatively low drop-out rate.
The new treatment has a favorable cost-effectiveness.
The management as a whole supports the choice for the new treatment.
Institutes increasingly work with treatment programs for BPD.
The barrier for participating in the treatment is low for the patients.
The characteristics of the patients of the scientific study are
representative for the patients treated by the therapists.
questionnaires, case conceptualization, explanation of the mode
model, limited reparenting, detached protector mode (pros and
cons, imagery work, mode dialogue), diagnostic imagery, imagery
rescripting by the therapist, imagery rescripting by a helper,
imagery rescripting by the Healthy adult, Punitive parent mode
(multiple chair techniques), empathic confrontation, Angry child
mode, Angry protector mode, angry side of Healthy adult mode,
schema diary and mode diary, flashcard, downward arrow technique, historical role-play, motivating new behaviour, imagery
rescripting future, breaking through dysfunctional partner choices
and learning to make a healthy partner choice.
All segments were used in the training program, and were
evaluated by both instructors and participants.
Training program: method and components
A training course was developed to train psychotherapists,
psychologists and psychiatrists in schema therapy techniques for
the treatment of borderline patients. The training addressed the
theoretical model, treatment frame, different phases, and the use of
strategies and techniques (Arntz & Van Genderen, 2009; Van
Genderen & Arntz, 2005; Young, Klosko, & Weishaar, 2003; Young &
Klosko, 1999; Young, Klosko, & Weishaar, 2005). Central to ST is the
assumption of five schema modes specific to BPD. Schema modes
are sets of schemas expressed in pervasive patterns of thinking,
feeling and behaving (Lobbestael, Arntz, & Sieswerda, 2005,Lobbestael, Vreeswijk, & Van, Arntz, 2008). Change is achieved through
a range of behavioral, cognitive and experiential techniques that
focus on (1) the therapeutic relationship (2) daily life beyond
therapy and (3) past (traumatic) experiences. Recovery in ST is
achieved when dysfunctional schemas no longer control or rule the
patient’s life.
The training program consisted of the following components:
intake and assessment phase, case conceptualization, schema
questionnaire completion and results discussion, therapeutic relationship, empathic confrontation, setting limits, cognitive techniques, behavioral techniques, experiential techniques, and the
mode model. A great deal of attention was devoted to address
various modes of the borderline patient, such as the Abandoned
child, the Angry child, the Detached protector, the Punitive parent,
and the Healthy adult mode (Lobbestael et al., 2005, 2008). The
training program also emphasized how to set-up treatment and
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phase-in various techniques. Specific themes and techniques were
covered on each training day, starting with a short introduction by
the instructors on a given topic, a DVD demonstration, and dyadic
role-playing in sub-groups. Two instructors then offered feedback.
Finally, a plenary discussion of the techniques that had been
practiced occurred. Therapists were required to actively participate.
The course was organized within the norms of the Dutch
Association of Behavioral and Cognitive Therapy and the Dutch
Society of Psychiatry, and was accredited by these associations.
Accreditations by both associations ensured that the training
course could also be used for future implementation.
Participants and procedures of the training program
The training course (group format, 50 h, eight days) was delivered in 4 2 days from January 2005 to April 2005. Five practitioners of a regular mental health service and three practitioners of
an Out-patient Forensic Psychiatric Service participated. They
attended all sessions. Two trainers with expertise in ST and the
treatment of borderline patients trained the participants, who were
psychotherapists, psychologists and psychiatrists. The profile of
participants was: 1 male, 7 female; mean age 34 years-old (range
25–55); 5 licensed psychotherapists; all licensed in CBT.
Evaluation of the training program
Each training day was evaluated separately, documented in
a written report. The mean evaluation per day on a scale from
0 (bad) to 10 (very good) was calculated. Further, a final evaluation
over the complete course was also conducted on a scale from
0 (bad) to 5 (good).
To examine the participants’ competence as ST therapist after
the program, all participants were asked to participate in three 10minute role-playing situations with actors (script-based). During
the first role-play, an actress played a patient’s role in the Abandoned child mode, while the therapists demonstrated ‘limited
reparenting’ techniques. For the second role-play, an actress portrayed ‘the Punitive parent’ mode, and therapists recognized the
mode and demonstrated mode-specific techniques to address it. In
a third role-play, the actor dramatized the Detached protector
mode and therapists demonstrated how to break through the
detached mode.
All role-plays were videoed, and segments were coded and rated
by three independent evaluators: two therapists well versed in
schema therapy, and one BPDpatient who had been successfully
treated with schema therapy. The evaluators were trained before
completing the ratings. The Young Therapy Adherence and
Competence Scale (Young, Arntz, & Giesen-Bloo, 2006) was used to
rate the video segments. The purpose of this rating scale is to
determine if therapists are following the procedures and practices
of ST, and to assess their competence as an ST therapist. While there
may be some overlap, adherence differs from competence. Therapy
adherence addresses the question: is the therapist providing the
therapy according to the protocol. Therapy competency addresses
the issue: how skillfully is the therapist providing the therapy. As
for the rating, since only 10-minute video segments were evaluated, not all of the items on the Therapy Adherence Scale could be
demonstrated in such a short amount of time. Therefore, items that
were selected included the general therapeutic style, limited reparenting, therapeutic relationship, psycho-education about
schemas and modes, and connecting daily situations with schemas
and modes. The items were rated on a scale (0–2) with skills
ranging from (0) ‘not present’ to (2) ‘strongly present’. An independent research assistant entered all of the data. There were no
missing values.
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M. Nadort et al. / Behaviour Research and Therapy 47 (2009) 938–945
Analysis
Results of the evaluation of the training program were analyzed
by calculating the means and the standard deviations. The intra
class correlation coefficients (ICC) of the therapy adherence and
competence scores were analysed by means of reliability analyses.
A two way mixed model (consistency) was used.
Results of the training program
The mean evaluation of the training program and the DVD series
of therapy techniques per day was 8.77 (SD 0.56) (range 0–10; badgood), and the mean of the final evaluation was 5 (SD 0) (range 0–5;
bad-good). Overall, the training program received a very good
evaluation. The participants evaluated the instructors’ introduction
as good, the examples as good and illustrative, and the exercises
and instructors’ feedback as educational and useful. All participants
evaluated the program as good and educational.
Competence tasks
Although the competence tasks only demonstrated brief
therapy segments, they gave a good illustration of the therapists’
style and the therapeutic techniques.
Analysis of the results showed that adherence to ST and
competence, as for overall appropriateness of used methods and
techniques in SFT, was sufficient (mean 1.18; ICC ¼ 0.88). The global
competence/quality ST therapist rating was moderate-good (mean
1.39; ICC ¼ 0,84), with a cut off score of 1. One therapist had a score
below 1.
Discussion
Based on the information presented, it can be concluded that the
50-h training program, supplemented by the DVD series of therapeutic techniques, was a good basis for the training of practitioners
in schema therapy. But experiences from the RCT learned us that
providing a training program is not sufficient for learning ST. Also
following the guidelines of Grol and Wensing (2006) that ‘usually,
a single method of measure is insufficient and it is better to look for
a cost-effective mix of methods tailored to the identified obstacles
and incentives to change’ in addition, actual practice under
supervision, supplemented by peer supervision, is necessary and
strongly recommended (Van Vreeswijk, Broersen, & Nadort, 2008).
Study III: 2008 survey
Introduction
In 2008, the Dutch government changed the organization and
payment of mental healthcare dramatically, from a tax-based
system to a commercial, insurance-based system. This shift
necessitated a re-evaluation of potential barriers and factors supporting the implementation of ST through the creation of a new
survey in 2008. Additional factors since the 2004 survey had also
come to light. For instance, early experiences training ST therapists
warned that telephone availability beyond office hours (which is
also a component of dialectical behaviour therapy for BPD) was
potentially problematic for the implementation of ST. Since this
issue had not been addressed in the 2004 survey, it was added to
the new survey. Based on the experiences during the implementation study, specific questions were included regarding the
therapist’s phone support beyond office hours, the organizational
problems regarding travel time for therapists from different institutes, and problems with reorganization and cooperation among
the different institutes. A shortened version of the questionnaire of
Arntz and colleagues (Arntz, Dirksen, & Bleecke , 2005) was used.
Additional issues that had to be addressed included recent changes
in the Dutch Health Insurance System. Insurers became more
critical of mental health treatment providers and costs. Moreover,
insurers focused more on the demands of patients, who could
easily switch to a competitor if they did not receive the care they
desired. Insurers measured the quality of provider care through
performance indicators, such as patient satisfaction and improvements in General Attainment Scores (GAS). Treatment providers
who exceeded quality measurements received higher compensations and more patient referrals, entering into a ‘‘preferred partnership’’ contract with insurers.
To understand the opinion of insurers regarding the efficacy and
cost-effectiveness of schema therapy, a questionnaire was mailed to
15 large insurance companies. Insurers were asked four short
questions: a) what kind of information do you need from a mental
health institute to purchase specific mental healthcare, such as
schema therapy b) what are important factors in your decisionmaking process when you can choose between different institutes
for purchasing specific mental healthcare c) what kind of information do you need to assess the quality of the provided mental
healthcare d) what are the conditions for a ‘‘preferred partnership’’
contract.
Of the 15 companies, only 20% responded to the questionnaire,
and most of the respondents were not familiar with schema
therapy. All respondents preferred evidence-based or best practice
care.
Participants and procedures of the 2008 survey
In 2008, a list of 31 Dutch mental healthcare institutes
providing outpatient treatment for BPD patients was created
encompassing 12 Dutch provinces. In each of the institutes, one or
more managers and one or more therapists involved with the
treatment of BPD patients were mailed the survey and asked to
complete and return it.
Of the mental healthcare institutes that were approached, 5
institutes refused to participate, so data were collected in the
remaining 26 mental healthcare institutes agreeing to participate.
Of the 26, 13 were already familiar with the Schema Therapy
Implementation Study of Nadort and colleagues (see the paper
regarding implementation in this special issue Nadort et al., 2009).
Of these 13 institutes, 8 had already participated in the implementation study. For various reasons, five of the thirteen institutes
had previously refused to participate in the implementation study.
These five institutes were then asked to complete a survey to gather
more information about their objections to participating. Thirteen
‘new’ mental health institutes providing outpatient treatment for
BPD patients were mailed surveys and asked to complete and
return them..
The number of responding institutes was 22. Respondents were
distributed as follows: 60.5% were therapists, 26.3% were financial
managers, and 13.2% were directors of treatment teams.
Analysis
For the survey data, descriptive statistics were calculated.
Results
Mental health care institutes
Most of the institutes provided a specialized program for BPD
patients (71.1%) and were already using some form of ST for
M. Nadort et al. / Behaviour Research and Therapy 47 (2009) 938–945
Table 4
Promoting factors for implementation.
Percentage
ST gets positive attention in the media
The patient’s personality is structurally changed by ST.
ST fits in with evidence-based working.
ST is ‘‘evidence-based’’.
Immediate colleagues are positive about ST.
ST is a clearly identifiable part of the total package of
treatments.
The employer financially stimulates participation in ST training
ST has a promptly noticeable effect for the patient.
ST training is provided by an external expert.
The ministry of health admits ST in the treatment package.
ST has a favorable cost-effectiveness.
ST fits in with the existing structure of and collaboration
between treatment programs.
Peer supervision and supervision are important parts of the
learning phase of ST
ST has a flexible treatment protocol
ST is supported by BPD patient organizations.
An important opinion leader in the organization supports ST.
89.5%
89.4%
89.4%
86.9%
84.2%
84.2%
81.6%
81.5%
78.9%
78.9%
76.3%
76.3%
73.7%
73.7%
73.7%
71.1%
borderline patients (84.2%). Most patients were treated with
outpatient therapy (92.1%). Managers rated their average satisfaction of current therapy programs for BPD patients 5.1 (SD 1.9) on
a scale from 1 to 10, (1 ¼ minimal satisfaction, 10 ¼ maximum
satisfaction), and the therapists satisfaction score was 5.5 (SD 2.1).
39.5% of the respondents worked in institutes where no evidencebased treatments were investigated. 15.8% of the respondents
reported that there were evidence-based treatments that were
investigated, but that they were not personally involved. 42.1% of
the respondents were personally involved in BPD treatment
investigations. The respondents received information about new
therapies from written specialized reports (78.9%), conferences
(76.3%), and workshops (52.6%).
Factors that may promote or hinder successful implementation
of schema therapy were described in 25 propositions. The following
factors were rated most often as moderately or highly promoting
(percentage is proportion of respondents rating the proposition as
moderately or highly promoting):Tables 4 and 5
Discussion
Based on the respondents’ answers, the situation in 2008
seemed encouraging for future implementation of ST. Most of the
institutes already had treatment programs for BPD (either as such
or as part of broader defined PD treatment programs), but present
treatments of BPD were not viewed as particularly effective, and
a clear interest in new and better treatments was expressed. 84% of
the respondents were already using some form of ST. It was unclear
from the results whether the programs were structured, and the
Table 5
Hindering factors for implementation.
Percentage
Travel time necessary for peer supervision and supervision
Telephone support by the therapist outside office hours
The choice for ST is based on financial or organizational arguments,
not on the basis of its effectiveness.
Therapy sessions of 45 min twice a week
Patients have to pay a personal contribution for sessions
Treatment period takes 3 years
ST requires weekly peer supervision.
Changes on organizational level
The implementation is region coordinated
ST requires monthly supervision
ST requires a training program of 8 fulltime days
ST requires specialized care providers
68.4%
57.9%
50%
50%
39.5%
39.5%
36.8%
34.3%
29%
26.3%
23.7%
23.7%
943
high percentage of respondents already using a form of ST may be
partially explained by the fact that 8 institutes already participated
in the implementation study of Nadort and colleagues.
General discussion
The three preparatory studies followed the guidelines of Grol
and Wensing (2006), using a ‘good planning and systematic
approach,’ and both surveys offered ‘a diagnostic analysis of the
target group and settings,’ an ‘analysis of the care as usual,’ and
‘deviation from the proposed behaviour’. The situation in 2004
seemed favorable to start implementation of ST as treatment of BPD
in the regular mental health service. Many cognitive therapists were
working in these institutes, with an excellent background preparing
them for further training in ST. Generally, enough cognitive therapists were already working in mental health institutes to create peer
supervision groups, a key component for an optimal implementation of ST. Most of the institutes already had treatment programs for
BPD (either as a specialized program, or as part of broader defined
PD treatment programs), and their existence would facilitate the
implementation of ST. Present treatments of BPD were not particularly satisfying, and a clear interest in new and better treatments
was desired. Most of the respondents indicated that their most
important sources of (initial) information were specialized reports
(i.e., articles, books) and conferences, relatively easy outlets to relay
information on ST’s (cost-) effectiveness.
Grol and Wensing recommend to make a ‘choice of implementation activities that are linked with results of the diagnostic
analysis’ and to use a ‘cost-effective mix of methods that are
tailored to the identified obstacles and incentives to change’. It is
important that the target group is involved in the development,
adaptation and planning of the implementation,’ and to ‘focus on
organizational and practical issues’ (2006, p 66–70).
Factors rated by many respondents as highly important or
supportive were incorporated. The surveys indicated that information about ST should include several components. First, ST is
evidence-based. Second, ST leads to a structural change in the
patient’s personality, not merely (temporary) symptomatic
improvements. Third, ST generally leads to prompt reductions in
the patients’ problems. Considering the average rapid decrease of
BPD manifestations and other problems in the first six months of ST
treatment, this seemed easy to support. Fourth, ST is suitable for
a broad range of patients, with low drop-out rates. Given the nonstringent in- and exclusion criteria and the finding that baseline
severity at the start of treatment did not predict recovery (but
instead predicted more relative improvement), even more severe
BPD patients benefited from ST treatment. Finally, the vast majority
of the BPD patients in the RCT were able to adhere to the treatment
protocol. The results of the RCT (Giesen-Bloo et al., 2006) and the
study by Van Asselt et al. (2008) on the cost-effectiveness of ST
support all five points.
The survey’s results concluded several important suggestions
for the implementation study of Nadort et al. (2009). First, participants clearly wanted to have an important part in choosing the
treatment, especially the therapists. Management mandating
therapists to practice a particular treatment without the therapists’
say was not advised. Creating a positive and supportive environment between management, opinion leaders, and colleagues plays
an important role for successful treatment. Additional recommendations included forming a project group in the institute, starting
peer supervision groups, creating an appropriate crisis facility and
policy, and allowing trained therapists to experiment with the new
treatment before the implementation becomes finalized. Supervision by an external expert was also advised. Despite the time
needed to employ a new treatment, the objective is to create
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M. Nadort et al. / Behaviour Research and Therapy 47 (2009) 938–945
a specialized treatment integrated within the institute’s total
program.
In 2005, preparations for the actual implementation study that
began in 2006 were made. According to the survey’s outcome, the
target group was involved in the development and testing of the
training program and in the implementation process. Elements that
had been stressed as important by the respondents of the survey
were incorporated into the ‘implementation package’. Information
about the (cost-) effectiveness of ST was provided. Therapists and
managers of healthcare centers were invited to participate in the
implementation study. Therapists were offered an 8-day training
program, with supervision provided on location by an external
expert. Another part of the implementation package included the
formation of peer supervision groups and appropriate crisis facilities and policies.
According to Grol and Wensing (2006), ‘evaluation of both the
implementation process and its results is necessary,’ as well as
‘feedback to the target group’. Implementation should become an
‘integral part of the existing structures and long-term effects should
be the aim’ (p 66–70). These elements were also integrated and the
therapists were informed about the results of the implementation
study on a regular basis.
One of the supportive factors mentioned in the survey is the
positive media attention for ST. Following publication of the main
outcome study (2006), publicity was generated by informing
insurance companies, the ministry of Public Health, patient organizations, the press, and the Dutch health counsel about the positive results of ST. The goal was to expand the availability of ST as
a treatment of BPD.
Finally, there are some important factors beyond mental
healthcare institutes. In the first survey it was emphasized that ST
needed to be recognized in the Dutch reimbursement system.
Recently, ST has been recommended as one of the evidencebased treatments in the Dutch Guidelines on Personality Disorders
(2008), and insurance companies reimburse for treatment.
In the second survey, some obstacles for implementing ST were
noted, including telephone availability of the therapist beyond office
hours. The impact of telephone support was investigated in the
implementation study of Nadort et al. (2009), and the results of
the treatment with and without telephone support can be found
separately in this special issue on Implementation.
Some limitations existed in this study, however. The response
rate of the insurance companies was very low (20%), probably due
to the questionnaire being emailed to potential respondents.
Ideally, insurers would have received the questionnaire via mail,
followed by a personal interview.
Nevertheless, the 20% of insurers who responded did not have
a broad knowledge of schema therapy, which is disappointing. For
nationwide implementation it is recommended to offer insurance
companies detailed information about the (cost-) effectiveness of
schema therapy based upon the studies of Giesen-Bloo et al. (2006),
Van Asselt, Dirksen, Arntz, and Severens (2007, 2008) and the
preliminary results of the study completed by Nadort et al. (2009).
The competence task of therapists was another limitation of this
study. Therapists’ adherence and competence to the model were
assessed directly after the training, based upon three short video
segments. While showing a good sample of treatment, they were
not actual sessions, so the entire Therapy Adherence and Competence Scale could not be applied, possibly influencing the outcome.
Partly based on what we learned in our 2004 survey, we used
a broad dissemination and implementation strategy that produced
some clear successes. For instance, more than 1000 Dutch therapists were trained in ST. Many copies of the protocol book were
sold. The majority of post-graduate training programmes in
Psychotherapy and Clinical Psychology incorporated ST into their
programmes. Also a Dutch Registry was set-up with three levels of
ST therapists (junior, senior and supervisor) that can be found on
a website that was created to serve the public and to promote
exchange among therapists (www.schematherapie.nl (2005)).
From 2007 until 2009 the website had more than 28,000 unique
visitors. Additionally, schema therapy received a lot of positive
media attention. However, we did not assess to what degree ST was
actually implemented in regular practice, nor did we assess how
effectively such applications of ST for BPD were. Our implementation study (Nadort et al., 2009) demonstrated that the effectiveness
of an implemented ST treatment can be surprisingly high, but this
was assessed in the context of a scientific study, which may not
fully represent what therapists and institutes actually do in their
regular practice when applying ST. Further studies are needed to
assess this issue.
Finally, we want to emphasize the use of different elements in
the learning process of ST. Because the training program and series
of therapy techniques were all rated positively during the implementation study, we think these elements provide a sufficient basis
to learn ST. In addition, as discussed in the second survey, to achieve
successful implementation we strongly advise peer supervision and
supervision as important elements in the learning phase of ST.
It is recommended for future implementation studies to plan
these type of preparatory studies in order to achieve successful
implementation.
Funding/Support
This research was funded by Grant application Doelmatigheid/
deelprogramma Implementatie van ZonMw, aanvraagnummer
945-16-313, 2006.
Role of the sponsor
The sponsor played no role in the data collection and analysis,
manuscript preparation, or authorization for publication.
Acknowledgements
Acknowledgements: We wish to acknowledge Hannie van
Genderen en Remco van der Wijngaart for their contributions to the
training program. We would like to express our gratitude to Travis
Atkinson for his invaluable help in correcting the manuscript.
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