Addressing the punitive parent mode in schema therapy for borderline personality disorder: Short-term effects of the empty chair technique as compared to cognitive challenging

The Subjective Experience of the Punitive Parent Mode in Individuals With Borderline Personality Disorder Following Schema Therapy: A Qualitative Study

Borderline personality disorder (BPD) is often characterized by self-critical and punitive thoughts, emotions, beliefs and behaviours, conceptualized in schema therapy (ST) as the punitive parent mode (PPM). This mode involves internalized punitive messages from childhood from the behaviour and reactions of significant others, leading to self-hatred, guilt and self-denial. Although patients with BPD frequently report auditory verbal hallucinations (AVHs) as manifestations of the PPM, this phenomenon is often overlooked in ST studies. We conducted semistructured interviews with 16 (ex)patients (63% female) from two Dutch mental health institutions to explore their experiences with the PPM before, during and after ST. An independent, double-coded systematic content analysis was performed. Approximately half of the participants reported AVHs linked to the PPM before therapy. The patients characterized the PPM by pervasive self-critical messages, contributing to intense emotional and physical distress and maladaptive coping strategies. Participants reported that ST techniques, including group therapy, imagery rescripting (ImRs) and the empty chair technique (ECT), effectively reduced the power and credibility of the PPM, including AVHs. The self-reported improvements included more adaptive coping mechanisms, increased social support and a general experience of reduced PPM. This study highlights the prevalence of the PPM as AVHs in individuals with BPD and demonstrates the efficacy of ST in reducing the impact of PPM, including in cases involving AVHs. Clinical implications include the need for relapse prevention plans and further exploration into how ST's effects can be enhanced. Future research should explore the broader spectrum of psychotic experiences in BPD and consider integrating PPM-related AVHs into the assessment and treatment of BPD.

A person-centered, transdiagnostic schema and mode profile approach to predict outcome in time-limited schema group therapy

OBJECTIVE

This study employs a person-centered transdiagnostic approach to examine how schema and mode profiles predict symptom severity reduction in schema group therapy for patients with personality disorders and enduring clinical syndromes.

METHOD

We analyzed symptom reduction in 248 patients across three formats of manualized, time-limited schema group therapy. Latent profile analysis and mixed multilevel modeling were used to determine the extent to which schema/mode classes predict symptom reduction, and whether the inclusion of individual schemas and modes enhances these predictions.

RESULTS

No significant differences in treatment outcomes were found across the group modalities. A three latent profile solution for schemas and modes showed external validity with clinical variables and demonstrated that declines in symptom severity varied by schema and mode class, even after adjusting for baseline symptom severity. Adding the Vulnerability to Harm schema and Vulnerable Child mode to the model increased the explained variance.

CONCLUSION

Patients with more severe personality problems show more substantial symptom reduction. Both schema and mode profiles significantly contribute to predicting post-treatment symptom levels. Understanding these profiles may help therapists tailor interventions more effectively, consistent with Young's theoretical model.Trial registration: ISRCTN.org identifier: ISRCTN17262253.

Addressing self-criticism in depression using CBT-based emotion-focused chairwork: study protocol of a randomised controlled trial

INTRODUCTION

Self-criticism is a key feature in people diagnosed with depression, resulting in significant psychological distress. Despite the fact that cognitive-behavioural treatments are readily available, a significant number of patients report experiencing cognitive, but not emotional, change following therapy, resulting in the maintenance of psychological symptoms. Additionally, interventions targeting emotional experiencing, such as chairwork, are generally implemented within large-scale therapeutic treatments. Therefore, within the present study, we aim to evaluate the efficacy and safety of a short intervention using emotion-focused chairwork to target self-criticism in patients diagnosed with depression.

METHODS AND ANALYSIS

The study is designed as a randomised controlled trial with two parallel arms. 62 patients diagnosed with depression will be randomised to the intervention group or the waiting-list control group receiving treatment as usual. The intervention comprises of three treatment sessions using the chairwork technique over the course of 3 weeks. Outcome assessments will take place 1 week before the first treatment session, as well as 1 week and 3 months after the last treatment session. The primary outcomes are self-criticism and self-compassion. Secondary outcomes assess depressive symptoms, emotion regulation and overall self-esteem. Statistical analysis will be performed using intention-to-treat analysis, as well as per-protocol analysis implementing linear-mixed models.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the State Chamber of Physicians in Baden-Wuerttemberg, Germany (approval number: F-2023-12). Scientific findings shall be published in peer-reviewed journals to inform prospective clinical studies focusing on the implementation of chairwork within clinical practice.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register (DRKS00031307; https://drks.de/search/de/trial/DRKS00031307).