Skip to main content

Schema Therapy for Personality Disorders: a Qualitative Study of Patients’ and Therapists’ Perspectives

  • Noor de Klerk (a1), Tineke A. Abma (a2), Lotte L.M. Bamelis (a3) and Arnoud Arntz (a4)

Background: Several studies have evaluated the (cost) effectiveness of schema therapy for personality disorders, but little research has been done on the perspectives of patients and therapists. Aim: The present study aims to explore patients’ and therapists’ perspectives on schema therapy. Method: Qualitative data were collected through in-depth semi-structured interviews with 15 patients and a focus group of 8 therapists. A thematic analysis was performed. Results: Most patients and therapists agreed that helpful aspects in schema therapy were the highly committed therapeutic relationship, the transparent and clear theoretical model, and the specific schema therapy techniques. About unhelpful aspects, several patients and some therapists shared the opinion that 50 sessions was not enough. Furthermore, patients lacked clear advance information about the possibility that they might temporarily experience stronger emotions during therapy and the possibility of having telephone contact outside session hours. They missed practical goals in the later stage of therapy. With regard to imagery, patients experienced time pressure and they missed a proper link between the past and the present. For therapists, it was hard to manage the therapeutic relation, to get used to a new kind of therapy and to keep the treatment focused on personality problems. Conclusions: Patients and therapists found some aspects of the schema therapy protocol helpful. Their views about which aspects are unhelpful and their recommendations need to be taken into consideration when adjusting the protocol and implementing schema therapy.

Corresponding author
Correspondence to Noor de Klerk, NPI Specialist in Personality Pathology, Amsterdam, the Netherlands. E-mail:
Hide All
Abma, T. A., Nierse, C. J. and Widdershoven, G. A. M. (2009). Patients as partners in responsive research: methodological notions for collaborations in mixed research teams. Qualitative Health Research, 19, 4014015. doi:10.1177/1049732309331869
Arntz, A. (2011). Imagery rescripting for personality disorders. Cognitive and Behavioral Practice, 18, 466481. doi:10.1016/j.cbpra.2011.04.006
Arntz, A. (2012). Schema therapy for cluster C personality disorders. In van Vreeswijk, M., Broersen, J. and Nadort, M. (Eds.), The Wiley-Blackwell Handbook of Schema Therapy: theory, research and practice (pp. 397414). Chichester: Wiley- Blackwell.
Bamelis, L. L. M., Evers, S. M. A. A. and Arntz, A. (2012). Design of a multicentered randomized controlled trial on the clinical and cost effectiveness of schema therapy for personality disorders. BMC Public Health, 12, 75. doi:10.1186/1471-2458-12-75
Bamelis, L. L. M., Evers, S. M. A. A., Spinhoven, P. and Arntz, A. (2014). Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. The American Journal of Psychiatry, 171, 305322. doi:10.1176/appi.ajp.2013.12040518
Bamelis, L. L. M., Arntz, A., Wetzelaer, P., Verdoorn, R. and Evers, S. M. A. A. (2015). Economic evaluation of schema therapy and clarification-oriented psychotherapy for personality disorders: a multicenter, randomized controlled trial. Journal of Clinical Psychiatry, 76, e1432e1440. doi: 10.4088/JCP.14m09412
Barbour, R. (2001). Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? British Medical Journal, 322, 11151117. doi: 10.1136/bmj.322.7294.1115
Braun, V. and Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77101. doi:10.1191/1478088706qp063oa
Dickhaut, V. and Arntz, A. (2014). Combined group and individual schema therapy for borderline personality disorder: a pilot study. Journal of Behavior Therapy and Experimental Psychiatry, 45, 242251. doi:10.1016/j.jbtep.2013.11.004
Farrell, J. M., Shaw, I. A. and Webber, M. A. (2009). A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder: a randomized controlled trial. Journal of Behavior Therapy and Experimental Psychiatry, 40, 317328. doi:10.1016/j.jbtep.2009.01.002
Giesen- Bloo, J., van Dyck, R., Spinhoven, P., van Tilburg, W., Dirksen, C., van Asselt, T., et al. (2006). Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Archives of General Psychiatry, 63, 649658. doi:10.1001/archpsyc.63.6.649
Green, J. and Thorogood, N. (2004). Qualitative Methods for Health Research. London: Sage.
Gude, T. and Hoffart, A. (2008). Change in interpersonal problems after cognitive agoraphobia and schema-focused therapy versus psychodynamic treatment as usual of inpatients with agoraphobia and cluster C personality disorders: health and disability. Scandinavian Journal of Psychology, 49, 195199. doi:10.1111/j.1467-9450.2008.00629.x
Gude, T., Monsen, J. T. and Hoffart, A. (2001). Schemas, affect consciousness, and cluster C personality pathology: a prospective one-year follow-up study of patients in a schema-focused short-term treatment program. Psychotherapy Research, 11, 8598. doi:10.1093/ptr/11.1.85
Guest, G., Bunce, A. and Johnson, L. (2012). How many interviews are enough? An experiment with data saturation and variability. Field Methods, 18, 5982. doi:10.1177/1525822X05279903
Katsakou, C., Marougka, S., Barnicot, K., Savill, M., White, H., Lockwood, K., et al. (2012). Recovery in borderline personality disorder (BPD): a qualitative study of services users’ perspectives. PLoS ONE, 7, e36517. doi:10.1371/journal.pone.0036517
Kuper, A., Lingard, L. and Levinson, W. (2008). Critically appraising qualitative research. British Medical Journal, 337, 687692. doi:10.1136/bmj.a1035
Morgan, D.L. (1996). Focus groups. Annual Review Sociology, 22, 129152. doi:10.1146/annurev.soc.22.1.129
Nadort, M., Arntz, A., Smit, J. H., Giesen- Bloo, J., Eikelenboom, M., Spinhoven, P., et al. (2009). Implementation of outpatient schema therapy for borderline personality disorder with versus without crisis support by the therapist outside office hours: a randomized trial. Behaviour Research and Therapy, 47, 961973. doi:10.1016/j.brat.2009.07.013
Nordahl, H. M., Holthe, H. and Haugum, J. A. (2005). Early maladaptive schemas in patients with or without personality disorders: does schema modification predict symptomatic relief? Clinical Psychology and Psychotherapy, 12, 142149. doi:10.1002/cpp.430
Pope, C., Ziebland, S. and Mays, N. (2000). Qualitative research in health care: analysing qualitative data. British Medical Journal, 320, 114116. doi:10.1136/bmj.320.7227.114
Renner, F., Van Goor, M., Huibers, M., Arntz, A., Butz, B. and Bernstein, D. (2013). Short-term group schema cognitive-behavioral therapy for young adults with personality disorders and personality disorder features: associations with changes in symptomatic distress, schemas, schema modes and coping styles. Behaviour Research and Therapy, 51, 487492. doi:10.1016/j.brat.2013.05.011
Sholomskas, D. E., Syracuse-Siewert, G., Rounsaville, B. J., Ball, S. A., Nuro, K. F. and Carroll, K. M. (2005). We don't train in vain: a dissemination trial of three strategies of training clinicians in cognitive-behavioral therapy. Journal of Consulting and Clinical Psychology, 73, 106115. doi:10.1037/0022-006X.73.1.106
Skewes, S. A., Samson, R.A., Simpson, S.G. and van Vreeswijk, M. (2015). Short-term group schema therapy for mixed personality disorders: a pilot study. Frontiers in Psychology, 22, 1592. doi:10.3389/fpsyg.2014.01592
Spinhoven, P., Giesen-Bloo, J. H., van Dyck, R., Kooiman, K. and Arntz, A. (2007). The therapeutic alliance in schema-focused therapy and transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 75, 104115. doi:10.1037/0022-006X.75.1.104
Stake, R. (2004). Standards-based and Responsive Evaluation. London: Sage.
Stein, D. M. and Lambert, M. J. (1995). Graduate training in psychotherapy: are therapy outcomes enhanced? Journal of Consulting and Clinical Psychology, 63, 182196. doi: 10.1037/0022-006X.63.2.182
Ten Napel-Schutz, M. C., Abma, T. A., Bamelis, L. and Arntz, A. (2011). Personality disorder patients’ perspectives on the introduction of imagery within schema therapy: a qualitative study of patients’ experiences. Cognitive and Behavioral Practice, 18, 482490. doi:10.1016/j.cbpra.2011.04.005
Tong, A., Sainsbury, P. and Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal of Quality in Health Care, 19, 349357. doi:10.1093/intqhc/mzm042
Van Asselt, A.D.I., Dirksen, C.D., Arntz, A., Giesen- Bloo, J.H., van Dyck, R., Spinhoven, P., et al. (2008). Outpatient psychotherapy for borderline personality disorder: cost-effectiveness of schema-focused therapy versus transference focused psychotherapy. British Journal of Psychiatry, 192, 450457. doi:10.1192/bjp.bp.106.033597
Weertman, A. and Arntz, A. (2007). Effectiveness of treatment of childhood memories in cognitive therapy for personality disorders: a controlled study contrasting methods focusing on the present and methods focusing on childhood memories. Behaviour Research and Therapy, 45, 21332143. doi:10.1016/j.brat.2007.02.013
Wetzelaer, P., Farrell, J., Evers, S.M.A.A., Jacob, G., Lee, C.W., Brand, O., et al. (2014). Design of an international multicentre RCT on group schema therapy for borderline personality disorder. BMC Psychiatry. 14, 319. doi:10.1186/s12888-014-0319-3
Young, J. E., Klosko, J. S. and Weishaar, M.E. (2003). Schema Therapy: a practitioner's guide. New York: Guilford Press.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Behavioural and Cognitive Psychotherapy
  • ISSN: 1352-4658
  • EISSN: 1469-1833
  • URL: /core/journals/behavioural-and-cognitive-psychotherapy
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed