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Well-being in Psychotherapy for Individuals with Personality Disorders

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Chakhssi, F., Schaap, G.M., Bohlmeijer, E.T., & Westerhof, G.J. (2017,  May). Well-being in psychotherapy for individuals with personality disorders  [Web article]. Retrieved from:

Individuals with personality disorders (PDs) are a heterogeneous group with complex presentations that are characterized by significant distress and/or functional impairment. Whereas the traditional aim of psychotherapy for PDs is to alleviate psychopathology, well-being has been gaining increasing attention in psychotherapy. In addition to alleviating distress, enhancing well-being may improve treatment outcome, studies suggest. In this piece, we argue that the treatment of patients with PDs may benefit from explicitly encompassing well-being as an outcome in therapy.

Traditionally, influenced by the medical model, clinical psychology has not been primarily concerned with the promotion of well‐being but with the alleviation of symptoms. However, studies suggest that well-being and psychopathology are two moderately correlated but separate constructs (e.g., Westerhof & Keyes, 2010). An important implication of this relationship is that the treatment of symptoms does not necessarily result in improved well-being (Trompetter et al., 2017). Thus, a persistently low level of well-being can remain even after a successful treatment of symptoms. However, low levels of well‐being form a substantial risk for psychological distress, including relapse or recurrence of symptoms (Lamers et al., 2015; Wood & Joseph, 2010).

Although well-being can be defined in several ways, empirical examination suggests that well-being can be divided into emotional well-being, psychological well-being and social well-being (Keyes, 2005). As measured with the Mental Health Continuum-Short Form developed by Keyes (2002; Lamers et al., 2011), well-being consists of experiencing happiness, personal growth, and societal involvement. The questionnaire consists of 14 questions that assess aspects of emotional, psychological and social well-being in order to classify respondents’ mental health as flourishing (high well-being), languishing (low well-being), or moderate (neither flourishing nor languishing). Based on the notion that well-being and psychopathology are separate constructs, mental health can thus be defined as a combination of flourishing and adequate coping with/or absence of a disorder.

Recently, our group synthesized the current evidence on psychotherapeutic interventions that specifically aim to improve well-being, and we found that these interventions have significant effects not only on well-being but also on depression, anxiety and stress in clinical samples with various psychiatric disorders (Chakhssi et al., 2017). In the treatment of individuals with personality disorders, who are marked with persistent and prolonged impairment in interpersonal and social functioning, well-being, itself, can be an important outcome category. One such psychotherapeutic model that aims to improve both well-being and psychopathology in patients with PDs is schema therapy (Young et al., 2003). Although there are several other psychotherapeutic models for PDs that aim to improve well-being, such as compassion-focused therapy (Gilbert, 2010) and dialectical behavior therapy (Linehan, 1993), our focus here is on schema therapy, as we recently published a study on schema therapy outcomes of patients with PDs (Schaap et al., 2016).

Schema therapy aims to enhance and strengthen the positive aspect of the self, as well as reduce those aspects which are negative. Two positive aspects are central within the schema therapy model: the Healthy Adult and the Happy Child modes. The Healthy Adult mode represents healthy and balanced ways of living, including working, parenting, and taking responsibility. Healthy Adults pursue activities that they enjoy, such as cultural, aesthetical, and intellectual interests. This mode also includes looking after one’s own physical health. The Happy Child mode represents the capacity to experience and express playful happiness and a situation in which the core emotional needs are adequately met. This focus on positive aspects, combined with a focus on reducing the impact of negative aspects, is in line with the notion that well-being and psychopathology are two separate constructs.

In our study (Schaap et al., 2016), we found evidence, albeit tentative, that schema therapy improved well-being, as measured with the Mental Health Continuum-Short Form, in patients with PDs after inpatient schema therapy. This is in line with earlier findings from a pilot study that showed an increase in happiness in outpatients with borderline PDs after schema therapy (Dickhout & Arntz, 2014). While these results suggest that addressing well-being itself during psychotherapy shows promise, more systematical investigations and interventions of well-being in the treatment of PDs are necessary.


Individuals with PDs are characterized by significant distress and/or functional impairment. Besides alleviating their distress, enhancing well-being may be an appropriate goal itself in psychotherapy for these individuals. Although there are psychotherapy models that address both the positive as well as the negative aspects of the self, we need to further our understanding of the role of well-being in the treatment of personality disorders. A promising start would be to systematically implement additional measures of well-being in psychotherapy evaluations.

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Chakhssi, F, Kraiß, J. T., Spijkerman, M., & Bohlmeijer, E. T. (2017). The effect of positive psychology interventions on well-being in clinical populations: A systematic review and meta-analysis. Under review.

Dickhaut, V., & Arntz, A. (2014). Combined group and individual schema therapy for borderline personality disorder: a pilot study. Journal of Behavior Therapy and Experimental Psychiatry, 45, 242-251.

Gilbert, P. (2010). Compassion focused therapy: Distinctive features. London: Routledge

Keyes, C. L. (2005). Mental illness and/or mental health? Investigating axioms of the complete state model of health. Journal of Consulting and Clinical Psychology, 73, 539.

Keyes, C. L. (2002). The mental health continuum: From languishing to flourishing in life. Journal of Health and Social Behavior, 43, 207-222.

Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford press.

Lamers, S. M. A., Westerhof, G. J., Bohlmeijer, E. T., ten Klooster, P. M., & Keyes, C. L. (2011). Evaluating the psychometric properties of the mental health continuum‐short form (MHC‐SF). Journal of Clinical Psychology, 67, 99-110.

Lamers, S. M. A., Westerhof, G. J., Glas, C. A. W., & Bohlmeijer, E. T. (2015). The bidirectional relation between positive mental health and psychopathology in a longitudinal representative panel study. The Journal of Positive Psychology, 10, 553-560.

Schaap, G. M., Chakhssi, F., & Westerhof, G. J. (2016). Inpatient schema therapy for nonresponsive patients with personality pathology: Changes in symptomatic distress, schemas, schema modes, coping styles, experienced parenting styles, and mental well-being. Psychotherapy, 53, 402-412.

Trompetter, H. R., Lamers, S. M. A., Westerhof, G. J., Fledderus, M., & Bohlmeijer, E. T. (2017). Both positive mental health and psychopathology should be monitored in psychotherapy: Confirmation for the dual-factor model in acceptance and commitment therapy. Behaviour research and therapy, 91, 58-63.

Westerhof, G. J., & Keyes, C. L. (2010). Mental illness and mental health: The two continua model across the lifespan. Journal of Adult Development, 17, 110-119.

Wood, A. M., & Joseph, S. (2010). The absence of positive psychological (eudemonic) well-being as a risk factor for depression: A ten year cohort study. Journal of affective disorders, 122, 213-217.

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner's guide. New York: Guilford Press.

Farid Chakhssi, PhD is affiliated with Scelta, GGNet, Apeldoorn, the Netherlands / The Centre for eHealth and Well-being Research, Department of Psychology, Health, and Technology, University of Twente, the Netherlands.

Grietje M. Schaap, MSc is affiliated with Mediant, Enschede, the Netherlands.

Professor Ernst T. Bohlmeijer is affiliated with the Centre for eHealth and Well-being Research, Department of Psychology, Health, and Technology, University of Twente, the Netherlands.

Professor Gerben J. Westerhof is affiliated with the Centre for eHealth and Well-being Research, Department of Psychology, Health, and Technology, University of Twente, the Netherlands.

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