Results of a Multicenter Randomized Controlled Trial of the Clinical Effectiveness of Schema Therapy for Personality Disorders

Personality disorders are complex mental health problems associated with chronic dysfunction in several life domains (social, work, self-care) (1, 2), reduced quality of life (3), high societal costs (4), and a high prevalence rate (3%–15% in the general population) (5). Although psychological treatment is considered to be the treatment of choice for personality disorders (6, 7), research into its effectiveness is still in its infancy, troubled with methodological issues and strongly focused on borderline personality disorder. Studying the effectiveness of treatment for understudied personality disorders is a highly prioritized recommendation in several reviews (8–10).

Schema therapy is a form of psychotherapy that has proven to be efficacious for borderline personality disorder. A randomized controlled trial comparing schema therapy with transference-focused psychotherapy found dominance of schema therapy over transference-focused psychotherapy on all outcome measures and a significantly lower dropout rate in schema therapy (11). Schema therapy also proved to be a more cost-effective treatment (12). A subsequent study found that schema therapy can be successfully implemented in regular mental health care (13). Another study reported superiority of schema therapy over treatment as usual for borderline personality disorder (14). However, the effectiveness of schema therapy for personality disorders other than borderline personality disorder remains to be evaluated.

The main objective of the present randomized controlled trial was to examine the clinical effectiveness of schema therapy for a group of six personality disorders: cluster C (avoidant, dependent, and obsessive-compulsive), histrionic, narcissistic, and paranoid personality disorders. Other personality disorders were excluded because they were deemed to require highly specialized and lengthier treatment protocols. A treatment protocol of 50 schema therapy sessions was compared with treatment as usual, which is primarily psychological treatment in the Netherlands, varying from supportive low-frequency contacts to advanced psychotherapy. Because any novel specialized psychotherapy might be more effective than treatment as usual, we also wanted to compare treatment as usual with a specialized psychotherapy other than schema therapy. Therefore, we added clarification-oriented psychotherapy, a form of client-centered therapy developed for personality disorders (15). We hypothesized that schema therapy would be superior to treatment as usual in preventing treatment dropout and on primary and secondary outcome measures. We explored whether similar effects would be found for clarification-oriented psychotherapy. If both experimental conditions could be superior to treatment as usual, follow-up tests could compare schema therapy and clarification-oriented psychotherapy. Schema therapy therapists were trained in two cohorts with different educational formats, one mainly based on lectures and the other on structured experiential training of techniques. Training therapists in two cohorts at different time points was necessitated by the need for additional therapists during trial execution (since one center withdrew participation before the start of the study). Investigating the effects of therapist training on treatment outcome is an important, though neglected, topic (16, 17). Therefore, although initially not a research question, we tested schema therapy cohort differences and controlled condition effects for cohort.

Method

In this multicenter, pragmatic randomized controlled trial (parallel-group design), patients from 12 Dutch mental health institutes were enrolled (18), and three of the 12 centers had enough client-centered-therapists available to add clarification-oriented psychotherapy as a third arm (hence, comparisons involving clarification-oriented psychotherapy had a smaller sample size). Participants had at least one of the personality disorder diagnoses discussed above, based on the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID II [19]), as the principal diagnosis (diagnosis for which the patient seeks help). Additional inclusion criteria were availability to participate in the study and age 18 to 65. Exclusion criteria were the presence (also subthreshold) of antisocial, schizotypal, schizoid, or borderline personality disorder; lifetime prevalence of psychosis or bipolar disorder; IQ <80; and immediate suicide risk or substance abuse needing clinical detoxification. With 125 participants per arm, the study was powered at 90% to detect a schema therapy versus treatment as usual recovery difference of an odds ratio of 2.70 at an alpha of 0.05 (80% power to detect for clarification-oriented psychotherapy [N=50] versus treatment as usual) (18). An independent statistician generated computer-based lists using adaptive biased urn randomization for small strata (20). After checking the inclusion and exclusion criteria, an independent research assistant randomly assigned patients to two groups (schema therapy compared with treatment as usual with equal prior rates) per center in nine participating centers and to three groups (schema therapy compared with treatment as usual compared with clarification-oriented psychotherapy with equal prior rates) per center in three participating centers. Matching of patient to therapist was done through local schema therapy and clarification-oriented psychotherapy peer-supervision groups or by local staff in treatment as usual. A test battery including assessor-based and self-report instruments was administered at 6, 12, 18, 24, and 36 months. At 36 months (the 3-year follow-up), diagnostic interviews were repeated. Assessments were conducted by independent research assistants at local sites, except for 3-year follow-up diagnostic interviews that were conducted by central blinded interviewers. All patients provided written informed consent before participating in the study, and the study was approved by the medical ethical committee of Maastricht University.

The primary outcome measure was recovery from all personality disorders (defined as not meeting criteria for any personality disorder), as measured with SCID II by blinded independent interviewers at the 3-year follow-up. Data from 42 double-rated audiotaped interviews demonstrated good interrater reliability, with the mean intraclass correlation coefficient between interviewers being 0.84 (from 0.50 to 0.97 over subscales). Missing SCID II assessments were replaced by personality disorder diagnoses obtained from the most recent scores on the Assessment of DSM-IV Personality Disorders Questionnaire (21), using the categorical scoring algorithms (22). Assessor-based secondary measures were axis I mood and anxiety disorders (assessed with SCID I [23] by SCID II interviewers) and Global Assessment of Functioning Scale (24) and Social and Occupational Functioning Assessment Scale (24) scores, assessed by research assistants at regular assessments, who also monitored medication use. Self-report secondary measures included the Assessment of DSM-IV Personality Disorders Questionnaire dimensional subscales, the Symptom Checklist-90 (25) for general symptoms, the Work and Social Adjustment Scale (26) for social functioning, the Miskimins Self-Goal-Other Discrepancy Scale (27) for actual-ideal self-discrepancy, and the modified World Health Organization Quality of Life Assessment [28]).

Treatment, Therapists, and Treatment Integrity Check

Descriptions and comparisons of schema therapy and clarification-oriented psychotherapy are presented in Figure 1 and Table 1; our design for specific characteristics of treatment conditions has been described elsewhere (18). Schema therapy and clarification-oriented psychotherapy were both individual outpatient psychotherapies (initially) delivered weekly and included a standardized treatment protocol (15, 29). Schema therapy consisted of 40 sessions in the first year and 10 booster sessions in the second year, while clarification-oriented psychotherapy was open-ended. Therapists in both conditions received a 4-day training session at the start of the study, yearly national supervision, and weekly local peer supervision. Clarification-oriented psychotherapists were required to be accredited client-centered therapists or trainees, while any theoretical orientation was allowed for schema therapists. Therapists eventually included in the schema therapy arm were recruited through self-expressed interest to learn schema therapy. All other therapists could be treatment as usual therapists. In treatment as usual, local intake staff chose a specific treatment method and modality for a particular patient, depending on the patient’s capacity, needs, and circumstances. In this way, treatment as usual was optimized and mimicked usual practice. Treatment as usual did not include a standardized study protocol or training/supervision of therapists. Treatment as usual therapists had standard, local peer supervision. Therapists in this condition were expected to follow the clinical guidelines for personality disorders in the Netherlands. All primary treatment as usual was psychological treatment (insight-oriented psychotherapy, 42%; supportive therapy, 32%; cognitive-behavioral therapy, 19%; eye movement desensitization and reprocessing, 1.5%). For all three conditions, if the patients discontinued treatment or were referred again for treatment after treatment termination, another treatment was offered with a different therapist, if deemed necessary or helpful. Because of the naturalistic treatment flow of this trial, it was possible that patients could still receive treatment at the 3-year follow-up. Baseline demographic and clinical characteristics of patients and the treatments they received are presented in Table 2.

Sixty-four therapists treated one patient (schema therapy, N=13; treatment as usual, N=50; clarification-oriented psychotherapy, N=1), 55 treated two (schema therapy, N=32; treatment as usual, N=15; clarification-oriented psychotherapy, N=8), 32 treated three (schema therapy, N=17; treatment as usual, N=11; clarification-oriented psychotherapy, N=4), nine treated four (schema therapy, N=4; treatment as usual, N=2; clarification-oriented psychotherapy, N=3), and one treated five (treatment as usual). Training of schema therapy therapists occurred in two waves (referred to as cohorts) (18). Cohort 1 received mainly lectures and video demonstrations, while cohort 2 was trained by another trainer, actively participated in compulsory role-play, and received individual feedback (see the data supplement that accompanies the online version of this article). Cohort effects were incorporated in the analyses. All therapists had previous experience in psychological treatment (mean years: schema therapy, 16.05 years [SD=7.72]; treatment as usual, 16.10 years [SD=9.82]; clarification-oriented psychotherapy, 20.38 years [SD=8.58]), with no between-group differences. Therapists were asked to rate their experience with delivered treatment on a scale from 0 (none) to 5 (professional). As expected, treatment as usual therapists (4.12 [SD=1.43]) were more experienced than schema therapy (2.20 [SD=1.81]) and clarification-oriented psychotherapy (1.82 [SD=2.24]), p<0.001) therapists with regard to treatments delivered to study patients.

Treatment integrity (adherence to protocol) was monitored by means of supervision (see reference 18). Independent blinded raters scored randomly selected audiotapes on a series of 7-point Likert scales, indicating the amount of time specific therapeutic interventions were heard. In addition to specific schema therapy and clarification-oriented psychotherapy techniques, we assessed two general therapeutic styles, taken from the Collaborative Study Psychotherapy Rating Scale, version 6 (30): facilitative conditions (e.g., supportive encouragement, involvement) and explicit directiveness (e.g., level of verbal activity, explicit guidance). While 16.87% of audiotapes were missing or lost because of poor sound quality, the remaining audiotapes were rated by nine independent raters who were blind to allocation. The mean intraclass correlation coefficient across subscales of 78 double-rated audiotapes was 0.52, ranging from 0.33 (explicit directiveness) to 0.85 (schema therapy items). Results of 631 audiotapes are presented in Table 2. Condition-specific techniques were highest in schema therapy and clarification-oriented psychotherapy (p<0.001), respectively, although schema therapy also differed significantly from treatment as usual on clarification-oriented psychotherapy techniques. Therapists in the second-cohort schema therapy group scored significantly higher on schema therapy-specific techniques (p<0.05). The two general therapeutic styles were most prominent in schema therapy.

Statistical Analyses

A detailed description of statistical procedures is presented in the online data supplement. Results were analyzed according to the intent-to-treat principle using SPSS, version 19.0 (SPSS, Inc., Chicago), for logistic and linear mixed regression, with center as random effect. For repeated measures, unstructured covariance was used. Cohort and baseline severity were used as covariates (the latter in analyses of diagnostic outcomes unless indicated). Baseline severity index was a composite measure based on standardized baseline values of the number of axis I and II disorders, Assessment of DSM-IV Personality Disorders Questionnaire trait and distress scores, Symptom Checklist-90 score, Global Assessment of Functioning Scale score, Social and Occupational Functioning Assessment Scale score, and disability (internal consistency, 0.77). For the primary outcome, a series of sensitivity analyses was conducted. Dropout was analyzed with survival analysis controlling for severity and cohort, as well as with mixed logistic regression, using the same model used in the primary outcome analysis. Because estimation failed in mixed analyses of depressive and anxiety disorder presence at the 3-year follow-up (as a result of missing data), multiple imputation followed by logistic regression was used. For diagnostic outcomes, we report effects of all condition comparisons, schema therapy-by-cohort, and severity and sensitivity covariates when applicable. For repeated measures, we report effects of time, all condition comparisons of time effects, and (schema therapy compared with treatment as usual)-by-cohort-by-time as relevant to the research questions.

Results

Patient Accrual

The study was conducted between May 2006 and January 2011. The CONSORT diagram for the study is presented in Figure 2. A total of 624 patients were initially referred to the study, 285 of whom were excluded during the screening procedure. A total of 140 individuals did not meet diagnostic criteria; 108 met exclusion criteria (89 had a diagnosis or subthreshold diagnosis of borderline, antisocial, schizotypal, or schizoid personality disorder; 11 had lifetime psychotic disorder; four had lifetime bipolar disorder; two had an IQ <80; and two suffered from substance abuse needing detoxification); and 37 declined further participation (21 did not agree with the study procedure; seven did not show; six did not want to focus on personality; one had a life-threatening disease; one had insufficient availability; and one felt too miserable to participate). Another 16 patients dropped out before baseline assessment, and thus 323 patients were randomly assigned (schema therapy, N=147; treatment as usual, N=135; clarification-oriented psychotherapy, N=41). Despite extending the inclusion period originally allowed by the grant, inclusion at sites offering clarification-oriented psychotherapy progressed too slowly to achieve the intended 50, while in schema therapy and treatment as usual more than the planned minimal 125 were randomly assigned. Four patients in schema therapy and eight in treatment as usual did not start treatment (no single session).

The percentage of missing data ranged from 8.4% (at 6 months) to 24.6% (at 3 years; schema therapy, N=28; treatment as usual, N=44; clarification-oriented psychotherapy, N=7 [Figure 2]). The SCID assessments at follow-up took place apart from other assessments, with 35.9% missing data (schema therapy, N=43; treatment as usual, N=61; clarification-oriented psychotherapy, N=11). Three randomly assigned patients were excluded from analyses: one withdrew consent (treatment as usual), and two withdrew participation during the randomization procedure because of their decision to move (schema therapy). The trial ended when the scheduled closure date was reached (3 years after patients who were included last started treatment).

Thirty-eight patients in schema therapy (25.8%), 51 in treatment as usual (37.8%), and nine in clarification-oriented psychotherapy (22%) dropped out of indicated treatment (Figure 2, Figure 3). Survival analysis showed that patients in schema therapy had a significantly lower dropout risk than those in treatment as usual (Cox regression: β=−1.22, p=0.002; relative risk=0.30, 95% confidence interval [CI]=0.14–0.65), while a significant interaction between therapist cohort and condition revealed higher treatment retention in schema therapy compared with treatment as usual with the second-therapist cohort relative to the first (β=−1.72, p=0.03; relative risk=0.18, 95% CI=0.04–0.85). Comparing clarification-oriented psychotherapy and treatment as usual revealed a significant difference in favor of clarification-oriented psychotherapy with regard to dropout risk (β=−0.81, p=0.03; relative risk=0.45, 95% CI=0.21–0.93). Schema therapy and clarification-oriented psychotherapy did not significantly differ. Covariate severity was not significant. Mixed logistic regression revealed similar effects when controlling for baseline severity (Table 3). When not controlling for baseline severity, clarification-oriented psychotherapy lost its dominance in treatment retention over treatment as usual.

There was one serious adverse event reported: one patient in treatment as usual died, and postmortem analysis revealed that the patient may have committed suicide.

Treatment Outcomes

Primary outcome.

Results of primary outcome analyses are summarized in Table 3. Schema therapy was dominant over treatment as usual, with a significantly greater proportion of recovered patients in this group than in the treatment as usual group (Figure 4), while the significant condition-by-cohort interaction showed that recovery was relatively higher among those receiving schema therapy from second-cohort therapists. The comparison of treatment as usual with clarification-oriented psychotherapy revealed greater recovery in treatment as usual but did not reach statistical significance. The severity effect reflects less recovery among patients with worse baseline severity. Effects were replicated in all sensitivity analyses and also when recovery was controlled for assessment type (diagnoses based on SCID II compared with Assessment of DSM-IV Personality Disorders). Schema therapy outperformed clarification-oriented psychotherapy in the primary analysis and in all but two sensitivity analyses (recovery controlled for assessment type and recovery defined by absence of subthreshold personality disorder). Estimated recovery proportions and 95% confidence intervals by condition are presented in Table 3.

Secondary outcomes.

Results of mixed-regression analyses with estimated group differences and their effect sizes on secondary outcome measures are summarized in Table 4. On all outcome measures, the main time effect was significant, pointing at improvement during therapy (p<0.001). Global Assessment of Functioning Scale scores improved significantly more among patients in schema therapy than among those in treatment as usual (p<0.05), while no difference between schema therapy and clarification-oriented-psychotherapy was found. The time-by-condition-by-cohort interaction was significant, indicating a superior effect in the cohort with therapists who followed exercised-based training for schema therapy. Changes in Social and Occupational Functioning Assessment Scale scores revealed dominance of schema therapy over treatment as usual and clarification-oriented psychotherapy (p<0.03), while clarification-oriented psychotherapy and treatment as usual did not differ, and the three-way interaction was not significant. No significant effect involving condition or cohort was found on the Symptom Checklist-90, the Assessment of DSM-IV Personality Disorders Questionnaire, the Work and Social Adjustment Scale, the Miskimins Self-Goal-Other Discrepancy Scale, or the World Health Organization Quality of Life Assessment. The only exception was a significant time-by-condition-by-cohort effect on the Miskimins Self-Goal-Other Discrepancy Scale, indicating that patients receiving schema therapy from the second-cohort therapists achieved better results in reducing self-ideal discrepancy compared with patients in treatment as usual, whereas patients receiving schema therapy from first-cohort therapists did not (p=0.035). All within-condition effect sizes were large, ranging from 0.86 to 1.76 (Table 4). For depressive and anxiety disorders (measured assessor-based only at baseline and follow-up), multiple imputation-based logistic regression revealed a significant main effect of schema therapy on depressive disorder diagnoses, with an odds ratio of 0.23, reflecting lower risk of depressive disorder at follow-up in schema therapy. No condition differences regarding anxiety disorders were found.

Discussion

We compared the effectiveness of schema therapy and clarification-oriented psychotherapy with treatment as usual for cluster C, paranoid, histrionic, and narcissistic personality disorders. The primary analysis and all sensitivity analyses revealed consistently that schema therapy was superior to treatment as usual on primary outcome (greater recovery from personality disorder), as well as when recovery was defined more stringently, and when we controlled for assessment instrument. Patients receiving schema therapy showed greater improvement in scores on the Global Assessment of Functioning Scale and the Social and Occupational Functioning Assessment Scale and had lower depressive disorder rates at follow-up compared with patients in treatment as usual. The lower dropout rate in schema therapy suggests higher acceptability by patients. Patients receiving schema therapy showed greater improvement in recovery from personality disorders and in scores on the Social and Occupational Assessment Scale than patients receiving clarification-oriented psychotherapy, but schema therapy patients did not show a significant difference in dropout rate or in scores on the Global Assessment of Functioning Scale. Clarification-oriented psychotherapy did not outperform treatment as usual on any measure, countering the argument that any experimental treatment achieves better results than treatment as usual. On other secondary measures assessing anxiety disorders, general pathology, personality disorder traits, social functioning, quality of life, and self-ideal discrepancy, improvement over time occurred in all conditions, with large effect sizes. However, no between-condition differences emerged. The number of patients still in treatment after 3 years was lowest in the schema therapy group (13% compared with 26% in treatment as usual and 36.6% in clarification-oriented psychotherapy), pointing to the ability of schema therapy to achieve at least comparable results in less time. The type of schema therapy training among therapists influenced dropout, recovery, global functioning, and self-ideal discrepancy, with exercise-based training attaining superior effects. In trying to detect specific elements that may account for schema therapy superiority, several aspects can be mentioned. First, an adjacent qualitative study assessing patient and therapist perspectives on schema therapy (N. De Klerk et al., unpublished 2013 data) revealed that working with the mode model was highly appreciated by patients and therapists, since it guided therapists in choosing adequate techniques and helped patients to better understand their own behaviors and feelings. Schema therapy may also be highly effective because multiple channels are addressed to achieve structural personality change by using experiential, behavioral, cognitive, and interpersonal techniques. Experiential techniques have been experienced as very helpful by patients and therapists (M.C. Ten Napel-Schutz et al., unpublished 2013 data). Unlike most other treatments for personality disorders, schema therapy involves extensive processing of traumatic and other aversive childhood experiences, core factors in the development of personality disorders, which may be another reason for its effectiveness.

Since the present study was aimed to be an effectiveness trial, rather than an efficacy trial, many aspects resembled clinical reality (e.g., no preselection of therapists, no optimal training, no detailed treatment manual, no supervised pilot treatment before starting the study, and no intensive central supervision during the trial). Staying close to daily practice, our approach enhances the generalizability of our findings and yields a valid indication for effects of schema therapy implementation. Other strengths include a large sample size, multicenter design, long-term duration of the study, broad range of outcomes, intention-to-treat analyses, and an extensive integrity check with good results. Schema therapy and clarification-oriented psychotherapy share some conceptual overlap, but the techniques differ substantially, which was confirmed by our integrity check. Major differences include 1) the higher directiveness of schema therapy, which includes content (e.g., psychoeducation); 2) the therapeutic relationship, in which schema therapists attempt to meet the unmet childhood needs of patients; 3) extensive processing of childhood trauma; and 4) behavioral pattern breaking. Some limitations of this study also should be mentioned. Comparing experimental treatments with treatment as usual inherently means impossibility to control for factors such as session frequency and treatment dosage. Because treatment as usual therapists received no central training and supervision, there may have been between-group differences in treatment/study commitment. On the other hand, therapists in the schema therapy and clarification-oriented psychotherapy groups were less experienced in their methods and reported uncertainty. Strong conclusions about the three noncluster C personality disorders cannot be made because of the limited numbers of patients with these disorders. Conditions differed in the proportions of patients with substance abuse disorders, but given the low numbers of these patients, we could not control for this statistically. Another limitation is with regard to the fact that some intraclass correlation coefficients of scales assessing treatment integrity were only modest. Additionally, the fact that patients in the treatment as usual condition received a much lower number of sessions on average but completed treatment less often complicated simple interpretation of the results. Lastly, the clarification-oriented psychotherapy sample size limited power to detect clarification-oriented psychotherapy-treatment as usual differences, although no indications of superiority of clarification-oriented psychotherapy over treatment as usual were found, except perhaps with regard to dropout and depressive disorder.

Comparing results with previous studies, our findings resemble those of previous randomized controlled trials that demonstrated more recovery and less dropout with schema therapy among individuals with borderline personality disorder (11, 13, 14), while our effect sizes are in the same range as those found in previous research on schema therapy techniques for personality disorders (31). What is different is the fact that our study does not demonstrate overall supremacy of schema therapy (i.e., schema therapy did not excel on self-reported measures). The discrepancy in results obtained with self-reports compared with assessor-based instruments is remarkable but not without precedent. Other studies have found such differences (e.g., personality disorders [33] and mood disorders [34]). There are indications that interviews more validly assess objectifiable symptom manifestations and self-reports better capture symptom experience (35), while the discrepancy between these kinds of measures is related to personality characteristics, such as neuroticism (34). Especially in personality disorders, in which symptoms are ego-syntonic, other measures may better and more rapidly detect objective changes than the patients themselves, since it might take more time to change one’s self-representation than to change primary cognitions, feelings, behaviors, and impulse regulation. For example, the self-definition and thus self-report as a mature person may lag behind the new mature behavior that is observable by others. It may therefore be concluded that schema therapy is especially effective in the objectifiable domain of psychopathology manifestations, at least in the time scale of our study.

The finding that positive schema therapy effects on assessor-based instruments emerged with different interviewers for the SCID assessments, the Global Assessment of Functioning Scale, and the Social and Occupational Functioning Assessment Scale enlarges the validity of the study results. In addition, the schema therapy compared with treatment as usual contrast may have been limited by individual optimization of treatment as usual. Instead of low-intensive maintenance care these patients usually receive (36), psychotherapy was dominant in treatment as usual and was akin to what is also labeled as community treatment by experts (37).

Despite large effect sizes, we believe that there is room for improvement of schema therapy. First, further elaboration of the schema therapy protocol with techniques fine-tuned for specific personality disorders and the possibility to increase treatment duration when necessary might increase effects. Second, therapists reported the reluctance to undergo personality changing treatment among some patients as related to rigidity and motivational problems. Future studies should assess this formally. We advise assessing “readiness” for change and presence of autism-related disorders (since these often co-occur with personality disorder [38] and may indicate inability to change). A motivational module may prepare patients better. Third, as indicated in previous research, effectiveness might increase when therapists become more experienced (31). Fourth, training method influences outcome. Our adjacent qualitative study revealed that therapists who followed the exercise-based training felt better equipped to integrate all methods and techniques and to apply them in practice than those who followed the lecture-based training. Thus, exercise-based training using experiential learning (e.g., role-playing to exercise specific techniques with immediate feedback) may increase effects.

In conclusion, this trial found large improvements in time in all treatment conditions, with superior recovery from personality disorder and depressive disorder, better general and social functioning, and less dropout in schema therapy. Thus, with our study, we enlarge evidence-based support for schema therapy as a valuable treatment for personality disorders. We also found that how therapists are trained in a new method influences clinical effectiveness. The results point toward the possibility of schema therapy being not only clinically effective but also cost effective. Because the latter is an important additional aspect in evaluating new treatments, this is the topic of a separate article on the economic evaluation of the present trial.