Treating the the Untreatable Untreatable: : Treating Schema - - PowerPoint PPT Presentation

Treating Treating the the Untreatable Untreatable: : Schema Schema Therapy Therapy for for Psychopaths Psychopaths and and Other Other Forensic Forensic Personality Personality Disorder Disorder Patients Patients

David P. David P. Bernstein Bernstein, , Ph.D Ph.D. .

Department Department of

• f Clinical

Clinical Psychological Psychological Science Science, , Maastricht Maastricht University University Forensic Forensic Psychiatric Psychiatric Center Center ‘ ‘de de Rooyse Rooyse Wissel Wissel’ ’ Expertise Center Expertise Center for for Forensic Forensic Psychiatry Psychiatry

Dank u wel! Dank u wel!

Forensic Psychiatric Centers de Forensic Psychiatric Centers de Rooyse Rooyse Wissel Wissel, van , van der der Hoeven Hoeven, , Oostvaarders Oostvaarders, , Kijvelanden Kijvelanden, , Veldzicht Veldzicht, , Mesdag Mesdag, , and FPK and FPK Assen Assen The Netherlands Ministry of Justice The Netherlands Ministry of Justice Expertise Centrum Expertise Centrum Forensische Forensische Psychiatrie Psychiatrie Wetenschappelijk Onderzoek en Documentatiecentrum Wetenschappelijk Onderzoek en Documentatiecentrum Faculty of Psychology and Neuroscience, Maastricht Faculty of Psychology and Neuroscience, Maastricht University University And the And the many many patients patients, , therapists therapists, , researchers researchers, and , and

• ther
• ther clinical

clinical and and administrative administrative personnel personnel that that are are participating participating in in this this project! project!

Emotionless Emotionless Psychopaths Psychopaths? ?

One One psychopathic psychopathic patient patient broke broke down down crying crying at a at a memorial memorial patient patient for for fellow fellow patients patients that that had had died died

• f AIDS.
• f AIDS. On

On another another occasion,

• ccasion, he

he confessed confessed that that he he couldn couldn’ ’t t sleep at sleep at night night because because he he worried worried that that his his mother mother might might be be killed killed by by drug drug dealers dealers that that were were after after him him. . A A psychopathic psychopathic patient patient who who was was convicted convicted of

• f

rape rape became became overwhelmed

• verwhelmed by

by anxiety anxiety in a in a therapy therapy session

• session. He

. He said said that that he he now now realized realized how how terrified terrified he he was of was of women

• women. He had

. He had previously previously had had problems problems with with sexual sexual performance. performance.

Psychopathy Psychopathy: Predominant Views : Predominant Views

Psychopathy Psychopathy is is based based on

• n heritable

heritable callous callous unemotional unemotional traits traits

– – Highly Highly heritable heritable in in childhood childhood ( (Viding Viding et al., 2005) et al., 2005) – – Deficits in the Deficits in the recognition recognition of

• f fear

fear and and sadness sadness (Blair (Blair et al., 2001, 2005) et al., 2001, 2005) – – Reduced Reduced amygdala amygdala response ( response (Marsh Marsh et al., 2008). et al., 2008).

Psychopaths Psychopaths are are untreatable untreatable; ; therapy therapy makes makes them them worse worse

– – Little Little empirical empirical support support for for this this view ( view (D D’ ’Silva Silva et al., et al., 2004, 2004, Salekin Salekin, 2002). , 2002).

Schema Therapy (ST) Schema Therapy (ST)

An integrative form of psychotherapy combining An integrative form of psychotherapy combining cognitive, behavioral, psychodynamic object cognitive, behavioral, psychodynamic object relations, and humanistic/existential approaches relations, and humanistic/existential approaches (Young, (Young, Klosko Klosko, & , & Weishaar Weishaar, 2003). , 2003). Developed as a treatment for personality disorder Developed as a treatment for personality disorder patients and other longstanding problems. patients and other longstanding problems. Focus on modifying Early Maladaptive Schemas, Focus on modifying Early Maladaptive Schemas, Maladaptive Coping Responses, and Schema Maladaptive Coping Responses, and Schema Modes. Modes. A moderate A moderate-

• to long

to long-

• term form of psychotherapy.

term form of psychotherapy. Good Good evidence evidence of

• f effectiveness

effectiveness in ( in (non non-

• forensic

forensic) )

• utpatients
• utpatients with

with Borderline Borderline PD ( PD (Farrell Farrell et al., 2009; et al., 2009; Giesen Giesen-

• Bloo

Bloo et al., 2006; Nadort et al., 2009). et al., 2006; Nadort et al., 2009).

Schema Modes: Definition Schema Modes: Definition

An emotional state or An emotional state or “ “part of the self part of the self” ” that that temporarily dominates a person temporarily dominates a person’ ’s thoughts, s thoughts, feelings, and behavior feelings, and behavior Schemas = traits, modes = states Schemas = traits, modes = states Modes combine Early Maladaptive Schemas Modes combine Early Maladaptive Schemas and maladaptive coping responses and maladaptive coping responses In severe personality disorders, Schema Modes In severe personality disorders, Schema Modes are largely dissociated from one another are largely dissociated from one another Schema Mode Schema Mode “ “flipping flipping” ” or switching

• r switching

Schema Mode Model for Antisocial Personality Schema Mode Model for Antisocial Personality Disorder Disorder and and Psychopathy Psychopathy

Child Modes: Child Modes: Vulnerable Child (Abandoned, Abused, Humiliated) Vulnerable Child (Abandoned, Abused, Humiliated) Angry Child Angry Child Impulsive Child Impulsive Child Lonely Child Lonely Child Avoidant Modes: Avoidant Modes: Detached Protector Detached Protector Detached Self Detached Self-

• Soother/Self

Soother/Self-

• Stimulator

Stimulator Angry Protector Angry Protector Over Over-

• Compensator Modes:

Compensator Modes: Self Self-

• Aggrandizer

Aggrandizer Bully and Attack Bully and Attack Paranoid Over Paranoid Over-

• controller

controller Conning/Manipulator Conning/Manipulator Predator Predator

Adapted from Bernstein, Arntz, & de Vos, 2007

SFT Treatment Methods SFT Treatment Methods

Cognitive techniques Cognitive techniques – – restructures restructures cognitions cognitions Experiential techniques (e.g., guided imagery Experiential techniques (e.g., guided imagery and role playing) and role playing) – – reprocesses emotions reprocesses emotions Therapy relationship ( Therapy relationship (“ “limited re limited re-

• parenting

parenting” ”) ) – – provides for emotional needs, within limits provides for emotional needs, within limits Empathic Empathic confrontation confrontation – – Confronts Confronts maladaptive maladaptive behaviors behaviors Behavioral techniques Behavioral techniques – – Breaks maladaptive Breaks maladaptive behavior patterns behavior patterns Limit setting Limit setting – – Sets Sets limits limits on

• n destructive

destructive behavior behavior

Effectiveness of Schema Therapy Effectiveness of Schema Therapy versus usual treatment for forensic versus usual treatment for forensic patients with Personality Disorders: patients with Personality Disorders: A 3 A 3-

• year multi

year multi-

• center

center randomized randomized clinical trial and 3 clinical trial and 3-

• year follow

year follow-

• up

up

Funded Funded by by the the Netherlands Netherlands Ministry Ministry of

• f Justice

Justice, the , the Expertise Center Expertise Center for for Forensic Forensic Psychiatry Psychiatry, Maastricht , Maastricht University University’ ’s s Faculty Faculty of

• f Psychology

Psychology and and Neuroscience Neuroscience, , and the 8 and the 8 participating participating TBS TBS clinics clinics

Primary Primary Aims Aims: ST : ST Study Study

Test the Test the effectiveness effectiveness of ST versus TAU in

• f ST versus TAU in

male male forensic forensic patients patients with with Antisocial Antisocial, , Borderline Borderline, , Narcissistic Narcissistic, , Paranoid Paranoid PDs PDs with with regard regard to: to:

– – PD PD symptoms symptoms (SIDP (SIDP-

• IV, SNAP

IV, SNAP-

• I)

I) – – Institutional Institutional violence violence ( (incidents incidents) ) – – Resocialization Resocialization ( (authorized authorized leave leave) ) – – Recidivism Recidivism risk (HCR risk (HCR-

• 20, START)

20, START) – – Actual Actual recidivism recidivism ( (arrests arrests, , convictions convictions) )

Participating Sites: Participating Sites: ST Forensic Project ST Forensic Project

Sites enrolling Sites enrolling patients since patients since ‘ ‘07: 07: de de Rooyse Rooyse Wissel Wissel ( (Venray Venray) ) van van der der Hoeven Hoeven Oostvaarders Oostvaarders Sites beginning Sites beginning enrollment enrollment in in ’ ’09 09-

• ’

’11: 11: Kijvelanden Kijvelanden Veldzicht Veldzicht Mesdag Mesdag FPK FPK Assen Assen de de Rooyse Rooyse Wissel Wissel ( (‘ ‘Overmaze Overmaze’ ’) )

Total sample size needed = 114 (each site contributing 15-20 patients)

Patient Patient Enrollment Enrollment

Patients enrolled to date Additional candidates Final totals de Rooyse Wissel (Venray) 22 22 Van der Hoeven 15 15 Oostvaarders 7 7 Mesdag 20 20 Veldzicht 11 5 11-16 Kijvelanden 12 8 12-20 Assen 9 2 9-11 de Rooyse Wissel (Overmaze) 6 6 Total 102 15 102-117

Vulnerable Vulnerable Child Child Mode in Mode in Psychotherapy Psychotherapy and Arts and Arts Therapy Therapy: ST versus TAU : ST versus TAU

0,5 1 1,5 2 2,5 SFT TAU Psycho- Therapy Arts Therapy

SFT > TAU, z = 1.71, p = .09; SFT, N = 6, TAU, N = 4. Van der Broek, Keulen-de Vos, & Bernstein, in press

Cost Cost Analysis Analysis

Therapists Therapists costs costs per per patient patient over 3

• ver 3 years

years

– – Training and Training and supervision supervision = = € €5.403 5.403 – – Salary Salary = = € €14.989 14.989 – – Total Total costs costs = = € €20.392 20.392

Annual Annual cost cost of TBS

• f TBS stay

stay per per patient patient = = € €160.000 160.000 Reduced Reduced length length of

• f stay

stay to to recoup recoup full full costs costs

• f the
• f the therapy

therapy = 2 = 2 months months! !

Conclusions Conclusions

ST ST appears appears to to be be outperforming

• utperforming TAU

TAU with with respect to respect to reducing reducing risk, risk, permission permission to to receive receive leave leave, and , and number number of

• f days

days to to receive receive leave leave. . ST ST appears appears to to be be especially especially effective effective at at reducing reducing risk more risk more rapidly rapidly in in psychopathic psychopathic patients patients. . Patients Patients in ST show more in ST show more vulnerable vulnerable emotions emotions, , compared compared to TAU to TAU patients patients. . ST ST can can pay pay for for itself itself by by reducing reducing length length of

• f stay

stay. . However However, these , these findings findings are are not not yet yet significant, significant, and and need need to to be be confirmed confirmed in in our

• ur larger

larger sample. sample.

What What do we do we need need? ?

Randomized Randomized clinical clinical trials trials Cost Cost-

• effectiveness

effectiveness studies studies Treatment Treatment alternatives alternatives Experimental Experimental studies of studies of change change mechanisms mechanisms Optimism Optimism, , realism realism, , persistence persistence, and , and humility humility