Treating the the Untreatable Untreatable: : Treating Schema Therapy Therapy for for Schema Psychopaths and and Other Other Psychopaths Forensic Personality Personality Disorder Disorder Forensic Patients Patients David P. Bernstein Bernstein, , Ph.D Ph.D. . David P. Department of of Clinical Clinical Psychological Psychological Science Science, , Department Maastricht University University Maastricht Forensic Psychiatric Psychiatric Center Center ‘ ‘de de Rooyse Rooyse Wissel Wissel’ ’ Forensic Expertise Center for for Forensic Forensic Psychiatry Psychiatry Expertise Center
Dank u wel! Dank u wel! Forensic Psychiatric Centers de Rooyse Rooyse Wissel Wissel, van , van der der Forensic Psychiatric Centers de Hoeven, , Oostvaarders Oostvaarders, , Kijvelanden Kijvelanden, , Veldzicht Veldzicht, , Mesdag Mesdag, , Hoeven and FPK Assen Assen and FPK The Netherlands Ministry of Justice The Netherlands Ministry of Justice Expertise Centrum Forensische Forensische Psychiatrie Psychiatrie Expertise Centrum Wetenschappelijk Onderzoek en Documentatiecentrum Wetenschappelijk Onderzoek en Documentatiecentrum Faculty of Psychology and Neuroscience, Maastricht Faculty of Psychology and Neuroscience, Maastricht University University And the many many patients patients, , therapists therapists, , researchers researchers, and , and And the other clinical clinical and and administrative administrative personnel personnel that that are are other participating in in this this project! project! participating
Emotionless Psychopaths Psychopaths? ? Emotionless One psychopathic psychopathic patient patient broke broke down down crying crying at a at a One memorial patient patient for for fellow fellow patients patients that that had had died died memorial of AIDS. On On another another occasion, occasion, he he confessed confessed of AIDS. that he he couldn couldn’ ’t t sleep at sleep at night night because because he he that worried that that his his mother mother might might be be killed killed by by drug drug worried dealers that that were were after after him him. . dealers A psychopathic psychopathic patient patient who who was was convicted convicted of of A rape became became overwhelmed overwhelmed by by anxiety anxiety in a in a rape therapy session session. He . He said said that that he he now now realized realized therapy how terrified terrified he he was of was of women women. He had . He had how previously had had problems problems with with sexual sexual previously performance. performance.
Psychopathy: Predominant Views : Predominant Views Psychopathy Psychopathy is is based based on on heritable heritable callous callous Psychopathy unemotional traits traits unemotional – 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 of 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 are are untreatable untreatable; ; therapy therapy makes makes Psychopaths them worse worse them – Little Little empirical empirical support support for for this this view ( view (D D’ ’Silva Silva et al., et al., – 2004, Salekin Salekin, 2002). , 2002). 2004,
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, Klosko Klosko, & , & Weishaar Weishaar, 2003). , 2003). (Young, 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- - to long to long- -term form of psychotherapy. term form of psychotherapy. A moderate Good evidence evidence of of effectiveness effectiveness in ( in (non non- -forensic forensic) ) Good outpatients with with Borderline Borderline PD ( PD (Farrell Farrell et al., 2009; et al., 2009; outpatients Giesen- -Bloo Bloo et al., 2006; Nadort et al., 2009). et al., 2006; Nadort et al., 2009). Giesen
Schema Modes: Definition Schema Modes: Definition An emotional state or “ “part of the self part of the self” ” that that An emotional state or temporarily dominates a person’ ’s thoughts, s thoughts, temporarily dominates a person 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 “ “flipping flipping” ” or switching or switching Schema Mode
Schema Mode Model for Antisocial Personality Schema Mode Model for Antisocial Personality Disorder and and Psychopathy Psychopathy Disorder 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 – – restructures restructures Cognitive techniques cognitions cognitions Experiential techniques (e.g., guided imagery Experiential techniques (e.g., guided imagery and role playing) – – reprocesses emotions reprocesses emotions and role playing) Therapy relationship (“ “limited re limited re- -parenting parenting” ”) ) – – Therapy relationship ( provides for emotional needs, within limits provides for emotional needs, within limits Empathic confrontation confrontation – – Confronts Confronts Empathic maladaptive behaviors behaviors maladaptive Behavioral techniques – – Breaks maladaptive Breaks maladaptive Behavioral techniques behavior patterns behavior patterns Limit setting – – Sets Sets limits limits on on destructive destructive Limit setting 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- -year multi year multi- -center center randomized randomized A 3 clinical trial and 3- -year follow year follow- -up up clinical trial and 3 Funded by by the the Netherlands Netherlands Ministry Ministry of of Justice Justice, the , the Funded Expertise Center for for Forensic Forensic Psychiatry Psychiatry, Maastricht , Maastricht Expertise Center University’ ’s s Faculty Faculty of of Psychology Psychology and and Neuroscience Neuroscience, , University and the 8 participating participating TBS TBS clinics clinics and the 8
Primary Aims Aims: ST : ST Study Study Primary Test the effectiveness effectiveness of ST versus TAU in of ST versus TAU in Test the male forensic forensic patients patients with with Antisocial Antisocial, , male Borderline, , Narcissistic Narcissistic, , Paranoid Paranoid PDs PDs with with Borderline regard to: to: regard – 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 beginning enrollment enrollment Sites enrolling Sites beginning patients since ‘ ‘07: 07: in ’ ’09 09- -’ ’11: 11: patients since in de Rooyse Rooyse Wissel Wissel Kijvelanden de Kijvelanden (Venray Venray) ) ( Veldzicht Veldzicht van der der Hoeven Hoeven van Mesdag Mesdag Oostvaarders Oostvaarders FPK Assen Assen FPK de Rooyse Rooyse Wissel Wissel de ( ‘ Overmaze ’ ) ( ‘ Overmaze ’ ) Total sample size needed = 114 (each site contributing 15-20 patients)
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