Schema Therapy for Forensic Patients with Personality

Schema Therapy for Forensic Patients with Personality Disorders
Manual 1: “General summary and leeswijzer”
By David Bernstein and Lieke Nentjes
This manual has been prepared for review by the “Erkenningscommissie” at the request
of the “Programma Kwaliteit Forensische Zorg (KFZ).”
Table of contents
1. General summary ……………………………………………………………………4
2. How are the quality criteria for forensic Schema Therapy addressed?..............4
Criterion 1: Theoretical underpinnings…………………………………….… 4
Criterion 2: Selection of forensic patients………………………………….... 4
Criterion 3: Dynamic criminogenic factors and protective factors………… 5
Criterion 4: Effective (treatment)methods…………………………………... 5
Criterion 5: Skills……………………………………………………………..… 5
Criterion 6: Phases, intensity, and duration……………………………….… 6
Criterion 7: Engagement and motivation…………………………………..…6
Criterion 8: Continuity……………………………………………………….… 6
Criterion 9: Intervention integrity………………………………………………7
Criterion 10: Evaluation……………………………………………………..… 7
References……………………………………………………………………………….8
Appendix: Schematic overview of criteria and corresponding location………...… 10
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1. General summary
A high percentage of forensic patients suffers from one or more personality
disorders (e.g., Hildebrand & de Ruiter, 2004; Rasmussen, Storsaeter, & Levander,
1999; Timmerman & Emmelkamp, 2001), with the most prevalent diagnoses in this
population being Antisocial, Borderline, Narcissistic, and Paranoid Personality Disorders
(Hildebrand & de Ruiter, 2004).
As personality disorder diagnoses in forensic
populations are associated with an increased risk on criminal recidivism and violent
behavior (Hiscoke, Langstrom, Ottosson, & Grann, 2003; Yu, Geddes, & Fazel, 2012),
the availability of effective treatment options to forensic patients is of major importance.
However, the complex, long-standing nature of these disorders make offenders with
personality disorders a particularly challenging patient group.
Schema Therapy (ST; Young, Klosko, & Weishaar, 2003) is an integrative
therapy for personality disorders that combines cognitive, behavioral, psychodynamic
object relations, and experiential approaches. It was developed by Dr. Jeffrey Young in
the 1980’s, and is an empirically supported treatment for Borderline PD (Farrell et al.,
2009; Giesen-Bloo et al., 2006; Nadort et al., 2009). Because of the need for more
effective treatment methods for forensic patients, Bernstein and colleagues have
adapted ST for criminal offenders with the abovementioned personality disorders,
including those with a high level of psychopathy (forensic ST; Bernstein, Arntz, & de
Vos, 2007; Bernstein, Keulen-de Vos, Jonkers, de Jonge, & Arntz, 2012). Although
forensic patients are not selected for forensic ST on the basis of their risk level (as
assessed with measures like the Historical, Clinical and Risk management scheme
[HCR-20]; Douglas & Webster, 1999), those patients who are indicated for forensic ST
are usually characterized by medium to high levels of risk on criminal recidivism.
In forensic ST, patients’ internal risk factors for criminal and violent behavior
(e.g., aggression, disinhibition, substance use) are conceptualized in terms of schema
modes.
Schema modes are fluctuating emotional states that dominate a person’s
thoughts, feelings, and behavior at a given moment in time. Because patients with
severe personality disorders have poorly integrated personalities, they can rapidly flip or
switch from one extreme state to another, or remain rigidly “stuck” in a state (Young et
al., 2003). Forensic ST therapists draw from a variety of techniques to decrease the
intensity and frequency of these maladaptive schema modes, helping patients to
develop the capacity to modulate their emotional states in a more flexible and adaptive
manner (Bernstein et al., 2007). An essential part of this process is the development of
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an attachment bond between the patient and the therapist, in which the ST therapist can
provide the patient with corrective emotional experiences (Bernstein et al., 2007;
Bernstein et al., 2012).
The following manuals describe the theoretical underpinnings for forensic ST
(Theoretical Manual), the therapeutic techniques and methods used when practicing
forensic ST (Program Manual), the evaluation of the effectiveness of ST for forensic
patients with the aforementioned personality disorders (Evaluation Manual), the
implementation guidelines for forensic institutions and treatment providers who wish to
implement ST (the Management Manual), and the content of the training program for
forensic ST (Education Manual).
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2. How are the criteria for Schema Therapy for forensic patients addressed?
Criterion 1: Theoretical underpinnings
The theoretical underpinnings on which ST for offenders with personality
disorders is based are completely described in the Theoretical Manual. In this manual,
we start with a description of the major focus in forensic ST, i.e., schema modes, which
are fluctuating emotional states that dominate a patient’s thoughts, feelings, and
behavior at a given moment in time. In the theoretical model for forensic ST, patients’
internal risk factors for criminal recidivism are conceptualized in terms of these schema
modes.
We describe how schema modes relate to personality disorders, violence,
aggression, and substance use. Subsequently, we present a comprehensive explanatory
model that links predisposing factors, schema modes (internal risk factors), and external
risk factors (e.g., criminal networks, stressful life events) with each other. Moreover, this
explanatory model depicts the interrelations within and between these internal/external
risk factors, as well as with internal and external protective factors (e.g., healthy schema
modes like the “Healthy Adult mode” and social support, respectively).
After explaining the etiology of offender’ antisocial behavior in terms of the
dynamics between schema modes and external factors in this model, we present a
change model in which ST intervention methods are linked to treatment targets (i.e.,
dynamic risk and protective factors). We describe the mechanisms of change by which
ST reduces the internal risk factors that were involved in patients’ criminal and violent
behavior (i.e., attenuation of maladaptive schema modes) and strengthens the patient’s
capacities to regulate his own emotional states (i.e., strengthening patients’ “Healthy
Schema Modes”). Furthermore, this change model describes how ST helps the patient
to utilize external protective factors and avoid external risk factors that could trigger
relapse. Last, we describe the rationale for the selection of patients for forensic ST; we
provide an overview of the empirical support for the explanatory and change model; and
we provide (provisional) support for the effectiveness of ST in lowering risk of offending
in forensic patients with personality disorders.
Criterion 2: Selection of forensic patients
In the Theoretical Manual, we provide a description of when patients are
(contra)indicated
for
receiving
forensic
ST,
taking
into
account
factors
like
psychopathology, recidivism risk levels, criminal behavior, cognitive and intellectual skills
etc. This manual also describes the rationale for these indications. In the Management
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Manual we go into further detail on the instruments and procedures for assessing
patients’ (contra)indications for ST.
Criterion 3: Dynamic criminogenic factors and protective factors
In the explanatory model of antisocial behavior in the Theoretical Manual, we
describe dynamic (i.e., changeable) factors that influence recidivism risk. In this model,
we make a distinction between internal and external factors.
Maladaptive schema
modes are conceptualized as internal risk factors, whereas healthy schema modes are
hypothesized to be internal protective factors. Through the attenuation of maladaptive
schema modes, and the strengthening of healthy schema modes, ST aims to provide the
patient with a set of skills to avoid or deal with external risk factors (reducing their
impact), and to seek protective factors in his environment. In the Theoretical Manual, we
thus conceptualize schema modes to be related to antisocial behavior, implying that by
changing schema modes, ST decreases recidivism risk.
Subsequently, we present
empirical data that supports the notions that 1) schema modes are dynamic constructs,
and 2) schema modes are related to past criminal behavior, predicted risk levels, and
current institutional incidents.
Criterion 4: Effective (treatment)methods
In the Theoretical Manual, we link therapeutic goals to schema modes (internal
risk factors), and we give a brief overview of which techniques and methods are used to
reach these therapeutic goals. In the Program Manual, we give an extensive description
of the (treatment)methods that are central to forensic ST, and that we believe to be
effective in reducing schema modes, psychopathology, and recidivism risk. Empirical
data that supports the proposed working mechanisms of change in forensic ST, as well
as the effectiveness of ST for non-forensic PD populations is presented in the
Theoretical Manual.
Moreover, this manual describes preliminary data on the
effectiveness of the multicenter RCT on the effectiveness of ST for forensic patients.
Criterion 5: Skills
In the conceptual model of forensic ST in the Theoretical Manual, an explanation
is given of why forensic patients often lack the skills that ST aims to enhance.
Subsequently, an overview is given of which skills ST specifically aims to enhance in
forensic patients (translated in terms of therapy goals) and how we believe these skills to
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serve as a buffer for the risk on future offending (i.e., which maladaptive schema modes
[internal risk factors] are reduced by the strengthening of specific skills). In the change
model of forensic ST, we subsequently describe how the development of new, adaptive
skills (e.g., experiencing anger in a healthier manner, improving emotional regulation)
relates to a decrease in maladaptive (e.g., violent, impulsive, and emotionally detached)
behaviors that are reflective of maladaptive schema modes. In the Program Manual, a
description is given of how patients practice new skills.
Criterion 6: Phases, intensity, and duration
A description of the duration, intensity, and different phases is given in the
Program Manual.
In the Theoretical Manual, we provide the rationale behind these
aspects of treatment.
Criterion 7: Engagement and motivation
In the Theoretical Manual, we describe the rationale behind the techniques used
to motivate forensic patients (i.e., “schema modes work”). Furthermore, we describe
how working with schema modes to address motivational issues determines the content
of ST sessions. In the Program Manual, we go into further detail on the techniques and
strategies used to achieve motivational change. The Management Manual describes
what role motivation plays in selecting patients for forensic ST and how patients’
motivation and engagement should be monitored over time. Last, we provide guidelines
for the motivation of personnel delivering forensic ST.
Criterion 8: Continuity
In the explanatory model of the Theoretical Model, the associations between the
dynamic risk/protective factors that are targeted in ST, and the dynamic risk/protective
factors that are addressed elsewhere are depicted. In the Management Manual, we
provide a further description of which factors are the focus of ST, and which factors will
need to be addressed elsewhere. We describe how we feel forensic ST should be
embedded in the overarching TBS context, and how the ST therapist plays an essential
role in warranting concurrent continuity of care on an institutional level. Furthermore, we
address how the skills that patients develop in forensic ST are maintained, how ST
addresses after-care and relapse prevention, and how forensic ST guides patients’ reentry into the community (i.e., follow-up continuity). Within our description, we provide
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guideline for the roles of different professionals in creating concurrent and follow-up
continuity.
Criterion 9: Intervention integrity
In order to properly implement ST in forensic settings, there are a number of
conditions that need to be fulfilled in order to warrant the treatment integrity of ST. In the
Management Manual we describe these prerequisites (e.g., needed facilities and
organizational structure, professional competencies, monitoring of patients’ progress
etc.). Furthermore, we make recommendations on how to safeguard aspects that are
related to the quality and the content of forensic ST (e.g., warranting therapists’
competence and adherence to ST). In the Education Manual, we describe the training
program that we developed to train ST therapists for the forensic field, and explain how
we ensure a high level of quality of forensic ST via our program.
Criterion 10: Evaluation
We are currently conducting a multicenter Randomized Clinical Trial (RCT) on
the effectiveness of ST in a group of 102 forensic patients. In the Evaluation Manual, we
describe the aims and methodology of this large RCT. Preliminary results of the RCT
are presented in the Theoretical Manual.
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References
Bernstein, D. P., Arntz, A., & de Vos, M.E. (2007). Schema-Focused Therapy in forensic
settings: theoretical model and recommendations for best clinical practice.
International Journal of Forensic Mental Health, 6, 169-183.
Bernstein, D.P., Keulen-de Vos, M., Jonkers, P., de Jonge, E., & Arntz, A. (2012).
Schema Therapy in forensic settings (pp. 425-438). In van Vreeswijk, M.
Broersen, J. & Nadort, M. (Eds.), The Wiley-Blackwell Handbook of Schema
Therapy. Routledge.
Douglas, K.S. & Webster, C.D. (1999). The HCR-20 violence risk scheme: concurrent
validity in a sample of incarcerated offenders. Criminal Justice and Behaviour,
26, 3-19.
Giesen-Bloo, J., van Dyck, R., Spinhoven, P., van Tilburg, W., Dirksen, C., van Asselt,
T., & Arntz, A. (2006). Outpatient psychotherapy for borderline personality
disorder: Randomized trial of schema-focused therapy vs transference- focused
psychotherapy. Archives of General Psychiatry, 63, 649–658.
Farrell, J. M., Shaw, I. A., & Webber, M. A. (2009). A schema-focused approach to group
psycho-therapy for outpatients with borderline personality disorder: A randomized
controlled trial. Journal of Behavior Therapy and Experimental Psychiatry, 40,
317–328.
Hildebrand, M., & de Ruiter, C. (2004). PCL-R psychopathy and its relation to DSM-IV
Axis I and II disorders in a sample of male forensic psychiatric patients in the
Netherlands. International Journal of Law and Psychiatry, 27, 233-248.
Hiscoke, U., Langstrom, N., Ottosson, H., & Grann, M. (2003). Self-reported personality
traits and disorders (DSM-IV) and risk of criminal recidivism: a Prospective Study.
Journal of Personality Disorders, 17, 293-305. doi:10.1521/pedi.17.4.293.2396.
Nadort, M., Arntz, A., Smit, J. H., Giesen-Bloo, J., Eikelenboom, M., Spinhoven, P., &
van Dyck, R.
(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,
961–973.
Rasmussen, K., Storsaeter, O, Levander, S. (1999). Personality disorders, psychopathy,
and crime in a Norwegian prison population. International Journal of Law and
Psychiatry, 22, 91-97.
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Timmerman, I. G., & Emmelkamp, P. M. (2001a). The prevalence and comorbidity of
Axis I and Axis II pathology in a group of forensic patients. International Journal
of Offender Therapy and Comparative Criminology, 42, 198-213.
Young, J. E., Klosko, J., & Weishaar, M. (2003). Schema Therapy: a practitioner’s
guide. New York, NY: Guilford Press.
Yu, R., Geddes, J. R., & Fazel, S. (2012). Personality disorders, violence, and antisocial
behavior: A systematic review and meta-regression analysis. Journal of
Personality Disorders, 26, 775-792.
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Appendix: Schematic overview of criteria, paragraphs, and page numbers.
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