Schema Therapy for Psychopathic and other Forensic Patients ... - EFP

David P. Bernstein, PhD
Department of Clinical Psychological Science,
Forensic Psychology Section,
Maastricht University
Forensic Psychiatric Center ‘de Rooyse Wissel’
Expertise Center for Forensic Psychiatry

A former enforcer in a criminal network contracted
AIDS. When speaking of the people he’d hurt or
killed, he suddenly broke into tears, and expressed
remorse.
A psychopathic patient told his therapist not to
bother looking for emotions, because he was a
psychopath. However, when he was suddenly
hospitalized, and his girlfriend came to visit, he
began to cry.
A psychopathic patient hit a staff member and was
placed in separation. When his therapist visited him
and expressed sympathy, he cried.

Like other people, psychopaths aren’t the
same way all of the time.
They may be capable of vulnerable emotions
under certain conditions.
If we can break through to their vulnerable
side, they may develop empathy and other
“moral emotions.”

An integrative therapy, combining cognitive,
behavioral, object relations, and experiential
approaches (Young et al., 2003).
Treats personality disorder patients and other
longstanding problems.
Focuses on Early Maladaptive Schemas, coping
responses, and Schema Modes.
A moderate- to long-term therapy.
Good evidence of effectiveness in outpatients
with Borderline PD (Farrell et al., 2009; Giesen-
Bloo et al., 2006; Nadort et al., 2009).

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

Self-Aggrandizer
Bully and Attack
Paranoid -
Overcontroller
Conning -
Manipulator
Detached
Protector
Angry Protector
Detached Self-
Soother
Predator Abused/Humiliated/
Abandoned Child
Lonely Child
Impulsive Child
Angry Child
Bernstein, Arntz, & de Vos, 2007

Funded by the Netherlands Ministry of Justice, the Expertise
Center for Forensic Psychiatry, Maastricht University’s Faculty
of Psychology and Neuroscience, and the 7 participating TBS
clinics

Test the effectiveness of ST versus TAU in
male forensic patients with Antisocial,
Borderline, and Narcissistic with regard to:
PD symptoms (SIDP-IV, SNAP)
Institutional violence (incidents)
Resocialization (authorized leave)
Recidivism risk (HCR-20, SVR-20, START)
Actual recidivism (arrests, convictions)

Note: N = 30; High PCL-R: >= 25, Low PCL-R: < 25
Bernstein &
Nijman, submitted

N = 30; Bernstein & Nijman, submitted
N = 30

Therapists costs per patient over 3 years
Training and supervision = €5.403
Salary = €14.989
Total costs = €20.392
Annual cost of TBS stay per patient =
€160.000
Reduced length of stay to recoup full costs of
the therapy = 2 months! Bernstein & Nijman,
submitted

2,5
2
1,5
1
0,5
0
SFT TAU
SFT > TAU, z = 1.71, p = .09; SFT, N = 6, TAU, N = 4.
Psycho-
Therapy
Arts
Therapy
Van der Broek,
Keulen-de Vos, &
Bernstein, 2011

ST appears to be outperforming TAU with respect to
reducing risk, permission to receive leave, and
number of days to receive leave.
ST appears to be especially effective at reducing risk
more rapidly in psychopathic patients.
Patients in ST show more vulnerable emotions,
compared to TAU patients.
ST can pay for itself by reducing length of stay.
However, these findings are not yet statistically
significant, and need to be confirmed in our larger
sample and long-term follow-up.