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Treating Forensic Patients with Personality Disorders with Schema Therapy: Research Update

15 Feb 2015 12:33 PM | Eshkol Rafaeli
The view of the treatability of personality disorders has changed dramatically over the past thirty years.  Unfortunately, the pessimism with regard to personality disorders has persisted with regard to one group: forensic patients with personality disorders, especially patients with Antisocial Personality Disorder and Psychopathy.  Interestingly, new scientific evidence is beginning to challenge the pessimistic view regarding such patients. In this blog post, David Bernstein tells us about the development and empirical status of his exciting work developing and disseminating schema therapy for forensic patients.

David  Bernstein

Professor and Chair of Forensic Psychotherapy

Faculty of Psychology and Neuroscience, Maastricht University, & Forensic Psychiatric Center 'de Rooyse Wissel'.


When I was a young psychologist in training, the prospect for treating patients with personality disorders was decidedly pessimistic. I was told that people with personality disorders had little motivation to change or engage in therapy, because they weren’t suffering enough. According to one of my professors, “They don’t suffer themselves, but they do make other people suffer!” This view was so prevalent that many mental health professionals didn’t want to work with patients with personality disorders. During my clinical internship year, I observed that some staff members at the psychiatric hospital where I worked literally walked the other way when they saw a patient with Borderline Personality Disorder walking towards them. Yet, how does the view that patients with personality disorders don’t suffer accord with the fact that ten percent of individuals with Borderline Personality Disorder will commit suicide during their lifetime?

Fortunately, the view of the treatability of personality disorders has changed dramatically over the past thirty years. Marsha Linehan was the first to show that a specialized therapy, Dialectical Behavior Therapy, could greatly reduce the risk of suicide and self-harm behaviors in patients with Borderline Personality Disorder. Jeffrey Young introduced Schema Therapy, which went a step further. Studies show that Schema Therapy, which focuses on patients’ unmet emotional needs, reduces suicide risk while also improving core symptoms such as identity confusion and unstable relationships, and enhancing the quality of life in these individuals. These and other specialized treatments have brought new hope to people with personality disorders, who were often considered untreatable, while changing attitudes for the better in those who work with them.

Unfortunately, the pessimism with regard to personality disorders has persisted with regard to one group: forensic patients with personality disorders, especially patients with Antisocial Personality Disorder and Psychopathy. In forensic settings around the world, like forensic hospitals and prisons, personality disorders are the most prevalent form of psychiatric disorder. Antisocial Personality Disorder, which is defined in the DSM-V largely by a persistent pattern of antisocial behavior, affects up to eighty percent of the people in these institutions. Within this broadly antisocial group, the most severe subgroup is the so-called psychopaths, who have core psychopathic personality traits such as ruthlessness, callousness, and remorselessness. Research shows that twenty to thirty percent of individuals with Antisocial Personality Disorder also have significant traits of psychopathy. Compared with other individuals in forensic populations, psychopaths have much higher rates of recidivism and are more likely to commit severe offenses and acts of violence. Psychopathic individuals are often described as unmotivated for treatment. In fact, there is a widespread belief that therapy will only make them worse, teaching them the psychological skills to better con and manipulate other people. Research also shows that psychopaths have deficits in emotional functioning. And, of course, the frequent depiction in the media of psychopaths as inhuman monsters makes a powerful impression. Taken together, is it any wonder that many people believe that forensic patients with personality disorders, and especially psychopathic ones, are untreatable?

Interestingly, new scientific evidence is beginning to challenge these widespread views. First, research shows that environmental factors, such as childhood trauma, parental neglect, inadequate attachments to caregivers, antisocial peer groups, and growing up in impoverished and violent communities, play an important role in the development of Antisocial Personality Disorder and Psychopathy. These environmental influences are likely to interact with genetic vulnerabilities, such as inherited predispositions to emotional callousness and impulsivity, increasing the risk for antisocial behavior and psychopathic traits. Psychopaths appear to be a much more diverse group than we ever realized, both in terms of the causes of the disorder, and the kinds of emotional problems that they exhibit. While some psychopaths are emotionally under-responsive, others may be prone to strong emotions, such as anxiety, depression, and anger. Perhaps some of these diverse patients are more responsive to treatment than others.

Second, there is actually very little evidence that psychopathic patients cannot be treated, or that therapy will make them worse. In fact, most of the treatment studies of psychopaths have been marred by serious methodological problems. For example, the most famous study to show that treatment made psychopaths worse, carried out at a Canadian prison in the 1960’s, would never pass muster with an ethical review board today. The patients in the study were given a number of bizarre treatments, including psychedelic drugs such as LSD and participating in naked encounter groups, in an effort to break down their defenses. The “treatment” was largely given by the patients themselves, who could even prescribe their own medications, with little involvement of professionals. What are we to make of the finding that the psychopathic patients in this study had a higher rate of recidivism when followed up years later, compared to other patients? Yet, this study has until recently often been cited by experts as evidence that treatment makes psychopaths worse. Could it be possible that the field has been engaging in a self-fulfilling prophesy, withholding treatments from psychopathic patients on the basis of a largely unsupported belief? Psychopaths undoubtedly pose challenges, which should not be underestimated. However, it may be possible that, as was the case for Borderline Personality Disorder, our own views have blinded us to the potential for treating them.

My own research investigates the final frontier regarding the treatability of personality disorder patients. Can psychotherapy help forensic patients with personality disorders, including psychopathic ones, recover and lead safer and more productive lives? Since 2007, my colleagues and I have been conducting a large randomized clinical trial of the effectiveness of Schema Therapy at seven forensic hospitals (“TBS clinics”) in the Netherlands. One hundred and three patients are enrolled in our randomized clinical trial; fifty four were randomly assigned to receive three years of Schema Therapy, while the other forty nine received a comparable duration of usual forensic treatment at these institutions (“treatment as usual”). The patients were all male and had a DSM-IV diagnosis of Antisocial, Borderline, Narcissistic, or Paranoid Personality Disorder, or significant traits of these disorders (“Cluster B Personality Disorder Not Otherwise Specified”). We are particularly interested in seeing if Schema Therapy reduces recidivism risk and maladaptive personality traits, and speeds patients’ re-entry into the community, compared to treatment-as-usual. After treatment is completed, we will follow these patients for an additional three years, after many of them have returned to the community, to determine which ones have recidivated. The treatment phase of the study will be completed by August of 2015, while the three year follow-up will be completed by 2018.

Our preliminary findings suggest that Schema Therapy is outperforming treatment-as-usual. The patients who received Schema Therapy are showing more rapid reductions in their risk of recidivism, and are moving more quickly through the process of resocialization, where patients gradually re-enter the community under decreasing levels of supervision. These trends were already apparent when we analyzed the data in the first thirty patients to complete the study, but were not yet statistically significant in this small initial sample. However, these trends have persisted as we have continued to analyze our findings. We are waiting with bated breath for the final results of the study, which we will analyze later this year and submit for publication by the end of 2015. The Netherlands’ Erkenningscommissie (“Recognition Commission”) was sufficiently impressed by our findings that they have provisionally certified Schema Therapy as the first officially recognized evidence-based treatment for personality disorders in forensic patients. To my knowledge, this makes Schema Therapy the only evidence-based treatment for forensic patients with personality disorders that is recognized in any country.

Will Schema Therapy be significantly more effective for forensic patients with personality disorders, including psychopathic patients who are usually considered to be untreatable? Stay tuned! In the meantime, we have recently published a case study of our first, apparently successful treatment of a psychopathic patient with Schema Therapy. The article describes the therapy process for this psychopathic patient and uses multiple forms of assessment to measure his progress over a period of seven years. Three years after completing treatment, he was still crime-free, living in the community, holding down a job, and living in a stable relationship with his new partner and their child. Schema Therapy offers no guarantees for forensic patients with personality disorders. However, we do aim to reduce the risk of crime and violence in these patients, a goal that is of great importance for society. And perhaps our research can begin to change some attitudes about supposedly untreatable forensic patients with personality disorders.

Bernstein, D.P., Nijman, H., Karos, K., Keulen-de Vos, M., de Vogel, V., & Lucker, T. (2012). Schema Therapy for forensic patients with personality disorders: Design and preliminary findings of multicenter randomized clinical trial in the Netherlands. International Journal of Forensic Mental Health, 11, 312-324.

Chakhssi, F., Kersten, G., de Ruiter, C., & Bernstein, D.P. (2014). Treating the untreatable: A single case study of a psychopathic patient treated with Schema Therapy. Psychotherapy. Online First Publication, March 31, 2014. http://dx.doi.org/10.1037/a0035773

D’Silva, K., Duggan, C., & McCarthy, L. (2004). Does treatment really make psychopaths worse? A review of the evidence. Journal of Personality Disorders, 18, 163-177.

Giesen-Bloo, J., van Dyck, R., Spinhoven, P., van Tilburg, W., Dirksen, C., van Asselt, T., Kremers, I., Nadort, M., & Arntz, A. (2006). Outpatient psychotherapy for Borderline Personality Disorder. Archives of General Psychiatry, 63, 649-658.

Hemphill, J., Hare, R., & Wong, S. (1998). Psychopathy and recidivism: A review. Legal Criminology
Psychology, 3, 141-172.

Hicks, B., Carlson, M., Blonigen, D., & Patrick, C. (2012). Psychopathic personality traits and environmental contexts: differential correlates, gender differences, and genetic mediation. Personality Disorders: Theory, Research, and Treatment, 3, 209-227.

Keulen-de Vos, M., Bernstein, D.P., Vanstipelen, S., de Vogel, V., Lucker, T., Slaats, M., Hartkoorn, M., & Arntz, A. (2014). Schema modes in the criminal and violent behavior of forensic Cluster B PD patients: A retrospective and prospective study. Legal and Criminological Psychology, Article first published online: 24 February, 2014, DOI: 10.1111/lcrp.12047.

Linehan, M.M., Comtois, K.A., Murray, A.M., Brown, M.Z., Gallop, R.J., Heard, H.L., Korslund, K.E., Tutek, D.A., Reynolds, S.K., Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of Dialectical Behavior Therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63, 757-766.

Murray, J., Irving, B., Farrington, D. P., Colman, I., & Bloxsom, C. A. (2010). Very early predictors of conduct problems and crime: results from a national cohort study. Journal of Child Psychology and Psychiatry, 51, 1198-1207.

Seara‐Cardoso, A., & Viding, E. (2014). Functional neuroscience of psychopathic personality in adults. Journal of Personality.
Shi, Z., Bureau, J. F., Easterbrooks, M., Zhao, X., & Lyons‐Ruth, K. (2012). Childhood maltreatment and prospectively observed quality of early care as predictors of antisocial personality disorder features. Infant Mental Health Journal, 33, 55-69.

Vassileva, J., Kosson, D.S., Abramowitz, C., & Conrod, P. (2005). Psychopathy versus psychopathies in classifying criminal offenders. Legal and Criminological Psychology, 10, 27-43.

Viding, E., Blair, J.R., Moffitt, T.E., & Plomin, R. (2005). Evidence for substantial genetic risk for psychopathy in 7 year olds. Journal of Child Psychology and Psychiatry, 46, 592-597.

Young, J. E., Klosko, J., & Weishaar, M. (2003). Schema Therapy: A Practitioner’s Guide. New York, USA: The Guilford Press.

Why Schema Therapy?

Schema therapy has been extensively researched to effectively treat a wide variety of typically treatment resistant conditions, including Borderline Personality Disorder and Narcissistic Personality Disorder. Read our summary of the latest research comparing the dramatic results of schema therapy compared to other standard models of psychotherapy.

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