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SafePath: a Schema Therapy Based Program for Teams and Organizations

Implementation and First Research Findings in the Netherlands

by David Bernstein, Marjolein van Wijk-Herbrink & Theodoor de Kraker  

General Abstract:

SafePath (www.SafePath-Solutions.com) combines principles and practices of Schema Therapy and Positive Psychology to working with teams and organizations. It uses a systemic approach to promote change at different levels: individual (e.g., the patient), dyadic (e.g., the patient and a group worker on a ward), a team (e.g., a team working on a forensic, addiction, or psychiatric ward, a school, or the community), and an entire organization.

The central concept in SafePath is schema modes, fluctuating emotional states that dominate a person’s thinking, feeling, and coping behavior at a given moment. In SafePath, we teach teams to recognize and work with schema modes in organizational settings (e.g., on a ward).

Teams use a three-step process, which incorporates mindful acceptance, to work with modes: 1) observe the mode, 2) notice and accept your own modes (“recruiting your Healthy Adult mode”), rather than reacting to the patient’s mode, and 3) chose the correct intervention that matches the patient’s mode. We teach teams how to apply the Schema Therapy techniques of limited reparenting, empathic confrontation, and limit setting to group settings, where interventions often must be carried out quickly in complex living spaces (e.g., on an open ward with many other patients present).

We also use the schema mode approach to analyze and resolve complex dynamics, such as conflicts within the team, or dysfunctional interactions between the team and the patients, or the team and management. We use the iModes cards (www.i-Modes.com) as a medium to facilitate understanding of, and communication about, schema modes, both within teams and with patients.

We have trained more than 20 SafePath teams, and 33 SafePath trainer/coaches, in the Netherlands, with demand continuing to grow. In this symposium, we discuss our experiences in implementing SafePath in different settings, and present the first research findings supporting its use.

Segment 1

Title: Implementing SafePath on Two Wards for the Highest Risk Youth Forensic Patients in the Netherlands: Lessons Learned

Presenters: David Bernstein 

Several years ago, the Netherlands Ministry of Justice asked me to help them set up two new wards for the highest risk, most treatment-resistant youth forensic patients. We used SafePath to train these two teams, known as “ITA’s” (Individual Trajectory Departments). The wards have a very high staff to patient ratio and offer mostly one-to-one interactions with personnel, due to the high risk of aggressive incidents. In addition to applying SafePath on the wards, we trained therapists at these institutions to provide individual Schema Therapy. Lesson 1 – A consistent schema mode approach can resolve dysfunctional team dynamics. We observed many destructive patterns on the wards affecting the teams. Psychopathic patients would conspire together, using pressure, bullying, and manipulation to get the staff to submit to their wishes (e.g., for leave privileges). In response to the modes of the patients, the teams developed dysfunctional modes. For example, the patients set the team members against each other (“splitting the treatment team”), or the team began to exhibit the same aggressive and manipulative modes seen in the patients (“parallel process”). We confronted the team during biweekly coaching sessions, using the iModes cards to analyze and eventually resolve these destructive dynamics. Lesson 2 – Proper conditions need to be maintained for the ongoing implementation of SafePath. High staff turnover without prompt replacement and training, and the discontinuation of the coaching sessions, led the teams to resume their old patterns. When the proper conditions for SafePath were re-established, the teams returned to higher levels of functioning. Outcomes - Following successful implementation, nearly all of the patients agreed to follow individual Schema Therapy (after first refusing to do so), and many were transitioning to the community. In the periods of the teams’ best functioning, there were no serious incidents on either of the wards

Segment 2

Title: SafePath in Court-Mandated, Secure Residential Youth Care: Empirical Findings and Clinical Impressions

Presenter: Dr. Marjolein van Wijk-Herbrink

Group care workers of residential youth care settings face the challenge of creating a warm and involved treatment climate against the demands and restrictions of the treatment setting. SafePath supports staff to create and maintain such an open group climate for patients with aggression, addiction, and antisocial behavior. This presentation provides a clinical impression of SafePath in secure residential youth care in the Netherlands, the OG Heldering stichting, and addresses a research study we conducted to test the effects of SafePath during the first year of implementation on two secure residential treatment units compared to two control units (“care-as-usual”). Patients were assigned to the two kinds of wards using a naturalistic design depending on the availability of beds. Staff’s daily reports on 139 individual patients were coded on use of schema mode language (implementation check), occurrences of aggression (primary outcome), and repressive staff interventions. In addition, repeated questionnaires were filled out by patients (n = 87) on group climate and by staff (n = 50) on team functioning. The SafePath teams made significantly more use of the schema mode terminology in their daily reports compared to the care-as-usual teams, with increasing use over the course of the year. Compared to the care-as-usual units, the two SafePath units showed better team functioning, better climate on the wards, and less need for repressive staff interventions, such as physical restraints. Aggression decreased on all wards and was not significantly different between the two kinds of wards. This study is the first to support the notion that SafePath produce better team functioning, ward climate, and lessen the need for repressive, physical staff interventions.

Segment 3

Title: Adaptation of SafePath to a Dual Diagnosis Addiction Unit: Developing and Testing of a Novel Group Program Based on SafePath Principles

Presenters: Theodoor de Kraker

“De Hoop” (“The Hope”) is a Christian-faith based addiction treatment center that has successfully implemented SafePath over the past several years. This presentation describes a novel group therapy program that is being implemented on a new SafePath ward for dual diagnosis patients, most of whom have personality disorders or axis I disorders (e.g., depression, PTSD) in addition to substance or alcohol addiction. The patients on this closed ward reside for 12 weeks while they follow an intensive group therapy program. Of special interest is the development (by Theodoor de Kraker and David Bernstein) of three types of SafePath groups for the patients on the ward: a three-session Introduction Group that provides an introduction to SafePath; a 12-session Basic Group, covering a range of schema modes; and a 12-session Healthy Adult Group, focusing on strengthening the Healthy Adult mode. All of the groups combine a psycho educational approach and experiential exercises adapted from SafePath and Schema Therapy. The groups use the iModes cards and other recently developed SafePath materials for the exercises. For example, the central metaphor of a sailboat representing a person’s life journey (Alberts, 2018) is incorporated in the very first of the session of the Introduction Group, providing a thread that links the various group components. Many of the sessions incorporate mindful awareness (termed “attentional awareness” in this program) or guided imagery exercises, and fun and playful “serious games” to engage patients as they learn about modes. Patients also keep a daily diary that they use to monitor their schema modes and introduce healthy awareness and choices into their daily routine. In this presentation, we will describe the group program, our clinical experiences with the first cohort of patients to experience it, and the design of an open clinical trial, which is testing its effectiveness.

About Presenters:

David Bernstein
Dr. David Bernstein is a Clinical Psychologist (PhD, New York University, 1990) and Associate Professor of Psychology at Maastricht University in the Netherlands, where he has served as Professor of Forensic Psychotherapy (endowed chair, 2010-2018), and Chair of the Section on Forensic Psychology(2010-2015). He is a former President of the Association for Research on Personality Disorders (2001-2005) and Vice-President of the International Society for the Study of Personality Disorders (2003-2007). He was also Vice-President of the International Society of Schema Therapy(2010-2012) and is an Advanced Level Schema Therapist and Schema Therapy Supervisor. He is the author or coauthor of more than 120 publications on psychotherapy, personality disorders, forensic psychology, childhood trauma, and addictions. He is the coauthor of Schema Therapy: Distinctive Featureswith Eshkol Rafaeli and Jeffrey Young and the DVD series, Schema Therapy: Working with Modes, with Remco van der Wijngaart.He is also the author of the Childhood Trauma Questionnaire, a reliable and valid self-report questionnaire for child abuse and neglect, used worldwide. He is the creator of the iModes, a cartoon-based system for working with schema modes (www.i-Modes.com), and the founder of SafePath Solutions, a team-based program for adults and youth with personality disorders, aggression, and addiction (www.SafePath-Solutions.com). He was the Principal Investigator on a recently completed randomized clinical trial of Schema Therapy for forensic patients with personality disorders in the Netherlands.

Marjolein van Wijk-Herbrink

Marjolein van Wijk-Herbrink is a Dutch schema therapist who obtained her PhD in Schema Therapy with adolescents with severe behavior problems. She works in court-mandated, secure residential care, where she applies individual schema therapy, and trains and coaches youth care workers to work with Schema Therapy based principles and techniques. She is a member of the executive board of the Dutch Schema Therapy association.

Theodoor de Kraker

Theodoor de Kraker was raised in the Netherlands. He obtained is bachelor and master’s degree in psychology and neuropsychology at the State University of Groningen (2003). He started in the rehabilitation field with the training of executive functions with errorless learning principles. After this he moved to the south of the Netherlands. At RIAGG Maastricht het started to work with personality disorders. Inspired by his colleagues, who were schema therapists, he also started to follow Schema courses himself (2009).

From 2010 he worked in pioneer project of de Hoop GGZ, a small addiction treatment setting. There, he heard of the work of David Bernstein in the TBS setting with SafePath for the whole team and after while (2016) also the management of de Hoop Dordrecht embraced SafePath as important element of an integrated treatment for personality disorder (PD), trauma and comorbid substance use disorder. Nowadays he works in Dordrecht a clinical psychologist and treatment manager at 4life  (since 2021) in an inpatient setting of de Hoop, where he also played a key role in the implementation of Safepath.  

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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