1. health and fitness
2. therapy

Schema Therapy for Forensic Patients with Personality Disorders
Manual 5: “Management Manual”
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. Selection of forensic patients participating in ST………………………………… 3
1.1. Instruments used to assess (contra)indications for ST………………..3
1.1.1. Personality pathology……………………………………….….3
1.1.2. Axis I disorders………………………………………………… 4
1.1.3. IQ and neuropsychological impairment…………………....... 4
1.1.4. Cut-offs to determine indications and required expertise..…4
1.2. Selection procedure and discontinuation of ST……………………….. 5
1.2.1. Selection……………………………………………………...… 5
1.2.2. Timing…………………………………………………………....5
1.2.3. Discontinuation after the start of ST…………………………. 5
1.3. Engagement and motivation…………………………………………….. 6
1.3.1. Selection of offenders on the basis of motivation………...…6
1.3.2. Monitoring of motivation during the program………………...6
1.3.3. Getting sufficient patients to participate in ST…………….…8
1.3.4. Motivation of personnel and monitoring of this motivation… 9
2. Continuity……………………………………………………………………………...10
2.1. How does ST fit in the complete treatment approach?……….……….10
2.2. Patient guidance during ST and warranting of concurrent continuity..10
2.3. Criminogenic factors targeted in ST and addressed outside of ST…. 11
2.4. Attending to aftercare and relapse prevention in ST…………………..12
2.5. Maintenance of results obtained with ST………………………………. 14
2.6. Guidance in re-entering society and warranting follow-up continuity.. 14
2.7. Transfer, generalization, and durability of ST in other contexts……... 16
2.7.1. ST in other social contexts……………………………………. 16
2.7.2. ST in other institutional contexts………………….………….. 17
2.8. The duration of ST and aftercare……………………………………….. 18
2.8.1. Duration of ST……………………….…………………………. 18
2.8.2. Duration of aftercare…………………………………………... 20
2.9. Roles of professionals in concurrent and follow-up continuity………. 21
3. Intervention Integrity…………………………………...……………………………. 23
3.1. Means and facilities necessary for the implementation of ST……….. 23
3.2. Professional competencies required from the organization…………..23
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3.3. The organizational structure needed to implement ST……………….. 24
3.4. Selection, training, and supervision of ST therapists…………………. 24
3.4.1. Training…………………………………………………………. 24
3.4.2. Selection and competence……….…………………………… 24
3.4.3. Supervision, support, and continuity……….…………………25
3.5. The monitoring of patients……………………………………………….. 26
3.6. Implementation and monitoring the quality of ST………………….......27
References……………………………………………………………………………….29
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The purpose of this manual is to give institutions and treatment providers
direction in the implementation of forensic Schema Therapy (ST), providing guidance in
management decisions for ST patients in clinical or ambulant settings. First, we will
describe how to decide which patients are indicated for forensic ST and how patients’
motivation is addressed in its implementation. Then, we will give an outline of how ST
fits in the broader treatment context of forensic patients (i.e., “concurrent continuity”) and
of how its effects are warranted after treatment has ended (i.e., “follow-up continuity”).
Last, guidelines are given on how to safe-guard the quality of ST with respect to e.g.,
treatment integrity and the contextual conditions for successful implementation of the
program.
1. Selection of forensic patients participating in ST
As described in Theoretical Manual, the main indication for patients to start
forensic ST is the presence of a cluster B or Paranoid Personality Disorder (PD), or a PD
Not Otherwise Specified with 5 cluster B PD traits. Contraindications for ST include
comorbidity with a psychotic disorder, bipolar disorder, autism, and alcohol and/or drug
dependence. In addition, patients are contraindicated for ST when having a full scale IQ
of lower than 80. We refer to the Theoretical Manual for more detailed information on
these (contra)indications and a description of the rationale behind them. In order to
determine whether patients are indicated for ST, well-validated instruments should be
adopted. Below we discuss the types of instruments that should be used to screen and
select patients.
1.1. Instruments used to assess (contra)indications for ST
1.1.1. Personality pathology.
In our clinical trial on the effectiveness of ST,
patients were included if suffering from one or more of 4 PDs – Antisocial, Borderline,
Narcissistic, or Paranoid PD – or significant Cluster B traits, that is, Cluster B PD NOS
(operationalized by us as 5 or more Cluster B PD traits and no other DSM PD).
However, the indications for ST for forensic patients are broader, including any DSM-IV
PD or PDNOS (for more detail on the rationale behind the selection of PDs and
applicability of ST for other PDs, see the Theoretical Manual). The presence of DSM-IV
PDs might be determined using the SCID for Axis II Personality Disorders (SCID-II; First,
Spitzer, Gibbon, Williams, & Benjamin, 1994) or the Structured Interview for DSM-IV
Personality Disorders (SIDP-IV; Pfohl, Blum, & Zimmerman, 1995), which are semi-
3
structured interviews that assess PDs based on information provided by the patient
supplemented with collateral and dossier information. The interrater reliability of these
instruments has found to be very good in both forensic (e.g., Bernstein et al., 2012) and
nonforensic (e.g., Nentjes et al., 2013; Røysamb et al., 2011) samples.
1.1.2. Axis I disorders. The presence of Axis I disorders (except for ASS) is
preferably assessed using semi-structured methods as well, like the Structured Clinical
Interview for DSM-IV Axis I disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 1997).
Zanarini et al. (2000) found the interrater reliability of the SCID-I to be good to excellent;
test-retest reliability was also adequate for most disorders. A study by Lobbestael,
Leurgans, and Arntz (2011) revealed moderate to excellent interrater agreement of Axis
I disorders using the SCID-I. In order to determine whether a patient is suffering from an
ASS, multi–modal methods are recommended (e.g., patient and collateral informant
interviewing complemented with multiple observer ratings).
1.1.3. IQ and neuropsychological impairment.
Intelligence should also be
assessed using a psychometrically sound instrument, like e.g., the Wechsler Adult
Intelligence Scale–III (WAIS–III; Wechsler, 1997). In many TBS clinics, IQ is estimated
using all the scales of this measure, yet if for practical reasons test administration cannot
include a full WAIS-IlI, a shortened IQ test might be administered. For example, in our
clinical trial we have used a shortened version of the WAIS–III (based on the subtests
Block Design and Vocabulary, which correlates highly with IQs derived using all WAIS–
III scales; Jeyakumar, Warriner, & Raval, 2004). (See the Evaluation Manual, under
measures, for more details on other measures that might be used to assess other
variables that are relevant when treating forensic patients with ST, like psychopathy
level, predicted risk, and general symptomatology).
1.1.4. Cut-offs to determine indications and required expertise.
The cut–offs
used to determine the presence of the disorders that might constitute (contra) indications
for forensic ST are those described in the DSM–IV (American Psychiatric Association,
2000). The cut-off for intelligence a full scale IQ of > 80. In order to administer the
measures like those described above, a minimum level of expertise is required, including
being trained to reliably administer and score these instruments (e.g., reaching good
interrater agreement with other independent raters).
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1.2. Selection procedure and discontinuation of ST
1.2.1. Selection. When implementing ST in a forensic inpatient setting, one might
want to follow the selection procedure that we have adopted in our clinical trial on the
effectiveness of ST as a guideline (see the Evaluation Manual). In inpatient treatment,
such a process might entail a treatment coordinator clinically referring a patient on the
basis of the diagnostic procedures carried out in a clinic (i.e., on the basis of PD
pathology, sufficient cognitive functioning etc.). A patient is then approached by a ST
therapist, or another staff member that is knowledgeable about ST, who has a
conversation in which (s)he explained what ST entails, answers potential questions that
the patient might have about ST, and subsequently asks whether the individual would be
willing to start ST. (If a patient is unwilling to cooperate with any treatment, techniques
like motivational interviewing might be used [see below]). After this process, the patient
starts with his first ST session.
When implementing ST on an outpatient basis, one
might want to follow a similar process, in which patients are indicated for ST by an intake
team as part of the treatment process.
1.2.2. Timing. It ought to be possible for inpatients to start their initial ST session
three to four weeks after institutionalization, if sufficient resources are available (which is
very clinic dependent). However, the timing of ST might vary considerably, primarily
because of waiting lists caused by limited availability of therapists and varying patient
flow. Although ideally patients start psychotherapy as soon as possible, we believe that
ST will still be effective when given a while after the patient has entered TBS, as many of
these offenders are characterized by a long history of institutionalization to begin with.
1.2.3. Discontinuation after the start of ST.
There might be reason for
discontinuation of treatment after the start of ST. ST might be stopped when a patient
destabilizes, due to e.g., psychosis or mood disorders. In this case, attempts should be
made to stabilize the patient, so that after stabilization ST can be continued. Although
serious behavioral problems (like drug use or physical violence) might often times be a
reason to transfer an inpatient to a different forensic institution, ST generally tries to
address problems that might threaten treatment progress, providing the patient with
structural support to stop self–defeating behavior and to make adjustments in order to be
able to stay in a setting. Using ST, attempts should be made to address factors that
hinder treatment progress by conceptualizing lack of motivation and trouble engaging in
5
therapy in terms of Schema Modes, using techniques to flip patients into more
productive modes (see the Program Manual, for more detail on these techniques).
Because of the severity of the problems in many forensic PD patients, ST therapists
should fully engage in this latter process in a sustained effort to get patients to
cooperate. This latter process might even form one of the initial focuses of ST for many
patients. If, however, after 1.5 to 2 years little progress has been accomplished after
extensive efforts to overcome blockages, ST might have to be stopped.
1.3. Engagement and motivation
1.3.1 Selection of participating offenders on the basis of motivation.
As
described earlier (see the Theoretical Manual), patient motivation is not a
(contra)indication for forensic ST. In ST, motivation is seen as a dynamic rather than a
static concept (Drieschner, Lammers, & van der Staak, 2004), and stuck points in
therapy are conceptualized in terms of unproductive Schema Modes. In addressing
motivational issues, therapists use techniques in which reference is being made to these
emotional states in order to achieve therapy progress (see the Program Manual for a
description of these techniques). In this way, it is expected that over the course of
therapy modes will still fluctuate, yet, these fluctuations will get lesser in frequency and
intensity. In a sub-study in our RCT on the effectiveness of ST (see the Evalution
Manual for more detail on this RCT), for example, we are currently rating the modes of
several participating patients over three phases of therapy (3, 18, and 36 months). Of
each patient, the modes that occur within five videotaped therapy sessions of each
phase are rated using the Mode Observation Scale (Bernstein, de Vos, & van den
Broek, 2009). Over time we expect modes to be still fluctuating more or less around the
mean of the particular phase in therapy, yet we expect patients’ mean scores (of the five
tapes within each phase) on maladaptive modes to go down, and healthy mode scores
to go up as therapy progresses.
1.3.2. Monitoring of motivation during the program. An first important element of
therapists’ monitoring of patients’ motivation lies in attending to the therapeutic setting
and boundaries (i.e., “the frame of therapy”), such as the meeting time, the frequency of
therapy, what the arrangements are when a patient misses a session etc.
Patient
behaviors that have to do with the frame of therapy can be an indication for a change in
motivation, for example, when a patient misses sessions, does not come one time,
6
frequently asks for special favors etc. The ST therapist monitors such indications, and
conceptualizes them in terms of Schema Modes. For example, a patient tries to
manipulate the therapist into getting certain privileges could be reflective of the “Conning
and Manipulative Mode,” which the therapist can then address (see the Program Manual
for the techniques used to do so).
Secondly, patients’ motivational levels can be reflected in the therapeutic working
alliance, which has consistently found to be related to client’s motivation (e.g., Taft,
Murphy, Musser, & Remington, 2004) and is predictive of treatment outcome over a
variety of disorders and therapy schools (Horvath & Symonds, 1991). We teach our ST
therapists to be aware of these associations, stressing the importance of monitoring
changes in alliance as a means to keep track of patients’ motivation. A widely used
conceptualization defines this alliance, or therapeutic relationship as consisting of a)
agreement on the tasks assigned to both therapist and client, b) agreement on the goals
of therapy, and c) a strong emotional bond of mutual trust, acceptance, and confidence
(Bordin, 1979; Horvath & Greenberg, 1989). The therapist should monitor these three
aspects, and if the alliance seems deficient in some way, the ST therapist should also try
to conceptualize these obstacles in terms of Schema Modes. For example, when a
patient doesn’t want to engage in an experiential or behavioral exercise (i.e., a task of
ST), or when the patient has trouble trusting the therapist (interfering with the bond), the
therapist examines which mode(s) block the patient’s trust and willingness to carry out
exercises.
The therapist may want to use standardized assessment methods for the
assessment of the alliance, like the Working Alliance Inventory (Horvath & Greenberg,
1989).
We do not suggest that the use of such instruments is a requirement for
monitoring the therapy relationship in ST, yet it may enhance therapists’ ability to do so.
We do stress the importance of regularly assessing patients’ modes over the course of
therapy, using measures that tap into patients’ Schema Modes, e.g., the Schema Mode
Inventory (SMI; Lobbestael et al., 2010) in order to structurally asses the modes that
may underlie motivational issues, as these are the direct target of ST.
Although we do not have data on how forensic patients’ motivation is related to
therapy progress yet, our clinical trial will enable us to look at this relationship. That is,
in our RCT, a variety of measures of psychotherapy process variables are administered
to both patient and therapist (i.e., the Working Alliance Inventory, Horvath & Greenberg,
1989; Difficult Doctor-Patient Relationship Questionnaire – Ten item version, Hahn,
Thompson, Wils, Stern & Budner, 1994; the Treatment Motivation Scales for Forensic
7
Outpatient Treatment, Drieschner, 2005; the Treatment Engagement Rating Scale for
Forensic Outpatient Treatment, Drieschner, 2005). The measures are given in the early
(3 months), middle (18 months), and late (36 months) phases of therapy, enabling us to
investigate the relationship between clinical therapy progress variables (e.g., PD
symptoms, Schema Modes, recidivism risk) and motivation.
Indirect evidence that supports the notion that ST adequately motivates patients
to engage in therapy is its low drop-out rate. There is substantial evidence that PD
diagnoses are associated with elevated drop-out rates from a variety of therapies (e.g.
Gibbon et al., 2010; Miller, Brown, & Sees, 2004).
Keeping this in mind, the high
retention rates of around 75% that have been achieved with long term ST in nonforensic
patients with PDs are the more impressive (Bamelis & Arntz, 2012; Giesenbloo et al.,
2006).
Similarly, in our own preliminary sample of 30 forensic ST patients, only 3
(18.8%) of the ST patients dropped out (versus 5 of the TAU patients [35.7%]; Bernstein
et al, 2012), suggesting that the forensic adaptation of ST is successful in motivating and
retaining patients.
1.3.3. Getting sufficient patients to participate in ST. As forensic patients can
often times be very distrustful, it is especially important to be clear and transparent about
the goals and tasks of ST, and to give patients sufficient opportunity to ask questions
before and during therapy. Apart from that, we think that ST in itself is an effective
means to keep patients to participate in treatment. As mentioned earlier, ST has proven
to be successful at retaining nonforensic patients with borderline PD (Giesen-Bloo et at.,
2006), as well as with cluster-C, Paranoid, Histrionic and/or Narcissistic PD (Bamelis &
Arntz, 2012).
We believe this low drop-out to be at least partially dependent on the
nature of ST in that it is successful in fostering an attachment bond between therapist
and patient. Evidence for this notion comes from a study by Spinhoven and colleagues
(2007), who demonstrated the therapist and patient rated alliance to be significantly
higher in ST than in a psychodynamic form of psychotherapy. In turn, growth of the
therapeutic relationship was identified as an important mediating mechanism in the
reduction of BPD pathology. In working with forensic patients, we consider it to be
especially important to maintain a sufficient level of motivation through the working
alliance in order to be able to give patients a sufficient dosage of ST for it to have
beneficial effects, and to prevent patients from dropping out.
8
Another reason to believe that getting sufficient patients to participate in ST
should not be a problem is that in inpatient contexts, there is an incentive for patients to
participate in therapy: forensic patients know that engagement in therapy is necessary
as a means to re-entry the community at some point, as this will only take place if they
cooperate and are judged to have improved. In our ongoing RCT on ST, very few
patients have refused to take part or have dropped-out. However, we recognize that the
TBS inpatients population will likely shrink, creating a shift from inpatient treatment to
treatment in alternative contexts, like prisons or ambulant settings. We do not have any
data on ST’s drop-out rates in such institutions. Therefore, we will have to potentially
look at the institutional issues in these different settings in order to make adjustments to
the ST approach so as to assure sufficient patient retention.
1.3.4. Motivation of personnel and monitoring of this motivation
Given the challenges of learning ST and working with forensic patients with
severe PDs, we stress that therapists’ regular supervision or peer supervision sessions
are necessary to ensure the effective delivery of ST in forensic settings (Bernstein et al.,
2007). These meetings are extremely important in order to monitor, guide, and support
therapists, to warrant continuity in the delivery of ST, and to enable therapists to do their
job effectively.
As an example, in our RCT, therapists receive supervision on a bi-
weekly basis, during which their potential motivational issues are addressed. A striking
observation that we have made within our research project is that very few of the
therapists who have completed the forensic ST training program have discontinued their
involvement with forensic ST or left the setting in which they are treating patients. In our
RCT, we have had very few instances in which therapists had to be replaced. Anecdotal
evidence suggests that therapists consistently refer to ST as a means to keep them
motivated in the treatment of this difficult patient group, as well as supplying them with a
feeling of being more self-efficacious as a therapist.
Being nonspecific factors that
influence therapy, this self-efficacy and feeling of optimism that ST realizes are likely to
have a beneficial effect on patients. In our experience, ST seems to prevent therapist
burn-out, as well as to keep therapists feeling effective and engaged, which is very
important as therapist continuity is essential in forming an attachment relationship with
the patient.
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2. Continuity
2.1. How does ST fit in the complete treatment approach of the patient?
From a larger perspective, ST needs to be viewed as part of a trajectory of
treatment, an integrated part of a larger whole. This includes embedding ST in the
institutional contexts within which the therapy is delivered. This creates the ability to
transfer ST from an individual form of therapy to one that includes the entire therapeutic
milieu (i.e., ensuring concurrent continuity). For example, it is recommended that the ST
therapist presents the rest of the treatment team with patients’ case conceptualizations,
teaching other staff members to understand and discuss patients’ problems in terms of
Schema Modes.
This conceptualization can be mapped onto treatment indications
creating a shared focus for treatment. ST is also embedded in the institution, in that the
ST therapist uses the situations that patients deal with on a daily basis (i.e., conflicts with
other staff members or patients) as a basis for therapy. E.g., patients learn to identify
what types of situations trigger their modes, and later on in therapy, situations outside of
the therapy are used for behavioral experiments (see below, for more detail on this
embedding of ST in the overarching setting).
2.2. Patient guidance during ST and warranting of concurrent continuity
In forensic clinics, the responsibility for patients’ treatment usually lies with a
head of the treatment team (“hoofd behandeling”), whereas more daily coaching is
provided by psychiatric nurses (“socio-therapeuten”), one of which often times is a
patient’s primary mentor.
When implementing ST, it is recommended for the ST
therapist(s) to be getting a key role in the treatment process. (S)he provides the patient
with supervision in identifying and changing maladaptive behavioral patterns, which can
be done on the basis on the day to day interactions that the patient has within the
institution. We encourage the ST therapist to be a coach to the treatment team and to
school the team in the language of ST. The ST therapist presents the team with the
case conceptualization in which patients’ risk factors are conceptualized in terms of
Schema Modes, teaching the staff to understand patients’ problems in terms of ST
language and creating a shared focus for all the staff involved with a patient. In this way,
a common language is provided which the therapist can use to guide the treatment team
in their interventions in their daily interaction with a patient. In that sense, the therapist
plays an important role in overseeing the complete treatment, facilitating the continuity of
the treatment focus.
10
This approach also applies to other components of the patient’s treatment that
are guided by (para)professionals that do not necessarily have a therapeutic
background.
therapy).
An example would be conducting work within the clinic (vocational
Many patients have problems with adequately functioning in a working
environment, which means that such situations provide them with learning opportunities.
If a clinic is well coordinated, information on patients functioning and interaction in such
situations is communicated to the ST therapist, who uses this information to help the
patient understand the Schema Modes that block successful functioning in this situation.
Moreover, the therapist helps the patient to develop more healthy strategies to use in
similar situations.
In this manner, a variety of different aspects of patients’ life and
activities in the clinic can provide the interactions that can be used as practice and
learning experiences discussed in ST.
We recommend the ST therapist(s) to be given an explicit facilitative role in
communicating with the range of individuals that work with the patient in these different
situations, ensuring effective supervision of the patient by these other staff members.
Over time, we have observed more effective collaboration (“teamwork”) between the
various disciplines within institutions (e.g., nurses, psychotherapists, creative therapists),
and within each specialized treatment unit. Moreover, psychiatric nurses report greater
feelings of efficacy and more manageable counter-transference reactions, resulting in a
more supportive and less punitive stance towards patients.
Over time, these
developments contribute to a more positive atmosphere on the treatment units for both
patients and staff.
We have not yet conducted systematic research on the
implementation of ST; however, systematic evaluation of ST program implementation is
clearly indicated, as it provides a model that can be copied by other institutions.
2.3. Criminogenic factors targeted in ST and addressed outside of ST
In the context of generalizing the effects of ST after therapy has ended (i.e.,
ensuring follow-up continuity), we make a distinction between internal and external
dynamic risk factors. In ST, internal risk factors are conceptualized as dysfunctional
Schema Modes, which constitute the direct focus of treatment (see the Theoretical
Manual for more detail on this conceptualization). However, in order to prevent patients
from recidivating, it is also necessary to counteract the effects of external risk factors,
such as a social network in which the patient is confronted with criminals and drug users,
and stressors like poverty, homelessness, unemployment, stress brought about by
11
interaction with family and within relationships, and barriers to services like psychiatric or
psychological help.
In terms of these risk factors, ST operates in a more indirect
fashion, by virtue of changing the maladaptive modes that give rise to the amplification
of external risk factors, and by strengthening the healthy modes that protect the patient
from such influences. For example, after inpatient treatment, patients will inevitably be
confronted with stressful, difficult situations in the context of e.g., trying to obtain custody
over a child or experiencing frustration over unemployment and having to work with job
service agencies. ST teaches the patient to deal with the frustration that these types of
situations can trigger by decreasing the intensity of the maladaptive modes that would
normally be evoked (e.g., “Angry Child Mode” in which the patient feels and expresses
uncontrolled anger or rage in response to the feeling of being treated unjustly, Bernstein
et al., 2007). In addition, ST enhances the healthy side of the patient, by teaching him to
be patient and persistent in such stressful encounters, and not allowing himself to derail
and let situations escalate. In that way, ST has an indirect effect that can mitigate
external risk factors and potentiate protective factors, supporting follow-up continuity of
its effect.
We see that in order to warrant complete follow-up continuity of care for these
patients, it would be desirable to address external risk factors more directly after ST has
ended. However, we believe that this is beyond the scope of forensic inpatient ST and
should rather occur on a societal, systemic level. Whether this can happen is very much
dependent on factors like budgets in social services, financial circumstances, where the
patient comes to live, subtle influences of discrimination and stereotyping, etc. In order
to manage such criminogenic factors, these might have to be addressed by a
caseworker that would e.g., help the patient move to another locality away from the
patients’ criminal network, or that would facilitate contact with needed social services.
Such a direct influence on risk factors operating on patient’s environment would happen
outside of ST.
2.4. Attending to aftercare and relapse prevention in ST
In Dutch forensic clinics, the “resocialization” phase (which entails the gradual
reintroduction of the patient into the community) provides a bridge to patients’ aftercare.
As patients begin to go through resocialization, forensic ST increasingly focuses on
aftercare and relapse prevention planning. One aspect of treatment in the majority of
forensic clinics, is making a crime scenario analysis to base relapse prevention planning
12
on.
In ST, a patient’s crime scenario is explained in terms of Schema Modes and
triggers for these emotional states, forming the basis for the development of relapse
prevention plans. The therapist teaches the patient to recognize risk factors (Schema
Modes), and together with the therapist the patient begins to develop strategies to
address these risk factors. For example, if a patient has a strong addiction history,
relapse would focus on Schema Modes that represent risk factors for relapse. The
patient could e.g. be characterized by a pattern of getting involved in relationships with
dependent and unstable women, based on modes that represent the need for control.
Such relationships might have initiated a cycle where the patient and his partner, due to
the emotionally unstable nature of the relationship, both start to rely on alcohol and
drugs, resulting in the patient’s aggressive behavior.
In ST, relapse planning is
incorporated by having the therapist help the patient to identify such risk factors and
guide the patient in developing the capacity to choose for more healthy alternatives,
thereby avoiding such external risk factors in the future.
The Schema Mode conceptualization of a patient can also guide in choosing
appropriate aftercare. The type of support that patients would get within such aftercare
would be dependent on the type of problems that are salient for the patient.
For
example, if a patient’s criminal history involves being easily triggered in interactions with
other drug or alcohol users, resulting in violence and anger, this patient might not benefit
as much from treatment programs in which he is confronted with other addicts like e.g., a
twelve-step program in the context of relapse prevention. Such a program might put the
patient at risk for getting into situations similar to his crime scenario.
Rather, an
aftercare program might be preferred that has explicit and ongoing attention to the social
network of the patient, based on the people that he encounters there, as there is ample
evidence that healthy social networks play an important role in relapse prevention and
resocialization (e.g., Douglas & Reeves, 2010).
Another example of tailoring aftercare based on the Schema Modes that a patient
is characterized by is that of BPD patients who maintain to have difficulties in their daily
functioning due to a strong genetically based instability in their emotional regulation.
Even though PD pathology and risk have gone down over the course of inpatient
treatment, issues like instability in relationships, impulsivity and affective dysfunction
(conceptualized in terms of Schema Modes) can remain salient for these patients. In
these cases, aftercare should focus on these issues and help the patient to create
structure in his environment.
Relapse planning could in such a case also include
13
choosing
more
traditional
interventions
on
the
basis
of
patients’
schema
conceptualization, like daycare.
For patients who were institutionalized because of a diagnosis of Antisocial PD
(ASPD) or psychopathy, a particular concern that should be paid attention to in aftercare
is patients’ potential exposure to antisocial networks, which includes involvement in
antisocial activities in a covert way (i.e., having a hidden agenda; i.e., Conning and
Manipulative Mode, Bernstein et al., 2007). Recent research shows that a high-quality
bond between community correction officers and offenders is an important predictor of
offenders’ deterrence from criminal recidivism, protecting from re-arrest in both offenders
with and without personality pathology (Kennealy, Skeem, Manchak, & Eno Louden,
2012). A specific recommendation for ASPD patients would therefore be to provide the
patient with a (para)professional outside of the clinic who the patient can generalize his
attachment bond with his therapist to. Ideally, probation and parole officers would be
familiar with the concepts of ST in order to facilitate continuity of care and relapse
prevention as much as possible.
2.5. Maintenance of results obtained with ST
During ST, the therapist helps the patient as much as possible in developing the
abilities to make healthy choices after inpatient treatment has ended. Like described
before, this would include choices that enhance protective factors available in the
patient’s environment. Of course, only some of this process can be achieved by the time
the patient leaves the clinic. On the one hand, ST in the clinic can help to strengthen
patients’ capacity to make sound choices. Risky situations during resocialization can
provide the patient with opportunities in which these skills can be applied and further
developed. On the other hand, continued counseling in the form of e.g., ambulant ST
could be important in supporting and maintaining new skills, especially those needed to
deal with everyday life outside of the clinic, in that manner lowering patient recidivism.
2.6. Guidance in re-entering society and warranting follow-up continuity
Follow-up continuity becomes more challenging once the patient no longer falls
within the jurisdiction of the institution in which he received ST, for example, when he is
transferred from a TBS clinic to an ambulant, outpatient clinic, or is placed under the
supervision of parole or probation. These transitions can be periods of increased risk for
recidivism, because of the loss of institutional support.
Thus, maintaining and
14
strengthening gains from ST during and after these transitions is clearly warranted. In
some cases, patients can be transferred to outpatient facilities where they can continue
ST with a new therapist, if further therapy is indicated. We believe that PD patients in
general, especially those who already got ST, would benefit greatly from such continued
care with ST in an ambulant setting. However, in some cases, this is not possible to
arrange.
We haven’t developed guidelines of what aftercare should look like after inpatient
forensic ST, yet, if one were to develop such guidelines these should be evidence-based
on what we know about the risk and protective factors after release. That is, on the
short-term, aftercare should focus on factors like education and work, housing, and
financial stability (Nicholls, Brink, Desmarais, Webster, & Martin, 2006), and, on the long
run, on the development of a prosocial network and avoidance of criminal social
influences (Douglas & Reeves, 2010). The planning of such reintegration (e.g., housing,
social support) has found to be essential in preventing recidivism (see Willis & Grace
[2008] for an example in sex offenders). In general, guidelines for case-managers that
work with the patient after discharge should focus on the awareness and facilitation of
these factors and should prescribe case-managers to perform regular risk assessments
using psychometrically sound methods, monitoring risk and protective factors in a
structural way so that quick and effective intervention is enabled when necessary.
Ideally, caseworkers are trained to have a basic understanding of the ST concepts so
that after patients have received inpatient ST, caseworkers can continue to talk about
patients’ potential risk factors and problems in terms of Schema Modes. When adopting
a compassionate stance towards the patient, in which a caseworker uses techniques like
limit setting and tries to understand patients’ problems in terms of Schema Modes, the
patient can generalize the attachment bonds that he formed with his ST therapist in
inpatient treatment to the case-worker, facilitating re-entry into the community.
To facilitate greater continuity of care for ST patients, Bernstein and colleagues
are developing a “self-help” model which makes ST accessible to offenders, their
families, and the people who work with them, as offenders re-integrate into the
community. The idea is to spread ST concepts via easy to use materials, such as selfhelp books, websites, and DVDs, which are specifically targeted to offenders and those
in their social networks. In addition, training programs would be created to teach basic
ST skills to non-professionals.
For example, training parole officers in basic ST
concepts and practices can provide continuity of care for ST patients who have
15
completed treatment, but are still under supervision.
Similarly, organizations that
provide outreach to offenders and their families could offer training courses in ST “selfhelp.” Such programs could be of great benefit to families who struggle to help exoffenders reintegrate into society. Because the ST “language” is easy to understand, it
can be readily taught to non-professionals. Thus, ST can become a medium which
makes greater continuity of care possible for offenders. David Bernstein and a Swiss
psychiatrist, dr. Dorothee Klecha, are completing work on a ST self-help book, which
they plan to pilot test in 2013. The book addresses the problems faced by offenders; it is
written in a simple, conversational style, using the “language” of Schema Modes. The
development of an ST self-help model could have significant benefits for offenders who
often “fall through the cracks” of the forensic system, when they leave detention.
2.7. Transfer, generalization, and durability of ST in other contexts
2.7.1. Transfer, generalization, and durability of ST in other social contexts. As
previously described, the patient and his ST therapist continually work together in using
all situations that the patient encounters on a daily basis to learn and develop new
insights and coping strategies. When the patient encounters difficulties outside of the
therapy, the therapist uses these examples to, together with the patient, identify the
Schema Modes that stand in the way of adequate functioning in interpersonal situations.
In this way, the patient’s activities in the clinic form the “grist for the mill” of ST, enabling
the patient to develop new skills to deal with such encounters.
For many forensic
patients, for example, Schema Modes that reflect distrust are highly salient. During the
first 1 to 1.5 years of therapy, ST focuses on the therapy relationship, slowly developing
trust. After this period, part of ST is to generalize this trust to other social relationships
that the patient has in the institutional environment e.g., a socio-therapist or treatment
coordinator.
The ST therapist makes the patient understand distress in these
relationships in terms of Schema Modes.
For example, when a patient has had a
conflict with someone, and avoided the situation as a means of coping, the therapist
might encourage the patient to engage in a behavioral experiment.
In such an
experiment, the patient would be motivated to approach the other person and talk about
the assumptions that underlie his avoidance behavior, like the notion that the other is not
interested in him, in order to correct such mistaken perceptions.
In this way, ST
functions as a platform that can be used to generalize the trust that has grown in the
therapist, to other individuals (i.e., concurrent continuity).
16
In the third year of treatment with ST, the patient is typically triggered more often
as he is going through resocialization. In this phase, he is being increasingly confronted
with stressors outside of the institution, e.g., in his relationship with family members or
when trying to start a romantic relationship. This phase opens up new issues for inquiry
that did not occur inside of the clinic yet. ST thus makes the resocialization process
more effective by teaching the patient to deal with situations when he is exposed to risk
factors that got him into trouble in the past (i.e., teaching the patient more adaptive ways
of coping and reducing the maladaptive Schema Modes that get triggered). By working
with these situations, ST supports follow-up continuity by teaching the patient to reduce
(the impact of) such risk factors and provides him with the means to further build up
protective factors conceptualized as healthy Schema Modes.
2.7.2. Transfer, generalization, and durability of ST in other institutional contexts.
There are many different components to the forensic system, e.g., prisons, inpatient
clinics, and outpatient addiction treatment programs. Ideally, ST will be increasingly
applied in this systemic context. One of the most significant contributions that forensic
ST could have is that it can facilitate continuity of care. In general, ST has the potential
to provide a linchpin function that combines a variety of forensic services to one another.
Introducing a common sense of concepts used to deal with the problems encountered in
forensic populations would provide greater coherence and continuity across context and
settings. Such a shared language would enable (para)professionals across different
settings to pick up treatment and/or supervision of forensic patients where treatment in a
previous context left off, supporting a continuum of care.
Already, many professionals
who are currently being trained in forensic ST are working in ambulant settings. The
spreading of this expertise allows patients to be treated according to the ST model in
their aftercare.
Another development that supports the multi-systemic implementation of forensic
ST is the fact that it is increasingly being offered in prisons. E.g., ST has already been
successfully implemented in a women’s prison population in Bern, Switzerland. Usually,
therapists in these types of settings have experience in the general mental health
system, yet have relatively little forensic training. Training therapists in the correctional
system in forensic ST could enhance the effectiveness of their work by teaching them a
framework that is directly linked to the problems they encounter with their patients on a
17
daily basis, and which provides them with interventions that have shown to be effective
in dealing with such issues.
Not only could ST provide therapists in the correctional system with a way of
treating offenders, it could also be a promising approach for prison guards. Part of the
reasoning behind this is that prison environments can include rather toxic interactions
between inmates and staff. ST could help to detoxify these interactions by teaching
guards to understand the behavior that inmates display in a more compassionate, nonjudgmental way, teaching guards alternative ways of intervening. In this way ST could
create a more benign environment by changing the punitive and controlling approach
that guards often times adopt reflexively. Not only would ST facilitate the fulfillment of
basic human values in this manner, it might potentially lower the risk of institutional
violence and recidivism at the time of release. Research supporting this notion shows
that the social climate in a prison has an impact on the behavior of violent offenders
(Cooke, 1992) and that correctional staffs’ interpersonal style (e.g., the use of pro-social
modeling) has been related to a lowering in criminal recidivism (Trotter, 1996). Ideally,
prisons will adopt ST programs that prepare prisoners to leave incarcerated settings.
Such a re-entry model would not only involve ST during incarceration, but also the
involvement of, e.g., parole and probation officers, as well as family members of the
patient or prisoner by familiarizing them with the ST model.
In fact, starting in April
2013, ST will be taught to a group of prison guards in “Penitentiaire Inrichting
Veenhuizen”, the Netherlands.
2.8. The duration of ST and aftercare
2.8.1. Duration of ST. As was described in the Theoretical Manual we
recommend ST for forensic patients with PDs to be delivered for three years, starting
with a frequency of two times per week. Part of the justification for this duration comes
from the changes we see in patients during different phases of ST. What we notice is
that most of the patients enrolled in our study enter therapy while in the high risk
category of the Historical, Clinical and Risk management schema (HCR-20, Douglas &
Webster, 1999), and that most of them shift into the medium category over
approximately the first 18 months of therapy. It is during this period of time that the ST
therapist persistently focuses on modes that are in the way of developing a therapeutic
relationship, such as the “Detached Protector Mode” (in which the patient uses
emotional detachment to protect oneself from painful feelings and avoids getting close to
18
anyone; Bernstein et al., 2007), and tries to reach more vulnerable modes of the patient.
In the second 1.5 years of the three year treatment, we see a further diminishment in
patients’ risk levels. We also so see though, that this not a monotonic trend, yet that
there are ups and downs in this attenuation in risk, which is reflected on patients’ scores
on short term risk assessment instruments like the Short Term Assessment of Risk and
Treatability (START; Webster, Martin, Brink, Nicholls, & Middleton, 2004; Webster,
Martin, Brink, Nicholls, & Desmarais, 2009). After a period of being described by the ST
therapist and other staff members as being cooperative, forensic patients receiving ST
often times show some changes in their behavior when moving into the last part of their
therapy in which the resocialization process takes place.
That is, as patients are
transitioning from the protective environment that the clinic has provided them with into
the world outside of the institution, they encounter new challenges, like interacting with
their family or a partner, getting back into the work field, the temptation of drugs, and
being exposed to their criminal network. During this phase, patients are more easily
triggered and may be increasingly involved in incidents as they try to deal with the
exposure to these external risk factors. Such new encounters are considered to be very
important in the ST treatment process, as they provide opportunities for the patient to
practice the skills that he learned in ST, as well as to identify new triggers for his
Schema Modes.
As it is outside of the clinic where the patient eventually has to
function, the use of these “practice” situations in ST are considered to be essential in
relapse prevention, with the ST therapist guiding the patient in finding and practicing
adaptive ways of dealing with environmental stressors. It is this last phase of ST that we
feel is a big part of the justification for offering forensic PD patients a full three years of
therapy.
There is anecdotal evidence that the combination of ST-based group therapy
offered in combination with individual ST can speed up treatment progress in forensic
patients.
The treatment for personality disordered offenders in Rampton Hospital
(Rampton, United Kingdom) for example, treats patients with a combination of group and
individual psychotherapy sessions (both ST based and provided once a week) for a
duration of 18 months, with which good results have been reported. It could be that the
success of this program is due to this treatment population suffering from less severe
psychopathology. However, it could also be that the most important element in offender
treatment is practicing and generalizing the skills that have been learnt in therapy in a
the context in which the patient will be confronted with real life risk factors. A parrallel
19
can be drawn here to the field of addiction treatment, as research has shown outpatient
(after)care for alcohol and/or drug using offenders not to be any less effective than the
often times more controlled inpatient treatment programs (e.g., Burdon et al., 2007;
Hser, Evans, Huang, & Anglin, 2004). It could thus be that when ST is provided in
ambulant settings it proves to be equally effective within a shorter period of time. The
effects of the duration and dosage of ST on treatment outcome, however, have not been
systematically evaluated. Therefore, RCTs should ideally be set up that investigate the
differential effectiveness of in- versus outpatient settings on ST’s effectiveness, as well
as the influence of offering ST in an individual versus group based fashion.
2.8.2. Duration of aftercare. We cannot with certainty state how long forensic PD
patients’ aftercare should go on for after release from a forensic psychiatric institution.
The patient group that we are targeting with ST (see Theoretical Manual) have an
increased risk to recidivate in comparison with those patients that do not have a PD
(Hiscoke, Långström, Ottosson, & Grann, 2003; Yu, Geddes, & Fazel, 2012), and among
these patients, especially those with an additional diagnosis of psychopathy are more
likely to reoffend (Hemphill, Hare, & Wong, 1998).
Literature suggests that the longer
these types of forensic patients desist from crime, the more their risk levels attenuate,
with risk reduction continuing particularly during the first three years following release
(e.g., Grann, Langstrom, Tengstrom, & Kullgren , 1999). We could therefore imagine
that these first three years following discharge would be critical ones to invest in helping
the patient to keep his environment as stable as possible, offering continued monitoring
and support. We believe it would be very beneficial for the ease with which patients’
transition from an institutionalized setting into outpatient care if this continued support
would take the form of ambulant ST. If this would not be feasible, some other type of
aftercare should warrant the monitoring of early signals, guiding the patient when he is
exposed to risk factors that trigger inadequate coping strategies. Continued monitoring
during the time after release should facilitate the availability of necessary resources in
some way or another.
As the risk levels of non-recidivating patients seems to gradually diminish over
three years, it might logically be expected that aftercare is not as crucial for patients that
reach a certain level of stability over this period, characterized by the presence of
protective factors like functioning within a prosocial network and having a relationship
with a person that does not suffer from major psychopathology or uses substances.
20
These notions are, however, somewhat speculative and need further empirical
investigation, as can be achieved through our RCT on the effectiveness of forensic ST.
2.9. Roles of professionals in concurrent and follow-up continuity
When implementing ST in forensic settings, an illustration from our RCT could
function as an example of role division in the process of concurrent and follow-up
continuity. For the implementation of ST in various clinics for our clinical trial, there are
agreements that we made between the treatment coordinator (“hoofd behandeling”), the
patient’s ST therapist, and his caseworker (who is usually one of the psychiatric nurses
that takes the role of the patient’s daily coach).
The treatment coordinator and
psychiatric nurses are informed about the goals of ST in two different ways. First, in
some clinics, we have given two-day ST trainings for treatment coordinators and
psychiatric nurses in understanding the basics of ST. More specifically, this training for
non-psychotherapists consists of a theoretical explanation of the Schema Mode model,
practicing in identifying Schema Modes in real life situations, as well as practicing some
basic ST interventions (such as limited reparenting, empathic confrontation, and limit
settings). The emphasis in this two-day program lies on putting ST into practice in the
situations that these staff members encounter with patients on a daily basis. Not only
does this training provide other staff than the ST therapists with a clear sense of the
goals of ST, it also provides the treatment team with a common language to discuss
patients’ problems and progress.
A second way in which staff is informed about ST is by having the ST therapist(s)
providing ongoing consultation about patients with the treatment team. In the early
phase of a patient’s treatment, the ST therapists makes a case conceptualization using
instruments like the Schema Mode Inventory (Lobbestael, et al., 2010) in which a
patient’s risk factors and problem behaviors are conceptualized in terms of Schema
Modes. As described earlier on, this conceptualization is subsequently presented and
explained to the treatment team. The treatment goals that have been implemented by
the team are then translated in Schema Mode concepts by linking them to the case
conceptualization, integrating ST in the overall aims of treatment.
E.g., when the
indication for treatment is patients’ anger regulation problems, the ST therapist might
translate the goal of treatment in reducing the “Angry Child Mode” by teaching the
patient to tolerate and handle situations that provoke anger. Every six months, the ST
therapist comes back with such a Schema Mode conceptualization as a basis for
21
collaboratively refining a patient’s treatment goals with the treatment team. In addition,
and depending on the forensic institution, the ST therapist might also act as a coach for
the treatment team. That is, once every one or two weeks, the therapist meets with the
treatment team for a coaching session in which psychiatric nurses have the opportunity
to present different situations that they have encountered with patients. In order or deal
with these situations in a more effective way, the ST therapist can e.g., use role playing
exercises to practice the implementation of ST interventions.
Over recent years, ST has increasingly been implemented in other types of
therapy for forensic patients. For example, forensic art and drama therapists have been
trained in the use of ST, providing ST through the form of these therapy modalities. The
main reason for why the combination of individual ST with creative ST therapy is
effective, it that creative therapy is an effective medium to reach emotional states in
forensic patients with PDs, many of which are characterized by high levels of emotional
detachment. In the case where a patient also receives either arts or drama ST, the
therapist that gives him individual ST also coordinates efforts with the creative
therapist(s). In Forensic Psychiatric Center (FPC) the Rooyse Wissel, ST has been
successfully implemented in such a multimodal way, with patients receiving individual
and creative ST therapy, as well as using schema mode language to talk with their
“mentors” (Kersten & de Vis, 2012).
At this moment, there have not been made any formal arrangements in
transferring patients who receive ST in forensic inpatient settings to other organizations,
beyond the transfer of information that normally takes place. For the future, it would be
a good idea to create such arrangements; ideally, there should be communication
between the inpatient facility and ambulant aftercare, in which the “Forensisch
Psychiatrisch Toezicht (FPT)” could play an essential role. We believe transfer could be
very much facilitated when both inpatient settings, as well as ambulant treatment
contexts provide ST.
22
3. Intervention Integrity
3.1. Means and facilities necessary for the implementation of ST
Materials that are needed to implement ST include recording material such as a
video camera in order to enable therapists’ competency ratings (see below). The major
financial costs associated with the implementation of forensic ST concern the costs for
training of ST therapists, paying for on sight supervision of ST therapists, the costs of
independent evaluations of practice therapy tapes by independent ST experts (see
below), and making the time available for biweekly supervision of therapists. Some
additional financial means might be necessary when the ST therapist takes the role of
supervising a liaison between different members of the treatment team (e.g., functioning
as a coach for psychiatric nurses, mentoring them in dealing with difficult interactions
with patients using Schema Mode concepts).
Based on our RCT on ST (see the Evaluation Manual), the estimated costs
involved in the training and supervision of a ST therapists over a three-year course are
approximately €5403,-. The full-time salary costs of a senior ST therapist, over and
above the costs of a “treatment as usual” therapist (taking into account the
recommended biweekly frequency of ST vs. the delivery of weekly therapy in TAU) is
estimated at €14989,-. It has to be noted that a trained therapist can obviously see more
than one patient, which would not change these financial estimates. The training and
supervision costs are fixed, yet the salary costs are high-end estimates, as they are
based on the salary of senior therapists. The actual costs of salary will depend on the
years of experience that a therapist has, as well as on the institution where a therapist
works.
Over the past years we have had extensive experience in the implementation of
forensic ST in the context of our RCT. Typically the costs of training and supervision
have been paid by the clinic or have been shared between therapist and clinic. It is not
unusual for therapists that go through training and education via the VGCT or other
credentialing mechanisms like the “GZ-opleiding” to pay for at least part of their own
educational costs in the context of their own professional development. Therefore, even
in his time of budget cutting, a doubling has been witnessed in the amount of therapists
wanting to participate in our training program over the past two years. Another indication
that the costs for training do not have to form an impediment is the fact that ST training
has been increasingly given to therapists in Dutch prisons, suggesting that the costs
seem sustainable by various institutions.
23
3.2. Professional competencies required from the organization
The professional competencies required to implement ST in forensic settings first
and foremost include therapists to successfully complete our training program for ST and
demonstrate sufficient levels of competence in practicing ST (see below, also for
competencies for other members of the project team).
3.3. The organizational structure needed to implement ST
The organizational structure that is necessary to imbed ST in requires the
formation of a project group. In both inpatient and ambulant settings, such a project
group should include a person who is responsible for the implementation of ST and who
leads the project from a clinical point of view (i.e., who leads the diagnostic staff that is
responsible for the diagnostic assessment of patients and the therapeutic staff members
who deliver ST to the patients), like the head of therapy services. In addition, a practical
manager is needed who is responsible for the practical requirements for implementation,
such as making enough time and money available for this purpose.
3.4. Selection, training, and supervision of ST therapists
3.4.1. Training. ST is a complex form of psychotherapy, which requires extensive
training to master. Since 2005, Bernstein and colleagues have established an annual
training program in ST for professionals working with offenders, offered jointly by the
Expertise Center for Forensic Psychiatry (EFP) and Dutch Cognitive Behavior Therapy
Society (VGCT). The content and structure of the program are found in the Education
Manual.
3.4.2. Selection and competence.
Our training program is open to
psychotherapists, clinical psychologists, psychiatrists, and other mental health
professionals, including members of other allied psychological disciplines (e.g., music,
drama, art, and movement therapists, socio-therapists).
While some previous
experience in doing psychotherapy or an allied form of therapy is desirable (i.e., at least
3 years of post-graduate therapy experience is recommended), we have found that
therapists at earlier stages of their training can also learn ST, though they may need a
longer supervision period in order to reach higher levels of mastery. A certain level of
self-selection is also involved in who successfully completes the program and
subsequently starts to treat patients as a ST therapist. That is, an essential part of ST
24
concerns the formation of an emotional bond with the patient. Therapists who are drawn
to ST usually have the capacity to do so. If not, we have adopted procedures (see
below) to assess the competency of therapists. In our experience, however, the majority
of participating therapists are rated as being competent enough after finishing the
course, only in some cases was it necessary to ask participants to follow additional
training.
The formal assessment of therapists’ competence includes having the therapist
make a Schema Mode case conceptualization of a patient, and by demonstrating
therapy skills (either by an in class demonstration or by providing videotaped material of
a session with a patient).
In order to successfully complete the training program,
therapists must also demonstrate competence in delivering ST by providing own videotaped sessions. For the ST training, therapists select one or two patients who they
practice ST with.
After 6 to 9 months of training, the therapist turns in 4 tapes of
consecutive, recent sessions. Therapists’ competency to provide ST is assessed by
independent, experienced ST experts who rate 2 randomly selected videotapes of
therapists’ sessions, using the Schema Therapy Rating Scale (STRS; Young, 2005).
Therapists need to demonstrate competence in ST according to the standards of the
International Society for Schema Therapy (www.isst-online.com), as indicated by an
average score of 4 or higher across the STRS’s domains. If by the end of the training,
therapists do not meet these standards, they are offered additional training. By the
adoption of such strict competency standards for the successful completion of our
program, we ensure a high quality of ST skills training. Moreover, when implementing
forensic ST, we recommend that such competency ratings for therapists become
standard practice, particularly in forensic settings in which the therapists’ competency
may affect patients’ recidivism risk (Bernstein et al., 2007).
3.4.3. Supervision, support, and continuity. After the therapists finish training,
supervision is essential for therapists in the early stages of their ST training. Many
therapists working in forensic settings have difficulty getting started with ST, even
after they have attended ST workshops, unless they have the support and
guidance of regular supervision sessions. This is not surprising, given the challenges of
learning ST and working with forensic patients with severe PDs. In our experience,
regular supervision or peer supervision sessions are necessary to insure the effective
delivery of ST in forensic settings, providing support and guidance for ST therapists.
25
ST has been widely implemented in the forensic system, including inpatient
(TBS) clinics, ambulant settings, as well as in addiction treatment programs, with the
majority of professionals delivering ST in these contexts having been trained by our
program. When setting up an ST program in settings like these, we recommend to
develop the same kind of supervision groups as those in the clinics that participate in our
research. In these clinics, we created supervision groups in which no more than 5 or 6
therapists participate, and which are held every two weeks and last for two hours. A
senior ST therapist is being brought in to guide these supervision meetings. During
these supervision groups, a variety of potential difficulties in the treatment of forensic
patients using ST are discussed, including the therapists’ stance towards patients, or
other potential obstacles that could hinder the effective implementation of ST. In our
RCT on the effectiveness of ST, we experienced that the replacement of therapists has
only been necessary very occasionally. We believe that this regular supervision plays a
significant role in coaching and guiding ST therapists in effectively delivering ST to their
patients and maintaining a sense of self-efficacy in doing so. In several clinics, senior
therapists have been hired and have been developing the competence for developing
peer-supervision to other ST therapists from within the clinic (i.e., FPC the Rooyse
Wissel, the Van der Hoeven Clinic, FPC Oostvaarders, and FPK Veldzicht). In order to
facilitate this process, we have been organizing a “train-the-trainer” program, which
takes places every one to two months and lasts for three hours. During these meetings,
which take place in the Van der Hoeven Clinic in Utrecht, ST therapists from throughout
the Netherlands are supervised and trained in developing the skills to become peersupervisors.
3.5. The monitoring of patients
ST therapists are motivated to regularly assess patients’ progress using
measures like the Schema Mode Inventory (SMI; Lobbestael et al., 2010).
Prof.
Bernstein and colleagues have developed a number of other additional assessment
tools that can be used to measure ST concepts (e.g., Schema Modes) and treatment
outcomes. The Mode Observation Scale (MOS; Bernstein, Arntz, & de Vos, 2009) is an
observer-based rating scale for assessing Schema Modes in therapy sessions or other
clinical settings (e.g., on inpatient wards).
The MOS is a useful tool for training
therapists to recognize Schema Modes—a key aspect of the ST approach—and to
monitor changes in modes over time. The MOS’s manual provides detailed descriptions
26
of 18 different Schema Modes (Bernstein et al., 2010) and has shown good interrater
reliability in studies in which patients’ therapy sessions have been rated by independent
observers (e.g., van den Broek, Bernstein, & Keulen-de Vos, 2011). To assess changes
in PD symptoms in forensic patients, Keulen-de Vos and colleagues (Keulen-de Vos, et
al., 2011) created forensic versions of the widely used SNAP personality questionnaire.
Because forensic patients often show response biases, such as a tendency to minimize
or deny problems, a forensic informant-version of the SNAP was created, which is not
dependent on patients’ self-reports, along with a self-report version. In an initial study
(Keulen-de Vos et al., 2011), the forensic informant- and patient-versions of the SNAP
showed good reliability and validity, with the informant version revealing more PD
symptoms than the patient version.
3.6. Implementation and monitoring the quality of the implementation of ST
For the implementation of ST, additional resources will have to be made available
in order to train and supervise therapists. In addition, a project group will have to be
formed in order to clinically and practically manage the implementation process (see
above).
After implementation, keeping track of the quality of the ST that is being
delivered to patients can be accomplished using the Treatment Integrity Scale (TIS;
Bernstein, de Vos, & van den Broek, 2009) that we developed to assess treatment
integrity. The TIS is an observer-based rating scale to monitor adherence to ST therapy
techniques. It consists of 7 subscales cover the entire range of ST techniques. The TIS
has demonstrated good interrater reliability from videotaped ratings of therapy sessions
(van den Broek et al., 2011).
In the course of our RCT, we have thoroughly assessed the treatment integrity of
ST delivered by the therapists trained through our program.
In the context of a
preliminary analysis of the treatment integrity of ST in our RCT, we randomly selected
videotaped therapy sessions of 26 forensic patients, from an early (3 months), middle
(18 months), and late (36 months) time point in the three years of therapy. Results
showed ST and TAU sessions to differ significantly on all TIS subscales, during all three
time points, suggesting that ST therapists were indeed using ST techniques, whereas
TAU therapists were not (Bouts, 2012). These results provide support for the notion that
our ST course is adequately training therapists to adhere to the ST model in delivering
their therapy. We are currently in the process of repeating these analyses for the rest of
the participating clinics, which we will be able to finish by the winter of 2014. The TIS is
27
available for other institutions that have implemented ST, enabling clinics to ensure
sufficient levels of treatment adherence by their ST therapists.
28
References
American Psychiatric Association (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text rev.). Washington DC: Author.
Bamelis, L., & Arntz, A. (2012, April). Schema therapy for personality disorders.
Congress of the Dutch Society for Psychiatry, NVVP 2012, Maastricht, the
Netherlands.
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(2), 169-183.
Bernstein, D. P., de Vos, M., & van den Broek, E. (2008). Schema Therapy Integrity
Scale. Unpublished manuscript.
Bernstein, D. P., de Vos, M., & van den Broek, E. (2009). Mode Observation Scale and
Manual. Unpublished manuscript.
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.
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.
Bernstein, D. P., de Vos, M. E., & van den Broek, E. P. A. (2009). Therapy Integrity
Scale (TIS). Unpublished manuscript.
Bordin, E. (1979). The generalizability of the psychoanalytic concept of the working
alliance. Psychotherapy: Theory, Research, and Practice, 16, 252–260.
Burdon, W.M., Dang, J., Prendergast, M.L., Messina, N.P., & Farabee, D., (2007).
Differential effectiveness of residential versus outpatient aftercare for parolees
from prison-based therapeutic community treatment programs. Substance Abuse
Treatment, Prevention, and Policy, 2, (16).
Bouts, L. (2012). Therapy adherence of schema focused therapists. Unpublished
thesis, Maastricht University, the Netherlands.
Cooke, D.J. (1992) Violence in prisons: A Scottish perspective. Forum on Correctional
Research, 4, 23-30.
29
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.
Douglas, K. S., & Reeves, K. A. (2010). Historical-Clinical-Risk management-20
(HCR-20) violence risk assessment scheme. Rationale, application, and
empirical overview. In R.K. Otto & K.S. Douglas (Eds.), Handbook of violence
risk assessment (pp. 147–185). New York, NY: Taylor & Francis.
Drieschner, K. (2005). Measuring treatment motivation and treatment engagement in
forensic psychiatric outpatient treatment: development of two instruments. Enschede,
the Netherlands: Febodruk.
Drieschner, K., Lammers, S., & van der Staak, D. (2004). Treatment motivation: an
attempt for clarification of an ambiguous concept. Clinical Psychology Review,
23, 1115–1137.
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. (1997). Structured Clinical
Interview for DSM-IV Axis I Disorders (SCID-I). New York, NY: New York State
Psychiatric Institute.
First, M. B, Spitzer, R. L, Gibbon, M., Williams, J. B., & Benjamin, L. (1994).
Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II).
New York, NY: New York State Psychiatric Institute.
Gibbon, S., Duggan, C., Stoffers, J., Huband, N., Völlm, B. A., Ferriter, M. & Lieb, K.
(2010). Psychological interventions for antisocial personality disorder. Cochrane
Database of Systematic Reviews, 16(6). CD007668.
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.
Grann, M., Langstrom, N., Tengstrom, A., & Kullgren, G. (1999). Psychopathy (PCLR) predicts violent recidivism among criminal offenders with personality disorders
in Sweden. Law and Human Behavior, 23, 205 – 217.
Hahn, S.R., Thompson, K.S., Wils, T.A., Stern, V., & Budner, N.S. (1994). The Difficult
Doctor-Patient Relationship: Somatization, Personality and Psychopathology.
Journal of Clinical Epidemiology, 47, 647-657.
Hemphill, J., Hare, R., & Wong, S. (1998). Psychopathy and recidivism: A review.
Legal Criminology Psychology, 3, 141-172.
30
Hiscoke, U.L., Långström, 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.
Horvath, A.O., & Greenberg, L.S. (1989). Development and Validation of the Working
Alliance Inventory. Journal of Counseling Psychology, 36(2), 223-233.
Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and
outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology,
38, 139-149.
Hser, Y.I., Evans, E., Huang, D., & Anglin, D.M. (2004). Relationship between drug
treatment services, retention, and outcomes. Psychiatric services, 55, 767-764.
Jamieson, L., & Taylor, P. (2004). A re-conviction study of special (high security)
hospital patients. British Journal of Criminology, 44, 783-802
Jeyakumar, S. L. E., Warriner, E. M., Raval, V. V., & Ahmad, S. A. (2004). Balancing the
need for reliability and time efficiency: Short forms of the Wechsler Adult
Intelligence Scale-III. Educational and Psychological Measurement, 64, 71-87.
Kennealy, P.J., Skeem., J.L., Manchak, S.M., & Eno Louden, J. (2012). Firm, fair,
and caring officer-offender relationships protect against supervision failure. Law
and Human Behavior, 36, 496-505.
Kersten, T., & van de Vis, L. (2012). Implementation of Schema Therapy in De
Rooyse Wissel Forensic Psychiatric Center. In M. van Vreeswijk, J. Broersen, &
M. Nadort (Eds.), The Wiley-Blackwell handbook of Schema Therapy: theory,
research, and practice. West Sussex, UK: John Wiley & Sons, Ltd.
Keulen-de Vos, M.E., Bernstein, D.P., Clark, L.A., Arntz, A., Lucker, T., & de Spa, E.
(2011). Patient versus informant reports of personality disorders in forensic
patients. Journal of Forensic Psychiatry and Psychology, 22(1), 52-71.
Lobbestael, J., Leurgans, M., & Arntz, A. (2011). Interrater reliability of the
Structured Clinical Interview for DSM-IV Axis I Disorders (SCID I) and Axis II
Disorders (SCID II). Clinical Psychology and Psychotherapy, 18, 75–79.
Lobbestael, J., van Vreeswijk, M., Spinhoven, P., Schouten, E., & Arntz. A. (2010)
Reliability and validity of the Short Schema Mode Inventory (SMI). Behavioural
and Cognitive Psychotherapy, 38, 437-458.
Miller, S., Brown, J., & Sees, C. (2004). A preliminary study identifying risk factors in
drop-out from a prison therapeutic community. Journal of clinical Forensic
Medicine. 11, 189-197.
31
Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for
change. New York: Guilford Press.
Nentjes, L., Bernstein, D.P., Arntz, A., van Breukelen, G.J.P., & Slaats, M.E. (2013).
Examining the influence of psychopathy, hostility biases, and automatic
processing on criminal offenders' Theory of Mind. Manuscript submitted for
publication.
Nicholls, T.L., Brink, J., Desmarais, S.L., Webster, C.D., & Martin, M-L. (2006). The
Short-Term Assessment of Risk and Treatability (START): A prospective
validation study in a forensic sample. Assessment, 13, 313-327.
Pfohl, B., Blum, N., & Zimmerman, M. (1995). Structured interview for DSM-IV
personality: SIDP-IV. Iowa City: University of Iowa College of Medicine.
Putkonen, H., Komulainen, E., Virkkunen, M., Eronen, M., & Lonnqvist, J. (2003).
American Journal of Psychiatry, 160, 947-951.
Rosenfeld, B. (2003). Recidivism in stalking and obsessional harassment. Law and
Human Behaviour, 27, 251-265.
Røysamb, E., Kendler, K. S., Tambs, K., Ørstavik, R. E., Neale, M. C., Aggen, S. H.,
& Torgersen, S. R. (2011). The joint structure of DSM-IV Axis I and Axis II
disorders. Journal of Abnormal Psychology, 120, 198-209.
Salekin, R., Rogers, R., & Sewell, K. (1996). A review and meta-analysis of the
Psychopathy Checklist and Psychopathy Checklist-Revised: Predictive validity of
dangerousness. Clinical Psychology, 3, 203-215.
Spinhoven, P., Giesen-Bloo, J., van Dyck, R., Kooiman, K., & Arntz, A. (2007). The
therapeutic alliance in schema-focused therapy and transference-focused
psychotherapy for borderline personality disorder. Journal of Consulting and
Clinical Psychology, 75, 104-115.
Taft, C.T., Murphy, C. M., Musser, P. H., & Remington, N. A. (2004). Personality,
interpersonal, and motivational predictors of the working alliance in group
cognitive-behavioral therapy for partner violent men. Journal of Consulting and
Clinical Psychology, 72, 349-54.
Trotter, C. (1996) The impact of different supervision practices in community
corrections: Cause for optimism. Australian and New Zealand Journal of
Criminology, 29, 29-47.
32
Van den Broek, E.P.A., Keulen-de Vos, M.E., & Bernstein, D.P. (2011). Arts
Therapies and Schema Focused Therapy; a pilot study.
The Arts in
Psychotherapy, 38, 325-332.
Webster, C.D., Martin, M., Brink, J., Nicholls, T.L., & Middleton, C. (2004). Short-term
assessment of risk and treatability (START). St. Josephs Healthcare, Hamilton
and British Columbia Mental Health and Addiction Services.
Webster, C.D., Martin, M., Brink, J., Nicholls, T.L., & Desmarais, S.L. (2009). Short-Term
Assessment of Risk and Treatability (START). Clinical guide for evaluation risk
and recovery (version 1.1). Ontario, Canada: St. Joseph’s Healthcare Hamilton
Wechsler, D. (1997). WAIS-III, Nederlandstalige bewerking, technische handleiding.
[WAIS-III, Dutch version manual]. Lisse (NL): Swets Test.
Willis, G.M., & Grace, R.C. (2008). The quality of community reintegration planning for
child molesters: Effects on sexual recidivism. Sexual Abuse: A Journal of
Research and Treatment, 20, 218-240.
Young, J. E. (2005). Schema Therapy Rating Scale, retrievable from
www.schematherapy.com
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.
Zanarini, M. C., Skodol, A. E., Bender, D., Dolan, R. Sanislow, C., Schaefer, E, et al.
(2000). The collaborative longitudinal personality disorders study: reliability of
axis I and II diagnoses. Journal of Personality Disorders, 14, 291-299.
33