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Effective treatment for involuntary committed patients with psychopathy

Schema therapy can benefit involuntarily committed patients (TBS) with personality disorders – even psychopathic patients previously considered untreatable. After three years of treatment, these patients had a reduced risk of recidivism and fewer psychological symptoms than those who received the conventional treatment. These were the preliminary results of a large-scale study in eight TBS clinics in the Netherlands. David Bernstein, Professor of Forensic Psychotherapy at Maastricht University, presented these findings during his inaugural lecture on 15 June. Should these results be confirmed in the entire research group, this may prove to be the first effective treatment for psychopathy.

The motivation for this research was a parliamentary study conducted in 2005/06 in response to serious incidents involving TBS patients on probation. In their report, the research committee advised universities and TBS clinics to work together on improving the effectiveness of TBS treatment options. This led to the appointment of Professor Bernstein to a joint chair position at Maastricht University and the Forensic Psychiatric Centre de Rooyse Wissel as well as the first and only randomised clinical study involving eight TBS clinics: de Rooyse Wissel (Venray and Maastricht), van der Hoeven (Utrecht), Oostvaarders (Almere), Mesdag (Groningen), Veldzicht (Balkbrug), Forensic Psychiatric Clinic Assen and Kijvelanden (Poortugaal).

The study tracks 103 male TBS patients with antisocial, borderline, narcissistic or paranoid personality disorders. The initial results pertain to the first thirty patients, who have since completed their treatment. All participants will have completed their treatment by 2015 and will be followed for an additional three years. Half will receive schema therapy and half will receive ‘treatment as usual’. This may vary per clinic, but it usually involves a combination of individual and group therapy, relapse prevention for aggression and drug abuse, supplemental therapy (such as music or performance therapy), medication and extra training and education courses.

The risk of recidivism was reduced much more quickly in the first thirty patients who received schema therapy. As a result, they were eligible for supervised probation 180 days earlier on average and for unsupervised probation 130 days earlier on average. Interestingly, the risk of recidivism declined fastest among those patients with the worst psychopathy. Other factors were also measured, including symptoms of personality disorders, incidents of violence and psychopathological symptoms in general. The results are not (yet) statistically significant due to the limited size of the target group at this stage in the study.

The researchers also examined the cost effectiveness of the study by weighing the cost of therapy against the amount of time spent in a TBS clinic. Three years of schema therapy costs roughly €20,000 whereas admittance to a TBS clinic amounts to roughly €160,000 per year. Researchers expect to see a four to six month reduction in the duration of TBS treatment. This profit calculation does not take into account the societal costs, which will dramatically decrease if the risk of recidivism also decreases, as is expected.

Schema therapy has been used to treat personality disorders for some time now. In 2006, researchers at Maastricht University demonstrated the effectiveness of this treatment in borderline patients. Schema therapy helps patients gain insight into the underlying patterns that trigger their behavioural problems. Bernstein developed five standard problems, or schemas, for the TBS research group: the Self-Aggrandiser Mode, the Bully & Attack Mode, the Conning Manipulative Mode, the Paranoid Over-controller Mode, and the Predator Mode. Treatment focuses on the relationship with the therapist, daily living situation and traumatic experiences from childhood. Schema therapy was developed early this century to treat patients with personality disorders who did not respond to conventional cognitive therapy. The intensive treatment consists of two sessions per week and is based on a combination of cognitive methods, creating an intensive therapeutic relationship (re-parenting), empathetic confrontation (confronting inappropriate behaviour in a way the patient accepts) and empirical techniques such as role play and imaginary rescripting.