Schema therapy for violent PD offenders: a randomized clinical trial.

BACKGROUND: Violent criminal offenders with personality disorders (PD's) can cause immense harm, but are often deemed untreatable. This study aimed to conduct a randomized clinical trial to test the effectiveness of long-term psychotherapy for rehabilitating offenders with PDs. METHODS: We compared schema therapy (ST), an evidence-based psychotherapy for PDs, to treatment-as-usual (TAU) at eight high-security forensic hospitals in the Netherlands. Patients in both conditions received multiple treatment modalities and differed only in the individual, study-specific therapy they received. One-hundred-three male offenders with antisocial, narcissistic, borderline, or paranoid PDs, or Cluster B PD-not-otherwise-specified, were assigned to 3 years of ST or TAU and assessed every 6 months. Primary outcomes were rehabilitation, involving gradual reintegration into the community, and PD symptoms. RESULTS: Patients in both conditions showed moderate to large improvements in outcomes. ST was superior to TAU on both primary outcomes - rehabilitation (i.e. attaining supervised and unsupervised leave) and PD symptoms - and six of nine secondary outcomes, with small to moderate advantages over TAU. ST patients moved more rapidly through rehabilitation (supervised leave, treatment*time: F(5308) = 9.40, p < 0.001; unsupervised leave, treatment*time: F(5472) = 3.45, p = 0.004), and showed faster improvements on PD scales (treatment*time: t(1387) = -2.85, p = 0.005). CONCLUSIONS: These findings contradict pessimistic views on the treatability of violent offenders with PDs, and support the effectiveness of long-term psychotherapy for rehabilitating these patients, facilitating their re-entry into the community.

Theory of Mind, Social Desirability, and Unlikely Symptom Reporting in Offenders With and Without Psychopathy.

The current study investigated the relationship between psychopathy and theory of mind (ToM), by comparing the performance of nonpsychopathic offenders (n = 40), psychopathic offenders (n = 42), and nonoffender controls (n = 26) on Happé's test of ToM (Happé, 1994). In addition, we investigated whether offenders' ToM skills would moderate the association between the antisocial psychopathy component (Factor 2) and self-presentation (i.e., the tendency to report social desirability and unlikely symptoms). Results showed groups did not differ in ToM performance. As expected though, ToM moderated the association between psychopathy and self-presentation: only for offenders relatively high in ToM, Factor 2 was strongly related to less social desirability and more unlikely symptom reporting. These results could indicate that offenders who are high in both ToM and Factor 2 exaggerate their mental dysfunction to express their need for clinical attention. Results are used to critically evaluate the interpretation of occurrences in which offenders overplay their psychopathology.

Examining the influence of psychopathy, hostility biases, and automatic processing on criminal offenders' Theory of Mind.

Theory of Mind (ToM) is a social perceptual skill that refers to the ability to take someone else's perspective and infer what others think. The current study examined the effect of potential hostility biases, as well as controlled (slow) versus automatic (fast) processing on ToM performance in psychopathy. ToM abilities (as assessed with the Reading the Mind in the Eyes Test; RMET; Baron-Cohen, Wheelwright, Hill, Raste, & Plumb, 2001), was compared between 39 PCL-R diagnosed psychopathic offenders, 37 non-psychopathic offenders, and 26 nonoffender controls. Contrary to our hypothesis, psychopathic individuals presented with intact overall RMET performance when restrictions were imposed on how long task stimuli could be processed. In addition, psychopaths did not over-ascribe hostility to task stimuli (i.e., lack of hostility bias). However, there was a significant three-way interaction between hostility, processing speed, and psychopathy: when there was no time limit on stimulus presentation, psychopathic offenders made fewer errors in identifying more hostile eye stimuli compared to nonoffender controls, who seemed to be less accurate in detecting hostility. Psychopaths' more realistic appraisal of others' malevolent mental states is discussed in the light of theories that stress its potential adaptive function.