Effectiveness of compassion-focused therapy for self-criticism in patients with personality disorders: a multiple baseline case series study.

OBJECTIVE: Targeting self-criticism, the tendency to negatively evaluate and judge aspects of oneself, may improve treatment efficacy for personality disorders (PDs). This study aimed to test whether adding 12-week group compassion-focused therapy (CFT) that explicitly targets self-criticism to treatment as usual (TAU) would reduce self-criticism in patients with PDs. METHOD: Twelve patients with PDs participated in a multiple baseline study, randomly allocated to different baseline lengths. The primary outcome was twice-weekly assessed self-critical beliefs during baseline, treatment, and follow-up phases. Secondary outcomes were self-criticism, self-compassion, and PD severity at the end of CFT and follow-up (trial registered: NL8131). Nine participants completed the intervention. No significant changes were observed during CFT, but at follow-up significant decrease in self-critical beliefs (Cohen's d = -0.43; 95% CI = -0.73 to -0.12) was reported compared to baseline. On secondary outcomes, most participants showed reliable improvement on self-reported criticism (66.7%) and self-compassion (55.6%), and a minority of patients showed reliable improvement in PD severity (33.3%). CONCLUSIONS: This study seems to provide preliminary evidence for the effectiveness of 12-week CFT for self-critical beliefs in patients with PDs compared to TAU. CFT for self-criticism in PDs may complement treatment offerings and warrant further research.

Life stories of patients with personality disorders before and after treatment: Change and stability in agency and communion.

Introduction: Studying written life stories of patients with personality disorders (PDs) may enhance knowledge of how they understand themselves, others and the world around them. Comparing the construction of their life stories before psychotherapy to their reconstruction after psychotherapy may provide insight in therapeutic changes in the understandings of their lives. Methods: As few studies addressed this topic, the current study explored changes in agency (i.e., perceived ability to affect change in life), and communion (i.e,, perceived connectedness to other persons) in written life stories of 34 patients with various PDs, before and after intensive psychotherapy treatment. Results: Life stories showed a positive increase in agency from pre- to posttreatment, in particular regarding internal agency, societal success, and occupational success. No significant changes were observed for communion as a whole. However, the perceived number and quality of close relationships revealed a significant positive increase. Discussion: The increased agency in the reconstruction of patients' life story after psychotherapy suggests that patients improved their perceived ability to affect change in their own lives. This can be seen as an important step in the treatment of PDs towards further recovery.

Effects of a brief compassion exercise on affect and emotion regulation in patients with personality disorders.

BACKGROUND AND OBJECTIVES: Cultivating compassion seems a promising strategy for ameliorating emotion dysregulation in patients with personality disorders (PDs). Thus far, empirical evidence is lacking. This study aimed to examine whether a brief compassion exercise compared to a neutral exercise would positively impact on (implicit) positive affect (PA) and (implicit) negative affect (NA) and foster the use of more adaptive emotion regulation strategies in an adult clinical sample with PDs. METHODS: A total of 24 patients admitted to a Dutch day-hospital treatment center for PDs participated in a two-group cross-over study. Participants were randomly allocated over two groups that were both given the compassion and neutral exercise, yet in a different order. Assessments took place prior to and following each exercise. Participants completed questionnaires assessing (implicit) PA and NA and emotion regulation strategies. RESULTS: Multilevel analyses did not yield significant differences between the neutral and compassion exercise in terms of adaptive and maladaptive emotion regulation and implicit PA. The compassion exercise was able to significantly decrease implicit NA among participants, relative to the neutral exercise. A significant interaction effect was observed between exercise and sequence of exercises on PA and NA. LIMITATIONS: Limitations include the brief duration of the exercises, the control exercise and the low reliability for the emotion regulation measure. CONCLUSIONS: The compassion exercise decreased implicit NA but seemed not able to impact on PA, NA and emotion regulation in patients with PDs.

Acceptance and potential clinical added value of biocueing in forensic psychiatric patients with autism spectrum disorder and/or intellectual disability.

Autism spectrum disorder (ASD) and intellectual disability (ID) are prevalent in forensic psychiatric samples. People with ASD and/or ID often experience difficulties in emotion processing which can lead to aggressive or self-harming behavior. The use of biocueing (using wearable technology to constantly monitor and provide feedback on bodily changes) shows promise for improving emotion processing and, thus, potentially reducing aggressive behavior in this population. Both qualitative and quantitative methods were used to examine the feasibility and acceptance of Sense-IT, a biocueing application, in a sample of forensic psychiatric patients with ASD and/or ID and their forensic psychiatric nurses. To our knowledge, the current study is the first to examine first-person experiences with biocueing in forensic psychiatric patients with ASD and/or ID. Results show that, in general, participants experienced the biocueing application as positive and are willing to use biocueing. This is an important finding since forensic patients are often unmotivated to engage with therapeutic techniques. An exploration of trends in aggression and self-harm prior to and during the use of biocueing showed no significant changes. Future research should focus on the way biocueing can be implemented in clinical practice.

Psilocybin-Assisted Compassion Focused Therapy for Depression.

Psilocybin-assisted psychotherapy, i.e., psilocybin treatment with psychological support, has demonstrated the efficacy of psilocybin to reduce depressive symptoms. However, in clinical trials, the structure of psilocybin-assisted psychotherapy is primarily based on preparation, navigation (support during dosing sessions), and integration. For psychotherapeutic guidance, the application of this structure is favored over the usage of theoretical models. The applied psychotherapeutic models may be of critical importance if the effects are augmented due to the psychologically insightful experiences during the navigation and integration sessions. One of the important next steps is to provide therapists with guidance on how to provide psilocybin-assisted psychotherapy. We present an integrated protocol for psilocybin-assisted psychotherapy for depression based on the theoretical model and psychotherapeutic framework of Compassion Focused Therapy (CFT). We hypothesize that CFT can provide the theoretical model and compassion practices that will reinforce the experiences during the navigation and follow-up therapy sessions. In this paper, we describe the rationale for selecting CFT, the compatibility of CFT and psilocybin-therapy, an overview of the psilocybin-assisted CFT protocol, the study protocol, and limitations to this approach.

Effect of Psychotherapy for Borderline Personality Disorder on Quality of Life: A Systematic Review and Meta-Analysis.

Whereas several meta-analyses have shown that psychotherapy is effective for reducing borderline personality disorder (BPD) pathology, the overall impact of psychotherapy for BPD on quality of life (QoL) remains as yet unclear. Because impaired QoL is associated with poor long-term outcomes after therapy for BPD, this seems a timely and relevant issue. The authors conducted a systematic review and meta-analysis of randomized controlled trials of psychotherapies for adults diagnosed with BPD that reported results of QoL at posttreatment. Fourteen trials were included (1,370 individuals with BPD). Psychotherapies for BPD relative to control conditions showed significant effect sizes for QoL (Cohen's d = 0.31; 95% CI [0.18, 0.44]), and for BPD pathology (d = 0.43; 95% CI [0.23, 0.64]). The effect on QoL was not significantly moderated by the effect on BPD pathology. Psychotherapies for BPD have a positive effect on QoL of patients with BPD. However, more studies are needed to examine the impact of psychotherapy on QoL and long-term outcome, including recovery.

Benefits of Art Therapy in People Diagnosed With Personality Disorders: A Quantitative Survey.

Art therapy is widely used and effective in the treatment of patients diagnosed with Personality Disorders (PDs). Current psychotherapeutic approaches may benefit from this additional therapy to improve their efficacy. But what is the patient perspective upon this therapy? This study explored perceived benefits of art therapy for patients with PDs to let the valuable perspective of patients be taken into account. Using a quantitative survey study over 3 months (N = 528), GLM repeated measures and overall hierarchical regression analyses showed that the majority of the patients reported quite a lot of benefit from art therapy (mean 3.70 on a 5-point Likert scale), primarily in emotional and social functioning. The improvements are concentrated in specific target goals of which the five highest scoring goals affected were: expression of emotions, improved (more stable/positive) self-image, making own choices/autonomy, recognition of, insight in, and changing of personal patterns of feelings, behaviors and thoughts and dealing with own limitations and/or vulnerability. Patients made it clear that they perceived these target areas as having been affected by art therapy and said so at both moments in time, with a higher score after 3 months. The extent of the perceived benefits is highly dependent for patients on factors such as a non-judgmental attitude on the part of the therapist, feeling that they are taken seriously, being given sufficient freedom of expression but at the same time being offered sufficient structure and an adequate basis. Age, gender, and diagnosis cluster did not predict the magnitude of perceived benefits. Art therapy provides equal advantages to a broad target group, and so this form of therapy can be broadly indicated. The experienced benefits and the increase over time was primarily associated with the degree to which patients perceive that they can give meaningful expression to feelings in their artwork. This provides an indication for the extent of the benefits a person can experience and can also serve as a clear guiding principle for interventions by the art therapist.

The concurrent validity of a Web-based self-report assessment for personality disorders.

Incorporating online tools in clinical practice could help improve routine assessments of personality disorders and their co-occurring clinical disorders. TeleScreen, a Web-based self-report questionnaire for DSM-IV disorders, has not yet been compared with well-validated structured interviews for clinical and personality disorders. Patients with personality disorders (n = 89) were assessed with TeleScreen and independently interviewed with Structured Clinical Interview for DSM-IV Axis-I disorders (SCID-I) and personality disorders (SCID-II). The concurrent validity was examined using sensitivity, specificity, and positive and negative predictive values. Five personality disorders had a prevalence rate higher than 4% and could be examined in the analyses: borderline, obsessive-compulsive, dependent, avoidant and paranoid personality disorders. TeleScreen showed moderate to good validity for borderline personality disorder and obsessive-compulsive personality disorder but suboptimal validity for the dependent, avoidant and paranoid personality disorders. Clinical disorders showed moderate to good values, except for social phobia, dysthymia and eating disorders. These findings provide preliminary evidence for the concurrent validity of TeleScreen for some personality disorders, such as the borderline personality disorder, and pave the way for larger studies to confirm these results. © 2018 John Wiley & Sons, Ltd.

The effect of positive psychology interventions on well-being and distress in clinical samples with psychiatric or somatic disorders: a systematic review and meta-analysis.

BACKGROUND: Although positive psychology interventions (PPIs) show beneficial effects on mental health in non-clinical populations, the current literature is inconclusive regarding its effectiveness in clinical settings. We aimed to examine the effects of PPIs on well-being (primary outcome), depression, anxiety, and stress (secondary outcomes) in clinical samples with psychiatric or somatic disorders. METHODS: A systematic review and meta-analysis was conducted following PRISMA guidelines. PsycINFO, PubMed, and Scopus were searched for controlled studies of PPIs in clinical samples between Jan 1, 1998 and May 31, 2017. Methodological quality of each study was rated. We used Hedges' adjusted g to calculate effect sizes and pooled results using random-effect models. RESULTS: Thirty studies were included, representing 1864 patients with clinical disorders. At post-intervention, PPIs showed significant, small effect sizes for well-being (Hedges' g = 0.24) and depression (g = 0.23) compared to control conditions when omitting outliers. Significant moderate improvements were observed for anxiety (g = 0.36). Effect sizes for stress were not significant. Follow-up effects (8-12 weeks), when available, yielded similar effect sizes. Quality of the studies was low to moderate. CONCLUSION: These findings indicate that PPIs, wherein the focus is on eliciting positive feelings, cognitions or behaviors, not only have the potential to improve well-being, but can also reduce distress in populations with clinical disorders. Given the growing interest for PPIs in clinical settings, more high quality research is warranted as to determine the effectiveness of PPIs in clinical samples. TRIAL REGISTRATION: PROSPERO CRD42016037451.

Inpatient schema therapy for nonresponsive patients with personality pathology: Changes in symptomatic distress, schemas, schema modes, coping styles, experienced parenting styles, and mental well-being.

This study provides an evaluation of group schema therapy (ST) for inpatient treatment of patients with personality pathology who did not respond to previous psychotherapeutic interventions. Forty-two patients were assessed pre- and posttreatment, and 35 patients were evaluated at follow-up 6 months later. The results showed a dropout rate of 35%. Those who dropped out did not differ from those who completed treatment with regard to demographic and clinical variables; the only exception was that those who dropped out showed a lower prevalence of mood disorders. Furthermore, intention-to-treat analyses showed a significant improvement in maladaptive schemas, schema modes, maladaptive coping styles, mental well-being, and psychological distress after treatment, and these improvements were maintained at follow-up. On the other hand, there was no significant change in experienced parenting style as self-reported by patients. Changes in schemas and schema modes measured from pre- to posttreatment were predictive of general psychological distress at follow-up. Overall, these preliminary findings suggest that positive treatment results can be obtained with group ST-based inpatient treatment for patients who did not respond to previous psychotherapeutic interventions. Moreover, these findings are comparable with treatment results for patients without such a nonresponsive treatment history. (PsycINFO Database Record

Acceptance and commitment therapy group-treatment for non-responsive patients with personality disorders: An exploratory study.

Patients with personality disorders who did not respond to previous outpatient treatment are among the most challenging patients to treat and are often referred to specialized settings. Acceptance and commitment therapy (ACT) is an innovative therapy that has shown effectiveness in treatment-resistant cases with chronic or recurrent depression with or without co-morbid personality disorders. The central role that ACT accords to positive values and experiential avoidance may enhance treatment responsivity in patients with personality disorders that did not respond to previous treatments. The current nonrandomized study explored the effectiveness of a 26-week ACT-based group treatment (n = 60) for personality disorders compared to treatment-as-usual (n = 21) based on cognitive behaviour therapy (CBT-TAU) at a specialized setting for patients with personality disorders. Individuals in both treatment conditions demonstrated small to moderate decreases in general psychological functioning and personality pathology. There was no main effect of therapy condition. Overall, results suggest that ACT is a possible treatment option for individuals with difficult-to-treat personality pathology and further outcome research is warranted.

Treating the untreatable: a single case study of a psychopathic inpatient treated with schema therapy.

From its first conceptualization in modern psychiatry, psychopathy has been considered difficult if not impossible to treat. Schema Therapy (ST) is a psychotherapeutic approach that has shown efficacy in patients with borderline personality disorder. ST has recently been adapted for personality disordered forensic patients, including patients with high levels of psychopathy. The present case study examined the process of individual ST, combined with movement therapy and milieu therapy by the nursing staff, with a forensic inpatient with psychopathic features (Psychopathy Checklist-Revised total score = 28.4). The patient had been sentenced to a mandatory treatment order in relation to a sexual assault. We assessed change using independent assessments of psychopathic traits, cognitive schemas, and risk-related behaviors over the 4-year treatment period and a 3-year follow-up. We also assessed the quality of the working alliance. Reliable change analyses showed significant improvements in psychopathic traits, cognitive schemas, and risk-related outcomes. At 3 years posttreatment, the patient was living independently outside of the forensic institution without judicial supervision and he had not reoffended. While many questions remain about the effectiveness of psychotherapeutic treatment for psychopathic patients, our study challenges the view that they are untreatable.

Early maladaptive cognitive schemas in child sexual offenders compared with sexual offenders against adults and nonsexual violent offenders: an exploratory study.

INTRODUCTION: Although there is a growing body of research on the role of offense supporting cognitive distortions in child sexual offending, little is known about the origins of these distortions. According to cognitive theory, maladaptive cognitive schemas originating in adverse childhood experiences with caregivers have been hypothesized to underlie these cognitive distortions. AIM: This exploratory study investigates early maladaptive schemas (EMSs) in child sexual offenders compared with sexual offenders against adults and nonsexual offenders. MAIN OUTCOME MEASURES: EMSs were measured with the Young Schema Questionnaire, and psychopathy was measured with the Psychopathy Checklist-Revised. METHODS: Three groups of forensic inpatients-23 child sexual offenders, 19 sexual offenders against adults, and 24 nonsexual violent offenders-were assessed. Multivariate analyses of covariance were used to examine the hypothesized group differences in EMSs. RESULTS: Results showed that, after controlling for level of psychopathy, EMSs related to Abandonment (M = 2.61 vs. M = 1.73, P < 0.01), Social Isolation (M = 2.50 vs. M = 1.62, P < 0.01), Defectiveness/Shame (M = 2.05 vs. M = 1.42, P < 0.05), Subjugation (M = 2.28 vs. M = 1.57, P < 0.05), and Self-Sacrifice (M = 3.29 vs. M = 2.41, P < 0.05) were more prevalent in child sexual offenders compared with nonsexual violent offenders. Compared with sexual offenders against adults, child sexual offenders showed a trend to have higher scores on EMSs related to Social Isolation (M = 2.50 vs. M = 1.88, P = 0.066). CONCLUSIONS: Our findings suggest that EMSs may play a role in offending behavior in child sexual offenders and offer the possibility of informing treatment strategies.

Assessment of implicit sexual associations in non-incarcerated pedophiles.

Offences committed by pedophiles are crimes that evoke serious public concern and outrage. Although recent research using implicit measures has shown promise in detecting deviant sexual associations, the discriminatory and predictive quality of implicit tasks has not yet surpassed traditional assessment methods such as questionnaires and phallometry. The current research extended previous findings by examining whether a combination of two implicit tasks, the Implicit Association Task (IAT) and the Picture Association Task (PAT), was capable of differentiating pedophiles from non-pedophiles, and whether the PAT, which allows separate analysis for male, female, boy and girl stimulus categories, was more sensitive to specific sexual associations in pedophiles than the IAT. A total of 20 male self-reported pedophiles (10 offender and 10 non-offenders) and 20 male self-reported heterosexual controls completed the two implicit measures. Results indicated that the combination of both tasks produced the strongest results to date in detecting implicit pedophilic preferences (AUC = .97). Additionally, the PAT showed promise in decomposing the sexual associations in pedophiles. Interestingly, as there was an equal distribution of offenders and non-offenders in the pedophile group, it was possible to test for implicit association differences between these groups. This comparison showed no clear link between having these implicit sexual associations and actual offending.

Reliability and validity of the Dutch version of the Behavioural Status Index: a nurse-rated forensic assessment tool.

The Behavioural Status Index (BEST-Index) has been introduced into Dutch forensic psychiatry to measure change in risk level of future violence. The BEST-Index is a structured observational measure that assesses aggressive behavior, degree of insight, social skills, self-care, and work and leisure skills during inpatient treatment. Thus far, limited information regarding the psychometric properties of the Dutch version of the BEST-Index is available. The present study examines the reliability and validity of the Dutch BEST-Index in a sample of 291 mentally disordered offenders admitted to a forensic psychiatric hospital. Interrater reliability was investigated in a sample of 182 raters. Findings show that the Dutch BEST-Index can be used reliably and is significantly associated with risk of future violence and institutional aggression. Furthermore, this study revealed a different and clearer factor structure compared with the original one. Further research is needed to examine how these derived factors predict future recidivism.

Cost of care of patients with personality disorders in forensic psychiatric hospitals in the Netherlands.

BACKGROUND: Ter beschikking stelling (TBS) clinics form the mainstay of forensic psychiatric services in the Netherlands. Their costs are rising, but little is known about how these costs are distributed. AIM: To determine the distribution of service costs for patients with personality disorders in TBS medium security units in the Netherlands. METHOD: Data on service use were extracted retrospectively from the case files of 55 people with personality disorder who are residents in six medium security units within two TBS centres during 2006 (De Rooyse Wissel and Pompestichting). Standard unit costs were obtained for each service, and multiplied by frequency of service use to obtain the total cost of service per patient. A modified version of the Secure Facilities Service Use Schedule was completed. RESULTS: The average daily cost of a bed in a TBS hospital in 2006 was 388 Euros (402 (SD 37) Euros in De Rooyse Wissel; 375 (SD 48) Euros in the Pompestichting). Over half of this was spent on non-treatment fixed costs (overheads). There was considerable difference between patients and between unit variations in the other costs, but about one-third went on costs of staying in department (sociotherapists), and less than 10% each on specific therapeutic interventions or daily activities. About 3% of the budget overall was spent on other costs, but, as these included escorted leaves, at times these costs accounted for a much higher proportion of the per patient expenditure. CONCLUSION: Our results may provide a baseline measurement, with which future costs of TBS treatment can be compared as the services expand and develop. More attention to costs in this way may help to contain budget increases. New studies could examine more specific aspects of treatment or other specific patient groups.