Efficacy of Schema-Focused Therapy versus Usual Treatment in Forensic Patients with Personality Disorders: A Three-Year Randomized Clinical Trial

Personality disorders are highly prevalent in forensic institutions, both in
the Netherlands and worldwide (de Ruiter, & Greeven, 2000; Hildebrand & de
Ruiter, 2004; Leue, Borchard, & Hoyer, 2004; Rasmussen, Storsaeter, & Levander,
1999; Timmerman & Emmelkamp, 2001), and are associated with increased risk of
violence and criminal recidivism (Hemphill, Hare, & Wong, 1998; Hiscoke,
Langstrom, Ottosson, & Grann, 2003; Jamieson & Taylor, 2004; Putkonen,
Komulainen, Virkkunen, Eronen, & Lonnqvist, 2003; Rosenfeld, 2003; Salekin,
Rogers, & Sewell, 1996). Patients with Antisocial, Narcissistic, Borderline,
or Paranoid Personality Disorders are especially likely to commit violent acts
within forensic settings, and to engage in crime and violence after release
from incarceration. However, despite the risks posed by forensic patients with
personality disorders, only a few previous studies have examined the
effectiveness of treatments for these patients (Eveshed, Tennant, Boomer, Rees,
Barkham, & Watson, 2003; Greenen, & de Ruiter, 2004; Timmerman, & Emmelkamp,
2005), and no major randomized clinical trials of psychotherapy with this
population have been reported. These considerations suggest that developing
and testing promising treatments for forensic patients with personality
disorders should be a major priority.
Recently, progress has been made in developing new forms of psychotherapy that
have considerable promise for treating personality disorders that have usually
been considered *untreatable.* In a recent randomized clinical trial, Schema
Focused Therapy (SFT) - a novel form of cognitive therapy for personality
disorders - was found to be highly effective in ameliorating the symptoms of
Borderline Personality Disorder (Giesen-Bloo, et al., 2006). These findings
raise the possibility that SFT may prove effective in treating personality
disorders in forensic settings.

In this study, we will test the efficacy of SFT in forensic patients with 4
severe personality disorders -- Antisocial, Narcissistic, Borderline, and
Paranoid Personality Disorders -- in ameliorating personality disorder symptoms
and reducing risk of criminal and violence recidivism.

The specific aims of the proposed study are the following:
Aim 1 -- Test the three-year efficacy of SFT in male forensic patients with
Antisocial, Narcissistic, Borderline, or Paranoid Personality Disorder for
reducing personality disorder symptoms and lowering the risk of future violence
and recidivism, compared to treatment as usual (TAU).
Hypothesis 1a: Patients given SFT will show greater improvement in symptoms of
Antisocial, Narcissistic, Borderline, and Paranoid Personality Disorder,
compared to patients given TAU.
Hypothesis 1b: Patients given SFT will show greater improvement in dynamic
(i.e., changeable) risk factors for violence and recidivism (e.g., predictors
of future violence and recidivism), compared to patients given TAU.
Aim 2 -- Investigate the effect of SFT on psychotherapy process variables, such
as treatment engagement and therapeutic alliance, and on treatment retention.
Hypothesis 2a: Patients given SFT will show greater engagement in the
therapeutic process, and a better alliance with their therapists, compared to
patients given TAU.
Hypothesis 2b: Patients given SFT will show greater treatment retention (i.e.,
lower rates of drop-out), compared to patients given TAU.
Aim 3 -- Investigate the effects of SFT on the personality constructs
hypothesized to mediate the effects of SFT on personality disorders.
Hypothesis 3: Patients given SFT will show greater improvements in Early
Maladaptive Schemas, Maladaptive Coping Mechanisms, and Schema Modes, compared
to patients given TAU.

One hundred male patients with Antisocial, Narcissistic, Borderline, or
Paranoid Personality Disorders will be recruited from 4 Dutch forensic
psychiatric hospitals (*TBS clinics*) - the Rooyse Wissel in Venray, the Van
der Hoeven clinic in Utrecht, the Oostvaarders clinic in Amsterdam and Utrecht,
and another site that we are pursuing. Only male patients will be assessed
because they are over-represented in criminal populations, and represent a
greater risk for future crime and violence. Twenty-five patients from each
clinic will be randomly assigned to receive either SFT or Treatment as Usual
(TAU). TAU is defined as the customary treatment at that facility, which is
typically a form of cognitive-behavioral, psychodynamic, or humanistic
psychotherapy. Patients receiving SFT will receive twice weekly psychotherapy
session, which is the recommended *dose* of SFT for patients with severe
personality disorders (Young et al., 2003). Patients receiving TAU will
receive once per week psychotherapy, because this is the customary practice at
TBS institutions. Thus, the two treatments will not be equated for frequency,
because the goal of the study is to determine whether SFT produces benefits
beyond that of usual TBS practice. Patients in both groups will receive 3
years of psychotherapy.

Patients will be assessed at the beginning of treatment and every 6 months for
the duration of the study. To circumvent the problem of patients* tendency to
*fake good,* we will base our assessments primarily on observations of
patients* behavior provided by knowledgeable staff members, rather than on
patients* own self-reports.

SFT is an integrative form of psychotherapy that combines cognitive,
behavioral, psychodynamic object relations, and humanistic/existential
approaches (Young et al., 2003). Unlike most other forms of
cognitive-behavioral therapy, SFT was developed explicitly as a treatment for
patients with personality disorders, who often respond poorly to traditional
therapeutic methods (Reich, 2003). The focus in SFT is on modifying
self-defeating patterns of thinking and feeling (i.e., Early Maladaptive
Schemas), and maladaptive emotional states (i.e., Schema Modes) that originate
in aversive childhood experiences in combination with the child*s innate
temperament. SFT is a moderate- to long-term form of psychotherapy. Treatment
usually occurs once to twice per week for a period of one to two years on
average, or longer, depending on the patient. For patients with severe
personality disorders, such as those that are most prevalent in Dutch TBS
institutions (e.g., Antisocial, Borderline, Narcissistic), a duration of at
least three years of therapy is often indicated. This duration of treatment is
necessary because longstanding personality features are only ameliorable with
intensive treatment (Giesen-Bloo et al., 2006; Young et al., 2003).

The control therapy will consist of *Treatment as Usual (TAU).* TAU is defined
as whatever form of verbal therapy is usually given at the participating
institutions. This may include cognitive, psychodynamic, humanistic, or other
commonly used forms of verbal psychotherapy.

There are only minimal risks associated with either of the psychotherapies that
will be delivered in this study. These risks are not different than the risks
posed by other forms of psychotherapy (e.g., possible feelings of discomfort
when disclosing personal information to a therapist). There is a possible risk
to patients' confidentiality posed by the collection and storage of data.
Precautions will be taken to protect the confidentiality of these data, such as
omitting identifying information from data bases, and identifying participants
only by identification number (a longer description of these procedures is
found in the research proposal under "Ethical Issues").

The risks associated with this study are expected to be minimal. On the other
hand, there are potential benefits for patients, who may experience improvement
in their personality disorder symptoms and risk of future criminal behavior as
a result of receiving the therapeutic interventions in this study. Moreover,
the potential benefit to society if this experimental treatment, Schema Focused
Therapy, proves successful, is great. Thus, the potential benefits of this
study are expected to far outweigh the risks.