Psychopathic patients prove to be a great danger to society, so it’s essential to contrive a treatment that is effective. Schema therapy, developed by Young, might be the solution for these hard to reach patients. The main features of this therapy are creating a safe attachment, which the therapist tries to achieve by connecting with the patient and reliving child trauma’s to unlock and process subconscious feelings. This might lead to reaching a more emotional state, which can promote recovery. However it is possible that the psychopathic patients will manipulate the treatment and even become more trained psychopaths. Nevertheless, results show that Schema Therapy appears to be rather efficacious.
As prisons are getting severely overcrowded, it is becoming more and more important to improve the prevention of crime. However, how can this problem be tackled, when it is not simply a matter of teaching a vandal norms and values with a community service or obligating an aggressor to a year of anger management. How do we rehabilitate someone, when any sense of repentance, guilt and deep emotion in most cases is lacking. What is the treatment for a psychopath with no conscience?
Psychopathy can be defined as a personality disorder which includes predatory behavior, emotional detachment, callousness, impulsivity and persistent antisocial behavior (Hare, 2003). Irresponsible, impulsive and egocentric lifestyles are often observed (Skeem, Polaschek, Patrick & Lilienfeld, 2011). Psychopathic patients tend to get involved in criminal activities, pathological lying and disregard of social convention. Psychopaths tend to lack feelings of empathy, guilt and remorse. They are known to use their superficial charm to obtain what they desire and can be extremely manipulative. Studies shows that they have noticeably lower fear levels and are highly stress tolerant (Skeem, Polaschek, Patrick & Lilienfeld, 2011). Unlike the most mental disorders, where the existence of the problem is concluded from difficulties experienced by the patient, psychopathy is a disorder which negative effects accrue more to those who come in contact with the psychopath than to the patient (Rice, Harris, & Cormier, 1992).
It seems that solely taking patients suffering from this disorder into custody for a certain amount of time is simply not sufficient. ´´Teaching them a lesson´´ will not commence recovery in psychopathic patients. Psychopaths commit more severe violent crimes after hospitalization or incarceration (Rice, Harris, & Cormier, 1992). There is also a higher risk for them to recidivate compared to nonpsychopaths. Psychopathic patients prove to be a tremendous challenge for mental health professionals in their attempt to safeguard society. These professionals are faced with the impediment that it is widely held that there is no cure for psychopathy and that treatment can even have adverse effects (Rice, Harris, & Cormier, 1992; Chakhssia, de Ruiter & Bernstein, 2010). This unfavorable effect was seen in a study where psychopathic and nonpsychopathic criminals were receiving an experimental treatment in a therapeutic community instead of being held in prison (Rice, Harris, & Cormier, 1992). The intention of the therapeutic program was to examine whether grouping criminals together and placing them into a position where they need to take care of each other, would have a positive effect on their recovery progress. They were bound to be each other´s therapists in order to keep the therapeutic community going. The number of professional staff was kept as low as ethically responsible to make sure that the patients would support each other. Patients who showed sufficient clinical progress, received leadership roles in the community. The program inventors believed that without professional therapists it would be much more likely to see some therapeutic change. Unfortunately, the psychopaths manipulated the program. They rose to the organizational apex in the therapeutic community without themselves being touched by the program (Rice, Harris, & Cormier, 1992).
Thus, if incarceration does not help, professional therapists can not always offer the right treatment and a therapeutic community will not likely rehabilitate psychopathic patients, what else can be done to ensure the protecting of the outside world? The fact that the psychopathic patients themselves do not experience heaps of negative effects from this disorder, consequently means that even when a treatment with positive results is feasible, there will always be the possibility that psychopathic patients will not cooperate and manipulate, lie and con their way to the treatment. To ensure that this will not be the case, there will need to be a way to influence psychopathic features. Is there a type of treatment that is proficient enough to alter the salient characteristics of psychopathy? There seems to a relatively new treatment with promising outcomes on the rise. It is called Schema Therapy Rafaeli, Bernstein, & Young, (2011). Thus how capable is this incoming treatment? Can psychopathic patients be rehabilitated and safely reintegrate into society without chances of recidivism using this innovatory Schema Therapy?
The efficacy of previous treatments
Although many researchers and clinicians assume that psychopaths are remediless, surprisingly few studies have actually tested this assumption. Despite the absence of empirical support, the assumption that psychopaths are untreatable has its intuitive appeal for a number of reasons. First, the number one priority for society is to reduce the risk of reoffending, thus making the society a safer place. The main concern is not particularly to fix the unpleasant personality characteristics of psychopaths. Not only is this not the number one priority, it is also believed to be impossible. It is argued that these traits are intractable and cannot be altered (Rice, Harris, & Cormier, 1992). However, can we just assume this is the truth?
In contrast with these despondent beliefs, recent studies show some optimistic results regarding the possibility of successfully treating psychopathic patients. A Dutch study in a forensic hospital examined potential improvement in forensic inpatients suffering from personality disorders (Chakhssi, de Ruiter, & Bernstein, 2010). To measure this alteration the BEST-index, a nurse-rated instrument, was used. This behavioral status index shows the change in the risk level of future violence and institutional aggression. 37% of the psychopathic patients showed improvement. The fact that this is a non-significant difference from the psychopathic group, falsifies the notion that psychopaths can not change. However only the psychopaths also showed an increase in aggression. These outcomes support the belief that psychopathic patients can ameliorate with treatment. Which means that the treatment is actually making them better psychopaths. However this study also shows us that there is also notable room for improvement in psychopathic patients, considering that 37% of the psychopaths actually did improve. This outcome invalidates the statement that psychopaths cannot be treated at all (Chakhssi, de Ruiter, & Bernstein, 2010).
The popular image of psychopaths, is that they are coldhearted monsters with an overall lack of emotions and feelings. A key point in the treatment of psychopaths is to keep in mind that the feelings, thoughts and actions of these patients do fluctuate, like those of regular people (Rafaeli, Bernstein, & Young, 2011). They can show signs of empathy, deep emotions and even guilt. These fluctuations are not in accordance with trait theory, which states that people are the same at all times and that one´s traits defines one´s personality. That assumption is what makes those treatments usually ineffective (Rafaeli, Bernstein, & Young, 201). As a consequence, efforts to apply one-size-fits-all public policies to psychopathic individuals are often doomed to failure. Thus instead of only explaining someone´s personality through somebody´s traits, there should also be an explanation for the gusts of change in feelings, thoughts and behavior. When this is achieved, there maybe is a chance to break down the walls of psychopaths, and other certain mental disorders, that these patients build up so diligently (Rafaeli, Bernstein, & Young, 2011).
To accomplish this breakthrough a cognitive therapy called Schema Therapy is used. Its aim is to use these fluctuations to reach the deeper emotions of hard-to-treat patients like sufferers from Borderline Disorder and Psychopathic Personality Disorder. Schema therapy was developed by Young in 1990 (Arntz, A. & van Genderen, H. 2009). This therapy combines cognitive behavioral therapy and experimental techniques. It includes the schema mode model that states that human beings change to different emotional-cognitive-behavioral states. These temporary states predominantly determine a person´s feelings, thoughts and actions for that moment. The treatment places a strong emphasis on the relationship between the patient and the therapist, as well as profound emotional processing of traumatic experiences, such as child abuse and neglect. One of the key acquirements of this therapy is repairing the unsafe attachment, which the patients in most cases had with their caregivers. The therapist tries to achieve this by bonding with the patient and creating a safe relationship. This is known as ‘limited reparenting’ (Rafaeli, Bernstein, & Young, 2011). By reliving trauma’s, which are the often the major cause of the emotional detachment and instability, the patients can unlock subconscious feelings and reach a more emotional state which can promote recovery. The heart of the therapy is correcting dysfunctional schema’s, which are the organized knowledge structures. It also aims at discontinuing dichotomous thinking, which is extreme ”black-and-white” thinking. Patients learn to tolerate, accept and handle strong emotions and learn new emotional skills. It is also key that they obtain a healthier view on life. Schema therapy, which is a relative long-term treatment, shows to be rather effective. For patients with severe personality disorders, therapy often lasts two to three years. It shows low drop-out rates and high effect sizes (Rafaeli, Bernstein, & Young, 2011). The results of Schema Therapy show more cases of improvement than usual treatment (Rafaeli, Bernstein, & Young, 2011). Since the aim is genuine personality alteration, this exceptional treatment stands out from the rest.
The degree of effectiveness of Schema Therapy has already been put to the test. In addition to the several successful schema therapy studies on Borderline Disorder, Bernstein and Nijman studied the effect of Schema Therapy on psychopaths (Bernstein & Nijman, submitted). To secure the internal validity a control group receiving treatment as usual was incorporated. Over the first 18 months of treatment those in the schema therapy condition showed a expeditious decrease in their risk levels declining form high to medium. This result opposes to the treatment as usual condition which showed no significant change at all in the patients risk levels in the whole first year of treatment. Thus, Schema Therapy appeared to offer more rapid improvements in psychopaths, a noteworthy finding given the supposed untreatability of these patients. These results were also recognizable in the data on the patients progress into the resocialization phase of treatment, which is a key aspect of the treatment. If a patient’s risk level is deemed to be sufficiently low, a permission to begin a gradual process of reintroduction into the community is granted. This process initiatively starts with brief periods of supervised leave. Eventually, if these shorts periods of leave proceed decently, longer periods of unsupervised leave are obtained. The consequences of receiving or not receiving permission for furlough are of great importance. Patients who do not acquire furlough because of persistent high risk levels are ultimately sent to adapted long-stay units, where they reside for an indeterminate period of time. Thus, the resocialisation process is crucial to the success of the therapy. It is the crucial distinction between re-integration into society and a life-long verdict of confinement. Results of the study showed that a larger proportion of patients receiving Schema Therapy obtained permission to go on leave than the patients receiving treatment as usual. This applied for both supervised and unsupervised leave. After two years of therapy, twice as many patients receiving Schema Therapy attained leave than patients following the treatment as usual (Bernstein & Nijman, submitted). Additionally, patients receiving Schema Therapy obtained furlough an average of four to six months earlier than those receiving treatment as usual. Thus, these findings all together suggest that Schema Therapy facilitates psychopathic patients’ reintegration into society (Bernstein & Nijman, submitted).
In closing, is it genuinely possible to alter the personality of psychopathic patients so that they can safely get reintegrated into society? This question would have been answered with a convincing no about twenty years ago. Until 1990, there was a certain therapeutic nihilism regarding the treatment of psychopathic patients. However, with the introduction of the innovative Schema Therapy and its pioneering results, the expectations are high. Instead of condemning psychopaths to a lifelong sentence or drugging them up so they do not have more of a personality at all, Schema therapy tackles the problem at its roots. Treating psychopaths requires a radical reconceptualization of their personality disorder pathology. It demands a state view instead of a trait view. This recovery process needs a therapy that lays strong emphasis on the deficient and distorted emotional states of psychopaths. If we can influence psychopathic patients to reach more emotional states, it might be possible for them to expand and cultivate their own feasibility for moral feelings, such as empathy, shame and guilt (Rafaeli, Bernstein, & Young, 2011).
However, there will always be the possibility that our psychopathic patients will manipulate, lie and con their way through the treatment. Or even worse, the chance that they will deteriorate from the treatment. In these treatments they learn better ways to manipulate
the system to their advantage and to play “head games” with the clinicians, which was exactly the retinue from the therapeutic community experiment. Not only did the psychopaths rose to the organizational apex without being touched by the program, they also impeded the other patients from recovery. (Rice, Harris, & Cormier, 1992).
A psychopathic mind can be a great danger to society, thus the fact that many are not really addressing the idea of helping psychopaths is comprehensible. However, we have to stop seeing psychopaths as only the great bad wolves. Psychopathic personality disorder is an impetuous derangement, nevertheless it is not an immutable verdict. The most profitable solution on the long-term is to pursuit personality alteration and now we might have the implements to conquest this arduous disorder right in our hands (Rafaeli, Bernstein, & Young, 2011).
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