Treating the untreatable: A single case study of a psychopathic inpatient treated with Schema Therapy.

Abstract

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.

Interpersonal Dynamics in Personality and Personality Disorders

“…Chakhssi, Kersten, de Ruiter, and Bernstein () described Andy, a young man who had been incarcerated for a sexually violent offense who had a high score on a measure of psychopathy. While recounting to his clinician how he could not trust other inmates, Andy became increasingly aroused and controlling.…”

Borderline Personality Disorder with Psychopathic Traits: A Critical Review

“…In this way of studying the possible relationship between these two disorders, the study by Chakhssi, et al [29] focused on a clinical case in which a schema therapy treatment is applied to a forensic patient with psychopathic features. Schema therapy is a psychotherapeutic approach with demonstrated efficacy in patients with borderline personality disorder.…”

“…Specifically, both studies have studied the efficacy of treatments applied to BPD, such as scheme therapy [29] or Dialectical Behavior Therapy (DBT) [28], in psychopathic patients, obtaining in both cases positive results.…”

Schema Therapy

“…This was then formally tested in a three-year randomized trial (N = 86) comparing schema therapy to transference-focused therapy. Chakhssi, Kersten, de Ruiter, and Bernstein (2014) have recently outlined a detailed case study of this approach for a forensic patient with personality disorder over a four year treatment period. A follow up implementation study demonstrated similar effect sizes when used in routine clinical practice and without the out of hours phone support which was a component of the treatment approach of the first trial (Nadort et al, 2009).…”