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BackgroundViolent 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.MethodsWe 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.ResultsPatients 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).ConclusionsThese 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.

PurposeA core element of Schema Therapy (ST) is schema modes' or fluctuating emotional states. ST assumes that particular personality pathology consists of specific combinations of maladaptive schema modes. There is confirmatory evidence for the modes hypothesized to be central to borderline and narcissistic personality disorder (PD) in non-forensic patients. In this study, we tested three aspects of the construct validity of schema modes in cluster-B personality disordered offenders, examining its factorial validity, and the relations among personality disorders and violence risk.MethodOur sample consisted of 70 offenders who were diagnosed with an antisocial, borderline, or narcissistic PD. Schema modes were assessed with the Schema Mode Inventory (SMI), personality disorders with the Schedule for Nonadaptive and Adaptive Personality-Forensic Version (SNAP-FV), and violence risk with the Historical, Clinical, and Risk management scheme (HCR-20(V2)).ResultsWhen controlling for the two other PDs, three schema mode factors distinguished antisocial PD as a disorder involving both low scores on internalizing and high scores on externalizing modes, and borderline PD as involving high scores on internalizing modes. Furthermore, the externalizing schema modes were a significant predictor for violence risk inside the hospital.ConclusionsThe hypothesized mode models were partially supported for all three PDs. The findings thus provide some support for the construct validity of schema modes in a forensic sample.

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.