New research by David Bernstein, who was recently appointed UM professor of Forensic Psychotherapy, challenges this theory. Bernstein is currently leading a large-scale study of over 100 TBS patients in seven TBS clinics. The preliminary results are promising. In their first group of patients, the team observed a faster decrease in the risk of recidivism. Crucially, this risk decreased the fastest in the group considered the most psychopathic – the very group often deemed untreatable. Bernstein stresses caution in interpreting the results, as they are not statistically significant and no fixed pattern has yet been established. “But if these results are confirmed for the entire research population, we will have found the first effective treatment for psychopaths.” This would be a real breakthrough for the field of psychopathy.
The treatment is called schema therapy, an integrated form of psychotherapy specially designed to treat personality disorders and ‘treatment-resistant’ patients. What makes this method unique is that it focuses not on unchangeable character traits, but on the patient’s emotional state. It uses a package of special treatment techniques, ‘limited reparenting’ being the most important of these. In establishing a relationship with the patient, the therapist assumes a parenting role. “Psychopaths are often antisocial and emotionally detached. They don’t trust anyone and refuse to cooperate”, Bernstein explains. “To gain their trust, the therapist adopts a caring and compassionate role.” The goal is to break through this emotional detachment and draw patients into a more vulnerable position, making them ‘softer’.
The next step is to teach patients how to discuss their emotions. This is done using the language of ‘schema modes’. A schema mode is an emotional state (intimidating, aggressive, manipulative) that can take over a patient temporarily and play an important role in violent behaviour. “Our hypothesis is that behind these extreme emotional schemas lies a more vulnerable side. That’s the key to accessing strong emotions. Many patients were abused or mistreated as children. The goal is to help heal these earlier wounds.” Further, the patient’s capacity for self-reflection is increased, and they learn to better control their frustrations and impulsive behaviours. “In short, schema therapy strives to transform a patient’s personality by changing their schema modes.”
Bernstein remains uncertain whether schema therapy will become the primary treatment for psychopaths. With psychopaths, he says, it is never fully clear in advance how emotionally open they can be. “I don’t expect schema therapy to work for all psychopathic patients, but I’d consider it a vast improvement if we were able to help 50 percent.” This would mean a radical change for the field of psychopathy: “People tend to think psychopathic disorders have biological underpinnings – which has never been proven, by the way – and so they go untreated. This leads to a self-fulfilling prophecy: if they can’t be treated, why bother in the first place?”
The impact of Bernstein’s research is profound. “Psychopaths are responsible for a disproportionate amount of crime. Consider the damage they cause; the devastation, the psychological and physical violence. If schema therapy works, the social benefits will be huge.” Not only that – there will also be substantial cost savings. Three years of schema therapy costs roughly €20,000, whereas admission to a TBS clinic amounts to €160,000 per year. The duration of TBS treatment is expected to be reduced by 18 weeks.
Going against the grain
Bernstein acknowledges the controversial nature of his research, which goes against the prevailing public opinion. He can also appreciate the scepticism with which this treatment method is viewed. “It’s good to be sceptical; in fact, we should be sceptical. People are right to be concerned about how dangerous these people are. After all, they’ve been considered untreatable for over 200 years. That’s why it’s so important that our research is methodologically sound. And it’s also why I keep emphasising that our claims are preliminary.”
One question remains of vital importance: does treatment change a psychopath forever? “With psychopaths, there’s no such thing as a ‘cure’. You can never guarantee they won’t commit another crime”, says Bernstein. “For me, the challenge is to reduce the risk. You can compare it to cancer: you try to keep someone cancer-free for as long as possible, but that doesn’t mean the risk is gone. That’s a good analogy for what we’re trying to achieve.”
David Bernstein (55) is professor of Forensic Psychotherapy, an endowed chair sponsored by Maastricht University and the forensic psychiatric centre De Rooyse Wissel. He received his PhD in Clinical Psychology from New York University in 1990 and moved to Maastricht University in 2004. He serves as chair of the Forensic Psychology Section in the Department of Clinical Psychological Science. His main research areas are personality disorders, psychological trauma and forensic issues. Bernstein is an internationally renowned expert in the field of schema therapy, an integrated therapy for personality disorders.