Download If you can`t convince them join them

Cognitive Behavioral Therapy, Group
therapy and Mentalization; a connection
with possibilities?
Anne van den Berg, clinical psychologist and
psychotherapist.
FPC The Rooyse Wissel, the Netherlands
IAFP 2009, Konstanz
[email protected]
 Short
overview Dutch forensic psychiatry
 Cognitive Behavioral Therapy
 ‘What Works’ principles, advantages and
disadvantages
 Offence Chain Module, advantages and
disadvantages
 Group therapy
 Mentalization Based Treatment
 Working apart, together or parallel connected
 A social answer to antisocial behavior
 Discussion
 Cognitive
Behavioural Therapy
 ‘What Works’ principles
 Risk Guided
 Focussed on offence relapse prevention
 Offence chain model
 Schema Focused Therapy
 dysfunctional
emotions, behaviors and
cognitions
 goal-oriented, systematic procedure
 cognitive skills, reducing criminal behavior
 monitor thoughts, assumptions, beliefs and
behaviors which are dysfunctional,
inaccurate, or unhelpful.
 replace with more realistic and useful ones.
Criticism: no room for irrational feelings and
internal conflicts
D.A. Andrews and J. Bonta. The psychology
of criminal conduct
Research Findings by Meta-Analysis
 Risk Principle
 Need Principle
 Responsivity Principle
 Integrity Principle
 Target
those offender with higher
probability of recidivism
 Provide most intensive treatment to
higher risk offenders
 Intensive treatment for lower risk
offender can increase recidivism
 Risks as detailed as possible
By assessing and targeting criminogenic needs for change,
therapists can reduce the probability of recidivism
Criminogenic
 Anti social attitudes
 Anti social friends
 Substance abuse
 Lack of empathy
 Impulsive behavior
Non-Criminogenic
Anxiety
Low selfesteem
Creative abilities
Medical needs
Physical conditioning
Barriers in contact:
- lack of motivation,
- anxiety,
- intellect
- the quality of the therapist, the team and
setting
 Don’t
drift program
 Treatment or instrument non-compliance.
 Don’t reverse the program.
 Suggestion
of a new way of thinking and
treatment
 Good Lives Model (T.Ward)
 No connection with the intra-psychic
often irrational world of (forensic)
patients
 Is is principally a research based model
and not a therapeutic model
 Meet
the requirements of the ‘What
Works’ model
 Far and wide used in the Forensic Care,
especially in the high security hospitals
like the TBS
 Originally developed in the addiction
care
5 Phases:
o Life lines with a cognitive case
conceptualisation diagram
o Offence scenario
o Offence chain
o Relapse prevention plan
o Offence presentation
6 patients in group. All results projected on
screen with laptop and beamer
Year
Major
events
Place of
living
1
Brother
born.
Mother
for 4
weeks in
hospital
Amsterdam. Don’t
8 weeks to
want to
my grand - eat
mother
12
Parents
Amsterdam
divorced Small flat
Stay with
mother
25
Married
with my
(ex)wife
Mother-inlaw. Living
in
Problem School
behavior Work
Relations/ Feelings
sexuality
At home
I don’t
know
Disstress
ed?
Skipping
school
Small
thefts
Special
primary
school.
Hate my
mother.
Teased on
school
Rage
Drinking
Fighting
Lost my
job as
painter
Extramarit Lost my
al relations way
Describe the offence in details:
-the circumstances,
-the behavior,
-the thoughts,
-feelings
from 6 hours before the offence, during the
offence till 6 hours after the offence.
The personal factors leading to offence:
- the traits of the offender,
- circumstances,
- sensitivities,
- fallacies,
- incentives,
- getting out of balance,
- pitfalls,
- high risk situations,
- planning and committing the crime
- the effects afterwards
Dynamic offence theory
How the patient can prevent in time the steps to
committing a crime?
Factors in the offence chain: How to handle?
- thinking in an other more constructive way
- stabilizing by doing more healthy things
- structuring your life
- coping strategies
A lot of alternative behavior applied on the
personal situation of the patient
Powerpoint presentation by patient:
- from life-lines till relapse prevention
- to the multidisciplinary team
- familiar patients, friends and relatives
The meaning:
- manifest results what he has learned
- public confession about his wrong doing
and positive plans
 Risks
are clear
 Needs behind the offence are clarified
 Structure and tasks for patients stimulate
the self activation
 The matter is logically and to understand
 Grip to use alternative behavior in the
relapse prevention
 Good cognitive insight with connections
to feelings, development
 Individual
therapy in the group by way of the
screen.
 Patient’s don’t learn with each other but about
each other.
 Patient’s speak about their offences
 Patients can use this model as a list to tick of
the items
 By focussing on the past there is a neglecting of
the present
 Premise: offences are committed by losing
one’s balance.
 Therapist
is too much focused on the explicit
offence material
 Therapist is focused on the content and not on
the relation between therapist and patient
 No attention to what a group makes successful
(Yalom). Encourages defences
The process of the offence chain group
encourages that behavior in terms of
content which it want to break down.
A classic example of a paradox
Healthy balance between:
o Content and process level
o Attention for the past and the present
o Explicit and implicit interventions
o Individual, interactional and group
interventions
 Recognition
of behavioral patterns in the
social Microcosm of the group
 Space for the correctional emotional
experience
 Connecting the destructive forces in the
group with the constructive ones.
Mentalizing is the ability to see one’s own
behaviour and that of others in terms of motives
and intentions. To develop the ability to reflect
and mentalize, a safe attachment with the
caretaker (later on between patient and
therapist) is necessary.
1.ensuring that the patient is able to regulate the
attention in therapy to the self or others.
2.ensuring that the patient can deal with the affects within
the therapeutic relationship,
3.discussing the affects in the present time
4. discussing how these play a role towards attachment
figures in the present and past.
5. encouraging the patient to verbalize his own intentions
and those of others;
Summary of MBT:
OCM
Group
MBT
Cognitive learning
++
+
-
Interactional learning
-
++
+
Reflexive learning
-
+
++
Offence connected learning
++
+
+/-
Internalizing
-
+
++
Keeping in account level of
development
-
+
++
Implicit learning
-
++
++
Common therapy factors
-
++
++
Structure and grip
++
+/-
+
Practising properly behavior
+/-
+
+/-
Starting point:
Join the forces of the different point of views but
bring no confusion in one group.
Solution:
1. Life-lines individual in a more diagnostic
framework. Patterns and Schema’s
2. Presentation about life lines as a start in a
closed group
3. Three kinds of groups which operate
separately but connected in time, in therapists
and in theme’s
1.
2.
3.
Cognitive behavioral group about offence
chain and relapse prevention with an attitude
of the therapists ‘keeping tot the point’.
Group dynamic therapy with more
interactional themes in the here and now with
space for corrective emotional experience.
More process and space for positive feelings
and intentions. Elements of MBT therapy.
Non-verbal therapies like drama, creative,
psychomotor for the more implicit
interventions. MBT elements
It is very important to revalue the
imperfect clinical experiences of the
therapists and those of the patients in
stead of, first to all, to trust in the
imperfect results of empirical research.
Research is for checking your
professional person as an instrument.
This is a social solution and answer as a
counterforce for patients with antisocial
behavior like those with ASPD
Are there any experiences with combining
CBT, group therapy and MBT? How are
those experiences?
Thank you for your attention!!!!
Information: [email protected]