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 anne@berg-op.nl

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 Non-Criminogenic Anti social attitudes Anxiety Anti social friends Low selfesteem Substance abuse Creative abilities Lack of empathy Medical needs Impulsive behavior 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

diagramo Offence scenarioo Offence chaino Relapse prevention plano Offence presentation6 patients in group. All results projected on screen

with laptop and beamer

Year

Major events

Place of living

Problem behavior

School Work

Relations/sexuality

Feelings

1 Brother born.Mother for 4 weeks in hospital

Amsterdam. 8 weeks to my grand -mother

Don’t want to eat

At home

I don’t know

Disstressed?

12 Parents divorcedStay with mother

AmsterdamSmall flat

Skipping schoolSmall thefts

Special primary school.

Hate my mother. Teased on school

Rage

25 Married with my (ex)wife

Mother-in-law. Living in

Drinking Fighting

Lost my job as painter

Extramarital relations

Lost my 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 afterwardsDynamic 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 strategiesA 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

relativesThe 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 levelo Attention for the past and the presento Explicit and implicit interventionso 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’s2. Presentation about life lines as a start in a

closed group3. Three kinds of groups which operate

separately but connected in time, in therapists and in theme’s

1. Cognitive behavioral group about offence chain and relapse prevention with an attitude of the therapists ‘keeping tot the point’.

2. 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.

3. 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: anne@berg-op.nl