هنردرمانی و طرحواره درمانی متمرکز: یک مطالعه مقدماتی

Arts therapies and Schema Focused therapy (SFT), use experiential techniques to help patients access and reprocess emotions. We conducted a randomized controlled pilot study to determine the effectiveness of these therapies at evoking emotional states (“schema modes”) in forensic patients, a group that is considered difficult to reach emotionally. Ten male forensic patients with Cluster B personality disorders who were enrolled in a randomized clinical trial of SFT versus usual forensic treatment (“treatment as usual,” TAU) participated in the study. We investigated the effect of Arts therapies versus verbal psychotherapy, and SFT versus TAU on modes. As hypothesized, patients showed significantly more healthier emotional states in their Arts therapy sessions than in their verbal psychotherapy sessions SFT evoked more childmodes than TAU, at a trend level of significance. Patients in the SFT and TAU conditions showed no differences in schema modes early in therapy, and were equivalent on all baseline characteristics. These findings, though requiring replication in a larger sample, suggest that Arts therapies and SFT have potential for evoking emotional states in difficult to reach patients.

Arts therapies,1 such as drama, art, music, dance and movement therapies, and psychomotor therapy, are increasingly used in psychiatric and forensic settings as an adjunct, or alternatives, to traditional verbal forms of psychotherapy. Dramatherapists use methods such as role play, masks, improvisation, text and poems. Role playing gives the patient and the therapist the opportunity to play with reality and to experiment and explore the facts of real life (Johnson, 1991). Forensic patients are a group of patients that are difficult to reach emotionally. Many forensic patients are emotionally detached, or tend to express their emotions inappropriately (Bernstein, Arntz, & de Vos, 2007; Day, 2009). Although drama therapy techniques are similar in both general and forensic psychiatry, the emphasis in forensic dramatherapy is on expression of emotions, exploring destructive behaviour and on the increase of self-control (Blacker et al., 2008 and Reiss et al., 1998). Art therapists use art methods such as drawing, painting, working with clay, wood or stone. Art therapy in forensic psychiatry aims at creating an art object in which patients’ internal processes are externalized into a concrete form. This form can also help the patient understand the events, thoughts and feelings that have led to an offense (Gerber, 1994 and Gussak, 2007). Music therapists use music instruments, singing, songwriting, rap, and body percussion. These methods can be experienced in a receptive and active manner. Forensic musictherapy specifically focuses on aggression and social interaction. For instance, the way you interact with others during musical play gives the music therapist an insight in the patients’ dominant social strategies (e.g. playing out loud, or subtle and very quiet). Also aggression can be explored and expressed in a safe and indirect manner, for example, via instruments (e.g. hitting the drums excessively) (Hakvoort, 2002 and Reed, 2002). Dance and movement therapy and psychomotor therapy are founded on the basis that movement and emotion are directly related (Hekking and Fellinger, 2011 and Payne, 2006). Forensic Dance and Movement Therapists use structured or free dance and movement exercises to explore the physical aspects of destructive behaviour such as aggression and poor impulse control (Smeijsters, 2005). The psychomotor therapist uses physical exercises that focus on posture, musculature, breathing, and the person's ability to adjust. Forensic psychomotor therapists address a patient's self-perception and self-regulation skills because these are often impaired in forensic patient's (Chakhssi et al., 2010 and Hornsveld et al., 2004). There are several potential advantages of Arts therapies, compared to traditional, verbal therapy approaches. First, increasing research suggests that much of cognitive processing is unconscious (e.g. Greenwald, 1992). Arts therapies may be more effective than verbal psychotherapies at facilitating processing at a non-verbal, unconscious level. Second, there is increasing evidence for the importance of emotion in various forms of cognitive processing (David et al., 2003 and David and Szentagotai, 2006). The Arts therapies incorporate a broader range of methods to evoke and reprocess patients’ emotions than in traditional verbal forms of therapy. Finally, many patients have difficulty in accessing and expressing their emotions verbally. Thus, traditional verbal therapies may prove to be unproductive for some patients, particularly for those who are very emotionally detached or cognitively challenged. Arts therapies may prove a more effective alternative especially for these patients. In this study, our primary aim was to test a central assumption of Arts therapies, namely, that they are more effective than verbal forms of psychotherapy at evoking emotional states, including both “vulnerable” emotional states, such as sadness, fear, and loneliness, as well as joyful, pleasurable emotional states. We tested this assumption using a sample of forensic patients with personality disorders – a group that is generally considered to be very emotionally detached, hostile, and mistrustful, and is often reluctant or unable to show emotions openly. Forensic patients with personality disorders often respond poorly to standard, verbal forms of psychotherapy, such as cognitive-behaviour therapy (Timmerman & Emmelkamp, 2005). Some of these patients, especially those with high levels of psychopathy, are generally considered to lack the emotional prerequisites for successful psychotherapy, such as the capacities for bonding, empathy, and experiencing feelings (D'Silva, Duggan, & McCarthy, 2004). Arts therapies are being increasingly used with forensic patients as a possibly more effective alternative However, the effectiveness of Arts therapies with forensic patients has never been tested, neither the key assumption that these alternative therapy forms are more effective than standard, verbal therapies at evoking emotions. A second aim of this study was to compare the effectiveness of Schema Focused therapy (SFT; Young, Klosko, & Weishaar, 2005) to usual forensic treatment for evoking emotional states. SFT is an integrative form of psychotherapy combining cognitive, behavioural, psychodynamic object relations, and humanistic/experiential approaches (Young et al., 2005). SFT has shown effectiveness in treating patients with borderline PD (Farrell et al., 2009 and Giesen-Bloo et al., 2006), and has recently been adapted for forensic patients (Bernstein, Arntz, & de Vos, 2007). In patients with severe personality disorders, the focus of SFT is on “schema modes”, also referred to as emotional states or “parts of the self” that temporarily dominate a person's thoughts, feelings, and behaviour (Young et al., 2005). According to SFT theory, these states are relatively dissociated from each other in patients with severe personality disorders. Thus, patients may shift rapidly between extreme emotional states, or remain rigidly “stuck” in one state to the exclusion of other states. For example, patients with Borderline PD may shift rapidly between states involving emotional pain (“Vulnerable Child mode”), anger or rage (“Angry Child mode”), emotional detachment or numbness (“Detached Protector mode”), and self-punitiveness (“Punitive Parent mode”). The goal of SFT is to ameliorate maladaptive schema modes that block access to emotions (e.g., “Detached Protector mode”), heal the patient's early emotional wounds (“Vulnerable Child mode”), and strengthen the patient's capacity for healthy self-reflection (“Healthy Adult mode”) and spontaneous joy and pleasure (“Happy Child mode”). Although SFT is primarily a verbal form of psychotherapy, it incorporates experiential techniques such as imagery rescripting and role-playing to reprocess patients’ emotions (Young et al., 2005). Thus, it bears some similarity to Arts therapies, which are also experientially oriented. On the other hand, Arts therapies incorporate a broader range of experiential methods, and are more focused on experiential as opposed to verbal learning, compared to standard SFT. Recently, some Arts therapists have begun to integrate elements of SFT into their work (Griffith, 2003 and Muste et al., 2009). The schema mode model appears to provide a useful conceptual framework for Arts therapies, given that Arts therapies use a variety of media (e.g., drama, music, dance) to evoke and reprocess emotions (Muste et al., 2009). From an SFT perspective, the methods used by Arts therapists can be conceptualized as “mode evoking techniques” – techniques for evoking emotional states (“schema modes”) that may be more difficult to access via conventional therapies. Thus, the integration of the schema mode conceptual model into Arts therapies may enhance the effectiveness of Arts therapy interventions. The present study investigated the effectiveness of Arts therapies and SFT in evoking emotional states in forensic patients. The study was conducted as part of a three year, multicenter randomized clinical trial of SFT that is currently taking place in 7 secure hospitals in The Netherlands. The larger clinical trial tests the effectiveness of SFT versus usual forensic psychotherapy (“Treatment as Usual”; TAU) in reducing personality symptoms and recidivism risk in forensic patients with Cluster B personality disorders (Bernstein, 2009). At one of the 7 sites for the clinical trial, Forensic Psychiatric Centre ‘de Rooyse Wissel,’ patients who were randomly assigned to either the SFT or TAU condition were also given Arts therapy as an adjunctive treatment. We assessed patients’ emotional states (“schema modes”) based on randomly selected videotapes of therapy sessions made after patients had received between one and one and a half years of therapy – enough time, we hypothesized, to observe differences in patients’ emotional states, if indeed, the treatments had the mode-evoking effects that we predicted. Although the sample size was small, we used several methods to increase the statistical power of our experiment: a repeated measures design, in which patients served as their own controls; two independent raters, whose mode ratings were averaged to improve reliability; and rating two videotaped Arts therapy and verbal psychotherapy sessions per patient (i.e., 40 total sessions were rated), to create more reliable and generalizable composite mode scores. We hypothesized that patients would show more vulnerable emotions (“Vulnerable Child mode”), less emotional detachment (“Detached Protector mode”), and more healthy modes, including states of healthy self-reflection (“Healthy Adult mode”) and spontaneous joy and pleasure (“Happy Child mode”), during: (1) Arts therapy sessions compared to verbal therapy sessions, and (2) SFT therapy versus TAU therapy. Moreover, we predicted that patients: (3) would show the most vulnerable and healthy states, and the least emotional detachment, during the sessions where they received SFT-oriented Arts therapies (i.e., a significant SFT by Arts therapy interaction effect).

To determine whether the patients that were randomly assigned to the SFT and TAU conditions were different regarding their baseline (i.e., pre-therapy) characteristics, we compared the two groups on the following baseline variables using independent samples t-tests on: age, time in treatment, DSM-IV personality disorder symptoms (by SIDP-IV interview), and PCL-R scores. At baseline, there were no significant differences in the aforementioned characteristics. Thus, the randomization procedure created groups that were equivalent at baseline on these variables. In addition, we compared the patients in the SFT and TAU conditions with regard to schema modes early in treatment, using MOS scores rated from videotapes of patients’ 3 month psychotherapy sessions. No equivalent tapes had been made from patients’ Arts therapy sessions early in therapy. Three-month psychotherapy session tapes were available for 8 of the 10 patients (SFT, N = 5, TAU, N = 3). There were no significant differences in patients’ 3-month mode domain ratings for Child Modes Avoidant/Compliant Modes Parent Modes, Over compensatory Modes or Healthy Modes Thus, at 3 months, the SFT and TAU patients were equivalent with respect to schema mode domains that were observed during psychotherapy sessions.