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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]
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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
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Cognitive Behavioural Therapy ‘What Works’ principles Risk Guided Focussed on offence relapse
prevention Offence chain model Schema Focused Therapy
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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
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D.A. Andrews and J. Bonta. The psychology of criminal conduct
Research Findings by Meta-Analysis Risk Principle Need Principle Responsivity Principle Integrity Principle
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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
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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
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Barriers in contact:- lack of motivation, - anxiety, - intellect- the quality of the therapist, the team
and setting
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Don’t drift program Treatment or instrument non-
compliance. Don’t reverse the program.
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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.
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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
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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
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Healthy balance between:o Content and process levelo Attention for the past and the presento Explicit and implicit interventionso Individual, interactional and group
interventions
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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.
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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.
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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:
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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
+/- + +/-
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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
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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
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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
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Are there any experiences with combining CBT, group therapy and MBT? How are those experiences?
Thank you for your attention!!!!
Information: [email protected]