Research ArticleEvoking emotional states in personality disordered offenders: An experimental pilot study of experiential drama therapy techniques
Introduction
Emotional disturbances are salient features among personality disorders (PD) (Kring & Bachorowksi, 1999). PD diagnoses are prevalent in offender populations where prevalence estimates range from moderate to high (Blackburn, Logan, Donnelly, & Renwick, 2003; Leue, Borchard, & Hoyer, 2004; De Ruiter & Greeven, 2000). Offenders with personality disorders (PDs) and the crimes that they have committed are regularly associated with emotional deficits (Day, 2009, Jolliffe and Farrington, 2004). For example, some crimes are characterized by a display of excessive anger or rage, while other crimes are more likely a result of a lack or over-control of emotions. The expression and experience of emotions may fluctuate over time; therefore the level of risk due to emotional deficits may also change over time (Douglas and Skeem, 2005, Howells, 2009). Given the risk posed by emotional disturbances, addressing these deficits should be an essential component of forensic treatment.
Therapeutic techniques that focus on subjective experiences, feelings and expression of emotions are called “experiential techniques.” These techniques aim to bring emotions into active awareness so that emotional disturbances can be addressed (Leahy, 2007, Mennin and Farach, 2007; Warwar, Links, Greenberg, & Bergmans, 2008). Typical experiential techniques are role-play, imagery and chair-work. Role-play involves re-enactment of original situations from the past or the present, or made-up situations. After the initial role-play, role reversal and rescripting is initiated (Kellogg, 2004, Landy, 2009). During rescripting, the therapists alters painful elements in the scenes that are relived, so that associated thoughts, feelings and behaviors are modified and change is facilitated (Rush, Grunert, Mendelsohn, & Smucker, 2000; Smucker & Niederee, 1995). In chair-work, the client switches between chairs and is invited to have dialogues between different parts or emotions of the self. These ‘conversations’ can also take place between the client and, for examples, a significant other (Kellogg, 2004, Paivio and Greenberg, 1995). Imagery is a technique in which the therapis asks the client to visualize an upsetting childhood memory or traumatic image of their past. Clients are invited to explore their emotions and later on to intervene in the scene with new, healthier responses. Imagery aims to better understand emotions, and how they are related to current triggers (Rafaeli, Bernstein, & Young, 2011; Smucker & Boos, 2005).
Techniques that focus on emotional states have a long history; they originate from Rogerian, existential, and Gestalt traditions (Greenberg, Watson, & Lietaer, 1998; Mennin & Farach, 2007). Today, there is a renewed interest in experiential techniques (sometimes also referred to as “emotion focused” techniques), as well as other therapeutic approaches that focus on emotions. For example, according to Emotion-Focused Therapy ([EFT]; Greenberg, 2002), emotions are intertwined with our basic needs, and create the blueprint of how we see ourselves and the world (Greenberg and Berger, 2001, Pos and Greenberg, 2012). This blue print can turn maladaptive when needs are frustrated and strong affect is ignored or suppressed. The aim of EFT is to reflect on emotional experiences and increase emotional awareness and regulation. Thus, emotions are both the target and the agent for change (Greenberg, 2006, Greenberg and Pascual-Leone, 2006). Several other forms of psychotherapy also target mental states, including aspects of emotional experience, including Cognitive Analytic Therapy ([CAT]; Ryle, 1995, Ryle and Kerr, 2002), Metacognitive Interpersonal Therapy ([MIT]; Dimaggio, Semerari, Carcione, Nicolo, & Procacci, 2007), and Mentalization Based Treatment ([MBT]; Bateman & Fonagy, 2004).
Arts therapies represent another important therapeutic approach that uses experiential techniques to work with emotions. Arts therapies refer to music, drama, art and dance and movement therapies (Carr et al., 2012). These therapies are experience based; they use experiential techniques to help clients access and reprocess emotions. They evoke feelings and explore interpersonal interactions using artistic media (Malchiodi, 2012, Malchiodi and Crenshaw, 2014, North American Drama Therapy Association, 2016). In this study we especially focus on drama therapy. Drama therapy uses different elements and techniques that originate from theatre such as masks, puppets, role-play, and improvisations. These methods are based on the belief that direct experience, rather than talking about experiences, will enable the client to re-experience inner feelings and thoughts (Landy, 2009). Also, play gives the opportunity to experiment, to find out more about a client’s inner feelings and thoughts (Johnson & Emunah, 2009).
There is little empirical evidence that substantiates the effectiveness of experiential techniques, although there is a growing body of literature on imagery. Research has shown that visual representations of events trigger more emotions than verbal representations do (Arntz and Weertman, 1999, Holmes and Mathews, 2005; Holmes, Mathews, Dalgleish, & Mackintosh, 2006; Holmes, Mathews, Mackintosh, & Dalgleish, 2008). In a pilot study, Van den Broek, Keulen-de Vos, and Bernstein (2011) examined whether arts therapies are more effective in evoking emotional states than standard psychotherapies in 10 male forensic clients with cluster B personality disorders. Participants were randomized to either Schema Therapy (ST; Young, Klosko, & Weishaar, 2003) or ‘Treatment As Usual’ (TAU), and also received equivalent arts therapy sessions. Participants showed significantly more healthy emotional states in arts therapy sessions than in their psychotherapy sessions, which was reflected by spontaneous joy and pleasure, attentive self-reflection. Also, clients who received ST, in both psychotherapy and arts therapy, showed twice as much emotional vulnerability as clients receiving TAU (Van den Broek et al., 2011). These findings, though preliminary, suggest that arts therapies in general, as well as ST in both psychotherapy and arts therapy, may be effective at eliciting emotions in forensic clients with PDs. However, this study did not examine the effectiveness of any specific arts therapy techniques at evoking emotional states.
Our study examined whether emotional vulnerability and anger could be evoked in forensic clients with cluster B PDs using an experimental protocol that consisted of experiential techniques carried out by a drama therapist. We aimed to evoke two specific emotional states: vulnerable emotions and anger. We chose these two states because they play an important role in reactive aggression, for example, in cases where offenders stalk or attack their partners in response to feelings such shame, mistrust, or abandonment (Bernstein, Arntz, & de Vos, 2007). Also, vulnerability and anger are basic emotions that forensic clients have difficulty managing. For example, our research suggests that vulnerability and anger are often triggers for acts of violence, which can be seen as a maladaptive means of coping with emotions (Keulen-de Vos, Bernstein, Vanstipelen et al., 2016). Offenders with PDs often remain emotionally detached or avoidant in standard verbal psychotherapy sessions, making it difficult to reach them emotionally. Research has shown the cognitive schemas are most susceptible to modification when clients’ schemas are activated (“hot cognitions”) (David & Szentagotai, 2006). When clients remain emotionally distant or detached, it therefore makes it difficult to modify the cognitive distortions that are involved in their offenses. Drama therapy interventions activate clients emotionally, triggering their schemas, so that therapists can more easily modify them. These types of interventions are being increasingly used in forensic settings with PD offenders, although these interventions have not previously been studied using experimental paradigms.
We operationalized the emotional states in terms of ‘schema modes’. Schema modes are a central concepts in Schema Therapy (ST; Rafaeli et al., 2011, Young et al., 2003), an integrative form of therapy developed specifically for clients with PDs, which incorporates,experiential techniques similar to those in drama therapy (Blokland-Blokland-Vos, Günther, & van Mook, 2008; Griffith, 2003, Weertman, 2012). ST defines schema modes as emotional states that dominate a person’s thinking, feeling and behavior at a given moment in time. According to ST theory, there are 4 types of schema modes: Child modes involve the direct experience of primary, negative emotions, such as sadness, fear, or shame. Maladaptive Coping Modes involve the use of dysfunctional forms of coping with emotion (e.g., avoiding emotions). Parent Modes involve self-directed criticism or demands. Healthy Modes involve healthy self-reflection and the experience of joyful, playful emotions.
We chose to assess schema modes because the mode concept includes the specific emotional states we wished to evoke in this study via drama therapy, namely emotional vulnerability (Vulnerable Child Mode) and anger (Angry Child Mode). Vulnerable Child Mode is an emotional state in which one feels vulnerable or overwhelmed with painful feelings, such as anxiety, grief, or humiliation. Angry Child Mode is a state in which one feels and expresses anger in an uncontrolled manner in response to perceived or real mistreatment or frustration (Rafaeli et al., 2011, Young et al., 2003).
The aim of the study was a specific one: to determine whether particular drama therapy techniques are capable of eliciting vulnerable emotions and anger, respectively, in forensic clients with cluster B personality disorders (i.e., clients with Antisocial, Borderline, or Narcissistic PDs). Although our previous research (Van den Broek et al., 2011) and anecdotal evidence from drama therapists suggests that this might be the case, no previous study has examined the ability of drama therapy techniques to evoke emotions in forensic clients. Thus, demonstrating that certain experiential drama therapy techniques can evoke emotions is a first step towards validating these approaches for use in forensic populations. We used a five session experimental protocol that consisted of an introduction session, three experimental sessions and a ‘wrap-up’ session. The experimental interventions were ones that are frequently used by drama therapists and were adapted by one of us (E.P.A.B.), a senior drama therapist, for use in this protocol. Hypothesis
- 1)
We hypothesized that the vulnerability-eliciting intervention would evoke more vulnerable emotions (“Vulnerable Child mode”); comparing ratings made before and after the eliciting intervention was initiated.
- 2)
We also hypothesized that the intervention to evoke anger would evoke more anger (“Angry Child mode”), comparing ratings before and after the intervention was initiated.
Section snippets
Setting
This study was conducted at Forensic Psychiatric Centre ‘de Rooyse Wissel’ (dRW), a maximum secure hospital in The Netherlands. This hospital provides treatment for mentally disordered offenders who are sentenced under the punitive measure ‘Ter Beschikking Stelling’ [TBS: disposal to be treated on behalf of the state]. Under Dutch criminal law, offenders can be sentenced to involuntary treatment if their accountability for their crimes is judged to be diminished because of a mental disorder.
Results
The minute by minute Vulnerable Child and Angry Child mode scores across the three experimental sessions is depicted in Fig. 1. Hypothesis 1 Participants expressed significantly greater emotions in the family table session (session 2) after the intervention was initiated than at baseline. Specifically, the intervention elicited more Vulnerable Child mode (M = 1.88, SE = 0.28) when compared to the baseline score (M = 1.0, SE = 0.006, t(7) = −3.13, p = 0.017). The effect size was Cohen’s d = 1.18. In contrast, clients did
Discussion
Forensic clients with cluster B personality disorders showed significantly more emotional vulnerability after the experimental interventions were initiated, compared to baseline mode ratings in the same sessions. This was true for all three experimental drama therapy sessions − the family table, vulnerability-induction, and anger-induction − and not only the session that was intended to evoke emotional vulnerability. Thus, all three of these procedures evoked emotional vulnerability in these
Acknowledgements
Thanks are due to Otmar van Deventer, Manon Peeters and Anne Vromen for their help in collecting the data; professor Gerard van Breukelen, and Eric Schouten for their statistical advise; and Susanne Vermeeren for providing expert ratings during the training process of the students. We are grateful for the collaboration of participants, the management board, and staff of our forensic psychiatric center.
References (86)
- et al.
Treatment of childhood memories: Theory and practice
Behaviour Research and Therapy
(1999) - et al.
Anger, over-control and serious violent offending
Aggression and Violent Behaviour
(2005) - et al.
Cognitions in cognitive behavioral psychotherapies: Towards an integrative model
Clinical Psychology Review
(2006) - et al.
PCL-R psychopathy and its relation to DSM-IV Axis I and II disorders in a sample of male forensic psychiatric patients in the Netherlands
International Journal of Law and Psychiatry
(2004) - et al.
Positive interpretation training: Effects of mental imagery versus verbal training on positive mood
Behavior Therapy
(2006) - et al.
Empathy and offending: A systematic review and meta-analyses
Aggression and Violent Behavior
(2004) - et al.
Mental disorders in a forensic sample of sexual offenders
European Psychiatry
(2004) - et al.
A comparative study of patients and therapists’ reports of schema modes
Journal of Behavioral Therapy and Experimental Psychiatry
(2009) Psychopathy and therapeutic pessimism: Clinical lore or clinical reality?
Clinical Psychology Review
(2002)- et al.
Evaluations of emotional noninterpersonal situations by patients with borderline personality disorder
Journal of Behavior Therapy and Experimental Psychiatry
(2005)
Selective activation of traits: Boundary conditions for the activation conditions of anger
Personality and Individual Differences
Arts therapies and schema focused therapy: A pilot study
The Arts in Psychotherapy
Diagnostic and statistical manual of mental disorders
Psychotherapy for borderline personality disorder: Mentalization-based treatment
Creating new cultures: Using drama therapy to build therapeutic communities in prisons
Schema Focused Therapy in forensic settings: Theoretical model and recommendations for best clinical practice
International Journal of Forensic Mental Health
Personality disorders, psychopathy and other mental disorders: Co-morbidity among patients at English and Scottish high security hospitals
The Journal of Forensic Psychiatry and Psychology
A combined drama-based and CBT approach to working with self-reported anger aggression
Criminal Behavior and Mental Health
Je vak in schema’s − deel 1: vaktherapie binnen een kader van schematherapie
Non-verbal Therapies in a Schema Therapy Framework]. Tijdschrift Voor Vaktherapie
Toenemende verblijfsduur in de tbs. De ontwikkeling van de gemiddelde duur in de laatste 20 jaar
Increasing length of stay in ‘TBS’. Developments over the last 20 years
Group music therapy for patients with persistent post-traumatic stress disorder: An exploratory randomized controlled trial with mixed methods evaluation
Psychology and Psychotherapy: Theory, Research and Practice
Faking good, bad, and ugly: Malingering in forensic psychiatric inpatients (Dissertation manuscript)
Revisiting the overcontrolled-undercontrolled typology of violent offender
Personality and Mental Health
Offender emotion and self-regulation: Implications for offender rehabilitation programming
Psychology, Crime & Law
Personality disorders in a Dutch forensic sample: Convergence of interview and self-report measures
Journal of Personality Disorders
Violence risk assessment: Getting specific about being dynamic
Psychology, Public Policy, and Law
Acting for real: Drama therapy process, technique, and performance
Psychopathy variants: Empirical evidence supporting a subtyping model in a community sample
Personality Disorders: Theory, Research, and Treatment
Psychodrama in de praktijk: therapie op de vloer
An emotion-focused approach to the overregulation of emotion and emotional pain
Journal of Clinical Psychology
Emotion in psychotherapy: A practice-friendly research review
Journal of Clinical Psychology
Handbook of experiential psychotherapy
Emotion-focused therapy: Coaching clients to work through feelings
Emotion-Focused Therapy: A synopsis
Journal of Contemporary Psychotherapy
Psychopathology and anger in interpersonal violence offenders
Journal of Clinical Psychology
Unconscious cognition reclaimed
American Psychologist
Cognitive Therapy and psychodrama: a model for treating clients with personality disorders
Journal of Group Psychotherapy, Psychodrama, & Sociometry
Emotion elicitation using films
Cognition and Emotion
Emotion regulation in adulthood: Timing is everything
Current Directions in Psychological Science
Psychopathy and the predictive validity of the PCL-R: An international perspective
Behavioral Sciences and the Law
Manual for the Hare psychopathy checklist–revised
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