New advancements in Evolutionary Systems Therapy

EST Advancements

We are collecting new advancements in Evolutionary Systems Therapy. This is a new form of psychotherapy that integrates evolutionary psychopathology, compassion focused therapy and metacognitively oriented treatments.

To date, Evolutionary Systems Therapy (EST) has shown promising results in the treatment of personality disorders with traits primarily related to psychoticism and detachment: one randomized controlled trial (RCT) suggested that EST without medication is at least as effective as CBT with medication for patients diagnosed with schizotypal personality disorder (Cheli et al, 2023); some case series have shown the feasibility of EST for paranoid and schizoid personality disorders and for autistic traits (Cheli et al., 2024; Cheli, Chiarello & Cavalletti, 2023; Cheli & Cavalletti, 2023); moreover, we suggest how it can work with adolescents with schizotypal traits (Cheli et al., 2023).

Now we are working on new advancements in Evolutionary Systems Therapy. First, a new RCT is closed to end and – fingers crossed – it should confirm and extend previous findings. Second, an open trial currently underway is investigating the clinical utility of EST for all personality disorders. Third, a single case on comorbid eating and personality disorder, plus a 5 case series on obsessive compulsive personality disorder have been submitted. The single case is accessible as preprint. It investigates the role of self-recriminatory dialogue in a young female diagnosed with anorexia nervosa, borderline and obsessive-compulsive personality disorder.

Psychotherapy on an Acute Psychiatric Ward

 Psychotherapy on an acute psychiatric ward is not that easy. In this study the team led by Ilanit Hasson-Ohayon – plus some external scholars such as myself – shows how Metacognitive Reflection and Insight Therapy is a feasible and reliable option.

This study investigated the efficacy of psychotherapy during hospitalization on an acute psychiatric ward. A controlled trial was conducted to assess the effects of Metacognitive Reflection and Insight Therapy (MERIT) upon metacognition and psychiatric symptoms. Data from 40 inpatient women were analysed.

Findings included significant interaction effects between group (intervention or control group) and time (preintervention and postintervention) in regard to the metacognitive abilities and general psychiatric symptoms. Participating in MERIT seems to improve one’s ability to use reflective knowledge to cope with psychological challenges and to improve symptomatology level.

This study confirms the importance of targeting general psychopathologycal factors – such as metacognition – in those struggling with severe mental disorders.

Cohen-Chazani, Y., Igra, L., Hamm, J., Leonhardt, B., Klion, R., Cheli, S. and Hasson-Ohayon, I. (2024), Psychotherapy on an Acute Psychiatric Ward: Preliminary Findings From a Controlled Study. Clinical Psychology & Psychotherapy, 31: e3002.

The State of the Art of The HiTOP Model


The State of the Art of The HiTOP Model is the title of a new review on the Hiearchical Taxonomy of Psychopathology (HiTOP). The paper is part of a special issue published by Behavior Therapy on new trends and approaches in psychotherapy. I am happy to have been part of the team led by David Cicero.

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a dimensional framework for psychopathology advanced by a consortium of nosologists. In the HiTOP system, psychopathology is grouped hierarchically from super-spectra, spectra, and subfactors at the upper levels to homogeneous symptom components and maladaptive traits and their constituent symptoms, and maladaptive behaviors at the lower levels.

HiTOP has the potential to improve clinical outcomes by planning treatment based on symptom severity rather than heterogeneous diagnoses, targeting treatment across different levels of the hierarchy, and assessing distress and impairment separately from the observed symptom profile.

Assessments can be performed according to this framework with the recently developed HiTOP-Self-Report (HiTOP-SR). Examples of how to use HiTOP in clinical practice are provided for the internalizing spectrum, including the use of the Unified Protocol and other modularized treatments, measurement-based care, psychopharmacology, and in traditionally underserved populations.

Future directions are discussed in this State of the Science review including HiTOP’s use in further developing transdiagnostic treatments, extending the model to include other information such as environmental factors, establishing the treatment utility of clinical assessment for the HiTOP-SR, developing new treatments, and disseminating the model.

The State of the Art of The HiTOP Model presents the potential of this new approach in promoting a dimensionally oriented conceptualization. At the same time, it highlights the need for further research about how to apply it in clinical practice. In previous works both David Cicero and I discussed the HiTOP potential in the field – for example – in the conceptualization and treatment of schizotypy.

Cicero, D. C., Ruggero, C., Balling, C., Bottera, A. R., Cheli, S., Elkrief, L., … Thomeczek, M. L. (2024, February 1). State of the Science: The Hierarchical Taxonomy of Psychopathology (HiTOP). Behavior Therapy, Online publication.

Preprint on OSF:

Psychotherapy for Paranoid Personality Disorder

Paranoid Personality

Just released a new paper we wrote on psychotherapy for Paranoid Personality Disorder. The research is a 7-cases series on the feasibility and efficacy of Evolutionary Systems Therapy for those struggling with paranoid traits.

Little is known about effective psychosocial treatments for paranoid personality disorder. This study explores the feasibility of a novel treatment, namely Evolutionary Systems Therapy, in supporting individuals diagnosed with paranoid personality disorder.

Seven patients attended 10 months of individual therapy without receiving any psychopharmacological treatment. The primary outcome was the feasibility of the intervention, while the secondary outcomes were remission from the diagnosis and reliable changes in personality pathology and paranoid ideation.

All the patients completed the treatment, and none of them reported adverse events or missed more than three sessions (less than 10%). Six out of seven patients (85.7%) achieved remission from paranoid personality disorder. diagnosis, which was maintained at the one-month follow-up. Only in the case of Case 7 was the diagnosis of paranoid personality disorder confirmed at both the final assessment and the one-month follow-up. The dimensional scores indicate a clinically significant reduction in maladaptive personality features for all the patients.

Kendall’s Tau and Spearman’s Rho analysis confirmed a significant downward trend in the means of personality pathology and paranoid ideation across the 12 measurements (p< .05). Likewise, Reliable Change Index values were reported (≥ 1.96) for both measures when comparing the initial and final assessments. Table 3 presents these reliable values for all seven participants. No differences were found in Reliable Change Index between the final assessment and the follow-up assessment. Finally, we explored measurements for an optimal treatment dose. Reliable changes (RCI ≥ 1.96) were reported for personality pathology and paranoid ideation by the sixth month of intervention.

This study suggests the feasibility and safety of psychotherapy as an option for individuals diagnosed with paranoid personality disorder. Specifically, Evolutionary Systems Therapy has shown promising, albeit preliminary, results in assisting individuals with paranoid personality disorder. We propose that the potential clinical effectiveness of Evolutionary Systems Therapy may be attributed to its early focus on the interpersonal schemas and cycles originating from paranoid ideation, where individuals perceive themselves as vulnerable and others as threatening, repeatedly perpetuating a self-fulfilling prophecy. The integrated utilization of relational and experiential techniques appears to be effective in reducing personality pathology and paranoid ideation. Further research is necessary to address the limitations inherent in the case series design employed in the present study.

Cheli, S., Goldzweig, G., Chiarello, F., & Cavalletti, V. (2024). Evolutionary systems therapy for paranoid personality disorder: A seven cases series. Bulletin of the Menninger Clinic, 88, 1, 61-80.

Automatic Self Recriminations and Perfectionism

Automatic self recriminations place an important role in perfectionism. Persons with perfectionistic traits usually experience internal dialogues in the form of elf-condemnatory, self-blaming spiraling.

In a new article published on the Journal of Personality Assessment, we present a new measure to assess this kind of internal dialogue. The new Automatic Self-Recrimination Scale (ASRS) has been tested in clinical and nonclinical sample showing it is best understood as a multidimensional measure.

Our findings highlight that the measure is composed of one higher-order factor and four lower-order facets: Not Mattering, Self as Failure, Undeserving Self, and Loathsomeness. The overall scale and four subscales demonstrated acceptable internal consistency and test-retest reliability.

Moreover, we show how Automatic Self-Recrimination Scale significantly correlates with measures of perfectionism, self-criticism, and dysfunctional attitudes. In short, we confirm how automatic self recriminations and perfectionism are two intertwined experiences.

Indeed perfectionism involves self-recrimination and an overgeneralized sense of the self as blameworthy and responsible that distinguishes it from other related constructs. Automatic self-recriminations are a unique and important element not only for research purposes but also as a key emphasis for clinical interventions.

As I have discussed elsewhere, Compassion Focused Therapy may cultivate – for example – a more compassionate self by promoting a healthier dialogue between parts of the self and starts with a focus on self-criticism. That is, if the goal is to help people with perfectionistic traits, an intervention that helps them reduce self-recriminations and increase a self-compassionate attitude is probably an effective choice.

Moreover, it is noteworthy how self recriminations (and interventions targeting these processes) are not only related to perfectionism. We have shown how they are pivotal – for example – in traits such as schizotypal ones.

Paul L. Hewitt, Sabrina Ge, Martin M. Smith, Gordon L. Flett, Simone Cheli, Danielle S. Molnar, Ariel Ko, Samuel F. Mikail & Thalia Lang (2024) Automatic Self Recriminations: Development and Validation of a Measure of Self-Condemnatory Internal Dialogue, Journal of Personality Assessment, DOI: 10.1080/00223891.2024.2303429

Is Compassion Focused Therapy Effective?

Is Compassion Focused Therapy Effective?

In a recently published meta-analysis we discuss this question: Is Compassion Focused Therapy effective? I was part of an amazing team led by Nicola Petrocchi on this topic. We conducted a series of meta-analyses on diverse positive and negative outcomes of trials on Compassion Focused Therapy.

The main finding is that Compassion Focused Therapy is effective. We worked a lot on this study since last March to get all the information available. We tried to overcome the main limitation of this research (i.e., heterogeneity) by running several meta-analyses on a bunch of different outcomes.

More specifically, we explored effectiveness in terms of reduction of depression and self-criticism, and increase of compassion for self and others. This analyses were conducted on both clinical and non-clinical samples.

Compassion Focused Therapy resulted effective in reducing overall negative mental health outcomes (k = 32, g = 0.72, p < .0001), depression (k = 23, g = 0.49, p < .0001), self-criticism (k = 17, g = 0.40, p < .0001) and in improving compassion for self and others (k = 24, g = 0.51, p < .0001).

A summary of the study has been published by the blog of the Society of Clinical Psychology of American Psychological Association.

Petrocchi, N., Ottaviani, C., Cheli, S., Matos, M., Baldi, B., Basran, J. K., & Gilbert, P. (2023). The impact of compassion-focused therapy on positive and negative mental health outcomes: Results of a series of meta-analyses. Clinical Psychology: Science and Practice. Advance online publication.

Finally published: A dimensional approach to schizotypy

Simone Cheli, Schizotypy, Dimensional Approach, Conceptualization, treatment

Springer finally published the book I edited with Paul H. Lysaker: A dimensional approach to schizotypy. Conceptualization and treatment. It is the first book discussing schizotypy from a clear-cut clinical point of view. Amazing scholars have previously discussed this topic, but usually through the lens of neuroscience or experimental psychopathology. I was happy to read the foreword by Bob Krueger and the endorsment by Carla Sharp and Anna Docherty highlighting this novelty.

Here we talk about how to treat the clinical manifestations of schizotypy. In doing so, we invited a team of experts in the field. The book is organized in three section. In the first one we present a common theoretical and experimental background, discussing diverse point of views. In the second one five transdiagnostic processes (metacognition, mentalizing, attachment, self-criticism, interpersonal criticism) are presented as core targets of conceptualization and intervention. And in the final section several therapeutic approaches (CBT, CFT, MBT, MERIT, ESTS, etc.) are described consistent with previous knowledge.

I hope that this book may foster clinical research in the field, considering how evidence suggests that one out of ten persons would present schizotypal traits. I’m just sorry that Paul has passed away unexpectedly just a few days after the submission. In the afterword, I tried to summarize these mixed feelings and how much I (and every one in the field) owe to Paul Lysaker. He was a wonderful friend, and an amazing scholar.

Cheli, S., & Lysaker P. H. (Eds.) (2023). A Dimensional Approach to Schizotypy. Conceptualization and Treatment. Springer.

Please note that foreword, introduction, conclusions and afterword are freely downloadable from Springer website.

Threatening beliefs in schizotypy

Threatening beliefs schizotypy cheli

A new paper on the role of threatening beliefs in schizotypy has been published. In this study we showed in a large sample (n= 2127) how threatening beliefs about self and others moderate the association between psychoticism and psychosocial distress.

We defined an overarching factor, consistent with my model of schizotypy (Cheli, 2023; Cheli et al., 2023), that comprises: severe form of self-criticism (hating, feel ingdisgusted with oneself), fear of other’s compassion (perceive the other’s compassion as threatening), and socially prescribed perfectionism (the others want me to adhere to standards I cannot achieve). The total factor and the single components were significant moderator of the association between schizotypal traits and distress (again an overarching factor comprising anxiety, depression and stress).

The paper supports the model of Evolutionary Systems Therapy for Schizotypy and its targets. Despite these factors are relevant also in other conditions, our analysis showed how schizotypy is particularly affected by with an explained variance which is double that of other personality traits.

Cheli, S., Cavalletti, V., & Hopwood, C. (2023). Threatening Beliefs About Self and Others Moderate the Association Between Psychoticism and Psychological Distress. The Journal of Nervous and Mental Disease ():10.1097/NMD.0000000000001726, September 21, 2023. |

IPOS Congress: Severe Mental Disorders and Cancer

IPOS 2023, cancer, severe mental disorder

Just concluded the XXIV IPOS Congress, where I presented a study on severe mental disorders in cancer patients. The presentation was part of a symposium, chaired by Prof. Gil Goldzweig, on communication and intersubjectivity in underserved populations.

I discussed challenges and the (poorly explored) state of the art of studies on the comorbidity between severe mental disorders and cancer. Below a brief video-summary of the slides.

How to treat clinical manifestations of schizotypy?


How to treat clinical manifestations of schizotypy? In an upcoming book, we try to anwser to this fascinating and elusive question. Paul H. Lysaker and I are the co-editors of a book to publish by Springer. The manuscript is finally in the hands of the production editor.

In the last year, Paul and I have involved twenty diverse teams of researchers and clinicians to address this question. Indeed, schizotypy represents a unique paradox. On one hand, we know that one out of ten persons presents schizotypal traits. On the other hand, there are no guidelines for treating schizotypal personality disorder or the clinical onset of schizotypal traits.

We don’t want to spoil the new book, but Paul and I have organized the contributions into three sections: (i) an introductory section discussing schizotypy as a feature of personality and psychopathology; (ii) a section dealing with 5 transdiagnostic processes relevant to schizotypy (attachment, mentalization, metacognition, self-criticism, interpersonal criticism); (iii) a concluding (and also the most extensive) section where numerous therapeutic approaches to schizotypy are presented.

To our knowledge this is the first book adressing clinical conceptualization and treatment of schizotypy, Despite several amazing books and papers have been puslished about, limited attention has been paid to the previous question, that is: How to treat clinical manifestations of schizotypy?