ESTS: A replication study

ESTS, schizotypy, evolutionary systems therapy

We are finally ready to start the replication study about Evolutionary Systems Therapy for Schizotypy (ESTS). ESTS is an integrative form of psychotherapy that is specifically tailored on schizotypal traits.

Last year we concluded the first randomized controlled trial (RCT) showing promising results about its effectiveness. Now we have registered the new RCT aimed to confirm these findings and question the limitations we highlighted. Indeed, we are going to increase the sample size of those sperimentally treated with ESTS, and will use cognitive behavioral therapy (CBT) e as an active treatment without any mandatory drug.

In the first RCT the control group accessed to a good psychiatric management comprising of CBT and psychopharnacological drugs. During the post-hoc analysis the interviews indicated how the control group may have been biased by a more stigmatizing approach along the treatment plan. On the one hand, we suppose how ESTS may benefit from an evolutionarily oriented and non-stigmatizing approach to conceptualization. On the other hand, the mandatory drug may have been perceived as stigmatizing or patronizing.

Thus, the new RCT will compare ESTS with CBT without any mandatory treatment. People will be allowed to access to psychopharmacotherpy, but this will be considered as an exclusion criterion from the study (regardless of the arm they are randomized to).

Another interesting difference between the new and the previous RCT will be the secondary outcomes. Despite we collected cases series about feasibility of ESTS in treating different features related to schizotypy, we want to explore the differential effectiveness on psychoticism and detachment. That is, we want to explore the differential effect of ESTS on diverse features of schizotypy, from oddity and disorganization to emotional and social withdrawal.

National Library of Medicine (U.S.). (2023, February- ). Evolutionary Systems Therapy for Schizotypy (ESTS). Identifier NCT05710926 . 

Mindful Compassion for Perfectionism: A new RCT!

Mindful compassion for perfectionism

Last week I posted about Roz Shafran’s paper on perfectionism, now I’m again here talking about the same topic! Another interesting news, so I hope I won’t bore you! (the worldwide database of funded clinical studies) has reviewed and published today our protocol of the new randomized controlled trial (RCT) on Mindful Compassion for Perfectionism (MCP).

As Shafran suggested, there are only three interventions specifically tailored on perfectionistic traits: cognitive behavioral therapy for perfectionism (Shafran et al., 2023), dynamic relational therapy (Hewitt et al., 2019), and MCP (Cheli et al., 2022). MCP is a form of group psychotherapy that integrates the conceptualization model of dynamic relational therapy with experiential techniques informed by or directly derived from Compassion Focused Therapy (Gilbert et al., 2014). Veronica Cavalletti and I developed this integrative intervention with the scientific support of Paul Hewitt.

To date, some case series have confirmed the feasibility of the MCP. This new RCT is aimed at pilot-testing the effectiveness of the proposed intervention. The study is a waiting-list controlled trial. We are going to start recruiting by nex Monday and have the first group as soon as possible!

National Library of Medicine (U.S.). (2023, January- ). Mindful Compassion for Perfectionism (MCP). Identifier NCT00103181.

Effective treatments for perfectionism


Roz Shafran and colleagues just published an overview of existing effective treatments for perfectionism. They presented their own model and then discussed the existing alternatives.

I was very surprised and happy to see how our protocol was one of the three interventions specifically tailored on perfectionistic traits! In short, Shafran was summarizing evidence and roots of the model with strongest evidence: that is, Cognitive Behavioral Therapy for Perfectionism. This is a tailored form of CBT targeting maladpative beliefs and biases in those struggling with perfectionism. The second model reviewed was the Dynamic Relational Therapy developed by Paul Hewitt and colleagues. Hewitt suggests to consider perfectionism as a set of interpersonal styles comprising of spefici traits, interpersonal and intrapersonal components. Finally, Shafran presented our Mindful Compassion for Perfectionism that integrates the Dynamic Relational Therapy with Compassion Focused Therapy.

As I anticipated, our model is far from being considered evidence-based. We published two cases series (see pubblications) where reporting preliminary evidence for the feasibility of the model, and we are now outlining a randomized controlled trial to better understand its clinical utility. Cavalletti, Hewitt, Flett and I published a first paper introducing the group format and its rationale, and then a second cases series about.

I appreciated Shafran’s recognition, which confirms the importance of specific interventions for specific traits or psychopathological manifestations.

Shafran, R., Egan, S.J., & Wade, T.D: (2023). Coming of age: A reflection of the first 21 years of cognitive behaviour therapy for perfectionism, Behaviour Research and Therapy,

Compassion and COVID-19 Pandemic

pandemic covid-19

The last paper of series on the role of compassion during the COVID-19 pandemic has been realeased. The new rsearch suggests that, in a time of elevated distress and shared human suffering such as the pandemic, people from multiple countries and nationalities seem to become more compassionate to self and others and less afraid of, and resistant to, compassion.

During pandemic I joined an international team led by Marcela Matos aimed to explore the role of compassion in adjusting to pandemic. 21 countries were involved and 4 waves of data were collected. First, we showed how all fears of compassion moderated (heightened) the impact of perceived threat of COVID-19 on psychological distress. Second, we confirmed how social connection is key to how people adapt and cope with the worldwide COVID-19 crisis and may facilitate post-traumatic growth in the context of the threat experienced during the pandemic. Finally, our findings highlight the universal protective role of compassion, in particular self-compassion and compas- sion from others, in promoting resilience by buffering against the harmful effects of the COVID-19 pandemic on mental health and social safeness.

The Italian team was led by Nicola Petrocchi and I, and supported by Tages Onlus.

Matos, M., McEwan, K., Kanovský, M., Halamová, J., Steindl, S. R., Ferreira, N., Linharelhos, M., Rijo D, Asano K, Vilas SP, Márquez MG, Gregório S, Brito-Pons G, Lucena-Santos P, da Silva Oliveira M, de Souza EL, Llobenes L, Gumiy N, Costa MI, Habib N, Hakem R, Khrad H, Alzahrani A, Cheli S, Petrocchi N, Tholouli E, Issari P, Simos G, Lunding-Gregersen V, Elklit A, Kolts R, Kelly AC, Bortolon C, Delamillieure P, Paucsik M, Wahl JE, Zieba M, Zatorski M, Komendziński T, Zhang S, Basran J, Kagialis A, Kirby J, Gilbert P. (2023). Improvements in Compassion and Fears of Compassion throughout the COVID-19 Pandemic: A Multinational Study. International Journal of Environmental Research and Public Health20(3), 1845. MDPI AG. Retrieved from

The role of externalizing traits in vaccine hesitancy

Vaccine hesitancy

Clinical Neuropsychiatry has published a paper about an action-research we run during the COVID-19 pandemic about vaccine hesitancy. The main research question was: How we can reduce the hesitancy or even refusal of anti-COVID-19 vaccine in cancer patients? Indeed, cancer patients were and are considered persons at risk for severe manifestation of SARS-CoV-2.

Preliminarily, we conducted a qualitative study thorugh focus groups. We were exploring those factors that may fuel an hesitant attitude. Then, we tested it in a large sample of cancer patients during the Italian vaccination campaign. Finally, we outline a communication strategy based on collected results.

In short, we found that the higher the externalizing traits (antagonism + disinibhition) the higher the association between risk perception and vaccine hesitancy. That is, persons with externalizing traits were at increased risk of a paradoxical response. Once they perceived a higher risk of being infected they reacted by being dubious or even suspicious about vaccination.

Therefore, the communication aimed to reduced the distress associated with this risk perception rather than disbuting the contents about vaccine safety. Our strategy led to a very low rate of cancer patients refusin vaccine. The study was run at the Florence Department of Oncology.

Cheli, S., Pino, M. S., Goldzweig, G., Scoccianti, S., Fabbroni, V., Giordano, C., Cavalletti, V., Bassetti, A., & Fioretto, L. (2022). The Relationship Between Covid-19 Risk Perception and Vaccine Hesitancy in Cancer Patients: The Moderating Role of Externalizing Traits. Clinical neuropsychiatry19(6), 355–364.

Psychotherapy for schizoid personality

schizoid personality disorder

The Journal of Contemporary Psychotherapy published a paper where we present a psychotherapy for schizoid personality disorder. This personality is a highly understudied area: Despite early conceptualizations were prosed one century ago, clinicians do not have guidelines to rely upon. Indeed, an early formulazion of schizoid mechanisms can be traced back to Eugen Bleuler and then to the emergence of psychoanalisis (see Fairbairn and Klein).

In a two cases series we discussed how an integration of evolutionary psychopathology, metacognitively oriented psychotherapy, and compassion focused therapy may be useful in targeting severe forms of emotional and social detachment. The paper is an attempt to apply Evolutionary Systems Therapy for Schizotypy (ESTS) to this complex and understudied pattern of personality.

The prosed intervention was a 10-month individual psychotherapy that resulted in a remission from diagnosis and reliable changes in personality pathology and general symptomatology. The focus of psychotherapy was an evolutionary conceptualization of maladative traits and then a progressive focus on critical beliefs about self (e.g. I’m not adequate enough to properly live in the society) and others (e.g. my peers constantly judge me as weird and bizzare).

Cheli, S., Chiarello, F., & Cavalletti, V. (2022). A Psychotherapy Oriented by Compassion and Metacognition for Schizoid Personality Disorder: A Two Cases Series. Journal of Contemporary Psychotherapy.

Oddity, Schizotypy and Evolution?

Oddity, schizotypy, evolution, evolutionary theory

My paper on an evolutionary model of schizotypy is finally out! New Ideas in Psychology has published it. As I anticipated in a previous post here, this study aims to summarize existing kowledge about proximate and evolutionary factors involved in schizotypy and oddity, and propose an integrative model.

Such a model suggests how schizotypy may be better understood by looking at the role of social brain in the evolution of our species and the neurodevelopment of those with prominents openness to experience and introversion.

The paper is also the foundation of the the shared conceptualization of newly developed treatment for schizotypal personality disoder, namely Evolutionary Systems Therapy for Schizotypy (ESTS). In the next few months the paper – figers crossed! – about a preliminary randomized controlled trial should be pulished.

Cheli, S. (2023). An evolutionary look at oddity and schizotypy: How the rise of social brain informs clinical practice, New Ideas in Psychology, 68, 10099,

European congress on personality disorders

I’ve attended at the 6th International Congress of the European Society (10-12 October) for the Study of Personality Disorders (ESSPD). Several very interesting keynotes and symposia were presented.

I was impressed by two relevant, innovative and recurring themes. First, something has finally changed in the way we discussed personality disorders. Even if this change has been long waited, many studies were focused on the search for a positive outcome, a recovery and personal growing rather than just discussing about reduction in symptoms or remission from a categorical diagnosis. This was evident since the first two keynotes on positive psychology (Meike Bartels) and borderline personality (Mary Zanarini). Second, there were three symposia exclusively dedicated to adolescence and early onset of personality disoders. Carla Sharp was present almost in all of them, as a leading expert in the field. I was very happy to see this new interest in adolescence, and I hope for more and more studies especially on clinical applications of a personality-informed approach.

Finally, I presented two researches: our RCT on schizotypal personality disoders and the longitudinal study on the relationship between narcissism and perfectionism. I previously presented here the results.

Adolescence and severe psychopathology

The dataset of our recently concluded cases series on adolescents with prominent schizotypal traits is available on OSF. In the study we extended the clinical utility of Evolutionary Systems Therapy for Schizotypy (ESTS) by applaying it in treating five adolescents diagnosed with schizotypal personality disorder.

The results were encouraging: 4 out of five remitted from diagnosis at the end of the 6-month intervention and all the adolescents reported reliable changes in symptomatology.

Personality pathology in adolscence is an understudied area of psychotherapy, even if researchers are publishing more and more studies on that. We know that personality and its disorders emerge during adolescence, but the “straighforward” approach to psychiatry seemingly generates a paradox by not allowing a diagnosis in adolescence!