Evolutionary systems therapy

1. Introduction

Version followed: Evolutionary Systems Therapy (EST) as developed by Simone Cheli and colleagues at Tages Onlus (Tages Charity Center for Psychology and Health, Florence). It is an individual talk therapy, and the only therapy known to be published under this exact name (see the scope note below). There are two published forms. The original is EST for Schizotypy (EST-S), tested in a pilot RCT (Cheli et al., 2023, BMC Psychiatry; NCT04764708). The trial protocol registered it as "Compassion and Metacognition Based Therapy" (CMBT), so CMBT-S in the protocol and EST-S in later papers name the same treatment. EST-S was then adapted for adolescents (Cheli et al., 2024, Psychosis). The extension is EST for Personality Pathology (ESTP), which covers all personality-disorder presentations and is being tested in a single-arm pilot sponsored by Tages Onlus (NCT06415812). The ESTP registry calls EST "an individual form of psychotherapy (talk therapy)". This guide follows the ESTP format and uses EST-S material where the two overlap. [source: NCT06415812 registry record and Tundra Space mirror; NCT04764708 protocol; Cheli et al. 2023 abstract; Cheli 2023 chapter abstract]

Scope: which "evolutionary systems therapy" this is. No family-therapy school or method published under this or a similar name (such as "evolutionary family therapy" or "systemic-evolutionary" family therapy) is known; the related literature is general family-therapy and Bowen-theory material [uncertain]. The programme of the 2026 international workshop "Evolution in Psychotherapy: Current Approaches and New Directions" (Centro Majorana, Erice), which brings together the evolutionary-psychotherapy field, Cheli included, lists no family or systemic evolutionary approach; its relational talks (on interpersonal motivational systems and control-mastery theory) concern individual therapy. [source: Centro Majorana programme page] So this guide follows Cheli's EST, the only therapy published under the exact name. EST is an individual therapy: neither trial protocol mentions family, couple or carer sessions, and it should not be presented or delivered as a family therapy. [source: NCT04764708 protocol; NCT06415812] Not covered here: Bowen family systems theory, a different school not called "evolutionary systems therapy" in any known source; Gilbert's compassion-focused therapy, which is one of EST's roots rather than a family method; and the Hayes–Hofmann "extended evolutionary meta-model" of process-based therapy. That model describes psychopathology as "evolution gone awry within networks of biopsychosocial processes", and Hofmann & Hayes (2024) say it is "not primarily a specific treatment approach". [source: NCT04764708 protocol for the CFT root; Hofmann & Hayes 2024, Clinical Psychology in Europe; Hayes, Hofmann & Ciarrochi 2020 abstract]

What was verified, and the limits. Verified from primary sources:

name and sponsor (Tages Onlus, Florence)
individual format
24 weekly sessions of 50–60 minutes ("maximum of 1 hour")
inclusion and exclusion criteria
measures and timepoints
the named components.

These come from the EST-S trial protocol (NCT04764708), the ESTP registry record (NCT06415812) and abstracts. The EST-S trial protocol describes no phases, session ranges, named techniques, manual, therapist training or fidelity checks, so where this guide lacks them, the source lacks them too. Session content is most likely set out in three texts that are not reproduced here [uncertain]: the full BMC Psychiatry paper, Cheli's 2023 chapter, and Cheli's 2026 chapter "Evolutionary Systems Therapy for Personality Pathology" (in Brüne & Cheli, The Evolution of Psychotherapy, Springer, pp. 197–217). The phase table and every step-by-step instruction below are therefore the writer's clinical translation, marked [synthesis]. No exercise name, sequence or wording here is Cheli's. Before delivering EST under its name, get the 2026 chapter or the full BMC Psychiatry paper and contact Tages Onlus. [uncertain]

What it is. EST is an individual psychotherapy aimed at "specific target mechanisms" rather than at diagnostic labels. It integrates four sources: evolutionary psychopathology, compassion-focused therapy, metacognitively oriented psychotherapy, and attachment theory. [source: Cheli 2023 chapter abstract] The ESTP version groups personality pathology into three macro-organisations: internalizing, externalizing (also called "antagonistic" in the registry) and schizotypal. [source: NCT06415812]

How change happens (as far as sources state). The trial protocol describes the therapy as a "Third Wave Cognitive Therapy targeting metacognitive dysfuctions" [sic], "rooted in metacognitively oriented psychotherapies and compassion focused therapy". Its background links schizotypal difficulties to deficits in metacognition and in "socially evolved systems". Its stated aim is to generate "a self-soothing response to suffering". In sessions, clients talk about problems and life experiences and "experiment with new coping strategies inside and outside the session". [source: NCT04764708 protocol, pp. 5, 7, 11, 18] The published outcomes fit this account. Metacognition (understanding one's own and others' minds) and general distress improved more under EST-S than under the comparison treatment. [source: Cheli et al. 2023 abstract] The available sources do not spell out how the evolutionary frame is used clinically, for example whether traits are reframed as evolved relational strategies. [uncertain; inferred from the chapter title in Brüne & Cheli 2026, "…One of the Many Relational Strategies?"]

2. Framework

Format (published). Individual, talk-based psychotherapy, delivered by a single psychologist-psychotherapist. No family, couple or carer sessions are described. 24 weekly sessions of 50–60 minutes ("maximum of 1 hour") over 6 months, followed by an assessment one month after treatment ends. [source: NCT04764708 protocol, pp. 5, 9, 18, 20; NCT06415812; Cheli et al. 2023 abstract]

Who it was tested with (published).

EST-S: adults (18+) with schizotypal personality disorder diagnosed on the SCID-5-AMPD. Exclusions were current psychotherapy or psychopharmacological treatment, schizophrenia-spectrum or other psychotic disorders, bipolar disorder, intellectual disability and neurological disease. The comparison arm was standard cognitive-behavioural therapy for personality disorders plus psychopharmacological treatment, also 24 weekly sessions. [source: NCT04764708 protocol, pp. 5, 9, 11; Cheli et al. 2023]
EST-S adolescent adaptation: five adolescents meeting criteria for schizotypal personality disorder under the DSM-5 Alternative Model of Personality Disorders (AMPD). Six months of individual therapy, no adverse events reported. [source: Cheli et al. 2024 abstract]
ESTP pilot: adolescents aged 16–19 and young adults aged 20–25, balanced across the three macro-organisations. Inclusion required a personality-pathology diagnosis confirmed with the SCID-5 AMPD module. Exclusions: schizophrenia-spectrum or other psychotic disorder, bipolar disorder, autism spectrum disorder, intellectual disability, and any current psychopharmacological or psychosocial treatment. [source: NCT06415812]
Related case series by the same group: schizoid PD (compassion- and metacognition-oriented, two cases), autistic adolescents (evolutionarily oriented therapy, two cases), paranoid PD (seven cases, Bulletin of the Menninger Clinic 2024). [source: NCT06415812 reference list; titles only]

Measurement schedule (published, ESTP pilot). The PID-5-BF (brief form of the Personality Inventory for DSM-5) is given 9 times: one month before therapy, at baseline, at the end of each of the 6 months, and one month after the end. Each month the team also checks completion, adherence, therapeutic alliance and adverse events. In the research protocol, ecological momentary assessment of interpersonal style runs twice daily for 10 days before and after therapy. Remission from diagnosis is reassessed at 6 months. [source: NCT06415812]

Measures in the EST-S trial (published). The primary outcome was the PID-5-BF total score. Secondary outcomes were SCID-5-PD diagnosis, the SCL-90-R (general distress) and the MAS-A (metacognition), at the same nine timepoints. Safety outcomes were dropout, completion (target: no more than 10% of sessions skipped) and adverse events, including suicidal behaviour, self-harm and psychotic episodes. [source: NCT04764708 protocol, pp. 5–8]

Phases. Neither the EST-S trial protocol nor the ESTP registry record gives any phases. A manual-level phase structure may be in Cheli's chapters, which are not reproduced here. [source: NCT04764708 protocol; NCT06415812; uncertain] The working structure below is the writer's. It fits the published format, components and measurement points, but it is not the EST manual. [synthesis]

Phase (synthesis)	Sessions (approx.)	Goals	Move on when
A. Assessment, engagement and formulation	1–4, plus the pre-therapy month	Confirm AMPD-based diagnosis and macro-organisation; take baseline PID-5-BF; build alliance; agree the target mechanisms	The client recognises the shared formulation of their pattern and at least one target, and there is a workable alliance
B. Mechanism work	5–20	Compassion-focused and metacognitive work on the agreed targets inside the therapy relationship; monthly review of PID-5-BF and alliance	Monthly scores trend downward and the client can step back from a pattern while it is happening (metacognitive gain)
C. Consolidation and ending	21–24, plus a 1-month follow-up	Consolidate gains, plan for setbacks, work through ending as an attachment event	The client can describe their pattern and their own ways of responding to it; follow-up shows gains held

Monthly review rule [synthesis]: if the PID-5-BF has not trended downward after two monthly measurements, or alliance or adverse-event checks raise concern, revisit the formulation before continuing (see section 5).

Training, licensing and fidelity. No certification body, licensing requirement, published manual or fidelity scale for EST is known [uncertain]. The EST-S protocol describes no therapist training, supervision or fidelity checks. Sites were chosen for "expertise in treating personality disorders", and adherence was tracked only through session completion (target: no more than 10% of sessions skipped). The ESTP pilot checks completion, adherence, alliance and adverse events monthly, but does not say how. [source: NCT04764708 protocol, pp. 8–9; NCT06415812] The ESTP sponsor and only site is the Tages Onlus centre for psychology and psychotherapy in Florence. [source: Tundra Space record of NCT06415812] A clinician who wants to use EST should contact Tages Onlus for the manual and supervision. Without that training, do not describe your work as "EST". [synthesis]

3. Guiding principles

Principles marked [source] are stated or directly implied in the cited sources. Those marked [synthesis] are the writer's translation of the named components into stance.

Treat mechanisms, not labels. Choose the processes keeping the pattern going (for example, poor metacognition or harsh self-relating) and aim the work at them. [source: Cheli 2023 chapter abstract, "specific target mechanisms"]
Think dimensionally. Assess and track personality functioning and traits on the AMPD / PID-5 model rather than with categorical PD labels. In practice, a monthly score trend steers the work. [source: NCT06415812; Cheli et al. 2024]
One therapy, three macro-organisations. The same treatment frame is used for internalizing, externalizing/antagonistic and schizotypal presentations, and is expected to work across all three. In practice, you tailor emphasis to the pattern but do not switch therapies. [source: NCT06415812 secondary outcome, "no significant difference" across patterns expected]
Use an evolutionary lens. Treat personality and suffering in terms of the evolved social-motivational and emotion-regulation systems people inherit. In practice, the therapist explains problematic patterns as understandable products of an evolved social brain meeting a particular history, not as defects. [source: component named in Cheli 2023; Brüne & Cheli 2026 TOC chapters on evolved emotion-regulation systems and the social brain; the clinical phrasing is synthesis]
Compassion as a target and a stance. In practice, the therapist models warmth and helps the client build a kinder, more soothing relationship with themselves, especially where shame or threat is high. [source: compassion-focused component named in all abstracts; stance wording is synthesis]
Metacognition as the main change target. In practice, the therapist keeps helping the client notice, name and reflect on their own mental states and other people's, at a pace the client can tolerate. [source: metacognitively oriented component; metacognition outcome in Cheli et al. 2023]
Use attachment within the relationship. In practice, ruptures, closeness and endings in therapy are material to work with, read through the client's attachment history. [source: attachment named in Cheli 2023 chapter abstract; application is synthesis]
Measure and adjust. In practice, review standard measures and alliance with the client each month and use them to adjust the work. [source: NCT06415812 measurement schedule; collaborative review is synthesis]
Do no harm; screen out what EST was not tested for. In practice, refer or combine with other care for psychosis, bipolar disorder or autism, or where another treatment is already running. EST was not tested in these groups (though a separate two-case autism adaptation exists). [source: NCT06415812 exclusions; clinical rule is synthesis]
Fit adolescents. In practice, the same six-month individual frame is acceptable to adolescents with prominent schizotypal traits. Adapt the language and involve the family as local law and practice require. [source: Cheli et al. 2024; family involvement is synthesis]

4. Intervention inventory

How complete this is. The available sources name EST's components, assessment tools and monitoring schedule. They contain one description of session process: clients talk about problems and life experiences and "experiment with new coping strategies inside and outside the session" (see 4.11). They name no exercises and give no scripts; the full EST-S trial protocol has none. [source: NCT04764708 protocol, p. 18; chapter content uncertain] Each entry below says what the source states. The steps are the writer's clinical translation, labelled [synthesis]. No exercise name, phrasing or sequence here should be taken as Cheli's. All example language is illustrative.

4.1 Dimensional diagnostic assessment (AMPD)

Purpose / when: At intake, to confirm personality pathology and its severity. Repeat at 6 months to judge remission. [source: NCT06415812; Cheli et al. 2024]
Steps [synthesis]: (1) Before the interview, explain that it looks at how the person relates to themselves and others, not at whether they are "bad". (2) Give the SCID-5 AMPD module as licensed, and only if trained in it; do not improvise items. (3) Screen for the published exclusions: psychotic disorder, bipolar disorder, autism spectrum, intellectual disability, other current treatment. (4) Write down which macro-organisation fits best (see 4.3). (5) Feed results back in plain language in the next session.
Example language (illustrative): "These questions help us map how you tend to see yourself and other people, so we can pick what to work on."
Watch for: Clients with schizotypal or paranoid features may read the interview as surveillance. Slow down, say what happens to the data, and allow "I'd rather not say". It is working if the client gives considered answers and accepts the feedback as recognisable.

4.2 Monthly outcome and alliance monitoring

Purpose / when: To track change across the course. The pilot schedule is one month before therapy, at baseline, monthly for six months, and at a one-month follow-up. Alliance, adherence and adverse events are checked monthly. [source: NCT06415812]
Steps [synthesis]: (1) Give the PID-5-BF (APA instrument; do not reproduce its items) in the last session of each month. (2) Plot the total score with the client. (3) Ask about the relationship: what has helped, and what felt off. (4) Ask directly about adverse effects such as more distress, suspicion or withdrawal. (5) If there is no downward trend over two points, review the formulation (section 5).
Example language (illustrative): "Let's look at your line together. Where has it moved, and does that match how the month felt?"
Watch for: Scores pushed down to please the therapist, and suspicion about why you are measuring. It is working if the client starts reading the trend themselves and links changes to events.

4.3 Macro-organisation formulation (internalizing / externalizing-antagonistic / schizotypal)

Purpose / when: Phase A, to place the client's pattern within the model's three macro-organisations and choose target mechanisms. [source: NCT06415812 names the three patterns; how to formulate is not given]
Steps [synthesis]: (1) From the assessment and recent interpersonal episodes, pick the dominant pattern: inward-turned distress and self-criticism (internalizing), confrontation, blame or dominance (externalizing/antagonistic), or odd beliefs, suspicion and social detachment (schizotypal). (2) For two or three recent episodes, map the trigger, what the client wanted from the other person, what they expected, what they felt, and what they did. (3) Frame the pattern through an evolutionary lens as an understandable social strategy (see 4.4). (4) With the client, agree one or two target mechanisms, for example difficulty reading one's own feelings, harsh self-criticism, or quick threat appraisals of others.
Example language (illustrative): "It sounds like when people get close, your system reads it as danger and you pull back. That made sense once. Let's look at what it costs you now."
Watch for: Mixed presentations; record secondary features rather than forcing a fit. It is working if the client adds to or corrects the formulation.

4.4 Evolutionary psychoeducation

Purpose / when: Phases A and B, to reduce shame and give a non-pathologising frame. The source names "evolutionary psychopathology" as a component. Specific psychoeducation content is not given in the available sources. [uncertain]
Steps [synthesis]: (1) Explain briefly that humans inherit social and emotion-regulation systems built for belonging, rank and protection (the Brüne & Cheli 2026 book has chapters on evolved emotion-regulation systems and the social brain). (2) Link one of the client's patterns to those systems. (3) Ask the client to say back in their own words how the pattern might once have protected them. (4) Separate "not your fault" from "your responsibility to work with now".
Example language (illustrative): "Our brains evolved to watch for rejection very closely. Yours learned to do that extra-carefully. It isn't a flaw in you, and it isn't fixed."
Watch for: Fatalism ("it's in my genes") or intellectualising. It is working if self-blame eases and curiosity about the pattern grows.

4.5 Compassion-focused work

Purpose / when: Phase B, for shame, self-criticism and threat-driven patterns. Compassion-focused therapy is a named root of the approach, and the protocol's stated aim is to generate "a self-soothing response to suffering". The available sources do not say which CFT practices EST uses. [source: NCT04764708 protocol, p. 7; EST abstracts; Brüne & Cheli 2026 ch. 10 "Compassion Focused Practices and Psychotherapy"; uncertain]
Steps [synthesis]: (1) Explore the client's relationship with themselves: how they talk to themselves after a setback. (2) Introduce compassion as a trainable capacity, not softness. (3) Offer a brief, optional, eyes-open practice of slowing the breath and imagining a kind, wise presence (internal or a remembered person). Ask permission first. Clients with schizotypal features may find closed-eye imagery strange or unsettling, so keep it short and grounded. (4) Practise taking a compassionate stance towards a recent painful episode. (5) Agree a short between-session practice and review it.
Example language (illustrative): "What would someone who really had your back say to you about that week?"
Watch for: "Fear of compassion" reactions (warmth feels threatening, undeserved or manipulative), and dissociation or perceptual oddities during imagery; stop and ground. It is working if the client can soften self-criticism even briefly and reports less threat.

4.6 Metacognitive work (reflecting on one's own and others' minds)

Purpose / when: Throughout. This is the main change target: the protocol calls the approach a therapy "targeting metacognitive dysfuctions" [sic] and measures metacognition with the MAS-A. Metacognition showed the largest gains in the RCT. [source: NCT04764708 protocol, pp. 5, 11; Cheli et al. 2023 abstract; the techniques of the metacognitively oriented component are not given in the available sources: uncertain]
Steps [synthesis]: (1) Ask for a specific, recent, concrete interpersonal episode (a narrative episode), not a general story. (2) Help the client name what they thought and felt, moment by moment. (3) Only once that is possible, move to the other person's possible mind, offering several alternatives. (4) Link episodes into a recurring pattern (wish, expectation of the other, response). (5) Pace by the client's current ability: start with naming one's own states before taking others' perspectives.
Example language (illustrative): "Let's slow down on that moment in the kitchen. What went through your mind just before you left?"
Watch for: Generalities, abstract theories about people, or fixed certainty about others' intentions. Go back to concrete detail. It is working if the client spontaneously notices "there I go again" and tolerates other readings of others.

4.7 Attachment-informed use of the therapeutic relationship

Purpose / when: Throughout, especially around ruptures, closeness and ending. Attachment theory is a named integration source. [source: Cheli 2023 chapter abstract; Brüne & Cheli 2026 ch. 5 on therapeutic relationships and ch. 7 on attachment; content uncertain]
Steps [synthesis]: (1) Notice when the client's pattern shows up with you (withdrawal, suspicion, challenge). (2) Name it gently and without blame. (3) Own your part. (4) Treat the repair as a live experience of a different relational outcome. (5) Start talking about the ending around session 18 and treat it as an attachment event.
Example language (illustrative): "I noticed you went quiet after I asked about your father. Did I push too hard?"
Watch for: Over-interpreting, which can feel intrusive to suspicious clients. It is working if ruptures repair faster and the client can talk about the relationship.

4.8 Ecological momentary assessment (EMA) of interpersonal style (research component)

Purpose / when: In the pilot, EMA checks whether the three-pattern model matches clients' everyday interpersonal styles: twice a day for 10 days before and after therapy. It is a study tool, not a stated therapy technique. [source: NCT06415812]
Clinical adaptation [synthesis]: A short daily diary of one social interaction (who, what I wanted, what I expected, what I felt, what I did) can supply material for 4.3 and 4.6. Keep it brief, voluntary and private.
Watch for: Paranoid clients worrying about written records; let them keep it on paper and choose what they share.

4.9 Adolescent adaptation

Purpose / when: Clients aged 16–19, or younger as in the five-case series. Published: the same six-month individual frame, no adverse events, rated satisfactory and sustainable. [source: Cheli et al. 2024; NCT06415812]
Steps [synthesis]: Use plainer, more concrete language and shorter practices. Agree confidentiality limits and parent or carer involvement at the start, following local law. Use school and peer episodes for metacognitive work. Avoid naming a personality disorder in a way that becomes an identity.
Watch for: Disengagement, and parents expecting reports. It is working if the young person attends and brings their own episodes.

4.10 Consolidation, ending and one-month follow-up

Purpose / when: Sessions 21–24 and the follow-up assessment one month after the end. [source: follow-up timing from NCT06415812; content is synthesis]
Steps [synthesis]: (1) Review the PID-5-BF trend and the formulation with the client. (2) Help them write their own summary: my pattern, early signs, what helps (compassionate response, slowing down to reflect). (3) Plan for setbacks. (4) Process feelings about ending. (5) Book the follow-up and say what happens if gains slip.
Example language (illustrative): "If the old pattern turns up in three months, what would you want to remember from here?"
Watch for: Rising scores or a crisis as the ending approaches; treat this as attachment material, not failure.

4.11 Experimenting with new coping strategies inside and outside the session

Purpose / when: Phase B onwards, once a target mechanism is agreed. The protocol's only description of session process is that clients talk about problems and life experiences and "experiment with new coping strategies inside and outside the session". [source: NCT04764708 protocol, p. 18] It does not say how experiments are chosen or set. [uncertain]
Steps [synthesis]: (1) From a narrative episode (4.6), pick one moment when the old pattern ran. (2) Agree one small alternative response linked to the target: for example, a compassionate self-statement in place of self-attack, or checking one alternative reading of the other person before withdrawing. (3) Try it in session first, with the therapist or in imagery, and ask what it was like. (4) Agree when the client might try it outside. Frame it as an experiment whose result is information, not a test. (5) At the next session, review what happened and what the client noticed in their own mind and in the other person's, then adjust.
Example language (illustrative): "Let's treat this as an experiment. You try the new response once this week, and whatever happens, we learn something."
Watch for: Experiments too big for the client's current metacognitive level; going along with the task without reflecting on it; paranoid clients reading the task as a test. It is working if the client reports trying the response, can describe what went on in their mind during it, and starts proposing experiments of their own.

5. Handling problems

The available sources report only three things here. The adolescent series had no adverse events. The pilots monitor feasibility, alliance and adverse events monthly. The EST-S trial counted suicidal behaviour, self-harm and psychotic episodes as adverse events. [source: Cheli et al. 2024; NCT06415812; NCT04764708 protocol, p. 8] Everything below is the writer's synthesis. [synthesis]

Stuck (no downward PID-5-BF trend over two monthly points). Check that the target mechanism is right: often metacognition is targeted too fast, before the client can name their own states. Go back to concrete narrative episodes (4.6). Check alliance and adverse effects. Ask whether the macro-organisation was misread (for example, schizotypal detachment taken for internalizing withdrawal). If still flat around session 12, discuss with the client whether to add or switch to an evidence-based alternative.
Resistance or scepticism about the evolutionary frame. Some clients hear "evolution" as "it's biological, so it's hopeless", or as dismissive. Keep the frame light, stress learning and change, and drop the vocabulary if it isn't helping. The frame serves the work; it is not the work.
Fear of or resistance to compassion. Warmth can trigger threat, especially in antagonistic or paranoid presentations. Make it more acceptable by framing compassion as courage and strength. Use smaller doses and eyes-open versions, and validate the fear as part of the pattern.
Overwhelm, or dissociative or perceptual reactions during imagery or emotion work (schizotypal clients). Stop the exercise. Ground in the room (feet, the objects around you, your voice). Reduce the dose. Move work towards concrete, external episodes. Screen for emerging psychosis: unusual experiences becoming more intense, frequent or held with more conviction. If present, refer for assessment; psychotic disorder was an exclusion criterion.
Paranoid suspicion of the therapist or the measures. Be transparent about records, measures and the reasons for them. Offer choice about written material. Name ruptures early (4.7). Do not argue about content; explore the felt threat.
Antagonistic or externalizing clients: challenge, blame, testing limits. Stay non-defensive and keep boundaries clear. Link the pattern to its function (protection from humiliation or loss of rank) and look at the costs together. Agree explicit safety and conduct limits early.
Non-adherence to between-session practice or diaries. Shrink the task. Ask what got in the way, as an instance of the pattern. Make the practice optional and do it in session instead.
Ruptures. Withdrawal ruptures (silence, missed sessions, compliance) are common in internalizing and schizotypal clients; confrontation ruptures in externalizing ones. Notice it, name it gently, own your part, explore it, and link it to the formulation only once things feel safe again.
Missed sessions or drop-out risk. Contact the client warmly after one missed session. Shorten or briefly space out sessions rather than ending. Note that the published format assumes weekly attendance over six months, so a shortened course is a deviation.
Risk of suicide or self-harm. Assess at intake and whenever distress rises, using standard structured clinical risk assessment. Write a collaborative safety plan, counsel on lethal means (safe storage or removal), and escalate to crisis or medical services as indicated. EST sources give no specific risk protocol. [uncertain]
Client already in another treatment or on medication. The pilot excluded such clients. In routine practice, coordinate with the other providers and do not present the combination as tested EST.
Clients outside the tested range (autism, bipolar disorder, intellectual disability, neurological disease, older adults). Evidence is thin or absent. Adapt carefully, and say clearly that what you are doing is an adaptation. Family or couple formats: neither trial protocol includes family, couple or carer sessions, so a conjoint format is not EST. If family work is needed, run an established family therapy alongside and say so. [source: NCT04764708 protocol; NCT06415812; the recommendation is synthesis]
Ending reactions. Rising symptoms near session 24 should be treated as attachment material (4.7, 4.10), not as a reason to extend automatically. Use the one-month follow-up as a planned bridge.

Sources

Web pages consulted:

Cited from abstracts or records:

Cheli, S., Cavalletti, V., Lysaker, P. H., Dimaggio, G., Petrocchi, N., Chiarello, F., Enzo, C., Velicogna, F., Mancini, F., & Goldzweig, G. (2023). A pilot randomized controlled trial comparing a novel compassion and metacognition approach for schizotypal personality disorder with a combination of cognitive therapy and psychopharmacological treatment. BMC Psychiatry, 23, 113. doi:10.1186/s12888-023-04610-5 (open access)
Cheli, S. (2023). Evolutionary Systems Therapy for Schizotypy: An integrated look at attachment, compassion and metacognition. In S. Cheli & P. H. Lysaker (Eds.), A Dimensional Approach to Schizotypy (pp. 269–285). Springer.
Cheli, S., Goldzweig, G., Lysaker, P. H., Chiarello, F., Wiesepape, C., & Cavalletti, V. (2024). An evolutionarily informed therapy for adolescents with prominent schizotypal traits: a pilot five case series. Psychosis, 16(3), 292–301.
Cheli, S. (2026). Evolutionary Systems Therapy for Personality Pathology. In M. Brüne & S. Cheli (Eds.), The Evolution of Psychotherapy (pp. 197–217). Springer. (The main manual-level source.)
Evolutionary systems therapy for personality pathology: a proof-of-concept single-arm trial (2026). (Listed on the Springer book page.)
Hayes, S. C., Hofmann, S. G., & Ciarrochi, J. (2020). A process-based approach to psychological diagnosis and treatment: The conceptual and treatment utility of an extended evolutionary meta model. Clinical Psychology Review, 82, 101908.

← Previous · V-030Family mode deactivation therapy Next · V-032 →Ecological counselling