Antisocial Personality Disorder

20 Pages·1999·0.18 MB·English

C H A P T E R 69
Antisocial Personality
Disorder
J. Reid Meloy, Ph.D., ABPP
Jessica Yakeley, F.R.C.Psych.
Antisocial personality
disor-
Psychodiagnostic
der (ASPD) is the most reliably diag-
nosed condition among the personality Refinements
disorders, yet treatment efforts are noto-
riously difficult. Many psychiatrists are
Before any treatment efforts are under-
reluctant to treat patients with ASPD be-
taken, diagnostic refinement is critical,
cause of widespread belief that such pa-
especially determination of the degree
tients are always untreatable. There is in-
of psychopathy, in the patient diagnosed
creasing evidence, however, that ASPD
with ASPD. The older, clinical tradition
may, in certain cases, be treatable.
for understanding ASPD used the term
In this chapter, we briefly review his-
psychopathy or psychopathic personality
torical and contemporary nosological
and was most thoughtfully delineated
controversies regarding the ASPD con-
by Cleckley (1941/1976). This tradition
struct, and summarize the general re-
is distinguished by attending to both
search findings for this condition. We
manifest antisocial behavior and per-
then discuss treatment planning in de-
sonality traits; the latter are described as
tail, based on thorough assessment of the
the callous and remorseless disregard
individual’s personality characteristics
for the rights and feelings of others (Hare
to determine prognosis, risk manage-
1991) or aggressive narcissism (Meloy
ment, and appropriate treatment. We con-
1992). Hare (1991, 2003) and colleagues
clude by evaluating the specific treatment
developed a reliable and valid clinical
approaches available for ASPD, drawing
instrument for the assessment of psy-
from our own clinical experience and the
chopathy, the Psychopathy Checklist—
research evidence to date.
Revised (PCL-R). This is a unidimen-
1015
1016 Gabbard’s Treatments of Psychiatric Disorders, Fifth Edition
sional observational scale that quantifies substantial body of research has shown
clinical interview and historical data on that, at most, only one of three individu-
the patient. Individuals scoring 30 or als in prison with ASPD has severe psy-
more on the PCL-R are considered psy- chopathy, and those with severe psy-
chopaths for research purposes (Hare chopathy have a significantly poorer
1991, 2003). In our clinical experience— treatment prognosis than do other antiso-
consistent with research—a score in the cial patients with measurably fewer psy-
range of 20–29 would indicate moderate chopathic traits (Hare 1991, 2003). The
psychopathy, and a score of 30 or higher measurement of psychopathy and the
would indicate severe psychopathy. use of other psychological tests help to
Psychopathy is not synonymous with delineate subgroups of antisocial indi-
behavioral histories of criminality or a viduals who have lower psychopathy
DSM-5 categorical diagnosis of ASPD scores and higher levels of anxiety, and
(American Psychiatric Association 2013; who may show a better response to treat-
see Box 69–1), although it is often a corre- ment (Hodgins 2007; Hodgins et al. 2010;
late of both in severe cases. Notably, a Ulrich and Coid 2010).
Box 69–1. DSM-5 Diagnostic Criteria for Antisocial Personality Disorder
301.7 (F60.2)
A. A pervasive pattern of disregard for and violation of the rights of others, occurring since
age 15 years, as indicated by three (or more) of the following:
1. Failure to conform to social norms with respect to lawful behaviors, as indicated by
repeatedly performing acts that are grounds for arrest.
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for
personal profit or pleasure.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
5. Reckless disregard for safety of self or others.
6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent
work behavior or honor financial obligations.
7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt,
mistreated, or stolen from another.
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of schizo-
phrenia or bipolar disorder.
ASPD is associated with considerable quarter have a depressive disorder (Len-
and complex comorbidity with other zenweger et al. 2007). The Epidemiologic
psychiatric conditions (Swanson et al. Catchment Area study found that sub-
1994), particularly substance misuse stance abuse occurred in 83.6% of indi-
(Robins et al. 1991), and increased mortal- viduals diagnosed with ASPD (Regier et
ity through reckless behavior (Black et al. al. 1990), although subsequent studies
1996). At least half of those with ASPD have reported prevalence rates of sub-
have co-occurring anxiety disorders stance use disorders in ASPD ranging
(Goodwin and Hamilton 2003), and a from 42% to 95% (Uzun et al. 2006). Co-
Antisocial Personality Disorder 1017
morbid Axis I conditions are important to need (empirically established dynamic
diagnose, because the presence of ASPD criminogenic risk factors, such as crimi-
acts as a negative moderator of treatment nal attitudes, substance abuse, and im-
response when these conditions are pulsivity), and responsivity (delivering
treated by conventional approaches. Psy- interventions in a manner that maxi-
chopathy appears, however, to be inde- mizes offender engagement in the treat-
pendent of most Axis I conditions, except ment process). The effect sizes are typi-
for alcohol and other substance abuse cally one-half of the overall effects in
and dependence (Hart and Hare 1989; meta-analyses of psychological inter-
Smith and Newman 1990). ventions in general (Simon 1998).
Given the action-oriented nature of A review of the treatment research
these patients and the likelihood of head concerning criminal psychopathic pa-
injury, neurological and neuropsycho- tients, who have the most severe form of
logical impairments also must be ruled ASPD according to the criteria of Hare
out. Such impairments may exacerbate (2003), has challenged the view that psy-
clinical expressions, such as the physical chopathy per se is always untreatable.
violence of this character pathology. Salekin (2002) conducted a meta-analysis
of 44 studies of a broad range of correc-
tional treatments with various samples of
General Treatment psychopathic subjects and found an over-
all positive treatment effect. Lengthier
Findings
and more intensive treatments—those in-
cluding an average of at least four ses-
Although the mainstay of treatment for sions per week of individual psychother-
ASPD is psychological therapy, only a apy for at least 1 year—were found to be
small number of high-quality treatment significantly more effective. However,
trials have been conducted among peo- this review was criticized for including
ple with ASPD, so the evidence base for case studies, use of therapist opinion re-
effective treatments for this patient group garding patient change, use of other mea-
continues to be very limited (Duggan et sures of psychopathy than the PCL-R,
al. 2007; Gibbon et al. 2010; National In- and including studies that did not use re-
stitute for Health and Clinical Excellence cidivism as an outcome measure (Harris
2009; Warren et al. 2003). Furthermore, a and Rice 2006). D’Silva et al. (2004) re-
comparative evaluation of available stud- viewed 10 studies of the treatment of psy-
ies is hampered by different diagnostic chopaths with high scores on the PCL-R,
criteria and conceptualizations of psy- and found that although four studies
chopathy versus ASPD, differences in de- concluded that psychopaths respond
fining and measuring outcomes, a focus poorly to treatment, another four sug-
on treating incarcerated patients rather gested the opposite. A more recent re-
than those in the community, and a focus view by Salekin et al. (2010), which in-
on behavioral and symptomatic rather cluded only studies using the PCL-R for
than structural personality change. diagnosing psychopathy, showed three
Programs that have the largest effect of eight studies with positive treatment
sizes adhere to the risk-need-responsiv- outcomes, whereas treatment of psycho-
ity model (Andrews 1995). These pro- pathic youths was more promising, with
grams focus on risk (targeting those pa- six of eight studies showing treatment
tients at greatest risk of reoffending), benefits.
1018 Gabbard’s Treatments of Psychiatric Disorders, Fifth Edition
Another comprehensive review of the disordered offenders remains unan-
literature on rehabilitating general, psy- swered (Völlm and Konappa 2012). The
chopathic, and high-risk offenders program has recently been disbanded in
(Skeem et al. 2009) gives rise to further favor of a reconfigured national strategy
optimism that intensive, targeted, ap- for managing offenders with severe per-
propriate psychosocial interventions sonality disorders based on a “whole
based on risk-needs-responsivity princi- systems pathway” across the criminal
ples reduce recidivism risk in some se- justice system and National Health Ser-
verely psychopathic individuals. The re- vice (Joseph and Benefield 2012).
duction in risk is more likely when
cognitive-behavioral techniques are ap- Treatment Planning
plied to address risk for recidivism, and
when the treatment relationship be-
Once the severity of psychopathy has
tween offender and provider is charac-
been assessed in the patient with ASPD
terized by caring, fairness, and trust as
and any other treatable psychiatric dis-
well as an authoritative—not authoritar-
orders have been identified, four clinical
ian—style. Interventions that are puni-
questions should guide further psychi-
tive or that focus on control and surveil-
atric involvement with the patient:
lance may increase risk of recidivism if
not combined with rehabilitative efforts.
1. Risk assessment: What are the risks
The Dangerous and Severe Personal-
posed by the patient, and is the treat-
ity Disorder (DSPD) initiative in the
ment setting secure enough to con-
United Kingdom (Department of Health
tain the relative severity of the psy-
and Home Office 1999) illustrates the
chopathic disturbance in the patient
challenges of treating and researching
with ASPD?
antisocial and psychopathic patients.
2. Personality characteristics and treatment
This ambitious pilot program for the
prognosis: What personality character-
treatment of patients with DSPD—pa-
istics, gleaned from clinical research
tients assessed as posing significant risk
on patients with ASPD or psychopa-
of harm to others and whose risk is
thy, are relevant to the treatment plan-
linked to their personality disorder—in
ning for this particular patient?
specialized intensive units in selected
3. Clinician’s reactions to patient: What
prisons and forensic hospitals was estab-
are the emotional and/or counter-
lished in the United Kingdom in 2001.
transference reactions that the clini-
Although cognitive-behavioral tech-
cian can expect in himself or herself
niques predominated in these treatment
when attempting to clinically treat or
programs, some programs also used psy-
help risk-manage (if no treatment is
chodynamic ideas to both manage staff
being attempted) this patient?
and tailor therapeutic interventions,
4. Specific treatment approaches: What spe-
such as using the therapeutic community
cific treatments, if any, should be ap-
model of treatment. However, despite
plied to this patient, given the re-
substantial investment into research and
sources available and the degree of
evaluation of the programs, no high-
containment necessary to effectively
quality trials of specific treatments or
intervene?
service environments were carried out,
so the key question as to what treatments Each of these questions is addressed in
are effective for high-risk personality- turn in the sections that follow.
Antisocial Personality Disorder 1019
purposeful. Research has shown that
Risk Assessment
psychopathic criminals are more likely
than other criminals to engage in both af-
An essential component of management fective and predatory violence (Cornell et
of the patient with ASPD is the setting in al. 1996; Serin 1991; Walsh 1999; William-
which treatment is delivered, wherein son et al. 1987; Woodworth and Porter
containment, risk, boundaries, and dis- 2002). Blair et al. (2005) noted that “no bi-
closure of information are paramount ologically based disorder other than psy-
(Meloy and Yakeley 2010). The treatment chopathy is associated with an increased
setting must be secure enough to ensure risk of instrumental aggression” (p. 155).
the safety of both patients and staff before Psychopathic criminals are typically
treatment planning can begin, depending three to five times more violent than
on the available resources. If it is not, staff nonpsychopathic criminals (Hare 2003),
may be put physically at risk by a deci- but even the most violent patients are
sion to commence treatment. Political not violent most of the time. Measure-
and bureaucratic pressures may be ment of violence risk in both psychiatric
brought to bear on clinicians to “treat” and offender populations has found that
currently untreatable patients with ASPD psychopathy typically accounts for the
and severe psychopathy, and a “not-to- largest proportion of explainable vari-
treat” decision may entail a variety of ance. We recommend such instruments
personal and professional dilemmas. as the Violence Risk Appraisal Guide
By far the most troublesome symptom (VRAG; Quinsey et al. 2006), the Classi-
of ASPD is violence, which is signifi- fication of Violence Risk (COVR; Mona-
cantly more frequent in the severely psy- han et al. 2005), the HCR-20 Version 3
chopathic patient (Hare and McPherson (Douglas et al. 2013), and the PCL-R.
1984). Reis (1974) labeled “affective” and Yang et al. (2010) have found, however,
“predatory” aggression, and Eichelman that most actuarial and structured pro-
(1992), Meloy (1988, 1997, 2006), McEllis- fessional judgment instruments are
trem (2004), Siegel and Victoroff (2009), equivalent in their moderately accurate
Siever (2008), and others have elaborated prediction of violence risk, and should
upon the physiological, pharmacological, instead be selected on the basis of spe-
and forensic distinction between the two cific relevance to the patient’s history of
types. These psychobiologically different violence. All risk-of-violence evalua-
modes of violence are most relevant to tions should be individualized and will
ASPD and psychopathy, although they benefit from a complete biopsychosocial
are not inclusive and should not be con- understanding of the patient.
sidered a standardized clinical nosology
for aggression (Eichelman and Hartwig
Personality
1993). Affective (emotional, reactive) ag-
gression is a mode of violence that is ac- Characteristics and
companied by high levels of sympathetic
Treatment Prognosis
arousal and emotion (usually anger or
fear) and is a reaction to an imminent
threat. Predatory (instrumental) aggres- Anxiety and Attachment
sion is a mode of violence that is accom-
panied by minimal or no sympathetic Hodgins and colleagues emphasize the
arousal and is emotionless, planned, and importance of co-occurring anxiety in
1020 Gabbard’s Treatments of Psychiatric Disorders, Fifth Edition
subtyping ASPD (De Brito and Hodgins any treatment that depends on the emo-
2009). Based on studies of children and tional relationship with the psychother-
adults, they propose that around half of apist will fail and may pose an explicit
individuals in the ASPD population are danger to the professional because a lack
characterized by anxiety as well as per- of empathy for the therapist will not in-
sistent antisocial behavior, and have low hibit aggression. The more severe the
levels of callous unemotional traits as psychopathy, the more the patient will
children and low levels of psychopathic relate to others on the basis of power
traits as adults. This group is more likely rather than affection (Meloy 1988).
to have experienced physical abuse as
children and resort to violence as a com- Narcissism
pensatory response to underlying emo-
tional conflict and distress. The other half Psychopathic patients can be conceptual-
have normal to low levels of anxiety and ized as aggressive narcissists, with the at-
varying levels of psychopathy, but in- tendant intrapsychic object relations,
clude a subgroup with high levels of psy- structure, and defenses that have been
chopathy. This group shows marked cal- described in the psychoanalytic literature
lous and unemotional traits as children, (Kernberg 1992; Meloy 1988). In a clinical
low levels of anxiety, more predatory (in- and treatment setting, the more severe
strumental) violence, and less amenabil- the psychopathic disturbance in the pa-
ity to treatment. There is also suggestive tient with ASPD, the greater the likeli-
research that severely psychopathic hood that aggressive devaluation will be
adults experienced less abuse and neglect used to shore up feelings of grandiosity
as children than moderately psycho- and repair emotional wounds. In some
pathic adults, which also supports the patients, this devaluation is defensive,
relative increase in biogenic contribu- whereas in others, a core, injured sense of
tions as degree of psychopathy increases self is not apparent. This behavioral den-
(Felthous and Sass 2007; Raine 2013). igration of others can run the clinical
Anxiety is a necessary correlate of any spectrum from subtle verbal insults to the
successful mental health treatment that rape and homicide of a female staff mem-
depends on interpersonal methods, be- ber. It also distinguishes the psycho-
cause it marks a capacity for internal- pathic patient from the narcissistic pa-
ized object relations and may signal tient, who can devalue in fantasy
other affects. As the severity of psychop- (Kernberg 1975) without resorting to the
athy increases in patients with ASPD, infliction of emotional or physical pain
anxiety likely lessens, and with it the on others.
personal discomfort that can motivate a In addition to the devaluation of oth-
patient to change. ers, the severity of psychopathy will de-
Attachment, or the capacity to form termine the degree to which the patient
an emotional bond, is considered to be will try to control other patients and
lower in severely psychopathic crimi- staff. This “omnipotent control” in the
nals than in mild to moderately psycho- actual clinical setting, often felt by staff
pathic criminals (Fonagy et al. 1997; as being “under the patient’s thumb” or
Frodi et al. 2001; Gacono and Meloy “walking on eggshells,” usually serves
1994; Levinson and Fonagy 2004; Meloy the purpose of stimulating the severe
2002; van IJzendoorn et al. 1997). For a psychopath’s grandiose fantasies and also
patient without an attachment capacity, warding off the patient’s fears of being
Antisocial Personality Disorder 1021
controlled by malevolent forces outside may be defensive and easily punctured.
himself or herself. When the grandiosity The treatment implications of these
of the mildly to moderately psycho- object relations surround the risk of vio-
pathic patient with ASPD is challenged lence by patients with ASPD. The more
by failure, there will be clinical manifes- psychopathic these individuals are, the
tations of anxiety or depression, both of more pleasurable, less conflicted, and
which are positive prognostic indicators more sadistic their aggressive acts will
(Gabbard and Coyne 1987). be (Dietz et al. 1990; Holt et al. 1999). The
psychopathic patient may wholly iden-
Psychological Defenses
tify with the aggressor (A. Freud 1936/
1966) and have no inhibitions. A history
ASPD patients with severe psychopathy
of violence, coupled with the predatory
most predictably use the following psy-
(instrumental) nature of their violence,
chological defenses: projection, devalua-
makes ASPD patients with severe psy-
tion, denial, projective identification, om-
chopathy very dangerous in a hospital
nipotence, and splitting (Gacono and
milieu without appropriate security
Meloy 1994; Hare 2003). For instance,
(Gacono et al. 1995, 1997).
projective identification is most apparent
in treatment when the psychopathic pa-
Affects
tient attributes certain negative charac-
teristics to the clinician and then attempts
The emotions of the patient with ASPD
to control the clinician, perhaps through
lack the subtlety, depth, and modulation
overt or covert intimidation. An aspect of
of those of psychiatrically healthy indi-
the psychopathic patient’s personality is
viduals. The patient with ASPD and se-
then perceived in the clinician and
vere psychopathy appears to live in a
viewed as a threat that must be dimin-
“presocialized” emotional world, where
ished. Higher-level or neurotic defenses,
feelings are experienced in relation to the
such as idealization, intellectualization,
self but not to others. Such a patient is un-
isolation, sublimation, and repression,
likely to have a capacity to experience
appear to be virtually absent in the pa-
emotions such as reciprocal pleasure,
tient with ASPD and severe psychopathy
gratitude, empathy, joy, sympathy, mu-
(Gacono 1990). If neurotic defenses are
tual eroticism, affection, guilt, or remorse,
present in the patient with ASPD, they
that depend on whole object relations.
suggest amenability to treatment.
The patient’s emotional life instead is
dominated by feelings of anger, sensitivi-
Object Relations
ties to shame or humiliation, envy, bore-
The severely psychopathic patient’s inter- dom, contempt, exhilaration, and plea-
nal representations of self are aggressive sure through dominance (sadism).
and larger than life—this person is a leg- Such feelings in the patient with ASPD
end in his or her own mind. At the same and severe psychopathy pose difficul-
time, this patient does not consider others ties for modalities that depend on emo-
as whole, real, and meaningful individu- tional access to the patient, such as cog-
als deserving of respect and empathy, but nitive-behavioral relapse prevention or
instead as objects to dominate and ex- psychodynamic approaches that require
ploit. Patients with ASPD without severe the patient to have a capacity to feel
psychopathy may see themselves as in- emotion in relation to the psychothera-
jured or devalued, and their grandiosity pist and to talk about it. Most trouble-
1022 Gabbard’s Treatments of Psychiatric Disorders, Fifth Edition
some and difficult to detect is the psy- ward others and show no need to justify
chopathic patient’s imitation of certain or rationalize their behaviors. Such indi-
emotional states for secondary gain or to viduals should not be considered for a
manipulate the psychotherapist. treatment setting because they place
both staff and other patients at risk.
Superego Pathology
The touchstone of psychopathy and Clinician’s Reactions
ASPD has been the absence of conscience,
to Patient
or serious deficits in moral judgment
(Cleckley 1941/1976; Hare 1991; Johnson
1949; Robins 1966). Although few con- Lion (1978), Symington (1980), Stras-
trolled studies of moral development in burger (1986), Meloy (1988, 2001), and
psychopathy have been done (Hare 2003; Gabbard (2014) explored the clinician’s
Trevethan and Walker 1989), clinicians response to the patient with psychopa-
agree that this characteristic is a marker thy or ASPD. Table 69–1 lists nine com-
for the character pathology (Kernberg mon countertransference reactions to
1984; Meloy 1988; Reid et al. 1986). such a patient. These reactions, each of
The presence of any superego devel- which is discussed in the following sub-
opment, whether a prosocial ego ideal (a sections, are likely to occur regardless of
realistic, long-term goal) or clinical evi- the treatment modality being applied
dence of a socially desirable need to ra- and will be felt more intensely when
tionalize antisocial acts, is a positive psychopathy is more severe in the pa-
prognostic sign. Certain mild to moder- tient with ASPD. These are reactive
ately psychopathic patients with ASPD emotions and thoughts and should not
may show evidence of harsh and puni- be construed as necessarily implicating
tive attitudes toward the self and as- a conflict in the clinician. Such subjective
sume a masochistic attitude toward the reactions can be used as an impetus for
clinician. This behavior signifies some further objective testing, a reevaluation
internalized value and attachment ca- of the appropriateness of the selected
pacity. ASPD patients with severe psy- treatment, or in some cases the cessation
chopathy are likely to behave cruelly to- of treatment.
TABLE 69–1. Common countertransference reactions to the patient with
antisocial personality disorder
1. Therapeutic nihilism
2. Illusory treatment alliance
3. Fear of assault or harm
4. Denial and deception
5. Helplessness and guilt
6. Devaluation and loss of professional identity
7. Hatred and the wish to destroy
8. Assumption of psychological maturity
9. Fascination, excitement, or sexual attraction
Antisocial Personality Disorder 1023
These countertransference reactions Fear of Assault or Harm
are most readily explored in individual
Strasburger (1986) noted that both real-
or group supervision or in carefully led
ity-based and countertransference fears
clinical staff meetings in which a wide
may exist in response to the ASPD pa-
range of emotional reactions toward pa-
tient with severe psychopathy. Real dan-
tients are tolerated and accepted. Clini-
ger should not be discounted and is
cians who are resistant to any under-
most readily evaluated by using con-
standing of their own emotional lives in
temporary measures to assess the risk of
relation to these patients should not be
violence (Monahan et al. 2001). Counter-
treating them and may put other mental
transference fear is an atavistic response
health professionals at risk.
to the psychopathic patient as a predator
Therapeutic Nihilism and may be viscerally felt as “the hair
standing up on my neck” or the patient
Lion (1978) used the term therapeutic ni- “making my skin crawl.” These are phy-
hilism to describe the clinician’s rejection logenetically evolved autonomic reac-
of all patients with an antisocial history tions that may also signal real danger,
as being completely untreatable. Instead even in the absence of an overt threat.
of arriving at a treatment decision based They appear to be widespread among
on a clinical evaluation, including an as- clinicians working with psychopathic
sessment of the severity of psychopathy, patients (Meloy and Meloy 2002).
the clinician devalues the patient as a
member of a stereotyped class of “un- Denial and Deception
touchables.” The clinician does to the
Denial in the psychotherapist is most of-
patient with ASPD what the patient
ten seen in counterphobic responses to
does to others.
real danger. Lion and Leaff (1973) sug-
Illusory Treatment Alliance gested that such denial is a common de-
fense against anxiety generated by vio-
The opposite of therapeutic nihilism is lent patients. It may also be apparent in
the illusion that there is a treatment alli- the unwillingness of mental health clini-
ance when, in fact, there is none. Percep- cians to participate in the prosecution of
tions of such an alliance are often the psy- a psychopathic patient who has seri-
chotherapist’s own wishful projections. ously injured someone (Hoge and
Behaviors by a severely psychopathic pa- Gutheil 1987), in the underdiagnosis of
tient that suggest such an alliance should ASPD (Gabbard 2014), or in clinicians’
be viewed with clinical suspicion and disbelief that the patient has an antiso-
may actually be imitations to please and cial history (Symington 1980) or that
manipulate the psychotherapist. The cha- psychopathy even exists at all (Vaillant
meleon-like quality of the psychopathic 1975). This reaction may lead to splitting
patient is well documented (Greenacre or contentiousness among mental health
1958; Meloy 1988, 2001). Bursten (1973) staff, especially in hospital settings.
elaborated on the “manipulative cycle” In our clinical experience, deception of
of the psychopathic patient, which leads the patient with ASPD is most likely to
to a feeling of contemptuous delight in occur when the psychotherapist is fright-
these patients when successfully carried ened of the patient, especially of the pa-
out. The clinician is left with feelings of tient’s rage if certain limits are set sur-
humiliation and anger. rounding treatment. It may also indicate
1024 Gabbard’s Treatments of Psychiatric Disorders, Fifth Edition
superego problems in the clinician, the talized patient with ASPD whom he was
avoidance of anxiety, passive-aggressive treating as they both stormed through the
rejection of the patient, or an identifica- hospital with flame throwers, destroying
tion with the deceptive skills of the pa- everything in sight. No other patient will
tient with ASPD. Rigorous honesty with- compel psychotherapists to face their
out self-disclosure is the treatment rule in own aggressive and destructive impulses
working with patients with ASPD. like the psychopath will. Because these
patients often hate goodness itself and
Helplessness and Guilt will destroy any perceived goodness
(such as empathy) offered by the clini-
In our experience, the novice clinician
cian, the clinician may react by identify-
may especially feel helpless or guilty
ing with the patient’s hatred and wish to
when the patient with ASPD does not
destroy. It may become a source of under-
change despite treatment efforts. These
standing and relating to the patient if
feelings may originate from the psycho-
brought into consciousness (Gabbard
therapist’s narcissistic belief in his or her
1996; Galdston 1987).
own omnipotent capacity to heal, what
Reich (1951) called the “Midas touch Assumption of
syndrome.”
Psychological Maturity
Devaluation and Loss of
The most subtle countertransference re-
Professional Identity action is the clinician’s belief that the pa-
tient with ASPD is as developmentally
If therapeutic competency is measured
mature and complex as the clinician, and
only through genuine change in the pa-
that the patient’s actual maturity only has
tient, the patient with ASPD will be a
to be facilitated by, and discovered in,
source of continuous professional disap-
treatment. This is particularly common
pointment and narcissistic wounding. In
when no other psychiatric disorder is
long-term treatment, the psychopathic
present and the patient has an above-av-
patient’s intransigence may compel the
erage IQ.
clinician to question his or her own pro-
fessional identity. Bursten (1973) noted Fascination, Excitement, or
that despite the psychotherapist’s most
Sexual Attraction
adept management of the patient’s con-
tempt, it is difficult not to feel despicable
Some clinicians are strongly drawn to pa-
and devalued because of the primitive,
tients with ASPD or psychopathy, and
preverbal nature of the patient’s manip-
provide an eager audience for these pa-
ulative cycle. The clinician’s emotional
tients to regale with their prowess and ex-
responses to the patient may range, in
ploits. Such an idealizing countertrans-
this context, from retaliation and rage to
ference can also be sexualized, which
indifference or submission.
may invite an exceedingly dangerous en-
counter, especially between a male pa-
Hatred and the Wish
tient with psychopathy and a female psy-
to Destroy chotherapist. Young mental health
professionals will often be enamored
One psychiatric resident recalled the em- with criminal forensic work for the sensa-
barrassing dream of being with a hospi- tion seeking that it promises and the un-