Introduction to Section II
Psychoanalysts tend to make their diagnostic formulations by beginning treatment. The interaction between themselves and their patients, principally through transference and countertransference, provides them with a sense of the patients’ personality organization and their amenability to treatment. This reversal of the medical model—which calls for diagnosis first, treatment second—also captures the evolutionary history of our understanding of psychopaths. Psychoanalysts have studied the psychic architecture of psychopaths during the past century by continuous interaction with them through treatment efforts. Relatively recently we have begun to make diagnostic formulations, both clinical and empirical, to spell out similarities and differences when such patients are compared to various other groups of narcissistic individuals.
The four treatment papers in this section—incisive works by August Aichhorn (chapter 15), John Lion (chapter 18), Neville Symington (chapter 19), and Larry Strasburger (chapter 20)—are the best offerings among the very few analytic treatment papers on psychopathy that exist. As one would expect, rather than focusing on technique, these papers offer a psychoanalytic way of knowing the psychopath—through the countertransference, or internal reactions of the analyst. The absence of papers on technique is easily explained: there is no clinical or empirical evidence that psychopaths will benefit from any form of psychodynamic therapy, including the expressive or supportive psychotherapies, psychoanalysis, or various psychodynamically oriented group psychotherapies (Meloy, 2001).
Why would we, then, pay attention to countertransference in reaction to an untreatable patient? Precisely because psychopathy is not just present or absent, black or white, but varies in degree from one patient to another. Countertransference, along with objective measures such as psychological tests, becomes our barometer for gauging the severity of psychopathy and therefore the treatability of any one patient. The lesser the psychopathy (imagine, if you will, a mild form of diabetes), the more effective the treatment and the better the prognosis.
Psychopathic patients, true to their core narcissistic personality traits, will emotionally seek to establish one of four transference positions with their analysts. In Kohut’s (1971) terms, a psychopathic patient will seek to idealize (I want to worship), to mirror (I want to be worshiped), to twin (I want to imitate), or to merge (I want to control). What differentiates the psychopathic transference from that of other narcissistic patients, however, is the behavioral, rather than the fantasized or verbalized, expression of these transference positions and the relatively rapid emergence of the most developmentally primitive of the four: the need and desire to control the analyst. This transference will be experienced by the analyst as the discomfort of “being under his thumb” or as a compelling need to “walk on eggshells” to avoid what is catastrophically imagined as rageful, explosive, and potentially violent affect (perhaps a complementary and fearful identification with how the psychopath felt as a child; see Racker, 1968).
Other predictable resistances in the psychopathically disturbed patient include manipulative cycling, deceptive practices, malignant pseudoidentification, and sadistic control.
Manipulative cycling was first identified by Bursten (chapter 17) and is a cognitive-behavioral sequence that is highly rewarding to the patient: there is a goal conflict, an intent to deceive, a successfully carried out deceptive act, and a subsequent feeling of contemptuous delight in the deceiver. The process unconsciously defends against envy and oral rage, which is likely felt when the analyst is initially idealized. It purges devalued introjects that are then projectively identified into the analyst and thus retain the homeostatis of the grandiose self-structure (Meloy, 1988). Deceptive practices are a component of most manipulation and are to be expected when one is working with psychopathically disturbed patients. Deceptive practices are consciously used to devalue the analyst by deceiving him and unconsciously ward off any persecutory anxiety. Often, acknowledging suspiciousness toward the patient can be a first step in the analysis of the need to deceive.
Malignant pseudoidentification refers to the conscious imitation and unconscious simulation of various identifications by the psychopath. They are typically short lived, resonate most easily with the narcissism of the analyst, and are used to hurt and control. Pseudoidentification will be apparent clinically in the imitation of certain emotions during analysis, usually through words that imply a certain feeling, and the unconscious simulation of analytically desirable emotional states without insight into the meaning of such emotions. The analyst will often be left feeling distant and skeptical, befuddled by the absence of any empathic resonance in herself. The patient does not gradually recompensate from intense emotion; instead the performance ends, the curtain has dropped, and the audience of two awaits another scene.
Sadistic control has been discussed by Kernberg (1984) as a component of malignant narcissism, along with paranoid regression in the transference, chronic self-destructiveness, and dishonesty. In analysis it may range from verbal devaluation of the process to blatant forms of psychological and physical aggression. It is a clinical manifestation of the prey-predator dynamic in which all relationships, including the one with the analyst, are defined by dominance and submission. The analytic question is the degree to which the desire for sadistic control by the patient is ego syntonic, or riddled with conflicts and dependencies. Heroic attempts to treat a sadism that is not ego dystonic will usually result in a profound dehumanization of the analysis and may place the clinician in actual danger.
COUNTERTRANSFERENCE
Lion (chapter 18), Symington (chapter 19), and Strasburger (chapter 20) spell out in detail a number of explicit countertransference reactions to the psychopath that help us diagnose the severity of his character pathology and our reaction to it.
Therapeutic nihilism, appropriate to the true psychopath, can spread to become a pervasive cynicism whenever the analyst encounters a patient with even the most mild antisocial history. It is a dismissive or derogatory attitude toward any patient who reports an illegal act or has been accused, or convicted, of a crime. The counterpoint to therapeutic nihilism is the mistaken belief that a patient has formed an attachment to the psychoanalyst, when, in fact, only an illusory treatment alliance exists. Such a false belief, often containing the wishful projections of the analyst that the patient has a capacity to form a bond, will be reinforced by the psychopath feigning affection for the analytic process and fawning attention on the analyst.
A fear of assault or harm is another countertransference reaction that is often felt as a physical sensation of goose bumps, piloerection, the skin “crawling,” or a sense of hotness or coldness when one first meets with a psychopathic patient—even though he is not overtly threatening in any way. These are phylogenetically old, biologically based autonomic signals of impending predatory danger. They may prompt a variety of systemic disturbances in the analyst, including gastrointestinal and cardiopulmonary reactivity, and may be signaling an actual future threat. In a large survey study of mental health and criminal justice professionals, we found that this countertransference response occurred in a majority of those surveyed when first encountering a psychopath (Meloy and Meloy, submitted).
Denial and deception by the clinician in this context are often counterphobic responses to the real danger a psychopathic patient may pose toward the analyst. For instance, the clinician visiting a psychopath in prison might insist that the inmate be unshackled during the interview despite the correctional staff’s dire warnings that the prisoner has assaulted two medical professionals in the past week. Deception may be the clinician’s response to anticipatory fear of an angry reaction by the patient, such as lying about a personal fact that the patient has demanded to know, instead of refusing to provide the information for both therapeutic and safety reasons.
The analyst feels helpless and guilty when treatment fails with the psychopathic patient. Young clinicians may be particularly vulnerable to this reaction, especially when captivated by their own “Midas touch”—their belief in their ability to heal others (Reich, 1951), often a facet of unresolved narcissistic issues. The loss of belief in one’s Midas touch is a blow. One psychology intern, when faced with the limits of his own therapeutic skill in helping a psychopathic patient, responded to his supervisor with exasperation, but also with insight into the true situation obtaining between him and the patient: “Why would I want to know about the patient’s inner life anyway?”
Devaluation and the loss of professional identity may follow. Psychopathic patients continuously devalue treatment to shore up their own grandiosity, and this takes a toll on the self-esteem of the analyst. They are also skilled in “gaslighting,” using persuasion and coercion to convince others that their values, beliefs, and perceptions are wrong or misguided (Calef and Weinshel, 1981), leaving the clinician confused and feeling that his mind has been “worked over.”
Feelings of hatred and a wish to destroy others, including patients, may also be felt by the analyst in his treatment of the psychopathically disturbed individual. Such feelings and wishes may be quite disconcerting and often signal the analyst’s identification with the aggressive narcissism, if not sadism, of the patient. The analyst’s spontaneous fantasies of destroying the patient may emerge during contact with the patient or following a treatment session:
A colleague spent 16 hours over two weeks evaluating a primary psychopath who had committed a particularly brutal sexual homicide of a 12-year-old girl. At the end of the evaluation, the patient was asked if he remembered the doctor’s name. He responded, “No, but I bet you won’t forget mine.” Later that evening the colleague had a graphic and violent fantasy of taking a .45 caliber pistol from his brief case during the evaluation and shooting the man in the chest and head. In the fantasy he then left the examining room quite exhilarated, turned over the firearm, and was arrested, tried, and unanimously acquitted by a jury. The colleague also reported several traumatic symptoms for two weeks after the examination.
The false assumption of psychological complexity in the psychopathically disturbed patient is the last countertransference reaction, often stimulated by his glibness and superficial charm. It may be enhanced by wishful projections on the part of the analyst that the patient be treatable and therefore be in possession of the requisite intelligence and ego strength to benefit from analytic work. There is a propensity for such an assumption when the psychopathic patient’s IQ is in the superior range. Unfortunately, intelligence can mask a severe character pathology. Theodore Bundy was admitted to two law schools, served as a crisis counselor on a suicide “hot line,” and was a rising young star in Republican political circles, while he was abducting, killing, raping, and dismembering young women in Washington and Utah (Rule, 1980).
The frequency and intensity of these countertransference reactions appear to correlate directly with the severity of psychopathy in the patient. Such intuitive signals should prompt careful and comprehensive psychological testing of the patient, ideally before psychodynamic psychotherapy or psychoanalysis begins. Data from other collateral sources should also be sought, with the patient’s permission, since chronic lying and deception—to maintain control, not to manage anxiety—are repetitive behaviors of the psychopath.
TREATMENT OR RISK MANAGEMENT
Treatment can proceed when the presence of psychopathy is measurably mild to moderate (Psychopathy Checklist-Revised; Hare, 1991); there is a genuine motivation for treatment and palpable emotional pain that is not primarily caused by the demands of others; there is a history of attachment to others, even if quite pathological, and concomitant evidence of some anxiety; there is evidence of some superego development, both within and outside of the consulting room; and there is enough intelligence and psychological insight to warrant the initiation of a course of treatment.
Treatment should not proceed if the patient is a primary psychopath. Interpersonal and intrapsychic features that contraindicate any form of treatment include sadistic behavior in the patient’s history that resulted in serious injury, maiming, or death of a victim; the need to justify or rationalize such behavior or a complete absence of any remorse; intelligence greater or less than two standard deviations from the mean; a historical absence of attachment without depression; and the presence of an atavistic fear of predation felt by clinicians when with the patient (Meloy, 1988).
PSYCHODIAGNOSIS
Psychoanalytic formulations of the psychopath depend on various maps of the mind, considered as a guide to behavior. But, as Korzybski (1954) noted, the map is not the territory. Psychoanalysis has always been enamored with maps, but also suspicious of them, since maps cannot describe the exact territory of the mind, nor are they strongly predictive of actual behavior. Thus, the generation of many psychoanalytic “maps” or models of the mind since Freud’s tripartite structure of mental functioning and the contentious debates among their adherents, which continue to this day.
Empirically based psychodiagnosis—in contrast to one or another theoretical map—has also never been wholely accepted in the psychoanalytic profession for similar reasons; it is typically used only for billing purposes or scholarship (Schafer, 1954; Lerner, 1998). Psychodiagnosis categorizes and classifies to order phenomena and thus facilitates, indeed enables, further communication among professionals—as typologies do for all scientific disciplines—but it is derived from nomothetic, large sample research. Its aim is to discern what is the same and different among groups of individuals. In the midst of such endeavors, individual differences that make each patient unique are diluted or washed out. Nomothetic reasoning subsumes idiographic reasoning, and the case study is lost, awash in a sea of correlations, regression equations, and large Ns.
It appears, then, that we do need our maps, both to understand individuals and to sort out the meanings to be derived from large-scale research. The goal, as Eysenck (1947) noted over a half-century ago, is to recognize the importance of both nomothetic and idiographic research. Inductive and deductive reasoning dynamically interplay within all scientific thought, just as data shape theory, and theory helps us to understand new data.
While most analysts were observing psychopaths, sometimes interacting with them in their practices and occasionally documenting both transference and countertransference reactions, a few were attempting to spell out the structural and dynamic qualities that could be used to diagnose these patients. The remaining four papers in this section are replete with psychodynamic formulations, as one would expect; but each author—Wilhelm Reich (chapter 14), Betty Joseph (chapter 16), Ben Bursten (chapter 17), and Otto Kernberg (chapter 21)—attempts to tackle the descriptive classification problem of psychopathy and how it can be differentiated from other pathologies. These authors help us locate psychopathy within our current psychodiagnostic systems.
PSYCHOPATHY AND LEVEL OF PERSONALITY ORGANIZATION
Kernberg (1970) formulated an approach to instinctual development that he evolved into a theory of personality organization at three levels: psychotic, borderline, and neurotic (Kernberg, 1984). He theorized that character pathology cut vertically across these horizontal levels of organization, the last distinguished by certain object relations, defenses, and reality-testing capacities. He thus shifts the clinician’s attention from characterologic features indicating, for example, hysteric or narcissistic styles to the level of psychic organization underlying the characterologic presentation.
In a series of Rorschach studies (Gacono and Meloy, 1994) we found that antisocial personalities (defined by DSM-III-R [American Psychiatric Association, 1987] criteria for antisocial personality disorder) and psychopaths (defined by the Psychopathy Checklist-Revised; Hare, 1991) were organized at a borderline level of personality. These studies, both nomothetic and idiographic, found part-object representations, preoedipal defenses (primarily devaluation, denial, and projective identification), and impairments in reality testing consonant with developmental object relations theory.1 Although we did find some psychopaths organized at a psychotic level, usually carrying a comorbid diagnosis of schizophrenia or bipolar disorder, we did not find psychopaths organized at a neurotic level of personality. Psychopathy in its most severe form did not coexist with Rorschach measures of neurotic personality organization (whole-object representations, mature defenses, and normative levels of reality testing). These empirical studies were among the first attempts to test Kernberg’s (1984) model of personality organization within a particular character pathology.
PSYCHOPATHY AND NARCISSISTIC PERSONALITY
Other analytically derived maps do not differentiate levels of organization from character style so sharply; rather they combine them in different ways. Thus, in chapter 17 in this section, Bursten differentiates personality into three general domains: complementary, narcissistic, and borderline. The aim of the narcissistic personality, of which he identifies four types, is to regain a state of blissful union between the grandiose self and the idealized parent image, what Rothstein (1980) described as a “felt quality of perfection” (p. 4). One of his types is the phallic narcissistic, a direct descendant of Reich’s “phallic-narcissistic” character, spelled out in chapter 14 in this section.
The exhibitionism and masculine striving of this personality type, however, though not identical with, is closely related to the manipulative type, Bursten’s term for the psychopath who exploits and deceives others. This behavior serves his intrapsychic need to devalue others (“put something over on them”) both to enhance his grandiosity and to ward off impulses of greed and feelings of envy. This impulse-feeling-defense triad (greed, envy, and devaluation) is also the centerpiece of Joseph’s (chapter 16) case study in which the psychopath spoils that which he wants—the goodness in others—therefore rendering it worthless. This is an adaptive aspect of his aggression as a predator2 and maintains his psychological homeostasis.
Similarly, vis-à-vis antisocial behaviors considered as a focus for diagnostic scrutiny, Kernberg theorizes a range of antisocial types (juxtaposing both continuums and categories) in chapter 21, in descending order of severity of psychopathology:
1. Dyssocial reaction
2. Antisocial behavior as part of a symptomatic neurosis
3. Neurotic personality disorder with antisocial features
4. Other personality disorders with antisocial features
5. Narcissistic personality disorder with antisocial behavior
6. Malignant narcissism
7. Antisocial personality disorder
What links the Reich, Joseph, Bursten, and Kernberg papers together is a clinical opinion to which I strongly adhere: pathological narcissism is a necessary core, but insufficient component, of psychopathy. The differential diagnosis of the psychopath from other, less severe forms of pathological narcissism can be difficult but psychodynamically centers on seven intrapsychic differences (Meloy, 1988).
First, aggressive drives predominate, and their gratification is the only significant means of relating to others, usually through the establishment of a dominance-submission (sadomasochistic) relationship with objects. Henderson (1939) noted both an “aggressive” and a “passive-parasitic” type of psychopath. In the latter, these aggressive drives are passively expressed by denying the importance of all object relations and, instead, idealizing receptive-dependent needs. The entitlement is to take what one wants from others while ignoring them—without being discovered.
One psychopath of this passive-parasitic type married a very wealthy woman and remained with her for a decade. He had received an MBA but was never employed during the marriage. What he did successfully was to impregnate his wife and produce four female offspring, whom she nursed continuously for seven years. He was uninvolved with the children and remained indifferent to them after her separation and divorce. He had once assaulted her, continued to threaten her life through third parties, and litigated alimony. She relocated to another state, changed her identity, and retained 24-hour protection.
Second, there is an absence of benign modes of narcissistic repair. This phrase, first used by Kernberg (1975), captures the narcissistic personality disordered-patient’s ability to repair emotional wounds through fantasy by devaluing the object of the felt or anticipated aggression and humiliation. The following vignette describes not a psychopath but a narcissistic personality:
A successful attorney in his early 40s remained single but desperately wanted to find “the right woman” to marry. His dating took a predictable course. Within months of beginning a new relationship, he would devalue the woman in fantasy—at least a certain aspect of her—until he was certain she was “wrong” and then would break off contact. The women never measured up to his idealized object of destiny, which partially served as a defense against much anger toward, and fear of, his own overbearing and intrusive mother. Although conscious of his devaluing, he felt powerless to do anything about it and resisted psychoanalysis.
This continuous repair of old emotional scars and anticipation of newly anticipated wounds also maintain the grandiose self-structure of the narcissist. Fortunately, no one is physically hurt or irreparably damaged, but he does remain lonely and isolated, always falling back on devaluation or intense competition to manage the envy he feels toward others’ happiness.
The psychopath, however, engages in an aggressive mode of narcissistic repair, wherein real objects must be behaviorally devalued to heal internally. The inability of the psychopath to do this in fantasy means that he will leave a trail of hurt, wounded, and angry people behind him as he moves through life. If one needs to know where the psychopath has been, one searches for the damage. This aggressive mode of narcissistic repair can range from teasing and incessant humiliation of others, to fraudulent business practices, to sexual murder. The following report is from a colleague:
About a decade ago my wife and I took a biking trip in the Canadian Rockies with a professional outfitter. There were about 20 of us, but the one who commanded the most attention was a gynecologist from Orange County, California. He carried himself with great confidence, almost arrogance, and I began to notice two disturbing behaviors: first, he was inappropriately suggestive and erotic in his conversations with the women on the bike trip, couched in a desire to “help them” professionally; and second, each day he would single out one vacationer to humiliate in front of others. The group dynamic took shape quickly, with many of the people sidling up to him so he wouldn’t humiliate them, and the rest of us alienated from him, angry, and on guard. The trip ended, and I was glad to see him for the last time. Six months later he was sued civilly and criminally charged with multiple counts of sexual battery and rape of many women in his professional practice, a lead story on the television program 60 Minutes.
The third intrapsychic difference between psychopaths and narcissists is sadistic behavior, implying the presence of primitive persecutory introjects or “sadistic superego precursors” (Kernberg, 1984, p. 281), which may at times be sexualized. Sadistic behavior most often occurs when objects are perceived as the embodiment of goodness and stimulate envy; or objects are perceived as helpless and dependent and stimulate hatred. We found in one study that various measures of sadism significantly correlated with psychopathy in both violent and sexually violent criminals (Holt, Meloy, and Strack, 1999). The relationships also showed a moderate-to-large effect. In related research among serial murderers, the diagnosis of sexual sadism and antisocial personality disorder show high degrees of comorbidity (Geberth and Turco, 1997). Sadism—pleasure derived from the dominance and suffering of another—is a logical affective outcome, given the psychopath’s primary mode of relating through dominance-submission and the absence of other, more affectional capacities.
Fourth, the presence of a negative idealized object (e.g., taking pride in one’s father’s criminality) that has its roots in a cruel and aggressive parent distinguishes the psychopath from the narcissist. This “identification with the aggressor” (A. Freud, 1936) may be due to traumatic bonding (Dutton and Painter, 1981) with an intermittently abusive parent or simply imitation of a criminal parent whose aggression toward others was observed by the child.
A serial sexual murderer recalled watching as a boy his biological father’s reaction at a party when his mother put an ice cube down his father’s shirt. The father grabbed the ice cube, tackled his wife in the living room, and, in front of the party guests, forced his hand down her dress, into her underwear, and shoved the ice cube into her vagina. The son did not consciously find this behavior shocking or disturbing when recalling it as an adult 30 years later.
Fifth, there is an absence of a desire or need morally to justify one’s behavior, which, if present, would imply some superego development or at least some awareness of socially acceptable behavior. Righteous anger or fear when “caught” engaging in criminal or antisocial behavior is evidence that a modicum of social values has been internalized, although probably not as an identification. Complete indifference to the judgment or moral outrage of others is an important clinical marker for the absence of conscience, as is likely to be seen in psychopaths: a shrug of the shoulders and silence may be the psychopath’s only response to confrontation, dashing the clinician’s hope that the patient might at least attempt to rationalize his nefarious activities. By contrast, narcissistic personalities with antisocial features, as Kernberg notes in his chapter, will show strong affective responses when their illegal, immoral, or criminal activities are challenged.
Sixth, anal-expulsive (ridding the self of devalued objects) and phallic-exhibitionistic (showing others one’s idealized objects) themes will be evident in a “manipulative cycle,” as Bursten notes in his chapter, in which the psychopath will repetitively have goal conflicts with others, intend to deceive, carry out the deceptive act, and feel contemptuous delight. This pattern is both an intermittent positive reinforcement for the psychopath, and therefore will be repeated, and a means by which he can psychodynamically maintain his narcissism by contemporaneously devaluing others (“They were really stupid to let me con them”) and idealizing the self (“I am certainly clever and shrewd”).
Other, less psychopathic individuals will display this pattern, but the emotional outcome of contemptuous delight will be spoiled by concurrent feelings of guilt or remorse, thereby decreasing the risk of repetition and diminishing its usefulness to the grandiose self-structure.
The seventh and final differential criterion is evidence of paranoia when the psychopath is under great stress, rather than the depression expected when narcissistic personalities come under characterological fire. This is most dramatically evident in charismatic psychopaths, such as David Koresh and Jim Jones, two cult leaders who killed hundreds of their followers in Waco, Texas, and Jonestown, Guyana, respectively.3 In both cases these men became increasingly paranoid over time as their cults came to the attention of state and federal authorities. Their paranoia was effectively communicated to their followers and led to increased grandiosity, cohesiveness, fear, and a group belief in a shared, final Armageddon-like destiny involving mass death. Unfortunately, government authority in both cases contributed to the conflagrations through tactical probes that confirmed the seeds of their paranoia and increased stress through physiological deprivation and social isolation.
These seven factors should help discriminate the psychopath from other narcissistically disordered individuals when the clinician’s theoretical framework is psychoanalytic. They allow us to discern certain forms of aggressive and malignant narcissism that preclude treatment since therapeutic engagement is not possible.
PSYCHOPATHY AND DSM-IV
The diagnosis in DSM-IV (American Psychiatric Association, 1994) that comes closest to psychopathy is, of course, antisocial personality disorder. This term represents a relatively recent “social deviancy” research tradition that has its roots in a book by Lee Robins (1966). Her study was the first longitudinal attempt to chart the nature and course of delinquency in children as they matured, and her work changed American psychiatry’s understanding of chronic antisocial behavior.
The first edition of DSM in 1952 subscribed quite closely to Cleckley’s (1941) ideas of psychopathy without using the term, but Robins’s (1966) work redefined antisocial behaviors by focusing on the degree to which such behaviors deviated from social, moral, and legal norms. Robins was a sociologist, not a psychologist, and therefore had little interest in the internal world of these individuals.
Although DSM-II in 1968 officially adopted the term antisocial personality and relegated the term sociopathy to the dustbin of psychiatric nomenclature, Robins’s work did not strongly influence the taxonomy until DSM-III in 1980. This edition ushered in the five-axis system of diagnosis, placed the personality disorders on Axis II, and defined antisocial personality disorder in behavioral, rather than personality, terms, unlike most of the remaining personality disorders. Its most recent incarnation in DSM-IV (American Psychiatric Association, 1994) identifies seven criteria, of which any three—a polythetic formula—must be present to meet the diagnostic threshold:
1. Failure to conform to social norms with respect to lawful behaviors.
2. Deceitfulness.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness.
5. Reckless disregard for safety of self or others.
6. Consistent irresponsibility in work or financial obligations.
7. Lack of remorse.
The only criterion that implies an emotional state, or the absence of one, is “lack of remorse,” which is then defined behaviorally. The advantage of the DSM model of antisocial personality disorder is its interjudge reliability: it is often the only personality disorder used in epidemiological studies because its reliability coefficients are the highest among the personality disorders. The disadvantages, however, are many. The diagnosis casts a wide net (approximately 5% of adult American males will meet the criteria), and it is confounded by education, social class, and intelligence, but not race (Robins and Regier, 1991). It purports to measure a final behavioral pathway that undoubtedly could have many internal causes. The antisocial personality disorder diagnosis in DSM-IV leaves clinicians yearning for more nuanced and refined descriptors of the psychological dynamics of these patients.
Conduct disorder, the necessary prelude to an antisocial personality disorder diagnosis in adulthood, makes things worse. Only three out of fifteen criteria are necessary to meet the threshold; the descriptors are largely behavioral; and arguably the most useful subcategories of conduct disorder (CD) were eliminated in DSM-IV.4 Instead, the age of ten now demarcates early and late onset conduct disorder, the former having a much worse prognosis.
Conduct disorder also overlaps with other mental and emotional disorders. Studies indicate that only 25% to 50% of conduct-disordered children / adolescents will grow up to become antisocial personality disorders: the earlier the onset, the more likely the antisocial personality disorder outcome. Cultural differences also abound. Rates of antisocial personality disorder are 20 times higher in the United States than in Taiwan, for instance (Compton et al., 1991), and studies suggest that the more “individualistic” a society is, the greater the rates of this diagnosis. “Collectivistic” societies, a sociological term for cultures that place the interests of the group before the individual, have typically low rates of antisocial personality disorder (Reavis, 1999). Phenotypic expression of antisocial personality disorder5 appears to be largely influenced by the expression of certain social values, such as the availability of multiple attachment figures for children and the provision of close supervision regarding acceptable social behavior. Gender differences also exist, with antisocial personality disorder rates five times greater in males than in females, although this ratio seems to have been decreasing in the United States during the past 20 years.
Where does this leave the psychoanalyst? The greater the number of DSM-IV criteria met, the greater the likelihood the clinician is evaluating Kernberg’s “antisocial personality” proper, or what I would refer to as a primary or severe psychopath. Morey (1992) has found, however, that the majority of people with one diagnosable personality disorder will meet criteria for another diagnosable personality disorder when DSM-IV is used. In other words, discriminant validity among personality disorders, especially within clusters, is poor. If a patient is diagnosed with antisocial personality disorder, for example, there is a better than even chance that he will also meet criteria for histrionic, narcissistic, or borderline personality disorder.
One can see this overlap in the contributions in this volume. Reich’s “phallic-narcissistic” character is likely to meet narcissistic personality disorder criteria in DSM-IV. Moreover, Bursten’s “manipulative” type of narcissistic personality is likely to meet criteria for antisocial personality disorder if there is sufficient information to establish a pattern of conduct disorder before age 15. Bursten’s “craving” subtype suggests both histrionic and dependent personality disorders in DSM-IV.
Gabbard (1989) reported two subtypes of narcissistic personality disorder that bear mentioning. The “oblivious narcissist” is consistent with the aggressive and exhibitionistic narcissistic personality in DSM-IV. His second subtype, the “hypervigilant narcissist,” refers to the more introverted, self-absorbed individual who is highly sensitized to criticism and empathic failures from others. This quieter adaptation to early deficiencies in narcissistic supplies may find antisocial expression in Henderson’s (1939) “passive-parasitic” psychopath: the criminal who engages in indirect exploitation of others, such as burglary or fraud, and idealizes his sense of entitlement and disavows his hostility toward a world that chronically disappoints. His passive-aggressive stance toward others is a behavioral means of exploiting without being confronted and criticized.6
PSYCHOPATHY AND THE HARE CHECKLISTS
Twenty years ago Hare (1980) published for the first time his Psychopathy Checklist (PCL). Based on Cleckley’s (1941) 16 clinical criteria for psychopathy, which appeared 40 years earlier, Hare’s unidimensional scale, subsequently reduced by two items (Hare, 1991), ushered in a dramatic increase in psychopathy research throughout the world. The items of the PCL-Revised (PCL-R) include glibness / superficial charm; a grandiose sense of self-worth; a need for stimulation and proneness to boredom; pathological lying; conning / manipulative; a lack of remorse or guilt; shallow affect; callousness and lack of empathy; a parasitic lifestyle; poor behavioral controls; promiscuous sexual behavior; early behavioral problems; lack of realistic long-term goals; impulsivity; irresponsibility; failure to accept responsibility for own actions; many short-term marital relationships; juvenile delinquency; revocation of conditional release; and criminal versatility.7 There are now different versions of this scale for various clinical and nonclinical applications,8 and they all represent an empirically reliable and valid method to determine the degree of psychopathy in any particular patient.
Items of the PCL-R illustrate how this older tradition for understanding chronic antisocial behavior differs from the social deviancy model of DSM-IV. It is a personality tradition that germinated in late 19th-century German psychiatry through the work of Emil Kraepelin and J. L. Koch. The history of this avenue of research, emphasizing the internality of the antisocial patient, can be found in Millon (1996) and Meloy (1988).
The checklists themselves are quantified observational instruments that are scored on the basis of interviews and a review of collateral documents. A clinical interview alone is insufficient owing to the mendacity of the psychopath. Individuals who score ≥30 on the PCL-R are considered psychopaths for research purposes. The scale, moreover, can be viewed as a continuum to define a degree of disturbance: mild (10–19), moderate (20-29), and severe (30-40). Severity of psychopathy has been shown to predict treatment failure, violence and sexual violence risk, and recidivism when measurements use different criterion variables, samples, and settings in the United States, Canada, and Europe (Millon et al., 1998).
Factor analysis of the PCL-R variables indicates two factors, or clusters of items, that correlate 0.50. Factor I has been labeled “aggressive narcissism” (Meloy, 1992) and contains eight of the items. Factor II has been labeled “chronic antisocial behavior” (Hare, 1991) and contains nine of the items. Three items load equally on both factors. Recent research employing item-response theory (Cooke and Michie, 1999) has identified three factors: affective, interpersonal, and behavioral. Factor analysis is a statistical method similar to an inductive psychoanalytic inference: for example, the psychoanalyst’s assumption of a mature superego, based on the patient’s many statements concerning his realistic aspirations and prohibitions, parallels the researcher’s statistical grouping of various items on a test to reach a “higher order” concept or factor.
Although the factors that constitute psychopathy are statistically distinct, the items within each factor may be predominately psychodynamic or psychobiologic. For instance, item 2 (grandiose sense of self-worth) is one facet of the psychopath’s pathological narcissism and is maintained through the behavioral devaluation of others, often using the “manipulative cycle” identified by Bursten (see chapter 17). Item 3 (need for stimulation / proneness to boredom) is biologically rooted in the chronic cortical underarousal (Raine, 1993) and peripheral autonomic hyporeactivity (Hare, 1970) of the psychopath. Both items load on separate factors, but overall there is no simple equivalence between the two factors and a biological / socialization distinction.
In our series of Rorschach studies using the PCL-R to divide incarcerated criminals into psychopaths and nonpsychopaths (Gacono and Meloy, 1994), we found that the former are significantly more pathologically narcissistic, less attached, and less anxious than the latter. In other words, our Rorschach studies found important psychodynamic differences, even among criminals, when the psychopaths were studied as a separate group.
Paradoxically, the more severe the psychopathy, the less severe are the internal conflicts—a state of mind we would predict given a dynamic context of no attachments and little anxiety—and the greater the likelihood of a “pure” alloplastic character (Ferenczi, 1930). One of our important, although counterintuitive findings, was that psychopaths do not produce an “aggression” response when taking the Rorschach: an articulated percept in which an aggressive act is occurring in the present, for example, “It’s two people fighting.” At least 50% of normals produce one of these responses when taking the test, and our finding of less “aggression” responses in virtually all the antisocial samples, including conduct-disordered children, was unexpected. As we scrutinized the psychodynamic meaning of aggression responses to the Rorschach, we found that Rapaport and his colleagues (1946) and Holt (1967) all considered such responses indicative of tensions of aggressive impulses, which were then symbolized and stated. In the absence of such tensions of ego-dystonic aggressive impulses in psychopaths, a population who would act out rather than channel or bind such drive derivatives, there would be no need to symbolize and verbally express aggression; our unexpected finding lends empirical support to the widely accepted clinical notion of alloplasticity in psychopaths.
Subsequent research by others has found that psychopaths in particular, and antisocial individuals in general, do produce more aggressive content—“It’s a gun”—than do normals; and this score, which we developed, is partially diagnostic of antisocial personality disorder (Baity and Hilsenroth, 1999). Aggressive content of this kind in Rorschach protocols may be indicative of a static, hard-object identification for the antisocial person, a facet of his identification with the aggressor, the predator part-object. Such an internalization may be more ideationally stable, and therefore more diagnostic, than the presence or absence of aggressive movement, a more affectively based Rorschach measure.
Although the Psychopathy Checklists were empirically derived and the items are not psychodynamically defined, Cleckley’s (1941) clinical work, on which most of the items are based, was decidedly psychodynamic. He emphasized a number of differential criteria, including a lack of remorse, pathologic egocentricity and an incapacity for love, and general poverty in major affective reactions. He wrote that the object-love deficits and “feebleness” of affect in the psychopath, “makes it all but impossible for an adequate transference or rapport situation to arise in his treatment and is probably an important factor in the therapeutic failure that, in my experience, has been universal” (p. 396).
PSYCHOLOGICAL TESTING
Although the psychodiagnosis of psychopathy from a psychoanalytic perspective is clinically important, and the location of such an endeavor among various diagnostic frames is theoretically useful, the task of diagnosis is often given short shrift by psychoanalysts. It is absolutely essential that it be done thoroughly and competently.
The diagnostic task, moreover, can be efficiently accomplished through the use of psychological testing, particularly with instruments that do not readily convey what they are measuring; or, if they do, there are measures of distortion and deception built into the instruments for appraisal by the clinician. The Rorschach, the Minnesota Multiphasic Personality Inventory-2, and the Millon Clinical Multiaxial Inventory-III meet these criteria and will provide the psychoanalyst with a wealth of data in a time-efficient manner to accept or reject the efficacy of treatment in any particular case. The primary reason for the use of psychological testing when psychopathy is considered is that the psychopath’s mendacity cannot be detected without it other than through multiple clinical consultations, or perhaps psychotherapy sessions, which may eventually place the analyst at risk by the time he discerns the truth. Risk may come in many forms with the psychopathic patient, usually involving money, emotion, or physical safety. Without the efficiency and depth of psychological testing, an unwanted and difficult-to-unravel transference may already be under way.
Despite the absence of controlled outcome data, certain treatment modalities have shown effectiveness with antisocial personality disordered patients who are not severely psychopathic.9 These modalities include pharmacotherapy for anxiety, depression, or impulsivity; family therapy with conduct-disordered children; milieu and residential therapy, such as token economies, therapeutic communities, and wilderness programs for adolescents; and cognitive-behavioral therapy (Meloy, 2001). The last method of treatment works best when there are clear and unambiguous rules and consequences; skills that are taught are commensurate with developmental level; cognitive distortions and criminal lifestyle patterns are identified and modified; tolerance for affect and its impact on others is stressed; and treatment continuity among providers is established (Gacono et al., 2001).
Treatment experience with psychopaths has historically preceded diagnostic competence. Unfortunately, the atmosphere of patient freedom, self-determination, mutuality, and honesty—hallmarks of psychoanalytic work—are rendered toxic by the mendacity and aggression of the psychopath. Analytic knowing, moreover, has charted the expectable but invariably malignant course of transference and countertransference and also contributed to empirical diagnosis to discern the patient for whom psychoanalysis offers no hope. As Partridge (1928) wrote, “The psychopath is one whose conduct is satisfactory to himself and to no one else” (p. 159).
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1Defenses were measured using Cooper, Perry, and Arnow’s (1988) defense mechanisms scale. Reality testing was measured using the X-%, the proportion of poor form quality responses in a Rorschach protocol. Object relations were measured by the ratio of whole human percepts (“it’s a person”) to part or quasi-human percepts (“it’s an arm, it’s a humanoid”) seen in a Rorschach protocol. Defenses were usually preoedipal, X-% averaged 22, which is high, and H:(H)+Hd+(Hd) averaged 22.5, which reverses the ratio of “whole to part” found in normals (Gacono and Meloy, 1994).
2There is a growing body of research that indicates psychopaths are much more inclined to predatory violence than are normals: a mode of violence that is planned, purposeful, and emotionless (Cornell et al., 1996).
3The Guyana mass suicide-homicide occurred in 1978 when 914 followers of Jones, including 294 minors, drank a cyanide-laced fruit drink or were shot to death. The incident in Waco, Texas, involved the burning of the Branch Davidian compound on April 19, 1993, which claimed the lives of 52 adults and 21 children. On March 19, 2000, a similar event was reported from Kanungu, Uganda, in which 780 members of a millennial sect, the Movement for the Restoration of the Ten Commandments of God, were either burned to death in their church or shot to death. Joseph Kibwetere, 68, founded the sect but was not among the dead victims.
4These subcategories parsed CD children and adolescents along two dimensions: aggression and socialization. The so-called solitary aggressive CD children of DSM-III were probably the fledgling psychopaths of their diagnostic time.
5Phenotype should be distinguished from the theorized psychopathic genotype, which may be stable in our species and unaffected by the values of any particular culture due to a paucity of internalizations.
6This psychodynamic is situationally apparent in the professional or employee who believes he is grossly underpaid and therefore engages in fraud or thievery to assuage his angry entitlement. Examples of these cases include a psychologist who billed Medicare for group therapy since he was treating a patient with multiple personality disorder, now called dissociative identity disorder.
7The PCL-R contains 20 items. Copyright 1990, 1991 by Robert D. Hare, Ph.D., under exclusive license to Multihealth Systems Inc. 1990, 1991. All rights reserved. In the USA, 908 Niagara Falls Blvd., North Tonawanda, N.Y. 14120–2060, 1–800–456–3003. In Canada, 3770 Victoria Park Ave., Toronto, ON M2H 3M6, 1-800-268-6011. Internationally, +I-416-492-2627. Fax, 1-416-492-3343.
8The Psychopathy Checklist: Screening Version, the Psychopathy Checklist: Youth Version, the Psychopathy Screening Device, and the P-SCAN are four of the additional marketed instruments.
9These are typically people who score below 30 points on the Psychopathy Checklist-Revised (Hare, 1991).