Outpatient Treatment of Psychopaths
This paper, by the psychoanalyst John Lion, was first published in William Reid’s The Psychopath: A Comprehensive Study of Antisocial Disorders and Behaviors in 1978. With a clear and elegant style, Lion provides a primer for the outpatient treatment of psychopathically disturbed patients. His chapter addresses the patient who has sufficient anxiety and attachment capacity to make the treatment endeavor worthwhile. Lion discusses the importance of sadness, if not the emergence of depression, as the patient’s narcissistic defenses are confronted over time; but, if the psychopathy is severe and biologically rooted, such emotional states will not occur. The therapist may find, instead, that his time has been squandered by a chameleon.
This chapter serves as a primer for the treatment of the psychopath. Existing literature by other workers deals with intensive psychoanalytic treatment of this type of patient (Eissler, 1950; Schmideberg, 1949) and with therapy within special inpatient and outpatient milieus (Aichhorn, 1925; Jones, 1953). More recent work has focused on the general clinical problem of manipulation (Bursten, 1973). In this section general principles of psychotherapy in an outpatient setting are presented.
GENERAL PRINCIPLES
Clinicians electing to treat psychopaths must be cognizant of the following principles. First, the therapist must be continually vigilant with regard to manipulation on the part of the patient. Second, he must assume, until proved otherwise, that information given him by the patient contains distortions and fabrications. Third, he must recognize that a working alliance develops, if ever, exceedingly late in any therapeutic relationship with a psychopath.
The above cautions mitigate against disappointments and frustrations which all too often become converted into therapeutic nihilism by those involved in working with these types of character disorders, for the therapeutic contract is most imperfect. Almost inevitably psychopaths are referred by third parties such as probation officers, courts or lawyers. Even when psychopaths do enter treatment “voluntarily” they usually come under some duress such as that of a spouse who is threatening to leave; hence, covert coercion is present. Coercion and the presence of a third party are not conducive to developing trust. When the clinician is under some obligation to report to an outsider the “progress” of a psychopath, initial mistrust is bound to linger. The only recourse the therapist has is to openly describe the state of progress by sharing with the psychopath all impressions he has about him. I show psychopaths all correspondence generated and received concerning them. Complete frankness and honesty are the only hope for these relationships and often lead to fruitful dialogue in therapy.
There are two sets of magical expectations surrounding the treatment of psychopathy. The first occurs on the part of the third party referring the patient for treatment. If the patient is seen as charming, articulate, and intelligent, he automatically becomes a “good candidate for insight psychotherapy” in the mind of the referring agent. Hence, marvelous things are expected to happen in the treatment process. The second magical expectation comes from the patient himself, who, sensing the alternative of treatment to incarceration or other legal action, sees a chance to manipulate as well as to acquire new skills with which to outwit others. The clinician is immediately endowed with enormous perspicacity and a power of observation which he in fact does not possess. In the initial stages of treatment, psychopaths will “lay themselves bare” and reveal interesting tidbits of information relevant to sexual exploits, grandiose dealings with money, and other matters which are designed to intrigue therapists, particularly those in earlier stages of training. The therapist must constantly be on guard for these distractions; he should be alerted when he finds himself fascinated by the accounts of the psychopath whom he has opted to treat.
Psychopaths are also prone in the early stages of treatment to lavish praise upon the therapist as the person who “genuinely cares” or “understands” him and who will listen to him patiently, in contrast to “those others who always want something.” The magnitude of praise and positive statement is proportional to the patient’s attempt to seduce the therapist into a position of lowered vigilance, at which point deviant behavior may be forthcoming. At the same time, if he is successful in his seduction, the psychopath reassures himself of the fact that his skills and charms still work, even in the face of a critical professional; the patient thus gains positive reinforcement from his ability to subtly shape the course of therapy.
I have often found it useful to tell psychopaths who are in early treatment phases that their stories are most engrossing but have nothing whatsoever to do with the treatment process. Often such a remark is met with the question: “What do you want me to talk about?” Here one must educate the patient in some respect, since the only language he knows is the language of manipulation. I generally make some statement to the effect that my job is to help him to recognize true and spontaneous emotions, emotions not clouded by the need to win or triumph over others. I also state that I am not interested in issues of money, sexual prowess, or personal glory, but merely wish to learn something about his mundane day-to-day life. This kind of statement needs constant repeating, for it forms the basis for therapy and inevitably causes some discouragement in the patient in subsequent treatment.
Irrespective of the etiology of psychopathy, one may take as an operating premise for therapy the concept that the psychopath not only lacks a conscience, but is unaware of the subtleties of affect and fantasy (Lion, 1974) that are adaptive for a normal lifestyle. Coupled with these deficits is a general narcissistic posture which is prominent in all phases of treatment. Our job is to hold a mirror up to the patient so that he sees his self-centered ways of behaving which, without foresight and reflection, and unencumbered by guilt, are ultimately so destructive for him. Seeing this reflection time and again hopefully converts that which is syntonic into that which is dystonic. Few psychopaths enjoy this process. Introspection and insight are foreign exercises and alien to a lifestyle of impulsive and hedonistic behavior. The psychopath wants and does; he is loathe to look and think. The narcissism and need to win or “con” are defenses against involvement and means of devaluing other individuals, effectively precluding intimacy.
Thus, in time the psychopath is ultimately put into the position of viewing himself. He will later be confronted with the problem of identity, a crisis he has eluded for too long and dealt with by borrowing the identities of others. In some instances, paranoia develops as the next stage and much anger at the therapist is seen in the transference. Eventually depression develops as the narcissism is relinquished and the patient begins to deal with his intrinsically low feelings of self-esteem.* Such is a rough, basic synopsis of treatment.
The psychopath enters treatment in the same way he starts any new endeavor. A gusto prevails during early sessions and a honeymoon period ensues. The honeymoon period is concurrent with the time during which the therapist is endowed with special qualities. Yet there exist within the patient underlying feelings of inferiority which mobilize him to take a position of attack. He is apt to launch himself into battles regarding philosophical issues and the treatment process. The patient may begin to read psychiatric texts. Discussions about styles of therapy and schools of psychiatry may dominate the hour, allowing little chance for the therapist to confront the patient with routine issues of affect and behavior. Yet such intratherapeutic contests siphon off adverse behavior. Thus, during the honeymoon phase, the patient becomes quiescent outside of the therapeutic hour and relatives or his spouse are quick to comment that he is making enormous gains in a relatively short time in treatment. These accolades of success, perhaps reported by the patient himself, must basically be ignored.
Sooner or later, the psychopath will “test” the therapist by behaving in some deviant manner at home or work. This “test” of deviance is usually subtle and ambiguous, confronting both patient and therapist with a new transgression in therapy and signaling the end of the honeymoon period. Since there is ambiguity in the transgression, it is difficult to analyze. Often the patient will have been fired from a job for stealing but will claim that he was fired because of union difficulties. Since the therapist cannot easily ascertain the validity of this claim, he is at a disadvantage. The only solution is to begin the painful business of discussing with the patient one’s doubts about his credibility, a tactic which ushers in the bilateral mistrust so prominent during the early stages of treatment. The concomitant disillusionment subsequent to this is reflected in anger on the part of the psychopath, accompanied by dismay, rejection, and either feigned or genuine hurt with regard to the therapist’s betrayal and mistrust of him. At this point, it is necessary to point out quite firmly to the patient that his primary difficulty is one of mistrust and that it is sad, indeed, that the therapist cannot trust him and that he in turn cannot trust the therapist. Since such general mistrust must exist in outside relationships as well, it must be most unsatisfying and may perhaps be a good focus of therapy.
Additional problems arise when spouses or third parties report deviations in behavior which reflect the return of psychopathic activities. Again, such unsolicited reports evoke the issue of confidentiality and the therapist must share with the patient such breaches, which are an inevitable part of the treatment process. The patient will accuse the therapist of being an agent of the court, etc., while the therapist must stand his ground and state that although his job is to sift the information given him while maintaining as much confidentiality as possible, he may indeed have some allegiance to the court, which places him in a precarious position. Many therapists do not like this and may share this dislike with the patient. Such a shared dislike does not preclude treatment but merely sets out in the open the unpleasantness of third party watchfulness. The following case example summarizes some of the issues involved in the early stages of treatment.
A 20-year-old psychopathic young girl was referred by her father, an attorney, because of pathological lying, shoplifting, and a general lifestyle of deceit. After the honeymoon period had been entered with magical results at home, the patient was mysteriously fired from her job. The details of this firing were obscure to me but, as often happens in these cases, I learned from a friend of the family that the patient had apparently stolen some money from the cash register and had been dismissed on those grounds. Not knowing what was the truth, and not wishing to act as detective, I confronted the patient with my ignorance of the basis for her firing but stated that I had heard from a third source—and named that source—that there had been some financial indiscretion which alarmed me greatly. I stated that while I was not a lawyer or detective, the patient needed to tell me what was going on. I had no choice except to believe her even though I doubted the veracity of her comments. The patient then launched into a thoroughly believable story about the incident, which led me to comment that her statement made sense but still left me with an uneasy feeling of mistrust, and that I would hope that trust could be reestablished at some time in the future. This made the patient unhappy but clearly stated my position in the treatment process.
In the foregoing case, the informer was a relative of the patient. These situations do indeed happen in treatment of psychopaths, since friends, family, and other third parties feel that the therapist may not “fully know the facts” and are eager to enlighten him with regard to actual behavior on the outside. I personally do not turn off such knowledge, although I do tell whomever calls that I will confront the patient with it and reveal the source. Such confrontations produce enemies, but open communication is the only salvation in the treatment of psychopathy and I cannot disregard outside messages. Again, the only ammunition the therapist has is direct and open honesty, even though the therapy is to some extent being performed in an arena with interested spectators. One can only hope that in time, as behavior returns to normal, the arena will empty and privacy will be restored.
Dealing with Anger and Absences
It is obvious that the therapeutic relationship is exceedingly fragile and delicate. The patient, sensing that the therapist has little faith in him or her, is often sullen and rebellious while alternately being grandiose, with a desire to please and manipulate. Anger is often a problem in the, early course of coercive therapies, since a patient whose lifestyle is psychopathic becomes frustrated when he or she cannot cope with situations in the usual manipulative manner. The fragile alliance suffers even more when scheduled appointments are missed because of illness, holidays, or vacations. Psychopaths take any opportunity to break routine and throw the therapist off guard. Absences on the part of the therapist have a demonstrably negative effect upon trust and often weeks of therapy are required to recapture gains previously made. Retaliatory absences are not uncommon even when the clinician goes to great pains to work this through. The following example is illustrative.
A psychopathic patient had been making reasonable progress in therapy, coming to grips with object relations. After treatment of a year, I developed hematuria necessitating frequent visits to a urologist for radiographic studies and cystoscopy. During one absence, I told my secretary that she should telephone the patient and explain to her that I would be absent from a session because of a cystoscopic examination for what was then believed to be kidney stones. I emphasized to the secretary that the detailed explanation was very necessary and the secretary complied. Following this workup, sessions were restored with the patient, at which time the patient entered my office with questions as to how I was feeling and if my “flu” was all better. I replied that I did not have the flu and questioned as to what she had been told on the phone. The patient adamantly stated that she had been told that I had a cold and had missed the session because of this. Subsequently, the patient cancelled a session for no valid reason.
I believe that example illustrates what I felt to be an inability to tolerate the affect evoked by a detailed revelation of my illness. She used denial and distortion as a defense. The anger having to do with unexpressed alarm over my health was reflected in a retaliatory absence; however, these speculative issues were not amenable to confirmation as we had not reached a level of therapy and trust appropriate to discussion of transference feelings. The point is that the therapy is highly vulnerable, perhaps more vulnerable than one would imagine when first confronted with the apparent coldness of the psychopath. Viewing the patient as a person with a narcissistic personality disorder may make this phenomenon more understandable.*
Absences on the part of the patient create problems, since one can never be sure whether the patient is actually sick or is feigning illness to avoid what he or she senses will be a difficult session. The following is an example.
A patient telephoned me to state that his automobile was broken and that he could not attend the session. I told him that I had some time in the afternoon and that he could call me when he knew the state of repair of his car. The patient promised to call, but never did. In the following week’s session, he stated that he had been tied up with the towing operations of his car and did not have the time to call me until late in the afternoon when he realized I could no longer see him. I told him that this explanation seemed plausible, but that there was some seed of doubt in my mind regarding the fact that he could not find the time to telephone and at least apprise me of the situation. Again, I reflected to him the issue of mistrust. The patient sat stonily and listened to me without acknowledgment, although I sensed he clearly understood my point.
While one cannot easily ascertain the causes of absences in patients, one can still share with them disbelief in a matter-of-fact way without accusation. It is wise to operate on a “gut level” in these instances, since there is little else to go on and therapists should refuse to be put in the position of being a detective. Patients who are psychopathic will often come armed with all kinds of ammunition and alibis, as though they were about to appear before a magistrate. The therapist should state that he is not equipped to handle evidence more appropriate for a court but must rely upon verbalizations rendered by the patient. He can believe or disbelieve these verbalizations according to his intuition, but this is all he has to go on. This makes it very clear to the patient that evidence plays little role in psychotherapy and that affect, not fact, is the issue at stake.
Early countertransference reactions on the part of the therapist fluctuate. During the honeymoon phase, many therapists become enthused with the apparent rapid progress being made by patients who are so verbal and articulate. Rescue fantasies become prominent, particularly with well-to-do psychopaths from influential families; but humility is called for. My own feelings about prognosis suggest that it takes a good working year of therapy in order to determine whether or not a patient is making any reasonable gains with regard to the development of true affective awareness, intimacy and trust.
Acting Out
Problems of acting out become important as the transference develops (Greenacre, 1947). Generally, the acting out is of an aggressive type having to do with authority figures. Patients who see the therapist as a parental figure may translate feelings into behavior on the outside against their own parents, personnel at school or employers in the job situation. In addition, sexual acting out may become problematic. Every attempt must be made to trace these behaviors to their transference source. This is very difficult for psychopathic patients, who appear to have some ingrained developmental difficulties in translating affective states to conscious and verbal awareness.
Acting-out behavior, particularly when deviant, poses problems in the therapy. Often the therapist is being “tested” to see how loyal he is. I have on occasion threatened psychopaths with the termination of therapy if acting out in the form of deviant behavior or absences from therapy does not cease. The injunction needs to be made very clearly; the patient must realize that the therapist will not tolerate certain behaviors and that limit setting will be imposed. The therapist must unambivalently set for himself a threshold for intolerable behavior. I have discharged patients whom I could not control with mutual acknowledgment of the poor therapeutic alliance; some have accepted the discharge while others clamor for return, espousing a new honesty which is certainly suspect.
Payment
Payment is an issue which must be discussed from the outset (Lion, 1974). Generally, I ask for payment prior to each session until such time as a therapeutic relationship is established. For some patients, this is several months; for others it may be longer. There are certain psychopathic patients who have problems with money; from these I accept only cash. Nonetheless, I have been misled on several occasions.
A charming and handsome middle-aged psychopath with a history of check forging was sent to me for treatment by his wife, an earnest and tearful woman who desired treatment for her “unfortunate” husband. The woman agreed to pay for the husband’s treatment and the husband came for three sessions with a check in hand written by his wife. All three checks were returned to me for insufficient funds. While the wife had indeed signed them, she had done so with inadequate bank assets.
That example illustrates the complexities of exacting payment and demonstrates the need for being firm with regard to money. This may be quite unpleasant for certain therapists who are used to billing monthly or having an agency or professional corporation bill for them. I explain to patients that their general behavior makes me more comfortable with regular weekly payments. Surprisingly, patients understand this, especially when roles are reversed in fantasy and they are asked to imagine how they would feel as the doctor treating a psychopath who is prone to skip payment.
Often patients will omit payment for one session to test the therapist; I allow two such sessions to occur and, if payment is not brought up-to-date, discharge the patient. I ask for cash or a money order from high-risk patients and accept checks from those deemed more trustworthy. In no case do I allow third-party coverage to reimburse me directly. Signed receipts should be given the patient for money and the money should be scrupulously counted, even though this appears an odious task. On several occasions, I have been underpaid and on one occasion overpaid by a patient who was testing to see whether I would return the extra money. Therapists have a tendency not to look at checks, as though it were a crass and mercenary act, but the amount written on the check should be noted and prompt discussion should ensue if it is incorrect.
Referrals
On occasion, the psychopathic patient may request referral to a lawyer or internist for consultation. In this case, I generally ask the patient to share his request for consultation and its reason with me. The following example illustrates the reasons for careful scrutiny and foresight with regard to a referral. Referrals should not be made casually.
A 30-year-old psychopath asked me for referral to an accountant for help in preparing his income tax form. Since the patient had a history of excessive spending and falsifying expense statements at work, I decided that the best course of action was to refer him to my own accountant, whom I knew to be an exceedingly conservative man. I knew in this instance that the patient would not easily dupe or fool the accountant and I also felt that he would receive reasonable service. I told the patient this, and explained my reasons for the referral. He accepted both and appeared pleased with the result.
On another occasion, the patient asked to be referred to a dentist for both necessary repair of a cavity and some elective restorative work. Again, the general grandiosity of this patient made me apprehensive lest he accumulate a large bill which could not be paid. Accordingly, I chose my own dentist, with the same rationale as above. The patient went to him, settled for a reasonable amount of both elective and necessary dental work, and arranged reasonable terms of payment to which he adhered.
It will be recognized that the foregoing examples illustrate principles quite deviant from the traditional ones in psychotherapy. Upon examination, however, they appear quite logical given the premise of mistrust which is at the heart of all treatment with psychopaths. In another instance, and with a more traditional patient, one might urge the patient to seek his own accountant and dentist in order to foster autonomy and independence.
PROGRESS IN THERAPY: DEPRESSION AND DESPONDENCY
Gains in therapy with these patients are exceedingly slow and arduous. The therapist, rather than accepting the hollow “improvements” mentioned earlier, should wait for despondency and depression to occur since, as previously mentioned, narcissism and grandiosity are the hallmarks of most psychopaths who seek exploitative ways of manipulating themselves out of unpleasant situations. With persistent confrontation, introspection occurs in time. One eventually reaches a point in therapy at which nihilism appears in the patient and genuine sadness ensues. I have seen such depression develop to the point of requiring antidepressant medication; however, both the patient’s capacity and his tolerance for depression must be learned and developed as an adaptive human trait (Lion, 1972b).
Psychopathic patients may come to sessions after therapy is well underway and verbalize such sentiments as “there is nothing for me to do.” At this point repeated acknowledgments of the despair induced by the absence of manipulative ability are necessary. At this time, even more acting out of the depression—and anger at the therapist for its induction—is a possibility. The patient may quit his job and start a new business venture or enter a grandiose entrepreneurial scheme to avoid this boredom and despondency. Premature attempts at termination and absences from sessions occur. These matters must be monitored closely. The therapist should constantly strive to teach the patient the process of insight and contemplation; the development of an active ability to fantasize and anticipate the consequences of action, as well as an affective awareness, is a prerequisite to efficacious treatment (Lion, 1972b).
When the patient can visualize what can happen to him if he should engage in a socially deviant piece of behavior, he has shown progress in treatment; when he can recognize anger, fear, and nuances of affective expression, he has made some improvement. A capacity for intimacy and trust, as revealed both within and outside of the therapy, is indicative of positive change.
Use of Medications
The treatment of aggressive psychopaths differs in several respects from the treatment of non-aggressive psychopaths. With the aggressive psychopath, in contrast to, say, the check forger or the “con artist,” problems in the direct handling of hostile urges are issues in therapy (Lion, 1972a). With the aggressive psychopath, depression is even more of a risk as the aggression abates and there is a dynamic shift from outwardly directed to inwardly directed anger. Medications may help in the reduction of impulsivity and lability of mood and affect associated with aggressive outbursts, but psychopaths quite often resist taking medication or abuse it.
For those patients who do show responsible willingness to accept drugs to curb aggressiveness and impulsivity, consideration should be made of anti-anxiety agents such as the benzodiazepines. This class of drugs reduces the tension which often propels patients into impulsive acts and can secondarily diminish the hypervigilance often seen as part of the paranoid symptoms shown by some psychopaths (Lion, 1975). The latter patients, in fact, will not usually tolerate antipsychotic agents even though suspiciousness is clinically evident, for these major tranquilizers markedly impair watchfulness and thus may heighten, rather than reduce, paranoia and the tendency to become aggressive. In addition, antipsychotic agents frequently produce subtle side effects intolerable to paranoid and narcissistic individuals.
The anticonvulsants have been shown to reduce aggressiveness in patients who demonstrate epileptoid outbursts of rage (Monroe, 1974, 1975). Confirmation of underlying brain dysfunction by electroencephalographic examination, neurological evaluation, and psychological testing may provide additional justification for the use of such drugs.
Lithium has also been shown to be of use in certain patients labeled “emotionally unstable.” These patients’ symptoms probably reflect variants of a bipolar affective disorder manifested not by typical mood swings but by fluctuations in levels of psychomotor agitation, irritability, and aggressiveness (Lion, 1975).
Two classes of experimental drugs bear mention. The central nervous system stimulants used with hyperkinetic children have been anecdotally reported to be of benefit in adults who show clinical pictures of impulsivity, aggressiveness, and antisocial behavior (Allen et al., 1975). Also, research with progestational agents on sexually deviant and aggressive patients has demonstrated positive effects of these drugs, which act by reducing sexual drive state and thus, secondarily, reducing aggressiveness (Blumer and Migeon, 1975). I have on one occasion administered reserpine to a patient with a severe character disorder with the hope of making him depressed to the point of introspection; such a tactic was experimental, in response to the intriguing question of how to induce depression in patients who deny it and handle it by behavioral means (Lion, 1975). I have felt the value of most psychopharmacologic agents in the treatment of psychopathy—such as the tranquilizers and anticonvulsants—to lie in the propensity of these agents to curb impulsivity and produce a mild state of depression conducive to reflection.
The “Burning Out” Process
Time is the greatest ally of the therapist. Thus it is observed that the longer an aggressive psychopath is kept locked up, the less likely he is to revert to his old manipulative and aggressive ways of behaving. This “burning out process” probably has to do with physiologic maturation and can be seen in impulsive and aggressive youths who show reduced impulsivity and hostility in their 30s and 40s, after having served comparatively long sentences within institution settings. Maturation is an important variable but one which is poorly understood. The burning out process most likely represents physiologic changes which have a general dampening effect on psychological parameters of lability and impulsivity. In the “natural experiment” one sees this in the differences between normal adolescents and adults. Maturation or burning out also plays a role in outpatient therapy, since the duration of treatment is long. It should be noted, however, that “burning out” may refer more to physically violent criminal activity than to antisocial behavior in general, since there are some data which suggest that psychopaths continue to be socially maladjusted as they age but are less often convicted of criminal activity (Maddocks, 1970).*
Development of Guilt
The development of guilt and a “superego” has been conceptualized as a major task of treatment for all psychopaths. Regrettably, the super-ego, a derivative of the ego, cannot be so easily shaped. It is felt by most clinicians that milieu treatment with 24-hour custodial and therapeutic care enables feedback to be present at all times so that some rudimentary forms of guilt develop, or, at the very least, the patient learns what is right and wrong. Many tactics in the treatment of psychopaths, including the precipitation of depression mentioned earlier, reflect the desire on the part of clinicians to forcefully confront the patient with issues of good and bad and to induce a state of hopelessness conducive to therapeutic insight.
A psychopathic girl was hospitalized at a private facility. Outpatient treatment had produced little change in her behavior and it was decided on this occasion to keep her on suicide precautions with a one-to-one patient-staff ratio in order to always have a nurse with her. It was thought that this might foster some form of discomfort conducive to reflection and identification. The hospital course proceeded rather smoothly with gains made in introspection. In time she was discharged and later committed suicide.
Another patient prone to violent outbursts was treated on an outpatient basis with anticonvulsants. His violent behavior was markedly reduced but he, too, ultimately killed himself (Monroe, 1975).
A third patient was hospitalized. His wealthy family agreed to pay for two staff members who traveled on the hospital grounds wherever he went and always confronted him with any deviant piece of behavior he demonstrated. Few gains were made of any lasting value.
These various examples illustrate complex problems as well as equally complex and imperfect solutions and their hazards.
GROUP THERAPY
Group therapy forms an important treatment modality for psychopaths, since they are apt to be brutally honest with one another while being devious with the primary therapist. There is much peer confrontation in the group setting and it is a useful means of self-confrontation (Lion and Bach-y-Rita, 1970). Enhancement of psychotherapy by videotape playback of sessions may also be helpful.
Some groups form on the basis of self-help organizations such as Synanon and Daytop and are, of course, a prime modality of treatment within any hospital milieu. Within the group therapy, it may be useful to pick one particular psychopath as a therapist-leader. This tactic utilizes the dynamic of reaction formation, often most prominently seen in prison settings where there appears to be a thin line between the prisoner and the guard. By elevating a psychopath to the position of responsibility, he may identify with and adopt some values of the therapist, internalizing valuable ideas and norms which become part of his way of behaving. Obviously, this process takes considerable time to develop.
EXPLOITATION IN A HOSPITAL SETTING
Mention should be made of one facet of the inpatient treatment of psychopaths which demonstrates the exploitative power of the patient. The psychopath can create dissension on a hospital ward and actively manipulate events in such a way as to produce staff and patient distrust. Subtle and flagrant violations of ward rules confront everyone with issues of compliance and at the same time produce splits in staff allegiances. The psychopath is particularly skilled at generating conflicts over power and authority, and may become an uncontrollably defiant member of the patient population. Administrative problem solving may center around the psychopath when other issues and other patients are equally important.
Staff impotence must be acknowledged and discussed. Limits must be set and maintained. At the same time, caution must be exercised so that the psychopath does not exploit and exhaust the time that the staff has at its disposal. In time, some manipulation may require benign neglect to be extinguished. I have seen rare instances in which the ward could not tolerate the destructive manipulation of a psychopath and transfer to another facility was warranted. All of these points illustrate the constant need for the therapist to be vigilant and aware of his limitations. Consultation with colleagues is useful for the latter, since psychopaths, inpatient or outpatient, regularly mobilize feelings of helplessness in therapeutic staff.
THERAPEUTIC QUALITIES
The final question remains as to which kinds of therapists are best, or even suitable, for treating psychopaths. There exist in every therapeutic community physicians, psychiatrists and therapists who are particularly willing and able to deal with behavior disorders and psychopaths. Generally, these clinicians are those who have had experience in forensic matters and who are more skilled at detecting manipulation than their more psychoanalytically oriented colleagues, who depend heavily upon the self-reporting and spontaneous introspective processes which are part of the analytic process. In addition, it has been my observation that the therapists most skilled at treating psychopaths have some degree of entrepreneurial spirit which puts them in touch with the narcissism and grandiosity inherent in these patients. Without this “window” into the psychopath’s tendency to exploit in a grandiose style, the clinician cannot understand and internally predict what the psychopath will do. He is thus almost constantly “off guard.” Also, the less attuned therapist is apt to be entrapped by his latent exhibitionism vis-à-vis mankind’s fascination with psychopathic entrepreneurs, as evidenced by many famous hoaxes and swindles.
The therapist who works with psychopaths carries burdens which require a balance of work with other types of patients—neurotic and psychotic—lest he become hardened in his style. The therapist must constantly suspect his patient’s intentions and behavior and work toward the day when an open honesty appears, one which is paradoxically, but quite predictably, accompanied by a depression. This melancholy heralds the beginning of a guiltlike process which can eventually lead to appropriate affects, attachments, and a normal lifestyle.
REFERENCES
Aichhorn, A. (1925). Wayward Youth. New York: Viking Press.
Allen, R. P., Safer, D. & Covi, L. (1975). Effects of psychostimulants on aggression. J. Nerv. Ment. Dis., 160:138–145.
Blumer, D. & Migeon, C. (1975). Hormone and hormonal agents in the treatment of aggression. J. Nerv. Ment. Dis., 160:127–137.
Bursten, B. (1973). The Manipulator. New Haven, CT: Yale University Press.
Eissler, K. R. (1950). Ego-psychological implications of the psychoanalytic treatment of delinquents. The Psychoanalytic Study of the Child, 5:97–121. New York: International Universities Press.
Greenacre, P. (1947). Problems of patient-therapist relationship in the treatment of psychopaths. In: Handbook of Correctional Psychology, ed. R. M. Lindner & R. V. Selinger. New York: Philosophical Library.
Jones, M. (1953). The Therapeutic Community. New York: Basic Books.
Lion, J. R. (1972a). Evaluation and Management of the Violent Patient. Springfield, IL: Charles C. Thomas.
Lion, J. R. (1972b). The role of depression in the treatment of aggressive personality disorders. Amer. J. Psychiat., 129:347–349.
Lion, J. R. (1974). Diagnosis and treatment of personality disorders. In: Personality Disorders, ed. J. R. Lion. Baltimore, MD: Williams & Wilkins.
Lion, J. R. (1975). Conceptual issues in the use of drugs for the treatment of aggression in man. J. Nerv. Ment. Dis., 160:76–82.
Lion, J. R. & Bach-y-Rita, G. (1970). Group psychotherapy with violent outpatients. Internat. J. Group Psychother., 20:185–191.
Maddocks, P. D. (1970). A five year followup of untreated psychopaths. Brit. J. Psychiat., 116:511–15.
Modell, A. H. (1975). A narcissistic defence against affects and the illusion of self-sufficiency. Internat. J. Psycho-Anal., 56:275–282.
Monroe, R. R. (1974). The problem of impulsivity in personality disturbances. In: Personality Disorders, ed. J. R. Lion. Baltimore, MD: Williams & Wilkins.
Monroe, R. R. (1975). Anticonvulsants in the treatment of aggression. J. Nerv. Ment. Dis., 160:119–126.
Schmideberg, M. (1949). The analytic treatment of major criminals: Therapeutic results and technical problems. In: Searchlights on Delinquency, ed. K. R. Eissler. New York: International Universities Press.
____________
*Editor’s Note: I do not assume low self-esteem in psychopathy unless it is evident from psychological testing.
*Editor’s Note: See Modell (1975) for a detailed expositionof the “affect block” and the illusion of self-sufficiency in narcissistic pathology: A. H. Modell. A narcissistic defence against affects and the illusion of self-sufficiency. Internat. J. Psycho-Anal., 56:275–282.
*Editor’s Note: As I have noted elsewhere, nonviolent criminality appears to lessen among psychopaths in their 40s, while violent criminality, for at least half, does not lessen. See R. D. Hare (1998). Psychopaths and their nature: Implications for the mental health and criminal justice systems. In. Psychopathy: Antisocial, Criminal, and Violent Behavior, ed. T. Millon et al. New York: Guilford, pp. 188–214.