Psychotherapy

Outpatient psychotherapy has been very discouraging, and most patients are unresponsive to psychodynamic approaches. Antisocial individuals may wish to escape from honest human relationships because of their fear of intimacy, and this causes difficulties in establishing a therapeutic alliance. They should be encouraged to find alternative defence mechanisms to acting-out, and protected from their self-defeating behaviour. Realistic conditions should be created, limits should be set, and all tertiary gains of treatment (escape from the law, and ongoing parasitic dependence on parents or other social support systems) should be eliminated.

Various treatment modes have been applied, with effectiveness depending on the severity of the disorder. Group treatment may be more beneficial than individual therapy.

Small groups should be homogeneous, preferably with two therapists who share responsibility and lead groups in a non-authoritarian way. Self-help groups may be useful and prognostically better, since antisocial individuals accept confrontation with their peers more easily than with therapists-authorities.

A therapeutic community, based on the principles outlined by Maxwell Jones (35> with a general social adjustment as a main task, might give positive results. Special programmes should be developed, providing firm structure, supervision, and direct confrontation of interpersonal behaviours and defences. Therapists should have an enthusiastic and non-controlling but firm attitude, and empathic and consistent behaviour. They should try to understand the split-off inner pain of antisocial patients and not punish them. Counter-transference problems are unavoidable, and true ambivalence in the reaction to antisocial patients is considered to be a healthy response.(31>

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