Therapy

Treatment is usually forced on antisocials by some form of threat, perhaps expulsion from school, termination of employment, impending divorce, or possible imprisonment. Many subjects have abused repeated opportunities to reform, even after many proclamations that they have finally "learned their lesson." Because antisocials are possessed of an absent or defective conscience, restraints must usually be provided by external forces. The consequences of their behavior do not concern them, nor do its effects on others. Antisocials display lack of empathy, lack of insight, and a deficient conscience. Ordinary forms of therapy, particularly individual therapy, are likely to be highly ineffective. Most interventions, in fact, are implicitly focused on containment, with only modest goals for change. This makes practical sense. Because antisocials are lacking in conscience, society must either function as the conscience they lack or suffer the consequences.

Nevertheless, some clinicians believe that the chances for real gains increase with advancing age of the clients. As the disorder begins to burn out from physical decline, perhaps accelerated by years of substance abuse and fast living, some antisocials eventually tire of aversive encounters with the forces of society.

Therapeutic Traps

For antisocials, therapy is just another game, another annoying encounter with the constraining forces of society. From their perspective, the goal is simply to make them into something other than what they are. Because antisocials are basically interested in shrugging off external constraints, the antisocial in therapy must seem to develop a sense of conscience, must seem to express guilt and contrition, and must express a sincere desire to reform and make amends. Antisocials know that apparent change must be paced, for quick reform naturally undermines any aura of sincerity. Instead, they should change slowly and mostly in response to the searching and confrontive questions of the therapist.

The antisocial, then, seems to have returned to the flock, with the therapist as his or her proud shepherd. Any therapist who consistently works with antisocial subjects will probably be duped many times over by seemingly sincere expressions of regret, ranging from guilt about the destruction of life and property, to an almost existential despair about the wasting of the potential of their own life. Beginning therapists may be especially nai've to the antisocial's wiles, as are those who "need" to cure their subjects and those who might compete against fellow therapists by displaying their pet psychopath, the one who grew a conscience.

Therapists often exhibit a variety of intense countertransference reactions to antisocial subjects. Some become so suspicious, angry, and resentful that they may miss opportunities to catalyze real change in the few subjects where a genuine therapeutic alliance can be created. Most antisocials have been rejected by others all their lives, and a cynical therapist simply becomes another in a long line. Another problem is that antisocials frequently feel threatened by their therapists, and therapists frequently feel threatened by antisocial subjects. Particularly when both are male, they may challenge each other for domination. Many subjects may even take a sadistic delight in sabotaging their own progress, and some therapists may even take a sadistic delight in allowing it, because any victory is ultimately a loss. Frances (1985) suggests that the therapist openly acknowledge the vulnerability of the therapy setting to the possibility of manipulation, as many subjects appreciate such frank disclosure.

Therapists with compulsive traits may be at risk for presenting themselves as dogmatic symbols of deference to the establishment. Compulsives rigidly adhere to social norms, and antisocials carelessly violate them; the two are likely to despise each other. As the antisocial acts out to test a compulsive therapist, the therapist may become implicitly condemning, thus sabotaging therapy. Such countertransference reactions indicate therapist issues and should be evaluated as objectively as possible. Beck et al. (1990) suggest that self-assurance, a reliable but not infallible objectivity, a relaxed and nondefensive interpersonal style, a clear sense of personal limits, and a strong sense of humor are particularly valuable when working with antisocial clients.

Strategies and Techniques

The ultimate goal of therapy with antisocial persons lies in their developing a sense of nurturing attachment (Benjamin, 1996). The object of attachment is technically unimportant. The first object of therapy, however, is to find some way of bonding with the antisocial person, to develop a therapeutic alliance that transcends a desire to con the counselor. Coerced into therapy, many antisocials feel a deep underlying sense of hostility that must be addressed before a sense of trust can develop. Likewise, if the therapist is perceived as an agent of Big Brother, nothing authentic will occur. Accordingly, the therapist may wish to suggest that because external forces have mandated a course of therapy, the time might as well be used constructively, even though the therapist has no personal investment in the outcome. Another difficulty that arises in developing this bond is the challenge to the therapist in regards to his or her reaction to the antisocial person. Antisocials, by virtue of their willingness to destroy others' lives, are capable of eliciting feelings of moral disgust in the counselor, and they are often aware that this has the capacity to derail intervention attempts. Psychodynamic treatments are not discussed because antisocials are not typically capable of change through insight.

Interpersonally, Benjamin (1996) suggests that antisocial subjects lack constructive socializing experiences administered through dominance or warmth. Antisocials learn early that they do best by anticipating and reacting to an indifferent and unreliable environment with defensive autonomy, if not suspicion and hostility. Extrapolating from Benjamin, treatment from a position of benevolent power, the basic assumption of effective parenting, would likely involve a highly structured environment in which both rewards and punishments are known well in advance of common misbehaviors.

When transgressions occur, punishment can be administered reluctantly, but consistently. Reluctance models continuing care and attachment to the welfare of the subject and consistency shows that the system cannot be exploited in the service of shameless antisocial motives and will not tolerate antisocial acting-out. Benjamin further notes a number of strategies that can be used to help antisocials internalize values. One method particularly effective with children and adolescents uses sports figures to model warm and benevolent attitudes. Another strategy puts the antisocial in a potentially nurturing position; the antisocial may be given a pet or allowed to instruct children in some supervised context, such as a skill or a sport. The hope, according to Benjamin, is that such dependency can draw nurturance from the antisocial.

Writing in Beck et al. (1990), D. Davis describes the use of cognitive therapy with the antisocial personality. Rather than attempt to induce shame and anxiety, these authors advocate a strategy that helps move the subject from a primitive to a more abstract level of moral reasoning. Most antisocials function at the lowest level, constructing the world in terms of their own immediate self-interest. The goal of therapy is the next level, which features a longer term, more enlightened self-interest that includes limited recognition of the effects of the individual's own actions on others. Specific problem areas can be identified through a thorough review of the subject's life. Following this, the use of cognitive distortions relevant to each problem is identified. An-tisocials may believe that just wanting something justifies any subsequent behavior, thoughts and feelings are always accurate, their actions are right because they feel right about what they are about to do, and the views of others are irrelevant. If antisocials can recognize that their actions affect others and have reciprocal consequences for themselves, they can at least move to a position of enlightened self-interest.

Further, these authors realistically suggest that antisocial behavior be described as a disorder with long-term negative consequences, such as incarceration, possible physical harm from others, and broken contact with family and friends. This minimizes the possibility that subjects will feel accused and thereby increases their chances of continuing therapy. Throughout therapy, therapist and subject draw clear priorities, evaluating a full range of possibilities and discussing advantages and disadvantages before making important decisions. This models delay of gratification and teaches skills necessary to make enlightened self-interest a reality.

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