Antisocial Personality Disorder:

A new look

4 objectives for workshop

• 1. To broaden your view of the antisocial population, define some subtypes and identify some struggles antisocial people face in life

• 2. Dispel some myths about treating people with antisocial character structure

• 3. Propose a rationale for why antisocials need special treatment environments and why they don’t respond to conventional addictions treatment

• 4. Develop some understanding & empathy for others whose lives are touched by antisocial people: Parents, children, partners and victims

A model for three psychiatric / psychosocial disorders

1. Disorders of brain chemistry / brain functioning: Schizophrenia, Bi-Polar disorders, anxiety disorders, most depressions2. Disorders of self in relation to others: Personality disorders, addictions, family disorders, some aspects of trauma disorders3. Disorders of self in relation to community and

society: the antisocial disorders

The Cast of CharactersMost males in “The Sopranos”Many people who live on the “margins” of society: family, jobs, finances, legal system, friends, drug use, cut corners in life

Professionals with a pattern of dishonesty: Accountants who specialize in creative book-keeping Lawyers who sue insurance companies because they know the insurance company will “settle” Doctors / health care professionals who file false claims and overbill Trades people who take advantage of elderly homeowners Industrialists who takeover and dismember companies

Many people who purposefully injure or torture animals or peopleMany drug dealers, prostitutes, pimps, petty thieves7-11 robbers who don’t know why they did itPeople with STD and know it and don’t tell their partnersPeople who steal from their parentsMany “end of the roaders”

Unifying characteristics of antisocial disorders

1. Acting out or acting on – aggression

2. Getting “over on” – power and control

3. Lack of concern and sensitivity for others –

Exploitive of others

4. Lack of self-care

5. Emotional deprivation

6. Inability to self-stimulate

7. Perception of self as victim, disowning responsibility,

Lack of guilt

The undercover side of the antisocial

1. Remarkably insecure, inadequate people2. Filled with shame .. Fear someone will find out / fears

exposure of real self Hides self from self as well as others3. Highly anxious, covers with action out/on or with angry

emotions4. Have an underdeveloped conscience and sense of

social responsibility …low on guilt, high on remorse5. Low on empathy and compassion6. Low on motivation to change – stimulus for change has

to come from the outside7. Hard time sustaining motivation – better on plans than

action8. Often look more like bad boys than men -

4 levels of impairment with antisocial disorders

• 1. Character Trait Disturbance Functions well in society

Antisocial part may be hidden from others May be highly “successful” (by society standards) While antisocial traits are present, there is some control over the trait May compensate for antisocial traits by doing well in other areas of life: glib and engaging, ingratiating nice and polite overly generous to others active in community affairs good parent protective of children and elderly

4 levels of antisocial impairment

Character pattern (character neurosis) Can’t hide antisocial symptoms as well

Less adaptable to change (Pattern more entrenched) Defense is more rigid More limited in interpersonal functioning Life is more defined by the limiting parts of the personality Childhood wounds may limit adult functioning Recognizable developmental failures in childhood and adolescence

4 levels of antisocial impairment

• Antisocial Personality Disorder A pervasive pattern of rigid character structure that

limits options in life. Failures in psychosocial development early in life set up a pattern of mal-adaptive coping, limited resources and skills and a poor sense of self. This inability to handle life maintains the trauma in adulthood.

Limited resources for staying out of trouble

Don’t learn from mistakes and keep shooting themselves in the foot.

Levels of antisocial impairment

• 4. Psychotically disorganized antisocials

Personality disordered people with periods of psychotic disorganization marked by dissociation, depersonalization, cognitive distortions, delusions and/or inability to control actions. These folks almost always end up in prison.

Childhood diagnoses of antisocials

• ADHD – restless, inattentive, don’t follow instructions or rules

• Conduct disorders – set fires, abuse animals and other children, low attention span

• Oppositional defiant disorder – oppositional, stubborn, negativistic, disobedient

Some attributes of higher functioning antisocials

Ambition – competitiveness, need to win

Take charge, like authority

Action oriented

High on risk taking

Low feeling (emotionality)

Rigid moral code (with lots of holes)

Low attachment – bonds with groups better than individuals

More attached to roles than people

Can talk his/her way out of jams

Suspicious of the motives of others

3 Types of Antisocial Character Structure

Amoral Personalities

Amoral extroverts (narcissistic)

Amoral introverts (schizoid)

Antisocial Impulse Disorders

Sadistic Antisocials

Millon’s Categories of Antisocials

• Covetous

• Nomadic

• Risk taking

• Reputation defending

• Malevolent

A matrix of antisocial disorders

amoral impulsive sadistic

Trait disturb.

Pattern disturb.

Personality dis.

Sadistic

Amoral Character

• Primacy of self needs over the needs of others – self centeredness

• Getting over on others – keeping others one down

• Grandiosity that masks “one-downness” & insecurity

• Competitiveness – not losing is primary – losing means having to get revenge

• Primary emotional dilemma is shame

Amorals (con’t)

• Impulse control allows individual to plan, plot and delay gratification

• Primary defenses are dissociation, grandiosity, omnipotence and denial

• Often quite glib, superficial in relationships

• Focus on image and impression management

2 subtypes of amoral antisocials

Extroverted (narcissistic) antisocials Grandiose, projects shame Entitled, flaunts privilege Arrogant, condescending to others Attracts “trophy” friends and mates Often high achievers, but cheats to get there Big on impression management Needs others for validation May hide grandiosity with false humility

2 subtypes of amoral antisocials

Introverted (Schizoid) amoral antisocials Loners, often little need for others hides shame Deficits in social skills Often seem aloof and disdainful of others Highly sensitive to real or perceived shaming Outwardly non-competitive, losing really hurts Good plotters – can delay gratification for years Can have an active paranoid flavor Poor relationships with opposite sex

Impulsive Antisocials

• Lack of impulse control• Low feeling (except anxiety) – feel through high thrills/

high risk• Often history of learning problems, school and social

failures, low self esteem• May be impulsively violent• High tolerance for pain, can dissociate easily• High risk for drug use, drug dependence• Trouble explaining motivations for actions, low insight• Low guilt, high remorse

Sadistic antisocials

• Willingness / desire to inflict pain on others for personal satisfaction

• Lack of caring and empathy for others• Low feeling tone, feel through the pain of others• Primary defense is dissociation and

omnipotence• Usually (but not always) history of pervasive

childhood trauma• Intense need to control and dominate

Does treatment really make antisocials worse?

Yes, if people are treated with inappropriate treatment methods

Yes, if treatment stops at confronting the primary, primitive ego defenses of the client:

grandiosity and omnipotence arrogance and glibness getting “over on”, glibness denial and dissociation Then client will either get severely depressed or will

regress and act out to re-establish defense.Therapy has to support the severely wounded self as it

emerges. Shame and degradation cannot be tolerated

Some principles of therapy with antisocials

1. Focus is on doing, not talking – behavioral orientation

2. Feelings don’t count (in the therapy)

3. Omnipotent control and grandiosity have to be confronted – can’t allow pt. to “get over” on you

4. Have to build a capacity for personal responsibility

5. Have to build a higher capacity for experiencing anxiety

6. Have to confront and refute client fears of being used

7. Focus on OUTCOMES of behavior, not meaning of the behavior

8. Have to build a basic capacity for a conscience

Some principles of therapy (con’t)

9. Heavy confrontation only works in institutions and in the movies

10. Have to confront the myth of “the heroic outlaw”. Robin Hood doesn’t live in your office

11.Therapist has to maintain authority without being authoritarian.

12. The paradigms that are the basis for therapy with other personality disorders don’t work with antisocials:

Insight = gaminess Empathy = weakness / manipulation Relatedness = intrusion Trust = stupidness

6 settings for treating antisocials

intensity cost

1. Mandated outpatient monitoring lo lo

2. Outpatient psychotherapy med lo

3. Structured outpatient

3A. Short term addiction setting med lo/med

3B. Specific for antisocials hi med

6 treatment settings (con’t)

intensity cost4. Halfway house and transition progs for addiction treatment lo/med med prison work-release lo/med lo/med antisocial specific med med

5. Therapeutic communities for addicts hi med/hi for antisocials hi med/hi

6. Institutional containment very lo very hi

4 preconditions for treatment for antisocials

1. Specify conditions of treatment

appointment times

# of visits

fees and payment

missed appts., arriving late, leaving early

conditions of communication with referral agents

(for instance, letters to judges on compliance)

conditions for termination of treatment

positive completion / ama / rules violations

Treatment preconditions (con’t)

2. Releases of information

to whom and what will be released

3. Child / elder / patient abuse reporting (especially for sadists)

4. “Duty to Warn” for threats of violence

Outpatient treatment of antisocials

1. Treatment engagement / beginning treatment a. defining treatment goals b. establishing the treatment contract – short term c. defining behavioral constraints & expectations d. early efforts in establishing the relationship being the authority w/o being authoritarian feeding the dragon e. acting out / testing in early treatment f. staying focused on treatment goals / behaviors g. using external structure (church, legal sanctions,

spouses actions)

Outpatient treatment (con’t)

2. Middle phases of treatment a. confronting the antisocial schema – watching as the antisocial acts out their “world view” in treatment b. curative factors in individual and group therapy begin to work c. managing 3 wounds as they emerge 1) “empty” depression 2) the “bully kid” 3) exposure of the developmental trauma d. other dynamics that begin to emerge: shame, neediness/deprivation, feeling repression, loneliness

Outpatient treatment (con’t)

3. Reconstructive phases of treatment a. developing a capacity for conscience, learning to care about the needs of others b. changing core schema, “world views” c. developing self-control d. developing more functional interpersonal, social, occupational and intimacy skills e. learning self-care .. self soothing, self support, self assessment f. developing / enlarging the positive support system g. living with (rather than running from) the “old way”

Outpatient treatment (con’t)

4. Developing a soul – being human

We have “soul” when we attach to something greater than self.

But to do this, their first has to be a self.

One develops soul by finding meaning in life, finding place in life, experiencing self in the context of the world.

AA calls this “humility”

Treatment of amoral antisocials with character trait disturbance

Being the authority w/o being authoritarian: the

incorruptible, well bounded, interested parent. The

interest is in the person, NOT the exploits

Early in treatment have to feed the dragons

Boundaries of therapy are behaviorally based

Clean confrontations of behavior, never shaming

Process of the therapy is behaviorally based while

nurturing the relationship

Building and nurturing the attachment with therapist,

AA sponsor, other significant non-antisocial others

Treatment: amoral trait disturbances (con’t)

Co-opting the antisocial traits: charm, manipulativeness, resourcefulness, reading others, survival skills

Supporting “conversion” experiences in church, AA, treatment

Managing the “zero state”, “narcissistic depression” (breakdown of old ego defenses) as it emerges in therapy and 12-step recovery

treatment of amoral character pattern disturbances

Clear behavioral contracts – therapy is about achieving behavior tasks

Clear, forced contracts for therapy – can’t quitBoundaries and process of therapy are behaviorally basedGoal is the maintain person in treatment long enough to

“move them up” to a character trait disturbanceTreatment of choice is initially intensive residential inpatientTherapy has to be a crucible to expose and contain the

rage w/o resorting to violenceCareful about using 12 step programs – Clients will

manipulate in AA to “get over” on the treatment process

Treatment of amoral personality disorders

Treatment needs to start in intensive, closed, residential, group support setting

Goal of treatment is to:

a. internalize behavioral boundaries

b. “conversion” experience to new value / ethical system

c. develop some sense of affiliation and connection.

Institutional constraints have to be able to contain the acting out that is result of breakdown of defense and break though of the shame and anxiety, wounded self

Treatment of impulsive antisocials with character trait disturbances

Strong set of boundaries for treatment –

has to show up & follow rules

Increased capacity to delay gratification

Increasing sense of control – internalizing locus of control

Strong emphasis in therapy on assessing consequences of behavior

Supporting compliance / conforming behaviors

Treatment of impulsive antisocials withcharacter pattern disturbance

Preferably treatment is begun in residential / TC settings

If non-institutionalized, strong, consistent constraints on behavior

Focus in therapy on cause-effect and consequences of behavior and impact of behavior on others

Clear consequences / penalties for rule violations

Staying away from people, places and things (drugs) that excite drives for impulsive behavior (lets have some fun!)

Developing self-responsibility

Treatment of sadistic antisocials withcharacter trait disturbances

Clear behavioral contracts for treatment that define:

conditions of treatment

proscribed behaviors

Treatment of choice is long term, intensive group that:

provides identification and affiliation

offers confrontation of proscribed behaviors

provides a “holding community”

Therapy has to confront, “victimization defense” early:

responsibility for acts

recognition that “victimization defense” is 1st step in

approaching sadist own trauma and victimization

Sadistic character trait disturbances (con’t)

Treatment has to ultimately address sadists own trauma

Abuse in treatment and rehab. Activates sadists trauma which activates defense which activates sadistic acting out

Sadists will “get over” by describing sadistic behaviors in the therapy setting;

e.g. “Am I making you uncomfortable?”

Aversive counter-transference with sadists has to be managed. Supervision is essential

Treatment of sadistic character pattern disturbance

Confrontation in a “contained”, controlled environment

no victimization, no excuses

Recognition by client and therapist of sadism as a “problem” and the need for treatment and recovery

Confrontation of attempts to draw others into the victimization defense

Confrontation of “blaming the victim”

Co-managing treatment and punishment for sadistic act(s)

Why Bother?