Transcript Antisocial Personality Disorder:

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 depressions
2. Disorders of self in relation to others:
Personality disorders, addictions,
family disorders, some aspects of
trauma disorders
3. Disorders of self in relation to community and
society:
the antisocial disorders
The Cast of Characters
Most 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 people
Many drug dealers, prostitutes, pimps, petty thieves
7-11 robbers who don’t know why they did it
People with STD and know it and don’t tell their partners
People who steal from their parents
Many “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
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Remarkably insecure, inadequate people
Filled with shame .. Fear someone will find out / fears
exposure of real self
Hides self from self as well as others
Highly anxious, covers with action out/on or with angry
emotions
Have an underdeveloped conscience and sense of
social responsibility
…low on guilt, high on remorse
Low on empathy and compassion
Low on motivation to change – stimulus for change
has to come from the outside
Hard time sustaining motivation – better on plans than
action
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
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
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Covetous
Nomadic
Risk taking
Reputation defending
Malevolent
A matrix of antisocial disorders
amoral
Trait disturb.
Pattern disturb.
Personality dis.
Sadistic
impulsive
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
3B. Specific for antisocials
med
hi
lo/med
med
6 treatment settings (con’t)
intensity
4. Halfway house and transition progs
for addiction treatment
prison work-release
antisocial specific
lo/med
lo/med
med
cost
med
lo/med
med
5. Therapeutic communities
for addicts
for antisocials
hi
hi
med/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 quit
Boundaries and process of therapy are behaviorally based
Goal is the maintain person in treatment long enough to
“move them up” to a character trait disturbance
Treatment of choice is initially intensive residential inpatient
Therapy has to be a crucible to expose and contain the
rage w/o resorting to violence
Careful 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 with
character 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 with
character 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?