The Clinician's Reactions to the Patient

Lion, Symington, Strasburger, Meloy, and Gabbard explored the clinician's response to the psychopathic or antisocial personality disorder patient. Table 82-3 lists eight common countertransference reactions to such a patient. They are likely to occur regardless of the treatment modality being applied and will be felt more intensely when psychopathy is more severe in the antisocial patient. These are reactive emotions and thoughts and should not be construed as necessarily implicating a conflict in the clinician. Such subjective reactions can be used as an impetus for further objective testing, a reevaluation of the appropriateness of the selected treatment, or in some cases the cessation of treatment.

Therapeutic Nihilism
Lion used the term therapeutic nihilism to describe the rejection of all patients with an antisocial history as being completely untreatable. Instead of arriving at a treatment decision based on a clinical evaluation, including an assessment of the severity of psychopathy, the clinician devalues the patient as a member of a stereotyped class of "untouchables." The clinician does to the patient with antisocial personality disorder what the patient does to others. Symington called this condemnation, and it psychoanalytically reflects the clinician's identification with this aspect of the patient's character.

Illusory Treatment Alliance
The opposite reaction to therapeutic nihilism is the illusion that there is a treatment alliance when, in fact, there is none. Often these perceptions on the part of the patient are the psychotherapist's own wishful projections. Although the presence of an alliance is a favorable prognostic indicator, in antisocial personality disorder patients with severe psychopathy, it should not be expected. Behaviors that suggest such an alliance should be viewed with clinical suspicion and may actually be imitations to please and manipulate the psychotherapist. The chameleon-like quality of the psychopathic patient is well documented. Bursten elaborated on the "manipulative cycle" of the psychopathic patient, which leads to a feeling of contemptuous delight in these patients when successfully carried out. The clinician is left with feelings of humiliation and anger.

Fear of Assault or Harm
Strasburger noted that both reality-based and countertransference fears may exist in response to the antisocial personality disorder patient with severe psychopathy. Real danger should not be discounted and is most readily evaluated by using contemporary measures to assess the risk of violence. Countertransference fear is an atavistic response to the psychopathic patient as a predator and may be viscerally felt as "the hair standing up on my neck" or the patient "making my skin crawl." These are phylogenetically old autonomic reactions that may also signal real danger, even in the absence of an overt threat. Although no empirical studies of this phenomenon have been done, it appears to be a widespread experience among clinicians working with psychopathic patients. A related clinical feature is overt sadistic triumph over the psychotherapist, what Kernberg cites as a symptom of "malignant grandiosity."