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August 31 2013

How do I work with a psychopath?

"I have a patient (drug addict) who is very sadistic, has tortured others in the past, and is himself a victim of severe physical abuse. He reports having no feelings, but projects that I do. I think he monitors my feelings to see if his sadism is gratified. Is it my urge to find something human under his behavior that keeps me looking for it? Is it possible that there are no feelings there? He tells me about his violent acts, then asks me if there is hope that I can help him. He says he has no feelings, but is anxious in social settings. He is very defensive with me (denial, projection), except when describing his sadism. He talks more freely about it, but always tells me that there is worse that he has not yet told me. Can ISTDP help?"

This type of psychopath projects onto others, then tries to omnipotently control them, often through physical abuse and violence. In this way, he tortures others as he claims he was tortured. Although many psychopaths were victims of abuse as children, many were not. Research shows that the pathway to psychopathy is partly genetic and partly psychological. Researchers such as Hare and Reid Meloy have described these issues in the deepest detail.

The patient is highly invested in the defense of omnipotence: he doesn’t have feelings; other people do. Thus, he relies on denial and projection. He tells horrifying stories to the therapist with the hope that he can induce those feelings of horror and repulsion in her. Thus, his splitting off of his feelings of guilt and anxiety works by relocating them in the therapist. Then, he watches her to ensure that she feels these horrible emotions. Then he feels sadistic gratification at being able to watch her feel tortured with pain and guilt while he is cool, calm, and collected. Thus, even the free association of a session is a means for him to act out his projection and sadism…on the therapist.

This patient obviously has feelings. Otherwise, he would not have to work so hard at denying them and inducing them in the therapist through projective identification. However, all of his defenses are designed to make sure that other people are feeling tortured by his feelings instead of him. He does not fear that he does not have feelings. He tries very hard not to have them.

The therapist asks if it is her urge to find something human in the patient that keeps her looking for it. No. This is another example of projective identification. The patient has a healthy urge to connect to his humanity. However, to avoid the conflict he would experience if he owned that urge, he projects it onto the therapist. She becomes the one who is trying to find the good in him. Simultaneously, this becomes the therapist’s denial of the bad in the patient. This is the typical projective identification and splitting the psychopath induces in women that leads women to form and keep masochistic relationships with psychopaths. Be sure to read J. Reid Meloy’s masterpiece on the relationships women have with psychopaths: Violent Attachments. As long as the psychopath can keep the women looking for the good guy, he can torture her any way he wants while she keeps looking for someone who never shows up. In this way, she can relate to the man she wishes she had and not face the sadist she is with. And this denial allows her to deny her anxiety over living with a man who wants to torture and perhaps one day kill her. Her unconscious anxiety about living with a torturer requires her either to leave (rare) or to use massive denial (looking for the good while ignoring the bad).

He tells her about his violent acts and asks if it is possible for her to help him. A trial interpretation in a psychodynamic therapy might go something like this: You torture others, rendering them helpless, and you try to torture me here with your stories, rendering me helpless. Then you fear that I won’t be able to help you with this destructive part of your mind that has been holding you hostage and destroying your life. And, in fact, if you continue to join forces with this destructive force in your mind, neither I nor anyone else will be able to help you. You know this. And this is what you fear. And you should. One reason you fear I can’t help you is that since you try to torture and dominate me, you assume I would want to torture and dominate you. Those are the only two roles you see: torturer and tortured. At the same time on another level, you fear that your wish to torture me would destroy my ability to think. That’s because there is a part of your mind that wants to destroy my ability to think because you fear that if I think and share a thought with you, you fear that I am sharing thoughts only so that I can torture you. Just as you try to torture me through sharing your sadism.

He is anxious in social settings because he projects onto other people. Since he is violent, sadistic, and wants to torture people, he projects that others want to do the same. He lives in a world peopled only by predators and prey. Thus, in a social setting, he immediately projects that some people are prey for him (like his therapist) or his projects that the other people are predators out to get him. That’s why he becomes anxious. In therapy, he fears the therapist will be a potential predator since there can be only two roles in therapy in his mind. Thus, he immediately becomes the predator to establish dominance.

He is very free describing his sadism because the description of his sadism in the session has a defensive function: to terrify the therapist, to induce feelings of anxiety, terror, guilt, and revulsion, to induce feelings of helplessness, and to evacuate any feelings he cannot tolerate. Since sharing his sadistic acts has a defensive function, naturally it does not evoke any anxiety or defenses. He tells the therapist there is much worse because it is true, in order to further terrify her and dominate her, and to seduce her into wanting to hear more and thus allow him to continue to torture her.

Can ISTDP help? No. Most psychopaths do not respond to therapy of any kind, much less a short term therapy. A few psychopaths with lower levels of psychopathy may respond to intensive psychoanalytic psychotherapy. But this is rare. As Perry’s recent article in Psychiatry showed, antisocial personality disordered patients rely on omnipotence and denial to ward off their experiences of worthlessness and helplessness. Omnipotence, devaluation, and idealization are their primary defenses. When those fail, these patients resort to acting out to control others so they conform to the projections and devaluation the patient imposes.

When this kind of patient claims he has no feeling, this is not repression of feeling. This is omnipotence: I am above such things. Only other lowly people, like my therapist, have feelings. Any treatment of this kind of patient must begin by assessing whether treatment is possible. Evidence shows that treatment of these patients makes many of them worse. Why? Because they learn emotion language and become more adept at manipulating others.

At this point in the field of psychotherapy, there are a number of disorders that are usually beyond our powers. Antisocial personality disorder is one of them.

— Jon Frederickson
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