Personality disorders are typically some of the most challenging mental disorders to treat, since they are, by definition, an integral part of what defines an individual and their self-perceptions. Treatment most often focuses on increasing coping skills and interpersonal relationship skills through psychotherapy.
Antisocial Personality Disorder
Because the main features of this personality disorder revolve around a pervasive lack of remorse or lack of exhibiting any feelings at all, they are assumed by many to not have any real feelings. Even professionals working with those with Antisocial personality disorder can become quite frustrated in the therapy process wondering how to work with a person who seems to neither show nor have any emotions, especially feelings of guilt after having done something wrong. This dynamic can lead to difficulties within treatment.
As with all of the personality disorders, there is a broad range in which this personality pattern can manifest. While it tends to be most common amongst those who run into trouble with the law, there are those individuals with a milder form whom we may know as the politician who feels comfortable lying continuously to the public, or the neighbor next door who constantly cheats on his wife, gambles away the family money, and runs a shady business operation cheating others out of their money. However, for the purposes of this treatment section, we will keep it simple by focusing on those who have more moderate to severe forms of antisocial personality disorder and have developed a criminal history.
Psychotherapy is nearly always the treatment of choice for this disorder; medications may be used to help stabilize mood swings or specific and acute Axis I concurrent diagnoses. There is no research that supports the use of medications for direct treatment of antisocial personality disorder, though.
As with most personality disorders, individuals with this disorder rarely seek treatment on their own, without being mandated to therapy by a court or significant other. Court referrals for assessment and treatment for this disorder are likely the most common referral source. A careful and thorough assessment will ensure that the person has antisocial personality disorder. This can often be confused with simple criminal activity (all criminals do not have this disorder), adult antisocial behavior, and other activities that do not justify the personality disorder diagnosis. As with a thorough assessment of any suspected personality disorder, formal psychological testing should be considered invaluable.
Because many people who suffer from this disorder will be mandated to therapy, sometimes in a forensic or jail setting, motivation on the patient's part may be difficult to find. In a confined setting, it may be nearly impossible and therapy should then focus on alternative life issues, such as goals for when they are released from custody, improvement in social or family relationships, learning new coping skills, etc. In an outpatient setting, the focus of therapy can also be on these types of issues, but a part of the therapy should be devoted to discussing the antisocial behavior and feelings (or lack thereof). Common in the population who suffer from antisocial personality disorder is the lack of connections between feelings and behaviors. Helping the client draw those lines between the two may be beneficial.
Threats are never an appropriate motivating factor in any sort of treatment, and least of all with this disorder. If the only way to motivate the patient is to threaten to report their noncompliance with therapy to the courts or warden, it is highly unlikely the clinician will make any type of gains within therapy anyway. It is appropriate, however, to try and help the individual with this disorder find good reasons that they may want to work on this problem further. For instance, ensuring that they not come into contact with the court system again, be incarcerated, have to submit themselves to additional psychological examinations, etc.
Effective psychotherapy treatment for this disorder is limited. It is likely, though, that intensive, psychoanalytic approaches are inappropriate for this population. Approaches that reinforce appropriate behaviors and attempting to make connections between the person's actions and their feelings are more beneficial. Helping the patient to gain greater accessibility to his/her emotions and to identify them are usually key aspects of treatment of this disorder. Also, since these patients often have had little or no significant emotionally rewarding relationships in their lives, the therapeutic relationship can be one of the first ones. This can be very scary for the client, initially, and it may become intolerable. A close therapeutic relationship can only occur when a good and solid rapport has been established with the client and he or she can trust the therapist implicitly.
Trust brings up the issue of confidentiality since often the patient with antisocial personality disorder is mandated to therapy. This means that the clinician may have to occasionally report on the patient's progress in therapy. While this can usually be done in a very general way, which reveals no significant details of the content of therapy, it is still an important issue for the client. He or she may be suspicious and distrustful of the clinician at first, since it will be unclear as to who has the highest priority -- the patient or the court. This fear can only be alleviated with an honest disclosure as to what the therapist will reveal to the courts, and with time, as the client learns that what he says in the therapy session does not become common knowledge. The limitations of therapy should be discussed with the patient up-front, in a clear and matter-of-fact manner, so there are no misunderstandings later.
The content of therapy should focus on the patient's emotions (or lack thereof). As the individual learns to experience various emotional states, one of the first may be depression. The client will likely be unfamiliar with the feelings associated with depression, and so it is beneficial for the clinician to be supportive and empathetic to the individual during this time. Reinforcing any emotions, outside of anger or frustration, is usually beneficial. Experiencing intense affect is usually a sign of progress in therapy. Staying on "safe issues," and discussing more real-life concerns, while one way of treating this disorder, is not likely to be as effective in long term behavioral change as an approach emphasizing the discovery and labeling of appropriate emotional states.
People who have antisocial personality disorder often experience difficulties with authority figures. The therapist should usually take a neutral stance in this matter, since it is a firmly held belief by the client. The clinician should avoid arguments and taking sides on authority issues and those who hold authority over the client. Their moral and ethical makeup may leave a lot to be desired as well. While this may be an appropriate topic for discussion in therapy, it will also likely be one of little progress. Usually one of the more effective ways for a person with this disorder to learn to change their ineffective behaviors is to have to face up to the consequences of their behavior. This sometimes means dealing with courts and jails, but it can also eventually be a motivating factor in the client's treatment.
Other modalities of psychotherapy, such as group and family therapy, can be helpful. Often people with this disorder find themselves in a group setting, because they aren't given any treatment choices. This is usually not conducive to their treatment, since in most groups, the individual can remain emotionally closed and has little reason to share with others. It also doesn't help that these groups are often made up of people suffering from a wide range of mental disorders. Groups that are devoted exclusively to this disorder, though rare, are the best choice. In such a group, the patient is given a greater reason to contribute and share with others. Care must be utilized by group leaders to ensure that the group doesn't become a "How-to" course in criminal behavior.
Family therapy can be helpful to increase education and understanding among family members. Families often misunderstand and are confused about the cause of the antisocial behaviors and the idea that it is a mental disorder. Phillip W. Long, M.D. adds, "This confusion, guilt, the temptation to make restitution for the patient's criminal acts, and the frustrations of working with someone who is seen to be quite ill but who will not be treated should all be discussed openly with family members."
Rarely is inpatient care appropriate or necessary for this personality disorder. Like most personality disorders, most people will go through their lives with little realization of the difficulty they have. In this case, though, the person is more likely to be seen as a criminal and have a history of difficulties with the law. Loss of freedom may be more of a motivating factor than in other personality disorders, so some specialized treatment facilities have started to treat people with this disorder.
One such program we've read about is the Patuxent Institute, located in Jessup, Maryland in the U.S. This hospital utilizes a strict behavioral approach of placing patients on a token economy based upon their treatment progress. This is a relatively new and radical approach to this sort of disorder and little research has been conducted to confirm its long-term effectiveness.
As with any treatment, the focus on feelings and connecting antisocial behavior to appropriate feeling states is appropriate. Since inpatient programs tend to be more intensive and expensive they are rarely sought out by the patient themselves. Community follow-up and support, either by the hospital or professionals, or with the use of self-help support groups, is imperative to maintaining treatment gains.
Medical doctors will typically use psychiatric medications to treat mood and disordered behavior symptoms (e.g., depression, poor sleep), and disorganized thought processes (looseness of thought) that are associated with the Personality Disorders. Please see the Medicines section of a Treatment section associated with the symptoms you are interested in learning about for more information. For example, to learn about the medical treatment of depression associated with Antisocial Personality Disorder, please visit our Depression Center. .
The medical profession often overlooks self-help methods for the treatment of this disorder because very few professionals are involved in them. Groups can be especially helpful for people with this disorder, if they are tailored specifically for antisocial personality disorder. Individuals with this disorder typically feel more at ease in discussing their feelings and behaviors in front of their peers in this type of supportive modality. Leaders of such self-help support groups, though, must be wary of individuals who come to group just to brag about their exploits and who may seek to use the group inappropriately. Usually a group can be very helpful and beneficial to most people with this disorder, once they overcome their initial fears and hesitation to join such a group. Many support groups exist within communities throughout the world, which are devoted to helping individuals with this disorder share their common experiences and feelings.
Portions are from Internet Mental Health, Copyright © 1995-1996 by Phillip W. Long, M.D.