chapter 7

I begin discussing the typological categories of personality organization with what are probably the most unpopular and intimidating patients encountered in mental health practice, those who are essentially psychopathic. I am following Meloy (1988) in using the older term for this personality type. The term “antisocial” looks at the phenomenon from the outside, at what is externally visible, with an emphasis on the social consequences of this psychology, whereas I try here to explore the subjective experience and internal dynamics of psychopathic people.

Research has supported Kernberg’s (1984) concept of a range of narcissistic conditions (disorders of the self), with extreme psychopathy on the far end (e.g., Gacano, Meloy, & Berg, 1992). Robert Hare (e.g., Hare et al., 1990) distinguishes true psychopaths from people with antisocial tendencies, using the term “psychopath” to denote only a fraction of the larger spectrum. This is a valuable distinction for research, and one that has had vital practical outcomes such as identifying job applicants who would be disastrous employees. For purposes of discussing dynamics that pervade the antisocial spectrum, however, I use the adjective “psychopathic” more loosely, as equivalent to “antisocial,” and the noun “psychopathy” for the whole antisocial range. But unlike my practice in 1994 and in deference to Hare’s differentiation, I use the noun “psychopath” only for the extreme version of this psychology, and I avoid using “sociopathic,” as that term now suggests a dated distinction.

Although there is overwhelming evidence that extreme psychopaths are not treatable (M. H. Stone, 2000), it is possible to have a therapeutic influence on many individuals with antisocial tendencies. People whose personalities are structured along psychopathic lines range from extremely psychotic, disorganized, impulsive, sadistic people like Richard Chase (Biondi & Hecox, 1992; Ressler & Schactman, 1992), who randomly murdered, dismembered, and drank the blood of his victims (in the delusion that his own blood was poisoned, and he needed it to survive), to urbane, polished charmers like the characters depicted by Babiak and Hare (2007) in their chilling work on American corporate psychopaths: Snakes in Suits. The psychopathic continuum loads heavily in the borderline-to-psychotic direction, because conceptually, the diagnosis refers to a basic failure of human attachment and a reliance on very primitive defenses.

With Bursten (1973a), however, I would argue that there are people in the higher ranges whose personalities show more psychopathy than any other features and who are reasonably construed as high-level antisocial personalities. Such people have enough identity integration, reality testing, and capacity to use more mature defenses to be considered neither borderline nor psychotic, but their core ways of thinking and acting show an antisocial sensibility. Some highly successful people have had an essentially psychopathic outlook; assuming good-enough ego strength, ruthless indifference to others can make competitive achievements easier than they are for those who are capable of loyalty and thoughtfulness.

In 1939, Henderson differentiated between “passive–parasitic” psychopaths and aggressive violent ones. An example of the former would be a developer of a Ponzi scheme who seems to have a warm family and good friendships (at least until the scam is exposed). As a society, we seem to be more taken aback by this more subtle version of psychopathy than by its more aggressive manifestations, but the exploitive orientation toward others is the same. Bursten’s (1973a) criterion for diagnosing a psychopathic person, that his or her organizing preoccupation is “getting over on” or consciously manipulating others, captures the essence of psychopathic psychology. Conceived this way, the diagnosis of characterological psychopathy has nothing to do with overt criminality and everything to do with internal motivation.

The fact that infants differ in temperament from birth (something any parent with more than two children always knew) has now been well established scientifically (Kagan, 1994; Thomas, Chess, & Birch, 1968). Some areas in which infants have demonstrated innate variability include activity level, aggressivity, reactivity, consolability, and similar factors that might tilt development in a psychopathic direction. Early studies of twins and adoptees (e.g., Vandenberg, Singer, & Pauls, 1986) concluded that people who become antisocial may have more constitutional aggressivity than others. In the years since the first edition of this book, there has been an explosion of brain research showing that our prior assumptions about the separability of what is constitutional and what is learned was naive: Genetic dispositions can be skewed by early experience, genes can be turned on or off, brain chemicals are altered by experience, and everything interacts. In a well-designed longitudinal study, Caspi and colleagues (2002) found that people with a variation in the expression of a gene that breaks down norepinephrine and related neurotransmitters (the monoamine oxidase A [MAOA] variation that can have permanent effects on the X chromosome), are much more likely when subjected to maltreatment to develop violent and antisocial patterns (see Fonagy, 2003; Niehoff, 2003).

Early neglect, abuse, and maltreatment can affect the development of the orbitofrontal cortex, which seems to be the moral center of the brain (Damasio, 1994; Martens, 2002; Yu, 2006). Thus, the biological substrate for the high levels of affective and predatory aggression in antisocial people may not directly implicate their genetic heritage, but may still be essentially “hardwired” by the interaction of experience and genes. Antisocial personalities have low serotonin levels, of whatever origin (Coccaro, 1996), and diagnosed psychopaths have remarkably low reactivity of the autonomic nervous system (Intrator et al., 1997; Lykken, 1995), a fact that may explain their sensation-seeking and long-noted “failure to learn by experience” (Cleckley, 1941, p. 368).

Louth, Williamson, Alpert, Pouget, and Hare (1998) found that psychopaths have anomalies in the brain circuitry that underlie linguistic and affective processes, suggesting that extremely antisocial people have not learned about feelings in the relationally grounded way that most of us do. Instead, they acquire emotional speech as a kind of “second language” that is used to manipulate others rather than to express inner states. Psychopathic individuals have poor affect regulation and a higher-than-average threshold for pleasurable excitement (Kernberg, 2005). Whereas most of us can get emotional satisfaction from good music, loving sex, natural beauty, a clever joke, or a job well done, they may need a sharper, more jolting experience to feel alive.

As for the main feelings of psychopathic people, it is hard to specify them because of their inability to articulate emotion. They act instead of talking. They seem to have a sense of basic arousal without the sense of having specific affects. When they do feel, what they experience may be either blind rage or manic exhilaration. In the section on relational patterns in this chapter, I suggest some reasons for what Modell (1975) first described as a “massive affect block.” One way the treatment of psychopathic individuals differs markedly from therapy with people with other personalities is that the clinician cannot expect to make an alliance by reflecting the client’s presumed feelings.

The primary defense in psychopathic people is omnipotent control. They also use projective identification, dissociation, and acting out. The need to exert power takes precedence over all other aims. It defends against shame and, especially in brutal psychopaths, distracts others from seeing the sexual perversions that often underlie criminality (Ressler & Schactman, 1992). The psychopath’s famous absence of conscience (Cleckley, 1941) evidences not only a defective superego (Johnson, 1949) but also a lack of primary attachments to other people. To the deeply antisocial person, the value of others reduces to their utility in allowing one to demonstrate clout.

Psychopathic people will brag outright about their con jobs, conquests, and scams if they think the listener can be thereby impressed with their power. There is nothing unconscious about this process; it is literally shameless. Law enforcement agents are repeatedly astounded at how readily criminals will confess to homicide yet will hide lesser offenses (sexual compulsions, taking a few dollars from a murder victim’s handbag), evidently because these are seen as signs of weakness (N. Susalis, personal communication, May 7, 1993). Kernberg (1984) refers to the psychopath’s “malignant grandiosity,” a phrase that rings true to anyone who has experienced such a person’s effort to triumph sadistically by sabotaging therapy.

It is important to distinguish between psychopathic manipulation and what is frequently labeled manipulation in hysterical and borderline patients. The former is a deliberate, syntonic attempt to use others; the latter makes others feel used, while the patient may be relatively unaware of a specific manipulative intent. As I noted in Chapter 4, I recommend restricting the term “manipulation” to the conscious, intentional psychopathic phenomenon. Hysterical and borderline patients may try to get their needs met by indirect means that exasperate others and provoke attributions of manipulation, but their behaviors have significantly different sources, and they are unconsciously intended to maintain relationships rather than to use others indifferently.

Early observers noted, and more recent research confirms (Robins, Tipp, & Przybeck, 1991), that many psychopathic people—those who have escaped self-destruction and incarceration—“burn out” in middle age, often becoming surprisingly upright citizens. They may become more amenable to psychotherapy then and may benefit from it more than younger people with psychopathic psychologies. This change may reflect hormonal decreases that reduce internal pressures toward action, but it also may reflect the loss of physical power that occurs at midlife. As long as omnipotent defenses are unthwarted by limits, a person’s motivation to develop more mature adaptations is minimal. Older adolescents and young adults of all personality types, especially healthy young men, typically have omnipotent feelings: death is far away, and the prerogatives of adulthood are at hand. Infantile grandiosity is reinforced. (I suspect that one reason psychopathy is more common in men is that females confront realistic limitation earlier: We are less physically strong; we live with the nuisance of menstruation and the danger of pregnancy; we are at greater risk of rape and physical abuse, and as primary caregivers, we are humbled by the discrepancy between our images of ideal maternal effectiveness and the emotional challenges of trying to rear civilized children.) But reality has a way of catching up with us, whatever our early advantages. By middle age, death is no longer an abstraction, physical strength has declined, reaction time is down, health cannot be taken for granted, and the long-term costs of hard living have begun to appear. These facts of life can have a maturing effect, interesting a person in less omnipotent adaptations.

As for projective identification, in psychopathic people a reliance on this process may reflect not only a developmental arrest and reliance on primitive defenses but also the consequences of their inarticulateness and emotional immaturity. Their inability and/or disinclination to express emotions verbally (except to manipulate) means that the only way they can get other people to understand what they are feeling is to evoke that feeling in them. The dissociative defenses of psychopaths are commonly noted but hard to evaluate in specific instances. Dissociative phenomena range from trivial instances of the minimizing of one’s role in some blunder to total amnesia for a violent crime. Disavowal of personal responsibility, which may have a dissociative quality, is a critical diagnostic indicator of psychopathy; the batterer who explains that he and his lover had a “tiff” and he “guesses he lost his temper” or the seemingly contrite cheater who claims to have “used bad judgment in this instance” is showing characteristic minimization. Interviewers who pick this up should ask for specifics: “What exactly did you do when you lost your temper?” or “What exactly did you judge wrong?” (usually the answer to the latter shows regret about getting caught, not remorse about cheating).

When a psychopathic person claims to have been emotionally dissociated or amnesic during some experience, especially during the perpetration of an offense, it is hard to tell whether the experience was in fact dissociated or whether words to this effect are a manipulative evasion of responsibility. Given the frequency of severe abuse in the histories of people diagnosed as antisocial, and given the causal relationship between abuse and dissociation, it would be unimaginable for dissociation not to be a frequent concomitant of a psychopathic personality. Still, the unreliability of accounts by antisocial people makes the topic a vexing one. I say more about this in the differential diagnosis section at the end of this chapter and in Chapter 15.

Acting out is virtually definitional of psychopathy. Not only do antisocial people have an internal goad toward action when aroused or upset, but they also have no experience of the increase in self-esteem that can come from control of impulse. Older clinical literature airs a controversy about whether psychopaths lack anxiety or whether their anxiety is invisible. Greenwald (1974) believed that they do feel anxious but that they act out so fast to relieve themselves of such a toxic feeling that the observer has no chance to see it (and they would never admit to anxiety if asked, as they would see it as “weak”). So far as we can investigate empirically, however, those who saw them as lacking anxiety were more accurate, at least with respect to true psychopaths: Their level of fear and upset tests way below that of nonpsychopathic people; they show no more reaction to a word like “rape” than to a word like “table” (Intrator et al., 1997), and they have virtually no startle response (Patrick, 1994). People with antisocial tendencies who are healthy enough to participate in therapy may have some anxiety, however (Gacano & Meloy, 1991; Gacano, Meloy, & Berg, 1992), and that anxiety may be a motivator that contributes to their capacity to benefit from treatment.

The childhoods of antisocial people are often rife with insecurity and chaos. Confusing amalgams of harsh discipline, overindulgence, and neglect have long been noted in the clinical literature (Abraham, 1935; Aichhorn, 1936; Akhtar, 1992; Bird, 2001; Greenacre, 1958; Redl & Wineman, 1951). Especially in the histories of violent psychopaths, one can find virtually no consistent, loving, protective influences. Weak, depressed, or masochistic mothers and explosive, inconsistent, or sadistic fathers have been linked with psychopathy, as have alcoholism and other addiction in the family. Moves, losses, and family break-ups are common. Under unstable and frightening circumstances like these, the normal confidence in one’s early omnipotent feelings and later in the power of others to protect the young self could not possibly develop normally. The absence of a sense of power at developmentally appropriate times may impel children in this predicament to spend the rest of their lives seeking confirmations of their omnipotence.

Even if they are aware of them, psychopathic people cannot acknowledge ordinary emotions because they associate them with weakness and vulnerability. It is probable that in their families of origin, no one helped them put words to emotional experiences. They have no concept of using language to state feelings and no internalized basis for knowing another role for speech. Clinical observations suggest that in their families, words were used mostly to control others. The deficits of their caregivers in responding to their emotional needs are related to another piece of clinical lore: Children who become psychopathic have often been indulged materially and deprived emotionally. The parents of an antisocial patient of mine used to get her extravagant gifts (a stereo, a car) when she seemed upset. It did not occur to them to draw her out and listen to her concerns. This kind of “generosity” is particularly destructive; in the case of my patient, it left her no way to formulate her lingering sense that there was something missing in her life.

The most penetrating recent psychoanalytic thinking about psychopathy (e.g., Kernberg, 2004; Meloy, 1997) emphasizes the failure (from whatever accidents of temperament and rearing) of attachment and consequent internalization. The antisocial person seems never to have attached psychologically, incorporated good objects, or identified with caregivers. He or she did not take love in and never loved. Instead, identification may have been with a “stranger selfobject” (Grotstein, 1982) experienced as predatory. Meloy (1988) writes of “a paucity of deep and unconscious identifications with, initially, the primary parent figure and ultimately the archetypal and guiding identifications with the society and culture and humankind in general” (p. 44).

Many an adoptive parent has learned the hard way that children from destitute orphanages or other profoundly negligent/abusive backgrounds can have attachment disorders that render them permanently unable to love, no matter how devoted their later care. Young children with such histories often show disorganized–disoriented attachment, or the apparent absence of an internalized, organized attachment strategy (D. Diamond, 2004; Main & Solomon, 1986), in which the object of attachment may also be a source of terror and rage, producing contradictory behaviors such as smiling at the mother and biting her. One subtype of the disorganized–disoriented style is a disorganized–controlling style that shows up by age 6 in some maltreated children (Hesse & Main, 1999) that sounds consistent with long-time observations of psychopathic psychology.

An alternative origin of a character organized around omnipotent fantasies and antisocial behavior is a history in which parents or other important figures were deeply invested in the child’s omnipotence and sent repeated messages that life should pose no limits on the prerogatives of a person so inherently entitled to exert dominance. Such parents, identifying with the child’s defiance and acting out their own hatred of authority, tend to react with outrage when teachers, counselors, or lawenforcement agents try to set limits on their youngster. Like all character types, psychopathy can be “inherited” in that the child imitates the defensive solutions of the parents. When the main source of someone’s characterological psychopathy is parental modeling and reinforcement of manipulative and entitled behavior, the prognosis is probably better than when the condition is rooted in chaos and negligence. At least the child of indulgent, corrupting parents has succeeded in identifying with someone and has some capacity to connect. It may be that this kind of family breeds healthier people with antisocial trends, and that more traumatic backgrounds breed more deeply disturbed individuals, including true or primary psychopaths.

One biological substrate of a disposition toward psychopathy is a degree of aggression that would make a child difficult to calm, comfort, and mirror. Children who are innately hyperactive, demanding, distractible, and headstrong need much more active, energetic parenting than placid, easily consoled youngsters. They also arguably need much more direct involvement by a father figure than most preschoolers in Western societies get (Cath, 1986; M. J. Diamond, 2007; McWilliams, 2005a; J. Shapiro, Diamond, & Greenberg, 1995), and would probably benefit from additional caregivers as well. I have known highly aggressive children who were observably too much for one parent but who attached firmly if provided with enough stimulation and loving discipline. Given contemporary Western cultural assumptions that a single parent is adequate, we may be raising many more psychopaths in this part of the world than we would otherwise see.

Sociological conjectures aside, the condition of being viewed from day one as a problem child would make it very hard for a potential psychopath to find self-esteem via the normal route of feeling the caregivers’ love and pride. When outside objects fail, the only object to invest in emotionally is the self and its personal power. Self-representations may be polarized between the desired condition of personal omnipotence and the feared condition of desperate weakness. Aggressive and sadistic acts may stabilize the sense of self in a psychopathic person by both reducing unpleasant states of arousal and restoring self-esteem.

David Berkowitz, the “Son of Sam” serial killer, began his murders of women after learning that his biological mother was something of a slattern rather than the elevated figure of his imagination (Abrahamsen, 1985). An adoptee, he had attached his self-esteem to the fantasy of having a superior “real” mother, and when this illusion was shattered, he went on a rampage. Similar connections between a crime spree and some blow to grandiosity have been noted in many sensational cases, but observation of manipulative people in ordinary life suggests that this pattern in its essentials is not limited to psychopathic killers. Anyone whose fondest images of self reflect unrealistic notions of superiority, and who runs into evidence that he or she is only human, may attempt to restore self-esteem by exerting power.

In addition, the more chaotic the environment of a child, and the more exhausted or inadequate the caregivers, the more likely it is that the youngster will not run into effective limits and will not have to take seriously the consequences of impulsive actions. From a social learning theory point of view, grandiosity in a child would be the expectable result of an upbringing that lacks consistent discipline. The condition of having much more energy than one’s caregiver would teach the lesson that one can ignore the needs of others, do whatever feels compelling at the time, and handle any adverse consequences by escaping, dissimulating, and seducing or bullying others.

One other feature of self-experience in the psychopathic patient that deserves mention is primitive envy, the wish to destroy that which one most desires (Klein, 1957). Although antisocial people rarely articulate envy, many of their behaviors demonstrate it. One probably cannot grow up unable to love without knowing that there is something out there that other people enjoy that one lacks. Active devaluation and depreciation of anything in the tenderer realms of human life are characteristic of antisocial people at all levels of severity; those in the psychotic range have been known to kill what attracts them. The serial killer Ted Bundy, for example, described his need to destroy pretty young women (who, others noted, resembled his mother) as a kind of “owning” them (Michaud & Aynesworth, 1983). The killers portrayed in Truman Capote’s In Cold Blood (1965) exterminated a happy family “for no reason” except presumably that they were a happy family toward whom the exterminators could not bear to feel their consuming envy.

The psychopathic person’s basic transference to a therapist is a projection of his or her internal predation, the assumption that the clinician intends to use the patient for selfish purposes. Not having had any emotional experience with love and empathy, the antisocial patient has no way to understand the generous aspects of the therapist’s interest and will try to figure out the practitioner’s “angle.” If the patient has reason to believe that the therapist can be used to promote some personal agenda (such as giving a good report to a judge or probation officer), he or she may be uncannily charming, so much so that an inexperienced clinician may be taken in.

The usual countertransference to the patient’s preoccupation with using the therapist or outsmarting the therapist’s presumably exploitive agenda is shock and resistance to the sense that one’s essential identity as a helper is being eradicated. The naive practitioner may succumb to the temptation to try to prove helpful intent. When that fails, hostility, contempt, and moralistic outrage toward the psychopathic person are common reactions. These “unempathic” feelings in ordinarily compassionate people should be understood, paradoxically, as a kind of empathy with psychopathic psychology: The client is unable to care about the therapist, and the therapist finds it almost as hard to care about the client. Outright hatred of the patient is not uncommon, and is no cause for worry, since the capacity to hate is a kind of attachment (Bollas, 1987). If one can tolerate the experience of internal coldness and even hatred, one will get an unpleasant but useful glimpse of what it is like to be a psychopathically organized person.

Other common countertransference reactions are complementary rather than concordant (Racker, 1968; see Chapter 2) and chiefly involve fear of a peculiarly ominous kind. People who work with psychopaths frequently comment on their cold, remorseless eyes and worry that such patients have them “under their thumb” (Meloy, 1988). Eerie forebodings are common. Again, it is important that the clinician tolerate these upsetting reactions rather than try to deny or compensate for them, since minimizing the threat posed by a true sociopath is highly unwise (both realistically and because it may prompt the client to demonstrate his or her destructive power). Finally, the experience of being actively, even sadistically depreciated can provoke intense hostility or hopeless resignation in the clinician. Awareness that devaluing messages constitute a defense against envy is cold intellectual comfort in the face of a psychopath’s unmitigated scorn, but it helps.

In light of the bad reputation of antisocial patients, I should say at the outset that I have known of many psychopathic people who were helped by psychotherapy. The therapist cannot be grandiose, however, about how much can be accomplished, and more than with individuals in other diagnostic categories, it is critical that a careful assessment be done to see whether or not any individual psychopathic patient is treatable. Some are so damaged, so dangerous, or so determined to destroy the therapist’s aims that psychotherapy would be an exercise in futility and naiveté. Meloy (1988) makes a key distinction between the roles of evaluator and therapist, a discrimination that is unnecessary with patients of most other character types, since they lack the psychopath’s aim of defeating the clinician. Meloy’s explanation of the phenomenon of therapeutic nihilism (Lion, 1978) fits my own experience:

It is the stereotypical judgment that all psychopathically disturbed individuals, or antisocial personality disorders, as a class, are untreatable by virtue of their diagnosis. Such a judgment ignores both individual differences and the continuous nature of severity of psychopathology. I have most commonly observed this reaction in public mental health clinicians who are assigned patients on referral from probation, parole, or the court; and assume, because of the coercive nature of the treatment referral, that ... any psychotherapeutic gain is impossible.

Such reactions are often the product of attitudes that have been internalized as an “oral tradition” during training from senior, teaching clinicians. They are rarely the product of direct, individual experience. It is, in a sense, a mass retaliatory attitude where moral judgment impinges on professional assessment. The behavioral pathology of the psychopath, to devalue and dehumanize others, becomes the concordant identification of the clinician doing to the psychopath what the clinician perceives the psychopath doing to others. (Meloy, 1988, p. 325)

Karon and VandenBos (1981) made a comparable critique of the equally prevalent, empirically unsupported belief that schizophrenia is not treatable; psychopathic patients at a psychotic level of personality organization thus may have two strikes against them.

Attitudes about the inherent untreatability of all psychopathic individuals may also reflect the fact that in most training programs—even those that send their students into internship and practicum placements at jails, youth correctional facilities, and drug treatment centers that contain many psychopathic people—very little if any attention is paid to the development of the skills appropriate for this group. When new therapists fail using approaches that are effective with other populations, they may blame the patient rather than the limitations of their training.

The assessment of treatability is beyond the scope of this text, but I recommend using Kernberg’s structural interview (B. L. Stern et al., 2004) to evaluate whether psychotherapy should be undertaken with any particular psychopathic person. DSM-IV is not useful here. Its criteria for antisocial personality disorder were normed on prison inmates and developed with researchers rather than therapists in mind. With the exception of lack of remorse, DSM-IV criteria for assessing antisocial personality disorder are all factors that can be observed externally by the clinically untrained; they do not necessarily pick up critical internal, subjective states. Hence, they tend to overdiagnose people with backgrounds of poverty, oppression, and marginality (who may run afoul of authorities for many reasons other than their individual psychology) and to underdiagnose successful, socially prominent psychopaths. As I write this, it appears that in DSM-5, antisocial psychology will be reframed as on the narcissistic spectrum and may be defined more internally.

Once one has decided to work with a psychopathic person—or has realized that a current patient is significantly antisocial—the most critical feature of treatment is incorruptibility: of the therapist, the frame, and the conditions that make therapy possible. It is much better to err on the side of inflexibility than to show, in the hope that it will be seen as empathy, what the client will see as weakness. Psychopathic people do not understand empathy. They understand using people, and they will feel a sadistic triumph over, not a grateful appreciation for, a therapist who wavers from the boundaries of the treatment contract. Any behavior that can be interpreted as weakness and vulnerability probably will be. Anthony Hopkins gave a chilling portrayal of the psychopath’s talent for finding someone’s Achilles’ heel in his character’s manipulation of the detective played by Jodie Foster in The Silence of the Lambs. The writers of the television series Dexter have clearly done their homework; like the authors of The Sopranos, they have managed a plot device that allows the viewer to care about a lead character who has extreme but not total psychopathy. Dexter is capable of some attachment, but the portrayal of his internal world through his voiceover comments shows a lot about the emotional limitations of the significantly antisocial person.

It is unrealistic to expect love from antisocial people, but one can earn their respect by coming across as tough-minded and exacting. When I work with psychopathic patients, I insist on payment at the beginning of each session and send the client away in its absence—no matter how reasonable the explanation offered. Like most therapists who were taught to bend over backward to consider the special needs of each client, I had to learn from experience that not bending at all is the right response to the needs of the antisocial patient. Early in therapy I do not analyze such patients’ assumed motives for testing the solidity of the contract, I merely remind them that our deal was that they would pay up front, and I repeat that I will hold up my end of the deal—the application of my expertise to help them understand themselves better—if they hold up theirs.

Related to incorruptibility is uncompromising honesty: talking straight, keeping promises, making good on threats, and persistently addressing reality. Honesty includes the therapist’s private admission of intense negative feelings toward the patient, both countertransferences and realistic perceptions of danger. If such reactions are denied, countertransferences may be acted out and legitimate fears may be minimized. To treat psychopathic clients we must make peace with our own antisocial tendencies so that we have a basis for identifying with the patient’s psychology. With respect to money discussions, for example, we should nondefensively admit selfishness and greed when giving a rationale for the fee. Some therapists cannot work with psychopathic people, as they cannot find in themselves enough antisocial features to permit any sense of commonality.

Except for admissions like the above that legitimately pertain to the therapeutic contract, honesty does not mean disclosure; self-revelation will only be interpreted as frailty. Nor does it mean moralizing. When considering the patient’s destructive actions, it is futile to invite the expression of assumed feelings of badness or guilt. The patient lacks a normal superego and probably committed the sins in order to feel good (omnipotent) rather than bad (weak). One must restrict oneself to addressing the possible realistic outcomes of amoral behavior. Probes into presumed struggles with conscience tend to evoke responses like the one attributed to Willie Sutton when he was asked why he robbed banks: “Because that’s where the money is.”

The therapist’s unrelenting emphasis on the realistic risks of each grandiose design need not be humorless just because the matters at hand have serious consequences. One of my colleagues, a woman renowned for her talent with antisocial clients, reports the following banter with a court-remanded car thief:

“The man was explaining to me how brilliant his scheme had been for the heist he had almost pulled off, how if only one little unforeseen thing hadn’t happened, it would have been the perfect crime. As he talked, he was getting more and more excited and animated, and I agreed with some admiration that he had almost gotten away with the theft. It started to feel like we were co-conspirators. Eventually, he got so carried away that he asked, ‘Would you do something like that?’

“ ‘No,’ I answered.

“ ‘Why not?’ he asked, a little deflated.

“ ‘Two reasons,’ I said. ‘First, there’s always some little thing that can go wrong, even with a brilliant plan. Life isn’t that controllable. And then I’d be in jail, or in a mental hospital involuntarily, like you are, talking to some shrink I didn’t choose myself. And second, I wouldn’t because I have something that you don’t: a conscience.’

“ ‘Yeah,’ he said. ‘You know how I could get one of those?’ ”

Of course, the first step in developing a conscience is to care about someone to the degree that that person’s opinion matters. Without moralizing, the therapist moves the patient along toward more responsible behavior simply by being a consistent, nonpunitive, nonexploitable object. Harold Greenwald (1958, 1974), who worked with antisocial people in the Los Angeles underworld, described how he would connect with psychopaths in terms that they could understand. He reasoned that since power is the only quality antisocial people respect, power is the first thing the therapist must demonstrate. He gives the following instance of claiming his own power:

A pimp came to see me and started to discuss his way of life. He said, “You know I’m ashamed to show myself and so on, but after all, it’s a pretty good way to live and most guys would want to live that way, you know, to live as a pimp. It’s not bad—you get girls out hustling for you—why shouldn’t you do it? Why shouldn’t anybody do it?” I said, “You’re a jerk.” He asked why. I replied, “Look, I live off the earnings of call girls. I wrote a book about them; I got respect for it; I got famous from it; they made a movie out of it. I made much more money off call girls than you ever will, and you, you schmuck, you can get arrested any day and be sent to jail for ten years, whereas I get respect, honor, and admiration.” This he could understand. He saw that somebody whom he considered similar to him had a superior way of accomplishing the same ends. (1974, p. 371)

Greenwald has his own free-wheeling but still essentially incorruptible style with psychopathic patients. He is not the only therapist who has discovered the utility of “outpsyching the psychopath” or “conning the con” as a way of demonstrating that he deserves respect. Like my colleague previously quoted, he can own enough psychopathic impulses in himself that he does not feel fully alienated from the emotional world of his clients. Tellingly, he reports that in the second or third year of intensive treatment with him, psychopathic patients often go into a serious, even psychotic depression. He sees this as evidence that they have started to care about him in a genuine way rather than as an object to manipulate and, realizing this, they descend into a state of misery about their dependency. This depression, which only slowly lifts, compares in its essentials to Klein’s (1935) description of the feelings of infants in the second 6 months of life, when the child makes the painful discovery that the mother exists as a separate person outside the baby’s control.

In contrast with appropriate therapy with people of other diagnoses, the therapist of a psychopathic client may have to adopt an attitude of independent strength verging on indifference. I assume this applies to cognitive-behavioral therapies, some of which have shown promise with this population (M. H. Stone, 2000), as well as to analytically informed ones. One cannot seem emotionally invested in the patient’s changing, because as soon as an antisocial person sees that need, he or she can sabotage psychotherapy to demonstrate the clinician’s impotence. It is better to invest in simply increasing one’s understanding, setting the tone that one will do one’s job competently, and to communicate that it is up to the patient to take advantage of therapy or not. This principle is analogous to the lesson every police officer learns about investigating a crime: Never show the suspect that it is important to you to get a confession.

The most skilled interviewer of antisocial people I know was for a long time the chief of detectives in my town, a man with an exceptional record of evoking confessions—often movingly tearful ones—from rapists, child torturers, murderers, and serial killers. Listening to tapes of his interrogations, one is struck by his attitude of respect and his quiet conviction that even the most monstrous perpetrator has a need to tell someone the truth. The suspects’ responsiveness to being treated with dignity is poignant—the more so in light of their knowledge that the interviewer’s agenda is to prosecute. No one interrogated by him has ever complained of betrayal, even as he testifies against them in court on the basis of their confession. “He treated me fair,” they report.

These phenomena raise the question of whether the fabled callousness of the psychopath is a response to environments that are either abusive (as was childhood, later replicated by a savage subculture) or incomprehensible (as is a therapist’s wish to help). The fact that these perpetrators are palpably relieved to confess to someone who wants to incarcerate them suggests that even an incorrigible felon may have a primitive sense of accountability and can gain something from a relationship. The sadistic murderer Carl Panzram (Gaddis & Long, 1970) had a lifelong friendship with a prison guard who once showed him ordinary kindness. Rigorous tough-mindedness and rock-bottom respect seem to be a winning combination with antisocial people. (This observation does not equate to an argument for “leniency” toward dangerous criminals. Understanding that psychopathic people are human beings who may be helped to some degree should not be confused with wishful thinking that therapy can transform a compulsive killer into a model of citizenship. The public needs protection from antisocial people whether or not their crimes are comprehensible psychodynamically and whether or not they can profit from a therapeutic relationship.)

The overall aim of work with a psychopathic individual is to help the patient move toward Klein’s depressive position, in which others are seen as separate subjects worthy of concern (Kernberg, 1992). Over the course of treatment, as the psychopathic person’s omnipotent control, projective identification, domination by envy, and self-destructive activities are dispassionately examined in an atmosphere of consistency and respect, the patient will in fact change. Any shift from using words to manipulate to using them for honest self-expression is a substantial achievement, one that may occur simply through the antisocial person’s repeated exposure to someone with integrity. Any instance where the client inhibits an impulse and learns something about pride in self-control should be seen as a milestone. Since even a small movement toward human relatedness in a psychopath may prevent an immense amount of human suffering, such progress is worth every drop of sweat the practitioner secretes in its service.

It is not usually hard to spot the antisocial features in any client whose personality has a psychopathic component. Whether those features are central enough to define the person as characterologically psychopathic is a more subtle question. Psychologies that can easily be misunderstood as essentially antisocial include paranoid, dissociative, and narcissistic conditions. The behavior of addicted individuals often mimics psychopathy. In addition, some people with hysterical personalities become misdiagnosed as psychopathic, a topic I discuss in Chapter 14.

There is considerable overlap between predominantly psychopathic psychologies and those that are more paranoid; many people have a lot of each sensibility. Both antisocial and paranoid people are highly concerned with issues of power, but from different perspectives. Unlike psychopaths, people with essentially paranoid character structure have profound guilt, the analysis of which is critical to their recovery from suffering. Thus, it is vital to assess with anyone who has both paranoid and psychopathic features which tendencies predominate.

There is also considerable overlap between psychopathic and dissociative conditions. It is critical for an interviewer to evaluate whether a patient is a basically psychopathic person who uses some dissociative defenses or whether he or she has a dissociative psychology with one or more antisocial or persecutory alter personalities. The prognosis for the former kind of patient is guarded, whereas many essentially dissociative people, when accurately diagnosed, respond favorably to therapy. Unfortunately, this evaluation can be exceedingly difficult, even when done by an expert. Both primarily dissociative and primarily psychopathic people have a deep distrust of others, and for different reasons (terror of abuse vs. omnipotent triumph), both may dissimulate, comply superficially, and subvert the therapist.

I do not recommend trying to make this differential diagnosis when some important consequence hinges on it—for instance, when a man who has committed homicide may plead not guilty by reason of insanity if he can convince a professional that he has dissociative identity disorder. The differential diagnosis is hard enough without that complication, although regrettably, it is such a pivotal legal distinction that evaluators are working to develop procedures to make it more reliable. Even trained forensic psychologists have a tough time with these calls. I say more on this differential in Chapter 15.

Finally, there is a close connection between psychopathic and narcissistic conditions: there is a continuum from minor narcissism through malignant narcissism to outright psychopathy. Both predominantly narcissistic and predominantly psychopathic people have a subjectively empty internal world and a dependence on external events to provide self-esteem. The dimensional formulation, originally suggested by Kernberg (1984), has always made sense to me and now has enough recent research support that, as of the time I write, the authors of DSM-5 are planning to put these disorders of self on one spectrum. But I would also suggest that antisocial and narcissistic people are different enough to warrant thinking in terms of a continuum for each.

Most psychopathic individuals do not idealize repetitively, and most narcissistic ones do not depend on omnipotent control. Many people have aspects of both character types, and self-inflation can characterize either one, but prognosis improves in inverse relation to the psychopathic pole. Because treatment considerations are quite different for the two groups (e.g., sympathetic mirroring comforts most narcissistic people but antagonizes antisocial ones), despite the things they have in common and the number of people who have aspects of each orientation, it seems to me clinically useful to differentiate carefully between them.

People struggling with substance use disorders are notoriously manipulative and exploitive, as the addictive substance becomes more important to them than human relationships or personal integrity. Because of their antisocial behavior, observers commonly infer that their personalities are psychopathic. Although some addicted people may be characterologically antisocial, the personality organization of substance abusers cannot be inferred reliably until the interviewer has obtained reliable information about their behavior prior to their addiction or until they have been in recovery for a considerable length of time and their basic personality has emerged.

In this chapter I portrayed the psychopathic personality as expressing an organizing need to feel one’s effect on other people, to manipulate them, to “get over on” them. I summarized some constitutional predispositions to antisocial behaviors and mentioned the rage and mania that may briefly interrupt the affect block characteristic of antisocial persons. I discussed psychopathy in terms of the defenses of omnipotent control, projective identification, dissociation, and acting out; of object relations marked by instability, pandering, emotional misunderstanding, exploitation, and sometimes brutality; and a self-structure dominated by grandiose efforts to avoid a sense of weakness and envy. I mentioned putatively unempathic transference and countertransference reactions and stressed the importance of the therapist’s incorruptibility, consistency, and self-conscious renunciation of the need to be seen as helpful. I differentiated psychopathic character from paranoid, dissociative, and narcissistic psychologies, and from the consequences of addiction.

Unfortunately, texts on psychotherapy as a general process rarely give psychopathic clients much attention, and there is a relative paucity of good analytic literature on this group. For an excellent collection of seminal psychoanalytic articles on psychopathy, I recommend Meloy’s edited collection, The Mark of Cain (2001). Bursten’s study The Manipulator (1973a) and Meloy’s The Psychopathic Mind (1988) are comprehensive and readable explorations with some attention to therapy issues. Akhtar also has a good chapter on the topic in Broken Structures (1992). Hare’s Without Conscience (1999) is excellent, and his account with Babiak of Snakes in Suits (2007) is compelling.