It may be useful to consider whether the antisocial actions are ‘reactive’, or ‘impulsive’ (far more common) on the one hand, or predatory, and potentially, therefore, far more complicated to manage on the other. Patients with severe borderline or psychotic states, those who rely on alcohol and drugs for their ‘defenses’, or those who have been grossly emotionally neglected or severely abused as children need especially careful assessment. A history of decompensations in the past—into violence or suicidal behavior—should be taken seriously. Essentially the question is ‘what sort of psychotherapy might prove effective?’ rather than a purist assessment that finds the subject unsuitable and is therefore likely to exclude the majority. Put another way, the assessor needs to consider positive aspects of the person that may be helpful to grow, as well as negative features.

There has been considerable work on the establishment of a therapeutic alliance with people with ASPD (see, e.g., Gerstley et al., 1989); that alliance is necessary, and a significant predictor of outcome. It is also true that the creation of the therapeutic alliance depends greatly upon the skills of the therapist, and upon his correct assessment of the appropriate mode of psychotherapy. Psychodynamically, one may ask oneself, what are the ego strengths that can ‘contain’ the anxiety that may arise from exploratory, in-depth psychoanalytic psychotherapy? Related to this, to what extent is nonexploratory, supportive psychotherapy, which accepts and seeks to buttress defenses, preferable in a given psychologically fragile case?

One particular danger is that of the severely narcissistic, envious patient, who may initially idealize the therapist by a process of profound splitting. He may experience the therapist, later, as withholding from him what he is certain would be his ‘cure’ and ‘salvation’. In ordinary psychiatric practice these patients may actually engage the therapist in excessively long interviews, as idealization of the health professional—yet disappointment with the ordinariness of what they seem to offer—becomes increasingly a provocation; the longer the interview goes on the greater the perceived withholding.

These patients underline the general rule of establishing set parameters of time for each session, which may be anything up to 2 hours for assessment, and from half an hour, up to an hour, for therapeutic sessions. The frequency of sessions may also vary from the more usual pattern of once or twice weekly, to once every 2 weeks (or even less frequency) for those who are psychologically fragile and cannot cope with interpretive psychotherapy, but instead need psychological support.

Much of the published literature assumes or implies a highly defensive and suspicious posture from the therapist, which may be an ‘acting out’ of a paranoid countertransference—even to the stereotype or ‘idea’ of the patient with ASPD. Aside from this suspiciousness of ‘dangerousness’, the potential therapist may come with a particular, and excessive expectation of the potential (and need) for the ASPD person to deceive or lie; after all, ‘deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure’ is one of the criteria—but, note, not a necessary criterion—for the DSM-4-R diagnosis of this disorder.

Frequently the apparent or real need to ‘deceive’ or ‘lie’ is actually a primitive defense at an unconscious level. Thus it may be (for example, by splitting and projection) a part of the covert psychopathology, i.e., that of the denial of psychic and actual reality, e.g., despair and bleakness too painful to experience directly, and not consciously mendacious at all. When deceit and lying do occur they need understanding and interpreting and should not—at least until a fair trial has been made—be assumed to be a contraindication to further therapy.

By contrast, one may be impressed by a naive honesty in some ASPD patients—itself possibly indicative of raw unsublimated id, as well as super-ego function—in which one may even feel, in the countertransference, they need protection from for themselves, particularly if they are in positions of potentially implicating themselves in further crime. Such patients may often be especially motivated to engage in treatment, offering the possibility of escaping from their cycle of offending. The human tendency towards repetition, in all its aspects, is however, an ever-present hazard.

The question of the psychotherapists’ attitude in these matters is all important. The stereotype of the universality of deceitfulness and ‘conning’ in ASPD patients can lead to an attitude of nihilism, both within therapeutic services and for the individual clinician. For example, a prison medical officer said—without a hint of apparent shame and with self-satisfied confidence; ‘personally I don't believe a word any of them (i.e., of the prisoners in his care) say’. A more sophisticated and necessary therapeutic position is to offer a trusting and listening ear, for both conscious and subtextual (less conscious and unconscious) communications, giving the benefit of the doubt, but with part of one's mind nevertheless prepared for not always being told the entire truth. It may even be helpful to tell the patient that this is one's position. Often such an intervention is met by considerable relief and greater use of the therapeutic relationship.

In arguing for emotional openness of the therapist to the person with ASPD we are not, of course, advocating collusion with severely psychopathic manipulative patients; but the experienced (and well supervised) therapist will (ideally) be able to keep these extreme possibilities in mind without polarizing the issues. It has been commented often that meeting the personality disordered individual in a withdrawn and emotionally defensive manner is antitherapeutic and, indeed, most likely mirrors the experience that engendered his problems, and with which he is only too familiar within his day to day life.

Gabbard (1994) offered six recommendations for the therapist who wishes to work with ASPD:

• ‘He (or she) must be incorruptible, stable and persistent’—and we would add always honest dealing and speaking. Many personality disordered patients, especially those with psychotic or prepsychotic structures, are highly attuned to factual and emotional truths or untruths by others.

• ‘He should be “willing to confront” the patients’ denial or minimization’—we would use the word ‘interpret’. Confrontation, while sometimes necessary, is more likely to mobilize defenses further and therefore prove counterproductive.

• ‘He should help the patient link his or her actions with his internal (emotional/attitudinal) states’.

• He should ‘confront the here and now behaviors’.

• ‘He should monitor countertransference so as to avoid “inappropriate” responses’.

• He should ‘avoid excessive expectations of improvement.’

While these recommendations are helpful, the reader will judge for him/herself whether they betray an excessive circumspection or a realistic one. The fine line between the psychotherapists’ judicious caution on the one hand, and excessive suspicion and emotional withdrawal on the other is a difficult one, but is crucial.

That said, there is no place for the inexperienced, untrained, or unsupervised to take on ASPD clients in psychotherapy. Fatalities have occurred (see, for example, Travers, 1994); the emotional and psychological toll is to an extent universal.

The sensitivity of the ASPD personality to perceived rejection or criticism cannot be overestimated. Thus, even more than usual, the therapist must work to engage the patient by his reliability, and by his sensitivity to potential causes of the patients’ ‘acting out’, e.g., by an excessive number of missed appointments. Holidays should be flagged up well in advance; in the early stages of engagement it is best to avoid any break or interruption of sessions altogether.

For example, a man who had been in prison for 25 years (since his teens) was referred to a therapist who agreed to see him once weekly. The patient felt disappointed, wanting more frequent sessions. These were offered then—twice weekly. For the next 3 weeks the patient did not attend, but attended on the fourth. The therapist felt that he had been ‘manipulated’ and then rejected. He had fortunately kept the treatment sessions open, and was able to engage the patient, despite continuing ‘shows’ of apparent ‘rejection’ of treatment by the patient. In this the patient was attempting to display a lack of need for a therapist and his independence, by using a ‘macho’ culture of self-presentation. In fact the obverse was the case; he felt particularly alone, unsupported, and generally rejected, and had communicated that by making the therapist feel these feelings of uselessness and unwantedness on his behalf. The danger is that in this situation, the therapist will ‘act out’ in revenge in a similar mode as the patient.

Many patients with ASPD have very low self-esteem or sense of self-worth. This may be related to a highly critical attitude to self, as in the harsh and cruel super-ego of the majority of offenders. Just as Riviere (1936) pointed out the need to balance interpretations of the bad (guilty) parts of the self with interpretations of good parts and capacities, so, too, there needs to be great sensitivity accorded in addressing the patients’ poor self-image. This raises the question of shame, which Gilligan (2000) considers the critical personality characteristic in violent offenders.

Shame is related to consequential feelings of grievance, grudge, and desire for revenge. A sense of shame and poor self-esteem makes the sufferer hypersensitive to humiliation—upon which, of course, criminal justice systems thrive. That the ASPD person is so vulnerable to humiliation reveals to us how fragile is his sense of self-worth. Whereas feelings of guilt will frequently be relieved by the opportunity for their expression, shame and the related sense of poor self-esteem seeks to hide itself and remain silent. Frequently a defensive bravura is the ‘face’ shown in everyday life, and especially, for example, among prisoners. The deep sense of shame and of failure of the ASPD patient, is one of the central technical problems for the psychotherapist in the treatment of many patients suffering ASPD. The aim of treatment is partly to evoke a concept of, and a hope for, the future, which process is itself gratifying and felt to be worthwhile.

Working with shame and humiliation is a central technical problem in psychotherapy with ASPD sufferers. The very act of self-revelation implicit in psychotherapy feels shameful, and makes the sufferer feel that he will be at the mercy of a therapist, who, armed with knowledge of his innermost feelings, will then use it to exact further humiliation. Tact and timing are crucial—knowing how much the patient can ‘take’ at any moment, when gently to probe, when to respect necessary defensive boundaries.

Other activities, too, including the arts therapies, and artistic and occupational involvement, as part of a multidisciplinary program—usually in an inpatient or residential setting—may be helpful in boosting the patient's sense of self-worth.

Central to the psychotherapy of ASPD is an awareness of the ‘negative therapeutic reaction’ (‘NTR’). This refers to the patients’ need, unconsciously, as well sometimes as consciously, to sabotage the psychotherapy especially when he feels it is most helpful or likely to bring about desired, positive change. Such sabotage may be the consequence of a fear of change per se, following, as it were, a basic conservatism—which, despite appearances to the contrary, is invariably at the psychological core of such personalities. Specifically, NTR may be traced to envy of those (including the therapist) who have the qualities that the patient wants for himself, or guilt that he (of all people) does not deserve to have a different and better life. Shame, too, as described under the previous subheading, may be a factor. The ‘NTR’ may be mitigated, if not completely avoided, by early interpretation encompassing such thoughts as; ‘it sounds as though you feel that everything is going wonderfully well at present, and all your goals are achievable, but there may come a time, quite soon, when you think that its all pointless, that I am useless and unable to help you, and you don't want to carry on’. Later, guilt or envy can be interpreted (if thought to be the active elements in a particular case). Such an interpretation would be best expressed (and repeated) in brief sentences communicating one idea at a time.

The psychological toll on the therapist is great and any therapist can only take on so many, or few, of such patients if proper intensive, transferential work is to be undertaken. There is no room for the ‘tyro’ who overextends himself, through some misplaced sense of omnipotence. Good and regular supervision is an absolute necessity. Many authors, e.g., Glover (1964), have recommended ‘teamwork’ in the treatment of ASPD, in order to dilute transferential issues, in a ‘distributive transference’, as Glover described. This is certainly necessary in the more extreme cases, but many psychotherapists will find themselves struggling alone with more mild cases. Generally one would advise working psychotherapeutically—whether individual or group—within a supportive setting, i.e., and outpatient psychotherapy building, and not in a consulting room at home. One danger that may render the psychotherapeutic experience not only useless, but actually a negative, damaging experience, is the case of therapists (who in public services may be inexperienced and out of their depth, or experienced and burnt out) who ‘shut off’ and disengage from the patients’ often urgent emotional communications. Such an experience is likely to be a repeat of previous negative, unrewarding, and traumatic emotional encounters of the patient's past, and as such merely reinforce expectations and psychopathology.

Treatment must ideally be long term: It is generally not possible to produce personality change by short-term treatments. Equally, if ‘supportive’ therapy only is being offered that is likely to be a long-term need. As trust is lacking in many of those manifesting ASPD, the longer the therapeutic relationship (in general terms) the better.

This runs counter to current fashions where short packages of just a few weeks or months are characteristically offered. Short ‘treatments’ may even be worse than useless, i.e., counterproductive. These patients’ lives are invariably characterized by repeated rejections and loss. Too often psychological treatments are perceived by patients as repeating these experiences. Equally, as previously emphasized, endings of therapy should be prepared for (as should all breaks) and as a rule the opportunity of working through the ending over a period of at least 6 months should be offered.

All these considerations apply to individual and group psychotherapy, and indeed to the institutional, social, and TC settings that are described later in this chapter. It is often felt that group psychotherapy provides a matrix of social and psychological interaction that is of greater benefit for the ASPD patient than the dynamic relationship of individual psychotherapy. This is especially the case for patients with sexual offending as their most prominent characteristic. On the other hand, group psychotherapy may be too intimidating for ASPD patients with poor self-esteem, paranoid functioning, and those for whom ‘sharing’ is hardly possible without overwhelming feelings of rivalry, jealousy, and rage. Individual judgments have to be made, case by case.

The first democratic TCs in the UK were developed in the World War II from the application of psychodynamic ideas in residential settings in the treatment of shellshock victims. In these experimental settings (e.g., Bion, 1961) it was noted that the facilitation of an exploratory psychodynamic process in a group and community living structure enabled interpatient learning therapeutic intervention as well as adding a social dimension to the treatment.

TC as with ASPD is a term that does not enjoy unequivocal definition. The term TC, first coined by Tom Main in 1946, is imprecise. Experts do not agree that certain treatment settings are ‘therapeutic communities proper’ as opposed to ‘therapeutic approaches’ (Clarke, 1965). Both ‘democratic’ and ‘hierarchical’ forms exist, see below (Kennard, 2000). The democratic variety has been construed as more ‘modality’ than ‘method’ (Kennard, 1998), meaning that it is primarily a general vehicle for other more specific approaches. The opposite view has been advanced, namely, that a TC refers to an institution in which is ascribed a deliberate, therapeutic, i.e., primary, role for its own social environment (Hunt, 1983).

It should not be forgotten that other cluster B subcategories of personality disorder, i.e., borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder typically exist comorbidly with ASPD especially in cases that warrant a specialist intervention such as the residential democratic TC approach. Comorbidity is the rule for those diagnosed as ‘psychopathic’ on the Hare PCL-R scale.

For Maxwell Jones, the TC represented a potential for the pooling of all the human resources contained within an institution. Importantly this included both professional members and their clients (Jones, 1952). Crucial to his pioneering method was a lessening or ‘flattening’ of the traditional hierarchies, between staff and between staff and clients, and a redistribution of staff power via its partial delegation to clients. To achieve this, conventional staff roles were ‘blurred’ in the service of a more egalitarian multidisciplinary team functioning than previously. It required a restructuring of the traditional hospital or prison, with management systems needing to be sympathetic to the therapeutic model and understanding of its greater democracy and power-sharing with service users.

For Main (1946) ‘treatment of the patient who suffers from a disturbance of social relationships cannot be… regarded as satisfactory unless it is undertaken within a framework of social reality which can provide him with opportunities for attaining fuller insight and for expressing and modifying his emotional drives according to the demands of real life.’ He saw the TC as providing such a ‘satisfactory’ environment, through facilitating the identification and analysis of ‘interpersonal barriers’ that stood in the way of the individual's full participation in community life. The TC environment thus provided, for the ASPD individual, opportunities for ‘interaction’, ‘exploration’, and ‘experimentation’ with others, both staff and fellow patients (Whiteley, 1986). For the therapeutic potential to be realized, this work needs to be carried out within a safe environment.

Safety within the democratic TC is maintained by a number of factors, including: the selection of those most likely to benefit (i.e., rejection of poor prognosis cases, often too violent or dangerous); an informal contract to take part actively in a range of group and communal activities; an agreement to abide by the rules of the TC, in particular, those proscribing damage to persons (including the self) and property; the provision of a predictably structured program of activities, involving both verbal and nonverbal modalities; the provision of support from the peer group; preparation for joining and leaving; and adequate support, training and supervision of staff (Norton, 2002). In this way, risk assessment and risk management depend not only on the identification of relevant factors relating to ‘pathology’ but also to ‘health’ (i.e., appropriate participation in the formal therapeutic program and also in the social life of the TC), and taking into account the containing capacity of the unit at a particular time.

Delegating to clients aspects usually considered to be the exclusive preserve of staff may be central to the success of the model. Such empowerment extends to the identification of signs of distress or disturbance through rule breaking or through over- or underparticipation in the program. The daily community meeting is the regular forum for confronting of such issues, as well as for the providing of relevant human, rather than pharmacological, support. However, there are emergency meetings of the whole community that can be convened at any time of day or night so that, in certain respects, the ‘therapy’ is potentially 24 hours per day. The model has been adopted in many countries and in secure, as well as open, settings.

In the UK the democratic TC approach has been most extensively described (Norton, 1992) and intensively evaluated at Henderson Hospital (Norton and Warren, 2001). A series of outcome studies have been undertaken, though falling short of the ‘gold standard’ of a randomized controlled trial. The patients, referred to as ‘residents’, are all diagnosed as suffering from a personality disorder by the referring practitioner, usually a consultant psychiatrist. The level of personality disorder comorbidity is high with patients each qualifying for an average of six subcategory diagnoses, according to the Personality Disorder Questionnaire (PDQ; Hyler et al., 1987). This instrument may be oversensitive, producing false positives, but its total score can be seen as a guide to overall severity of personality disorder and its subcategory profile as indicative of the distribution of subcategories and their morbidity (Dolan et al., 1995).

In the absence of randomization to a control population, hard to achieve both practically and ethically, a rigorous statistical method has been applied to the assessment of outcome. This data analytic method identifies reliable (i.e., unlikely to have been found by chance) and clinically significant improvement through measuring the size of change pre- and posttreatment and whether the posttreatment scoring is in the normal range for the instrument used (Jacobson and Traux, 1991). Accordingly, using the SCL-90, in an uncontrolled designed of 62 treated patients, 55% at follow-up (average 8 months posttreatment) showed reliable and 32% clinically significant improvement (Dolan et al., 1992). Using the Borderline Syndrome Index-BSI, 61% of admitted compared with 37% of those not admitted had improved reliably and 43% versus 18% both reliably and clinically significantly (Dolan et al., 1996). (NB All subjects admitted, regardless of their actual length of stay, were included in the treated sample.) In a cost–offset study of a cohort of 29 (Dolan et al., 1996), 24 of whom were traceable 1 year after discharge, a 90% reduction in the costs of service usage posttreatment were found in comparison with the 1 year before treatment (average length of stay 7 months—again including those who left or were discharged prematurely).

In a comparable study of convicted offenders, a 7-year follow-up of 700 male inmates admitted to a UK prison run along TC lines (Grendon Underwood, see below) between 1984 and 1989, found that the admitted group were less likely to reoffend than a waiting-list comparison group (Marshall et al., 1997; Taylor, 2000). These authors suggest the presence of a treatment effect for those staying more than 18 months in the program.

• Management structures need to be clear, and attitudes informed and supportive, for best results to be achieved. This is important as it is easy for managers to assume that risk can be unrealistically reduced or avoided. The latter is not possible, especially with an ASPD client group. However, to maintain harmonious relationships requires the TC to demonstrate to management the robustness of its own risk assessment and management processes.

• Also in the interest of safety, it is desirable that the referring agency remains in contact with the TC so that in the eventuality of premature discharge, not a rare event, this can be to a sufficiently safe destination.

• There is a place for clear leadership within the TC. With the latter this is to maintain clarity of task in the light of blurring of traditional staff roles (for example, the therapeutic role taken on by nursing staff, usually the preserve of other professions such as medical or clinical psychology) and flattening of the hierarchy—never entirely flat.

• It is part of the leader's role to ensure that there is adequate support for and supervision of staff.

• This is needed to avoid the destructive acting out of transference–countertransference relationships and to minimize the destructive, but inevitable, effects of splitting (Gabbard, 1988). ‘Victim–perpetrator’ dynamics are prominent, being played out in a variety of guises: staff as victims of residents; staff as perpetrators in relation to residents; a subgroup of staff as victim of another subgroup, such as managers within the TC; whole TC as victim of hostile outside world, etc. Ideally, the situation can yield advantages from the sustaining of, rather than suppression of, such countertransference ‘information’ in terms of an enhanced understanding of the internal worlds of the ASPD clients.

One of the main difficulties relate to problems with establishing an authentic treatment alliance or dealing with the emergence of an ‘illusory alliance’. The democratic TC has inbuilt ways of dealing with these, which have been implicit in the above description of its methods. First, there is an expectation that the individual will actively participate in the formal and informal life of the TC. Second, they should refrain from violent or other destructive behavior. Paradoxically, the latter is easier than the former for those ASPD residents who are well-used to ‘doing time’ in prison and ‘keeping their noses clean’. However, they may ‘fake good’, meaning that they may pretend to fit in to what they perceive expectations to be. In this case the issue is to make explicit what it is they ‘fake’ and why. However, this usually is associated with other ‘sins of omission’. There are mechanisms for detecting not only the rule-breaking but also a lack of participation—whether it applies to the formal or the informal aspects of the program. These latter aspects are monitored closely and fed back to the whole community on a daily basis by designated residents (monthly elected to such positions of power). This can lead to the peer group challenging inauthentic engagement as well as providing support to the negotiation of a genuine therapeutic alliance. Healthy peer group influences are optimized especially through the delegation of power to the residents to include the major say on issues of admission and discharge, usually the preserve of senior medical staff, as well as to more mundane matters. Ideally, over time, a basic trust replaces a basic mistrust in others and a sense of belonging to a more socialized group develops (Erikson, 1959).

In various jurisdictions, therapeutic work is carried out with ASPD clients in prisons. The advantages to the provision of such treatment in a prison setting include the presence of a captive audience—ASPD patients during prison sojourns are predictable in their location, unlike much of the rest of their lifestyle; the ‘hotel’ residential costs of the program (often the most expensive aspect of residential ASPD treatments) are assumed as the clients are incarcerated anyway, and because the outcome of the treatment process (greater insight and understanding of the context of the offending cycle) can be fed into the parole and pre-release risk assessment process.

Broadly there are two TC cultures in prisons. On the one hand, there are ‘concept’ or ‘hierarchical’ communities, based on a charted progression in treatment, for example away from drug use. Many prison drug TCs have this culture, with which parallels can be drawn with the self-help and 12-step movements originally pioneered for alcoholism. Patuxent Prison in Maryland and Herdstevester Prison in Denmark were among the pioneers in this type of treatment for ASPD in prisons (see De Leon, 1994). The ‘Stay n’ out’ program was the first to run prison TCs in New York in 1977. The ‘Anti-Drug Abuse Act of 1986’ earmarked funding for such projects, and they were coordinated federally, frequently with built in evaluation. An evaluation of the ‘Stay ‘n out’ program suggested a 32.4% reduction in rearrest at 3-year follow-up (Wexler et al., 1990).

In the UK and Europe, a version of TCs evolved based on a more egalitarian and democratic culture, influenced in particular by the development of group psychoanalytic psychotherapy. In these ‘democratic’ TCs, the notion of a treatment goal was eschewed in favor of an emphasis on exploration, understanding, and insight.

Grendon Prison in the UK is an example of such treatment facility. Opened in 1962, and with 230 beds divided up into five TCs, half the men are serving a life sentence, and a similar number score above 25 on the PCL-R (Hare, 1991). The small groups meet three times per week, resulting in a psychoanalytic-like process, and 2 days per week there is a longer community meeting, which is chaired by the resident chairman that acts as the democratic and social core of the treatment. There is an expectation that people will stay in treatment for about 2 years.

In the treatment of the more severe character disorders, such as ASPD, pathology is often impervious to the well-intentioned interpretative interventions of comfortably situated therapists. Effective challenge of the very entrenched and ingrained antisocial attitudes and values of the ASPD patient may often only be achieved by the verbal battery of an equally violent but slightly more insightful peer. For example, a bank robber crowing about having made 10 000 pounds ‘for an afternoon's work’ being aggressively challenged by a fellow bank robber pointing out that with a 10-year sentence he'd made about a thousand pounds per year; so was it worth it?

The TC and group psychotherapeutic technique enables the power, authority, and developing (hard won) insight of peers to be utilized in the treatment of newer patients, and in the formulation and delivery of insights that would be unheard if formulated by staff. The maintenance of a culture of enquiry about all aspects of living together promotes deep exploration of current behaviors as they reenact the index offending pattern and often aspects of developmental experience. Gradually, the ASPD patient can begin to integrate aspects of their personality, the often extreme levels of rage and destructiveness sparked or potentiated by developmental traumas, and the shame and loathing that can be both the precipitant and the result of the offending.

Methodological obstacles to the evaluation of psychotherapy for ASPD are formidable. Again, taking research on Grendon as an example, Gunn's work (1976) identified significant improvements in psychiatric status of those treated, and interesting positive changes of levels of respect for authority figures such as police and prison officers. Following this a series of papers suggested a change in reconviction rates following treatment in Grendon lasting more than 18 months (Cullen, 1994). This work was replicated by Marshall et al. (1997) using a cohort of 700 in a treatment group, with a combined waiting-list and risk-matched control group. A reduction in reconviction rates of 20–25% in the treated group at 4-year follow-up was found. This same group and control were reexamined at 7 years suggesting some treatment effect was sustained, and that there was a 60% reduction in recall rates for treated lifers (Taylor, 2000).

In interpreting these data it must be borne in mind that there are considerable technical difficulties in establishing meaningful control groups for these studies. Similarly, some follow-up evidence from a Canadian facility suggested that while in lower PCL-R scorers recidivism rate was reduced, higher scorers actually increased following treatment (Rice et al., 1992). This study has been influential but suffered major methodological difficulties; most significantly, those subjects who wished to leave the treatment group were forced to stay in ‘treatment’ and in the study. Much more research is required before any general ‘truths’ are further promoted. The most authoritative qualitative research of such a facility was by Genders and Player (1995) who described in Grendon the evolutionary process of dismantling antisocial defensive structures and discovering, then testing out and practicing, new ways of being and behaving.

Psychodynamic work with this client group can be very traumatizing for staff. From a psychodynamic perspective it is held that mutative work takes place when the therapist engages in a core relational aspect of the transference. It is thus a sobering thought that for half of Grendon's client group, this core relation has previously been the lethal prelude to their action against their victim(s). In the structure of the program, large amounts of time are given over to staff supervision and time to process the clinical material that they are dealing with.

A principal element of psychology for the ASPD patient is deception and manipulation (see Introduction). An occupational hazard for staff working with these clients is that they will be deceived or duped into supporting a particular clinical decision. The best safeguard against this is a well functioning multidisciplinary team, where staff can debate and challenge such deceptions, making decisions by majority vote if necessary. The clinical pluralistic approach to decision-making enables the multiple fragments of the patient to each find a voice in the form of different staff members or disciplines, who in the staff team matrix can balance the probabilities and agree on a compromise plan that will be the least worst option.

ASPD patients found in treatment facilities such as Grendon are high-risk offenders, and a crucial and potent disciplinary contribution is made by the custodial staff. In health settings, the skills of a prison officer or warder are seldom identified, but they possess a rich skill resource in the day to day management and maintenance of ASPD patients, as well as being custodial managers having the skills to manage organizations whose function is to contain ASPD clients.

There is a technique adopted by ASPD clients in prisons known as ‘collaring’ a staff member. A large intimidatory prisoner with a history of extreme violence will ‘collar’ a staff member demanding some form of concession, or that they investigate something, or to complain about some aspect of their experience. The experience is similar to being mugged—the staff member often ends up agreeing to the request, not because it is necessarily reasonable, but because agreement has effectively been extorted from (him).

The solution to this problem is the mantra ‘take it to your group’. All such requests are required to be discussed in the first instance in small therapy group setting, where it can be explored in terms of its reasonableness and in terms of its psychic significance. Often the intimidatory attitude with which the request is made to the individual staff member has some resentful origin that can be explored, and will diminish as a result.

In a similar vein, concern could be expressed about the risk involved in, for example, having a single female staff member in a small group of eight dangerous men, or of having a small staff complement of three of four in a large community meeting of 40 residents. In fact, the group settings are rather safe places; anecdotally, when being controlled by other residents, the order and control in the meeting has been maintained by client members of the group or the community.

The theoretical explanation of this is to be found in Foulkes’ assertion that as a collective, a group will contain the norm from which the individual members deviate. So while as individuals, each member of the groups will have made unreasonable demands, ‘collaring’ staff; as a collective, the aggressive and unreasonable nature of this can be recognized and challenged. Likewise, while all may be capable of violence individually, the group as a collective will have a more normal aversion to violence, leading to its suppression by the majority should it emerge.

A second difficult situation is where an ASPD patient manages to split a staff group, showing to one staff subgroup a reasonable and hardworking aspect of their personality, and showing to the other a more sadistic and vicious side, such that one subgroup wish to discharge the individual, and the other subgroup argue that this attitude is perverse.

The structuring into the program of multiple opportunities for staff to discuss and review their clinical work provides opportunities to reconcile these splits and to understand the origin. Following Main (1989) the understanding is that character pathology being exhibited by the client group will become located in the staff group, following this sort of mechanism. The task for the staff group is to recognize the splits and schisms that emerge between them, and to recast these observations of their own dynamics as information about the dynamics of the client group, and the individuals comprising them, that they are holding.

The cognitive therapy model is based on the notion that attributional bias is the main problem accounting for behavioral and affective dysfunction. The way in which information is perceived, interpreted and acted upon is problematic. Schemas are a central concept in the model and can be conceptualized as cognitive structures that organize experience and behavior. Schemas are thought of as a guiding behavior in a consistent rule bound manner. Cognitive therapy focuses on the product of schemas, the patient's behavioral and interpersonal problems, and the core beliefs that underlie them.

There is considerable evidence that personality is at least, in part, determined by genetic mechanisms and the cognitive model of personality disorder encompasses both a genetic and evolutionary perspective (Beck and Freeman, 1990). The possession of personality traits that are useful for procreation and obtaining resources are likely to have high survival value and are therefore likely to be passed on through genes. Take the trait of aggression as an example. In a situation where resources are scarce and there is not enough food and potential mates to allow a sufficient supply for all, an aggressive male may present as a threat to his competitors and drive them off. By doing so, the male may increase his social status and he may therefore be more likely to attract the available females. The aggressive trait has therefore been adaptive in scaring off competitors and in obtaining a sexual partner and through procreation, in passing on genes to future generations. In this way, aggressive traits may be selected for their survival value.

In Beck and Freeman's (1990) cognitive model of personality disorder, some individuals may show more extreme forms of the personality types or patterns that were once adaptive but are now maladaptive in the contemporary world. For example, in ASPD, combative and explorative behavioral patterns are overdeveloped and other behavioral patterns, such as sharing, group identification, and intimacy are underdeveloped. These latter patterns also have evolutionary survival value, particularly in maintaining relationships where consideration for others, kindness, and intimacy are valued, but in ASPD these patterns are underrepresented.

The concept of schema lies at the core of cognitive therapy and is of relevance to personality disorder. Schemas are unconscious stable cognitive structures through which knowledge about the world is gathered, processed, and stored. The meaning we attach to events is the result of information being processed through schemas. Schemas are stored in long-term memory and can be active or latent. They are thought of as being triggered by events that are similar to those that originally molded them. Schemas that are concerned with information processing are grouped together into constellations that are, in turn, grouped into modes of subsystems of the cognitive organization. It is these latter groupings that are considered of evolutionary survival value. They are concerned with the degree of adaptation of the organism to its environment and represent the basic underpinning of personality.

In personality disorder, several interlocking schematic subsystems will be involved in an ongoing process whereby information is perceived, interpreted, and ultimately acted upon. The schematic subsystems involved in this process are concerned with affect, cognition, motivation, action, and self-regulation. Different subschemas will have different functions. For example, the cognitive schema will be involved in the organization, interpretation, and recall of information received by an individual. In personality disorder, evaluation of self and others are dominant cognitive schemas. These schemas are hypervalent and are activated in a wide variety of situations, which results in overgeneralized of dysfunctional responses. It is the way in which these schemas are integrated and linked together with information from the environment that determines the degree of adaptation in response. Table 22.1 provides an example of a functional analysis of schemas in ASPD.

The aim of CBT for personality disorder is to identify and modify core beliefs and associated overdeveloped behavioral patterns, which are maladaptive and prevent the individual from functioning in an adaptive manner (Davidson, 2000). There are several differences between CBT for personality disorders and CBT for Axis I disorders. The length of treatment in personality disorder is one of the main differences when compared with the relatively brisk and short length of treatment for Axis I disorder. Owing to the long-standing ingrained nature of difficulties in personality disorder, an average course of therapy will require at least 30 sessions over a time period of at least a year.

Those with ASPD are often referred for treatment because other people regard them as having a problem. They seldom initiate treatment. As a result those with ASPD often require a thorough exploration of their problems, the consequences of these for them and others, how the problems arose and became ingrained before any agreement can be reached about embarking on change. This is in contrast to patients with Axis I disorders, where patients wish to get back to the state of well-being they experienced before and recognize that their current state of mind is different from how they are usually. With personality disorder, patients have usually no experience of what it could be like to behave, feel, and act differently. Patients need to recognize that they would be helped by developing new ways of thinking about themselves and other people and that changing behavioral patterns could lead to improvements in relationships and the overall quality of life.

Developing a coherent cognitive formulation of an individual's problems is therefore central to progress in therapy. As the patient's past history plays a role in the development of problems, there is a greater degree of historical information sought in cognitive therapy for personality disorder and in arriving at the formulation compared with therapy of an Axis I disorder. In an Axis I disorder, the patient's past history is usually helpful in highlighting potential vulnerability factors rather than being central to pathology.

The function of the formulation is to engage the patient in therapy by making explicit the relationship between beliefs about self and others and long-standing behavioral patterns, which in the case of those with ASPD, particularly those that are self-destructive or have a destructive effect on others. The cognitive formulation takes into account that patient's early as well as recent experience. Reaching a formulation is a time consuming process for the therapist but one that is essential if therapy is to remain structured and focused. It will point to the underdeveloped behavioral patterns that require to be strengthened and uncover the content of core beliefs about self and others that need to be replaced by more adaptive beliefs. Arriving at a formulation is not an intellectual exercise for the therapist as it must make sense to the patient and be readily understood in terms of his past experience. It is also the process through which the patient engages with therapy and through which the therapist demonstrates that he has been understood. A written formulation, either in narrative or diagrammatic form, is given to the patient and this becomes the springboard for discussing and agreeing the cognitive and behavioral changes that the remainder of therapy will focus on and which will help improve the patient's quality of life. Once the formulation has been agreed—at least as a working hypothesis—behavioral and cognitive change strategies are used to assist the patient in attaining his goals. Agreed goals have to be modest and achievable within the time frame of therapy. If a patient has unrealistic goals about what can be achieved in therapy, then the therapist has to be open and honest about what is likely to be possible. For example, for a homeless 50-year-old prison recidivist, with a history of alcoholism and drug addiction, getting married in the near future might be an unrealistic goal but forming a better relationship with specific individuals might be achievable.

As with all therapies with individuals with ASPD, there should be a transparent overall structure to therapy. Generally, ASPD patients are offered up to 10 sessions at the beginning of therapy to assess problems and agree a formulation. If it has been possible to agree the formulation and identify underdeveloped behavioral strategies and beliefs that are unhelpful and counterproductive to change, then the therapist negotiates the next stage of therapy focusing on change.

Cognitive therapy for those with ASPD will usually focus on developing and strengthening more adaptive behavioral strategies aimed at improving interpersonal relationships and managing conflict by learning to see the perspective of the other. Low self-esteem, a frequent problem, is often associated with negative thoughts towards others. Beliefs such as ‘I must not show that I am weak’ and ‘I have to get the better of everyone or they will get me’ need to be loosened or weakened by strengthening new more adaptive beliefs such as ‘it is okay to have both strengths and weaknesses’ and ‘if I behave in a reasonable way with others, they may treat me better’.

ASPD patients tend to interpret interpersonal situations as being more threatening than they are in actuality. They have poor ability to interpret ambiguity and tend to rapidly jump to negative conclusions about other people's intentions leading to actions that are often impulsive and aggressive toward others. Learning to ‘stop and think’ before acting helps build tolerance of uncertainty, providing that skills in the interpretation of events can be acquired. Learning that there may be more than one interpretation of an interpersonal situation is often, at first, a real revelation to individuals with ASPD.

The middle phase of therapy may take place over at least 20 sessions but regular reviews are scheduled at the beginning of this phase to assess progress. If there is a lack of progress, the therapist has to review possible reasons for this with the patient and some resolution has to be agreed before therapy proceeds. The end of therapy is flagged up long before it takes place. The final phase of therapy is also structured and the aim here is to review progress, identify what has been learnt, and to develop a behavioral and cognitive maintenance plan with the patient to increase the likelihood that change will be maintained.

Problems in engaging individuals with personality disorder in therapy are thought to be common. Those with ASPD have a tendency to view difficulties as being the responsibility and fault of others, not themselves. Most studies have treated antisocial patients with problems such as drug dependence and the focus has not been on antisocial characteristics or traits per se. It is, however, possible to engage ASPD patients in therapy (Davidson and Tyrer, 1996), with clear patient-oriented goals, especially if they are no longer youthful but in their thirties or older, when their dominance and prowess may be beginning to diminish and they recognize the need to develop more effective strategies to maintain their self-esteem.

Cognitive therapy has been useful in providing a theoretical model to aid understanding of ASPD and in developing treatment. As a therapy, cognitive therapy may have advantages over other psychological therapies and may be more able to engage patients with ASPD than other therapies. As a therapy, it is structured, open, and aims to give patients an understanding of their difficulties that is especially helpful in engagement. By encouraging patients to experiment with new ways of thinking and behaving and to assess the usefulness of these, a truly collaborative relationship can be formed with the therapist. With only a few randomized controlled trials of CBT for ASPD, the results so far are cautiously encouraging.