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Gordon, R.M. and Bottinelli, J. (2008), Ethics and the Difficult Patient: The Psychopath in Film and in Your Office. The Pennsylvania Psychologist Update, July/August Issue,10.
On May 9th, I held my 10th annual PPF Ethics workshop fundraiser. I compared the DSM criteria for Antisocial personality disorder to the Psychodynamic Diagnostic Manuals (PDM) criteria for Psychopathic personality disorder. The DSM and PDM compliment each other. The DSM is nosology based on symptoms, while the PDM is a nosology based on etiology, pathogenesis and symptoms. The PDM is more helpful at understanding the full range of people from the surface symptoms to the underlying personality dynamics. The PDM divides psychopathy into two subtypes: the passive/ parasitic (less aggressive, con artist), and the aggressive (predatory and violent).
Psychopaths can be physically dangerous, but in treatment they are more likely to act out the transference, and cheat or exploit you. They might set you up for a malpractice suit for the money. The main defensive style of the psychopath, is reaching for omnipotent control. They get pleasure over having power over, exploiting and conning others. Psychopathy is generally organized at the borderline level of severity and often combines with other personality disorders such as narcisstic, paranoid and sadistic personality patterns or disorders. There are a high number of psychopaths in prison, but the smarter ones are in any area that has power over others such as clergy, lawyers, CEOs, law enforcement, politics, etc.
They will at first seem cooperative and friendly, while they are assessing your physical, intellectual and moral capabilities. To test you, they may invade your personal space and then ask you for favors or to bend the rules for them.
Therapy is often counterproductive. Psychopaths learn how to use psychology to better manipulate others. Some limited issues may be the focus of treatment, such as anger management. Some patients with psychopathic traits who have some remorse and insight can improve in long-term psychotherapy. If they remain in treatment, they may learn to better contain their acting out.
When treating anyone with psychopathic traits, keep strict boundaries, keep them from testing your personal space, set limits consistently (or they will sense your weakness and play on it), keep goals focused, never do favors, get a consult and if you are frightened or uncomfortable, do not treatment them.
Remember APAs ethic code, 10.10 (b) Psychologists may terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship.
Dr. Jennifer Bottinelli showed film clips illustrating issues about psychopathy. The first set of clips was a scene from Joel and Ethan Coens Fargo (1996) , a film that depicts both aggressive and passive/parasitic psychopaths working together in a kidnapping. What was meant to be a simple kidnapping for money turns into multiples murders when the aggressive type explodes. It is a rare illustration of how the different subtypes react in the same situation.
In David Mamets House of Games (1987), a handsome con man sucks in a female psychiatrist by making a deal with her. She asked him not to have her patient injured because of his gambling debts. He claims that he will write off her patients debts in exchange for informing him about the tells of another poker player. He charms her, invades her space, touches her, and asks for a favor in the first few minutes of their meeting.
Finally, the relationship between an aggressive psychopath, his mother, and his therapist is a key plotline in the first season of The Sopranos (1999). Tony Sopranos mother is a cold hostile psychopath. She orders a hit on her own son. Tony is in denial about this. He argues that feelings are signs of weakness. He physically attacks his therapist when she confronts him about his mothers borderline personality and hostility towards him. Tony acts out both his negative transference and erotic transference to his therapist, rather than grieve the loss of a good enough mother.
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