Lion, Symington, Strasburger, Meloy, and Gabbard explored the clinician’s response to the psychopathic or antisocial personality disorder patient.

Table 82-3 lists eight common countertransference reactions to such a patient. They are likely to occur regardless of the treatment modality being applied and will be felt more intensely when psychopathy is more severe in the antisocial patient. These are reactive emotions and thoughts and should not be construed as necessarily implicating a conflict in the clinician. Such subjective reactions can be used as an impetus for further objective testing, a reevaluation of the appropriateness of the selected treatment, or in some cases the cessation of treatment.

Therapeutic Nihilism
Lion used the term therapeutic nihilism to describe the rejection of all patients with an antisocial history as being completely untreatable. Instead of arriving at a treatment decision based on a clinical evaluation, including an assessment of the severity of psychopathy, the clinician devalues the patient as a member of a stereotyped class of “untouchables.” The clinician does to the patient with antisocial personality disorder what the patient does to others. Symington called this condemnation, and it psychoanalytically reflects the clinician’s identification with this aspect of the patient’s character.

Illusory Treatment Alliance
The opposite reaction to therapeutic nihilism is the illusion that there is a treatment alliance when, in fact, there is none. Often these perceptions on the part of the patient are the psychotherapist’s own wishful projections. Although the presence of an alliance is a favorable prognostic indicator, in antisocial personality disorder patients with severe psychopathy, it should not be expected. Behaviors that suggest such an alliance should be viewed with clinical suspicion and may actually be imitations to please and manipulate the psychotherapist. The chameleon-like quality of the psychopathic patient is well documented. Bursten elaborated on the “manipulative cycle” of the psychopathic patient, which leads to a feeling of contemptuous delight in these patients when successfully carried out. The clinician is left with feelings of humiliation and anger.

Fear of Assault or Harm
Strasburger noted that both reality-based and countertransference fears may exist in response to the antisocial personality disorder patient with severe psychopathy. Real danger should not be discounted and is most readily evaluated by using contemporary measures to assess the risk of violence. Countertransference fear is an atavistic response to the psychopathic patient as a predator and may be viscerally felt as “the hair standing up on my neck” or the patient “making my skin crawl.” These are phylogenetically old autonomic reactions that may also signal real danger, even in the absence of an overt threat. Although no empirical studies of this phenomenon have been done, it appears to be a widespread experience among clinicians working with psychopathic patients. A related clinical feature is overt sadistic triumph over the psychotherapist, what Kernberg cites as a symptom of “malignant grandiosity.”

Denial and Deception
Denial in the psychotherapist is most often seen in counterphobic responses to real danger. Lion and Leaff suggested that it is a common defense against anxiety generated by violent patients. It may also be apparent in the unwillingness of mental health clinicians to participate in the prosecution of a psychopathic patient who has seriously injured someone, in the underdiagnosis of antisocial personality disorder, or in clinicians’ disbelief that the patient has an antisocial history or that psychopathy even exists at all. This reaction may lead to splitting or contentiousness among mental health staff, especially in hospital settings. It is most obvious in clinical records in forensic hospitals when a patient is referred to as having “allegedly” committed a certain crime after he or she has been tried and convicted by a judge or jury.

Deception of the patient with antisocial personality disorder is most likely to occur when the psychotherapist is frightened of the patient, especially of the patient’s rage if certain limits are set surrounding treatment. It may also indicate superego problems in the clinician, the avoidance of anxiety, passive-aggressive rejection of the patient, or an identification with the deceptive skills of the patient with antisocial personality disorder. Rigorous honesty without self-disclosure is the treatment rule with antisocial personality disorder patients.

Helplessness and Guilt
The novice clinician may especially feel helpless or guilty when the patient with antisocial personality disorder does not change despite treatment efforts. These feelings may originate from the psychotherapist’s narcissistic belief in his or her own omnipotent capacity to heal, what Reich called the “Midas touch syndrome.” Strasburger noted that these feelings may be transformed into rage that is passively expressed as withdrawal or an attempt to smother the patient with heroic treatment efforts and attention.

Devaluation and Loss of Professional Identity
If therapeutic competency is measured only through genuine change in the patient, the patient with antisocial personality disorder will be a source of continuous professional disappointment and narcissistic wounding. In long-term treatment, the psychopathic patient may stimulate the clinician to question his or her own professional identity. Bursten noted that, despite the psychotherapist’s most adept management of the patient’s contempt, it is difficult not to feel despicable and devalued because of the primitive, preverbal nature of the patient’s manipulative cycle. Emotional responses to the patient may range, in this context, from retaliation and rage to indifference or submission.

Hatred and the Wish to Destroy
One psychiatric resident recalled the embarrassing dream of being with a hospitalized antisocial personality disorder patient he was treating as they both stormed through the hospital with flame throwers, destroying everything in sight. No other patient will compel psychotherapists to face their own aggressive and destructive impulses like the severely psychopathic patient with antisocial personality disorder. Because these patients often hate goodness itself and will destroy any perceived goodness (such as empathy) offered by the clinician, the latter may react by identifying with the patient’s hatred and wish to destroy. It may become a source of understanding and relating to the patient if brought into consciousness.

Assumption of Psychological Complexity
The most subtle countertransference reaction is the clinician’s belief that the patient with antisocial personality disorder is as developmentally mature and complex as the clinician and that the patient’s actual maturity only has to be facilitated by, and discovered in, treatment. This is particularly common when no Axis I diagnosis is present and the patient has an above-average IQ. Certain aspects of IQ and ego functioning are not related, and the severely psychopathic patient with a very superior IQ, through glibness and superficial charm (

see Table 82-2), may mask a borderline personality organization.

Understanding and management of these emotional reactions to patients with antisocial personality disorder, whether psychopathic or not, will not only increase staff safety but also contribute to diagnosis and treatment planning. Such countertransference reactions are most readily explored in individual or group supervision or in carefully led clinical staff meetings in which a wide range of emotional reactions toward patients are tolerated and accepted. Clinicians who are resistant to any understanding of their own emotional lives in relation to these patients should not be treating them and may put other mental health professionals at risk. As Meloy wrote, “The interpersonal encounter with the patient fundamentally defines the humanity, or lack of humanity, of the treatment: a task that is most rigorously tested when the psychopathic patient is commonly perceived, at least in part, as inhuman”.