Treating the Morally Objectionable Patient: Countertransference Reactions

Did I request thee maker from my clay to mould me man?
Did I solicit thee from darkness to promote me?
—Prologue to Mary Shelley’s Frankenstein from John Milton’s Paradise Lost¹

Clinicians who treat patients with strong antisocial traits commonly struggle with the tension between conceptualizing them as either man or beast.² On one hand, there is the well-intended goal of helping the offender develop into a more functional “human being.” On the other, there are the common emotional reactions of anger, disgust, and even fear of predation.³

While general mental health clinicians are often taught to avoid treating antisocial patients, forensic clinicians frequently find themselves in circumstances that compel them to treat such patients. With the continuing trend of “forensification” of seriously mentally ill persons, some general clinicians will inevitably become involved with these patients in some form of a treatment relationship after they are released into the general community^.4-6

In this article, I will use the term morally objectionable (MO) to describe a small subpopulation of strongly antisocial or even psychopathic persons, whose attitudes and behaviors cause most clinicians to find them morally objectionable. Despite the presence of comorbid, treatable psychiatric symptoms, it is possible that the disturbing nature of the MO patient’s personality structure can make him or her not only difficult to treat but intolerable. In these circumstances, there is little guidance to help clinicians carry out their treatment duties competently and ethically. Since the classic article “Taking Care of the Hateful Patient” was published, open acknowledgment and discussion of physicians’ countertransference to very difficult patients became more widely accepted.⁷  MO patients may have been convicted of particularly heinous or callous offenses; this increases the tendency of the clinician to have strongly negative countertransferential reactions toward them.

The importance of recognizing and competently addressing countertransferential reactions to MO patients was underscored in a study of forensic psychiatric nurses’ approaches to treatment in a high-security psychiatric hospital.⁸ When a patient was judged to be particularly MO, the staff abandoned medical discourse and reverted to lay notions of badness or “evil.” The MO patients were viewed as being beyond help, which was reflected in their care plans. These patients were excluded from usual medical, symptom-centered approaches.⁹

But in no area of medicine do physicians reduce or eliminate care for victims of bad judgment.¹⁰ Indeed, refusal of care for those who have “caused their own problems” could arguably be applied to a very large percentage of the population. Even when there is clear evidence that the MO patient suffers primarily from the consequences of his antisocial spectrum disorder, it is important to acknowledge the current lack of clarity on the nature, etiology, and treatment response of these disorders.^11-13 At present, it would seem reasonable to avoid considering antisocial spectrum patients as uniform and instead consider whether there may be differential responsivity among particular subgroups.¹⁴

This article briefly addresses some important countertransference reactions that clinicians may have when treating MO patients.

Countertransference reactions
“His words had a strange effect upon me. I compassionated him and sometimes felt a wish to console him, but when I looked upon him . . . my heart sickened and my feelings were altered to those of horror and hatred.”¹⁵

Clinicians who work with MO patients inevitably come to the realization that treatment cannot be a “dispassionate technical endeavor.”² Whether the therapeutic relationship involves psychotherapy or is limited to pharmacotherapy, the clinician must be able to experience, tolerate, and “hold the patient’s feelings without retaliation.”¹⁶ For many MO patients, interpersonal conflict and aggression may be primary symptoms that the clinician will encounter. The clinician may reflexively seek to avoid the resulting internal discomfort by responding in an attacking or, conversely, a rejecting manner. In addition, MO patients with strong psychopathic traits may engender particularly corrosive countertransference emotions, causing the clinician to feel controlled or deceived.

Meloy¹⁷ has enumerated a number of “interpersonal and intrapsychic features” that he believes contraindicate any form of treatment. These features include:

• A history of sadistic and aggressive behavior

• A complete absence of remorse

• Absence of capacity for emotional attachment

• An experienced clinician’s fear of predation in the patient’s presence

These features appear to be derived from Meloy’s clinical experience and, as such, are certainly sagacious warning signs for the clinician to carefully consider. However, the fact remains that these signs can and will be found among many MO patients, particularly those who require treatment in a correctional or forensic setting. Forensic clinicians will find very little guidance in the literature regarding the particular countertransference reactions seen in the treatment of MO patients.

The Table lists some countertransference reactions that have been described by clinicians who treat psychopathic offenders and MO patients. The term “countertransference” is used here in its broadest sense to mean the emotional reaction of the clinician to the patient.^18,19