We've noticed that you're using an ad blocker

Our content is brought to you free of charge because of the support of our advertisers. To continue enjoying our content, please turn off your ad blocker.

It's off now Dismiss How do I disable my ad blocker?
❌

How to disable your ad blocker for our site:

Adblock / Adblock Plus
  • Click on the AdBlock / AdBlock Plus icon on the top right of your browser.
  • Click “Don’t run on pages on this domain.” OR “Enabled on this site.”
  • Close this help box and click "It's off now".
Firefox Tracking Prevention
  • If you are Private Browsing in Firefox, "Tracking Protection" may casue the adblock notice to show. It can be temporarily disabled by clicking the "shield" icon in the address bar.
  • Close this help box and click "It's off now".
Ghostery
  • Click the Ghostery icon on your browser.
  • In Ghostery versions < 6.0 click “Whitelist site.” in version 6.0 click “Trust site.”
  • Close this help box and click "It's off now".
uBlock / uBlock Origin
  • Click the uBlock / uBlock Origin icon on your browser.
  • Click the “power” button in the menu that appears to whitelist the current website
  • Close this help box and click "It's off now".
  • Topics
  • CME
  • Special Reports
  • Slideshows
  • Quizzes
  • Blogs
  • Conferences
  • Classifieds
  • Archives

Modern Medicine Network
  • Login
  • Register
Skip to main content
Modern Medicine Network
  • Login
  • Register
Menu
User
Home
  • Topics
  • CME
  • Special Reports
  • Slideshows
  • Quizzes
  • Blogs
  • Conferences
  • Classifieds
  • Archives

SUBSCRIBE: eNewsletter

Treating the Morally Objectionable Patient: Countertransference Reactions

  • James L. Knoll IV, MD
Apr 14, 2009
Volume: 
26
Issue: 
4
  • Antisocial Personality Disorder, Addiction, Forensic Psychiatry
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

Pages

  • 1
  • 2
  • next ›
  • last »
References: 

1. Milton J. Paradise Lost. With material originally published in 1688. New York: Oxford University Press; 2005.
2. Friedrich M, Leiper R. Countertransference reactions
in therapeutic work with incestuous sexual
abusers. J Child Sex Abus. 2006;15:51-68.
3. Meloy JR, Meloy MJ. Autonomic arousal in the
presence of psychopathy: a survey of mental health
and criminal justice professionals. J Threat Assess.
2003;2:21-34.
4. Slovenko R. The transinstitutionalization of the
mentally ill. Ohio North Univ Law Rev. 2003;29:641-
660.
5. Cuddeback GS, Morrissey JP, Cusack KJ. How
many forensic assertive community treatment teams
do we need? Psychiatr Serv. 2008;59:205-208.
6. Lamb HR, Weinberger LE, Marsh JS, Gross BH.
Treatment prospects for persons with severe mental
illness in an urban county jail. Psychiatr Serv.
2007;58:782-786.
7. Groves JE.Taking care of the hateful patient. N Engl
J Med. 1978;298: 883-887.
8. Mason T, Richman J, Mercer D.The influence of evil
on forensic clinical practice. Int J Ment Health Nurs.
2002;11:80-93.
9. Mercer D, Mason T, Richman J. Good & evil in the crusade of care: social constructions of mental disorders.
J Psychosoc Nurs Ment Health Serv. 1999;37:13-17.
10. Levinsky NG, Friedman EA, Levine DZ.What is ourduty to a “hateful” patient? Differing approaches to adisruptive dialysis patient. Am J Kidney Dis. 1999;34:v775-789.
11. Lee JH. The treatment of psychopathic and antisocial personality disorders: a review. http://www.ramas.co.uk/report3.pdf. Accessed January 7, 2009.
12. D’Silva K, Duggan C, McCarthy L. Does treatment really make psychopaths worse? A review of the evidence. J Personal Disord. 2004;18:163-177.
13. Kristiansson M. Incurable psychopaths? Bull Am Acad Psychiatry Law. 1995;23:555-562.
14. Looman J, Abracen J, Serin R, Marquis P. Psychopathy, treatment change, and recidivism in highrisk, high-need sexual offenders. J Interpers Violence. 2005;20:549-568.
15. Shelley M. Frankenstein; or, the Modern Prometheus. London: Colburn & Bentley Publishers; 1831.
16. Slochower J.Variations in the analytic holding environment. Int J Psychoanal. 1991;72:709-718.
17. Meloy JR. The Psychopathic Mind: Origins, Dynamics, and Treatment. New York: J Aronson; 1988. 18. Ursano RJ, Sonnenberg SM, Lazar SG. Concise Guide to Psychodynamic Psychotherapy: Principles and Techniques of Brief, Intermittent, and Long-Term Psychodynamic Psychotherapy. Washington, DC: American Psychiatric Press; 1991.
19. Ursano R, Sonnenberg S, Lazar S. Psychodynamic psychotherapy. In: Hales R,Yudofsky S, Gabbard G, eds. The American Psychiatric Publishing Textbook of Psychiatry. 5th ed. Arlington,VA:American Psychiatric Publishing, Inc; 2008.
20. Grounds A, Quayle MT, France J, et al. A unit for “psychopathic disorder” patients in Broadmoor Hospital. Med Sci Law. 1987;27:21-31.
21. Vien A, Beech AR. Psychopathy: theory, measurement,and treatment. Trauma Violence Abuse. 2006;7: 155-174.
22.Wong SC, Gordon A, Gu D. Assessment and treatment of violence-prone forensic clients: an integrated approach. Br J Psychiatry Suppl. 2007;49:s66- s74.
23. McNiel DE, Chamberlain JR,Weaver CM, et al. Impact of clinical training on violence risk assessment. Am J Psychiatry. 2008;165:195-200.
24. Douglas KS, Ogloff JR, Hart SD. Evaluation of a model of violence risk assessment among forensic psychiatric patients. Psychiatr Serv. 2003;54:1372- 1379.
25. Cacciacarne M, Resnick PJ, McArthur C,Althof SE. Burnout in forensic psychiatric staff. Med Law. 1986;5:303-308.
26. Kurtz A. The needs of staff who care for people with a diagnosis of personality disorder who are considered a risk to others. J Forensic Psychiatry Psychol. 2005;16:399-422.
27. Way I, VanDeusen KM, Martin G, et al. Vicarious trauma: a comparison of clinicians who treat survivors of sexual abuse and sexual offenders. J Interpers Violence. 2004;19:49-71.

Related Articles

  • Online Communities for Drug Withdrawal: What Can We Learn?
  • Opioid Overdoses and Naloxone: What Everyone Needs to Know
  • Opioid Use in the Elderly
  • Mini Quiz: Prescribing for Patients With SUDS
  • Mini Quiz: Alcohol and Sleep

Resource Topics rightRail

  • Resource Topics
  • Partner Content
ADHD
Schizophrenia
Bipolar Disorder
Geriatric Psychiatry
Major Depressive Disorder
Smart IOP – A New Kind of Intensive Outpatient Program
Three Things Mental Health Professionals Need to Know About Telemedicine – TODAY!
How Telemedicine Can Transform Patient Engagement

Current Issue

Psychiatric Times Vol 35 No 3
Mar 12, 2018 Vol 32 No 3
Digital Edition
Subscribe
Connect with Us
  • Twitter
  • Facebook
  • Google+
  • LinkedIn
  • RSS
Modern Medicine Network
  • Home
  • About Us
  • Advertise
  • Advertiser Terms
  • Privacy statement
  • Terms & Conditions
  • Editorial & Advertising Policy
  • Editorial Board
  • Contact Us
Modern Medicine Network
© UBM 2018, All rights reserved.
Reproduction in whole or in part is prohibited.