Treating the Morally Objectionable Patient: Countertransference Reactions

April 13, 2009

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

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.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

Many conscientious, principled clinicians will find themselves using isolation of affect to deal with unpleasant emotional reactions to their MO patients. Indeed, to an extent, this may be helpful and necessary for those whose work primarily involves MO patients. For example, clinicians who work with psychopathic offenders have described a process of practicing detached, ritualistic task performance to avoid unpleasant feelings of countertransference.20 Yet, an excessive absence or lack of feelings about the patient cuts the clinician off from important clinical data. Too much distance from one’s emotional reactions may result in a neglect of critical treatment or risk assessment issues.

Therapeutic nihilism is a common countertransference reaction experienced with MO patients as well as psychopathic offenders.17 It involves the global assumption that all such persons are similar in their lack of response to any treatment. Because of the heterogeneous nature of antisocial spectrum disorders, however, it is untenable to conclude that all such individuals are immune to all treatment efforts. Clinicians should be mindful that some therapeutic nihilism may be the result of “oral tradition,” passed down in the absence of objective data or experience.17 In contrast, it is vital to have realistic expectations when working with MO patients, and not to overestimate treatment goals. The clinician must carefully navigate between the Scylla and Charybdis of therapeutic nihilism and therapeutic naivet. Balancing and finding the appropriate stance on this continuum is a difficult, but nevertheless fundamental task facing the clinician working with MO patients. It necessarily requires an enormous effort to prohibit moral judgment from imping­ing on an objective, professional approach to the patient.

Another countertransference reaction to the MO patient has been termed “malignant pseudo-identification.” This reaction occurs when a psychopathic individual consciously imitates, or unconsciously simulates subtle narcissistic characteristics of the clinician.17 This process fosters the clinician’s identification with the patient, which ultimately renders the clinician vulnerable to manipulation. The process may involve the patient simulating mannerisms or beliefs of the clinician, or otherwise creating the (false) impression of identification and a therapeutic alliance. The following vignette is an example of malignant pseudo-identification.


Mr M was a 38-year-old man who was serving a life sentence without parole for an unusual triple homicide that involved the rape and torture of his victims. He had been given a diagnosis of depression, and an experienced forensic psychologist calculated the Hare Psychopathy Checklist–Revised (PCL-R) score to be 37 (a cutoff score of 30 defines psychopathy). Mr M was residing in a residential treatment unit of the prison because of his frequent threats of suicide and serious past suicide attempts.

Dr F-who was Mr M’s attending psychiatrist-was well known by staff and patients to be an academician interested in studying and understanding criminal behavior. One day on teaching rounds, Mr M observed that one of Dr F’s students was carrying a copy of Robert Simon’s “Bad Men Do What Good Men Dream,” along with her other notebooks. Unbeknownst to Dr F, Mr M subsequently ordered himself a copy through the prison mail. Several weeks later, during a routine evaluation, Mr M asked Dr F, “Do you think I am a monster?” Fascinated, Dr F began to listen as Mr M told him that he had been reflecting on his crimes and wanted to understand what drove him to do such things.

Mr M further garnered the interest of Dr F with statements such as, “I think that everyone has a ‘dark side’ . . . the difference is that for some reason, I let mine come out.” Mr M told Dr F that he would like to learn more about himself so that he might change and serve as an example for others. Mr M also told Dr F in a cautious, secretive tone: “There are things I have done that no one knows about.

Really bad things. I need to talk about them with someone I can trust.”

Dr F began to meet with Mr M more frequently, both to manage his medications and seek a better understanding of him. Eventually, Mr M offered to keep a journal of his thoughts about his crimes for Dr F to study. Dr F agreed to provide Mr M with pencils and journaling notebooks that were not on the prison canteen list. Mr M later told Dr F, “I think I am starting to see how messed up I was. You have been the only staff that listened and didn’t judge me.” Other prison staff began to notice how Dr F paid special attention to Mr M and began to subtly chide him about it with comments such as, “Mr M is Dr F’s pet ‘science project.’” Mr M seized this opportunity in a session with Dr F, stating “I can’t believe they have the nerve to disrespect you. You have more knowledge than anyone here! You need more competent staff.”

In this vignette, Mr M simulated Dr F’s narcissistic characteristics and successfully developed a pseudo-identification with him. Mr M made shrewd observations about what Dr F valued and what held his interest. Mr M carefully exploited the pseudo-identification so that Dr F began to treat him as a special case. This ultimately made Dr F vulnerable to Mr M’s strategy of creating a schism between Dr F and other staff. This is a potentially dangerous position for Dr F, because Mr M could use this schism as the beginning stage for further manipulation. It will be important for Dr F to develop a better understanding of how he is perceived by patients and staff, so that he might be able to recognize when this type of patient is attempting to simulate aspects of his narcissism.

An assumption that may help foster the MO patient’s pseudo-identification with the clinician is the clinician’s unfounded belief that he and the patient generally share similar psychological and/or emotional processes and functioning. Meloy has termed this reaction the “assumption of psychological complexity.”17 However, the projective assumption by the clinician may or may not be that the patient is psychologically complex. Rather, the clinician may simply assume that the patient generally “thinks like I do” or otherwise shares the same general emotional responses. Thus, the term assumption of similarity may be more accurate in certain cases. The dangers involved in making an assumption of similarity include vulnerability to pseudo-identification, misjudgments of the patient’s intentions or treatment responses, and misperception of risk.

Most experts now acknowledge that poor motivation for change remains a therapeutic dead end.21 Some MO patients may not perceive that they need to change and may be considered to be in a “pre-contemplation” stage.22 It has also been hypothesized that clinicians’ fearful responses to psychopathic persons are essentially the natural biological reaction of prey to a predator.3 In this sense, it is arguable whether “fear,” in its strictest sense, is truly a countertransference reaction instead of a normal physiological response. In either case, the clinician must not discount this signal, but should make an objective assessment of physical risk and prospectively take the necessary precautions in patient interactions. Thus, all clinicians who work with MO patients should have a sound understanding of basic risk assessment principles.23,24 It is helpful to view this process as ultimately protective of both oneself and the patient.

Both general and forensic clinicians are likely to encounter a small but significant population of patients whom they will find to be not only difficult to treat, but objectionable. Such patients may have been convicted of heinous or deviant crimes and may arouse strong feelings of moral disgust in the clinician. Many MO patients have been rejected by society and are often perceptive of the negative moral judgments of others. Bear this fact in mind, because it is common for the clinician to struggle with conflicting views of the patient as either a “monster” or a “human in need of treatment.” But “either/or” thinking is rarely helpful with such patients. Clinicians who work with MO patients will benefit from supervision of colleagues and attention to impending signs of compassion fatigue.24-27



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