Can Tony be cured by talk therapy?
A recent study on impulsivity, alcoholism, and personality disorders raises an interesting point. The authors are Gabriel Rubio and colleagues of Complutense University in Madrid, the article appears in ‘Alcoholism: Clinical & Experimental Research’.
Rubio says: “We may also need to rethink treatment options. Programs that emphasize immediate rewards for abstinence may have a better chance of succeeding with antisocial personality disorder. Conversely, psychotherapeutic and pharmacological interventions that focus on ‘behavioral control’ may work better with subjects with borderline personality disorders.”
The bit on treating the antisocial personality caught my eye. It matches psychoanalyst Nancy McWilliams’ notion that psychopaths differ in one fundamental way. While most people are governed by a love-principle; the psychopath is governed by a power-principle. This doesn’t mean that every psycho- or sociopath is a potential Charles Manson by any means. Many psychopaths are very good citizens. They make excellent salespersons, for example, precisely because of the pleasure they get from getting one over another person when making a good deal.
Dr. Melfi’s dilemma
In the final season of ‘The Sopranos’, Dr. Melfi is referred by her supervisor Dr. Elliot Kupferberg to a study which suggests that talk therapy may only serve to hone the sociopath’s manipulative skills.
The study actaully exists. Stanton Samenow and Samuel Yochelson have written the three-volume “The Criminal Personality”. Instead of blaming society, they insist that the sociopath engages in particular types of ‘thinking errors’ or ‘cognitive distortions’. The consequence of faulty understanding of situations is that she or he makes bad choices.
The good news, they assert, is that the sociopath has control over the choices they make and can learn to have less distorted cognition. The criminal is: very fearful; cut off from internal and external deterrents; a predator pursuing power and control; has never learned to fully function independently; feels put down when not getting his way; and, except for planning crime, fails to think long term. The criminal chooses a life of crime to get power, control, and excitement.
Treatment: the patient talks away in the first therapy sessions(s) but, unlike regular in talk therapy, the therapist doesn’t try to understand the past, to empathise, to interpret, etc. Rather, the therapist notices cognitive distortions. The patient is then educated on these distortions. In theory, a patient will use less and less cognitive distortion, eventually reaching a point where covert sensitization can be employed to abruptly halt criminal thinking patterns.
Three alternatives and one no-no
1. Rubio’s recommendation implies working with the sociopath’s difference. The sociopath does things for reasons that boost his or her power; what’s in it for me? Thus Rubio recommends a reward system that matches this kind of motivation.
2. Samenow and Yochelson’s alternative is more radical – they want to change the sociopathic thinking (and thus behavior) and they do this via addressing cognitive distortions. This may work well in prison where the criminal-minded are sometimes motivated to change because of where their behaviors have landed them. But in ordinary life sociopaths don’t present themselves for psychotherapy very often, and when they do it’s not for the sociopathy. More likely they come because someone recommended that they seem stressed, etc. Or they come with their spouse for couple’s therapy. (In this case they’re not there to make the relationship closer, but rather to win.)
3. How does one work with a sociopath who a. has no desire to change that aspect of their personality, and who b. nevertheless manifest all manner of manipulations and power-games? Answer: don’t practice talk therapy in the regular way.
4. McWilliams is good on this. Payment, she says, will be a problem with the psychopath who will ‘forget’ their chequebook, etc. Once the therapist is sure they’re dealing with a psychopath this manipulation must be confronted. Whereas with a regular patient one might interpret and/or say “OK, pay me next time,” a psychopath will see that as weakness and despise the therapist.
What the therapist must do, says McWilliams, is something that goes against the gain. The therapist must say something like, “I see that payment is becoming a problem for you. Here’s my new rule; I’m going to insist on payment in cash at the start of the sesison. If not I won’t see you that day.” A neurotic patient would be devastated by such treatment, but a psychopath will respect the therapist and may begin to settle down to work on the deep psychic issues which McWilliams believs lies beneath this personality disorder.
In this sense her approach is the most radical – it aims to get beneath the ‘cognitive distortions’ of the patient. And it here that Samenow and Yochelson are most pessimistic: sociopaths are not interested in change (wouldn’t an admission that somehthing was wrong be an admission of weakness?). Samenow: “The ‘why’ questions continue indefinitley. Do we ever have an answer? An even if we did, identifying the cause might only serve to perpetuate the behavior, not change it.”
Note: In a later post I will confound things a little and argue that Tony Soprano is in fact not a psychopath! In which case Dr. Melfi’s work with him is unobjectionable.