Ethics and the Difficult Patient

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Ethics and the Difficult Person: The Psychopath in Film and in Your Office

Presenters: Robert M. Gordon, Ph.D. ABPP and Jennifer Bottinelli, Ph.D.

•You will learn the difference between the DSM and the PDM criteria for antisocial and psychopathic personalities.

•You will learn about the Passive/Parasitic and Aggressive sub-types.

•You will learn how hard it is to spot clients who might try to put you in ethical and risk management dilemmas.

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Why the Psychopath is a risk in treatment

• They are very hard to detect.• They are con artists. They are experts at

sizing you up and exploiting your issues.• They can be charming one moment, and

dangerous the next.• They can seduce you and then destroy your

career.• They will make false claims against you for

the money.

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Examples of What Can Happen to You

• Victimized by “Victims:” A Taxonomy of Antecedents of False Complaints AgainstPsychotherapists

• Martin H. Williams (2000), Professional Psychology: Research and Practice, 31 (1), 75-81

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Victimized by “Victims”

Malingering and Fraud

A case in 1996 involved a patient who claimed to have suffered damages resulting from her having been kissed by her psychiatrist. The patient suddenly kissed the psychiatrist, and the psychiatrist initially failed to resist. He said he expected to discuss his mistake in subsequent sessions, however, he never got that opportunity. The patient set in motion a civil law suit within a day of the event. The patient was ultimately awarded nearly $160,000 by a jury in San Francisco.

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Revenge• The former employee, with a lengthy drug

abuse and criminal career, intentionally set out to ruin the psychologists who had terminated his employment. This former employee was able to influence current and former patients to assist him in “bringing to justice” the psychologist who, he alleged, was engaged in harmful practices and needed to be stopped. Both psychologists were ultimately exonerated, but only after lengthy and costly struggles.

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Escape from Unwanted Treatment• A psychologist sent a 16 year old student who

was undergoing treatment for amphetamine abuse to a physician for anti-depressant medications. Her other therapist did not know of her severe drug problem. The patient named both the physician and the referring psychologist as defendants in a civil case, claiming the physician sexually abused her and the referring psychologist should have known better. The jury in this case did not find her credible.

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Who Are They?They can look like anyone.

L to R: OJ, Husain,Lay and Skilling, Dahmer, Abagnale, Fisher, Bundy

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Psychopathic, Sociopathic, Antisocial or Dissocial?

• The official stance of the American Psychiatric Association as presented in the DSM-IV-TR is that psychopathy and sociopathy are obsolete synonyms for antisocial personality disorder.

• The World Health Organization stance in its ICD-10 refers to psychopathy, sociopathy, antisocial personality, asocial personality, and amoral personality as synonyms for dissocial personality disorder.

• The PDM uses “psychopathic” to relate to the personality not just symptoms, and considers all the terms as basically interchangeable.

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DSM-IV Antisocial Personality Disorder Diagnostic criteria

• A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since the age of 15, as indicated by three or more of the following:

1.Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest

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2. Deceitfulness, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure

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3. Impulsivity or failure to plan ahead

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4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults

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5. Reckless disregard for safety of self or others

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6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations

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7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

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DSM-IV Antisocial Personality Disorder Diagnostic criteria B-D

B. The individual must be at least 18 years.

C. There is evidence of Conduct Disorder with onset before age 15.

D. The antisocial behavior must not occur exclusively during an episode of Schizophrenia or a Manic Episode.

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The Psychodynamic Diagnostic Manual’s P Axis- Personality Disorders- Considers the

Following Factors:

Temperamental,

Thematic,

Affective,

Cognitive, and

Defense patterns

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P103. Psychopathic (Antisocial) Personality Disorder P103.1 Passive/Parasitic P103.2 Aggressive

• Contributing constitutional-maturational patterns: aggressiveness, high threshold for emotional stimulation

• Central tension/preoccupation: Manipulating/being manipulated

• Central affects: Rage, envy

• Characteristic pathogenic belief about self: I can make anything happen

• Characteristic pathogenic belief about others: Everyone is selfish, manipulative, dishonest

• Central ways of defending: Reaching for omnipotent control

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Psychopathic P.D. (PDM)

• Not all psychopaths are antisocial. Many are successful and social in certain roles (intelligence, law enforcement, attorney, clergy, etc.)

• Want power for its own sake• Pleasure in exploiting and duping others• Good at reading the emotions of others, but not their own• Lacking a moral center of gravity• Lose interest in people once no longer useful to them• Lack of remorse• Need high external stimulation• Organized mainly at the borderline level, and often

combines with other personality disorders or patterns (Paranoid, Sadistic, Narcissistic, etc.)

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Passive/Parasitic Subtype

• More dependent• Less aggressive, usually non-violent• Manipulator• Con artist

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Frank William Abagnale, Jr.• passed bad checks worth about $2.5 million in

26 countries. • between the ages of 16 and 18, Frank Abagnale

impersonated a pilot and flew over 1,000,000 miles on over 250 flights to 26 countries, at Pan Am's expense, through “deadheading.”

• Later, he impersonated a pediatrician in a Georgia hospital.

• He forged a Harvard University law transcript, passed the bar exam and got a job at the office of the state attorney general of Louisiana at the age of nineteen.

• His life story provided the inspiration for the film “Catch Me if You Can.”

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The Ideal Patient

• Born November 25, 1953, Pittsburgh, Pa.

• M.B.A.from Harvard Business School in 1979, graduating in the top five percent of his class

• CEO earning $132 million a year

• Presenting problem: depression

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Jeffrey K. Skilling

• Mr. Skilling was ordered not to drink by the court after a drunken scuffle with bar patrons in Manhattan in 2004. Soon after he was arrested for public intoxication and forced to spend a night in jail.

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Jeffrey K. Skilling

• Hundreds of thousands of people suffered artificially caused power outages across the state, causing then California governor Gray Davis to declare a state of emergency. Taking plants off-line was just one of countless manipulations that caused the cost of energy to skyrocket in California in 2000 and 2001.

• By the end of 2000, market manipulation had caused the price of electricity to soar to a 3,000 percent increase in cost, all of which was passed down to the customer. The California crisis was made explicitly off-limits in the trial.

• Skilling jokingly said that the difference between California and the Titanic ("At least when the Titanic went down, the lights were on").

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Jeffrey K. Skilling

• Enron's bankruptcy, the biggest in U.S. history when it was filed in December 2001, cost 20,000 employees their jobs and their life savings. The collapse wiped out more almost $2.1 billion in retirement savings. Investors lost $60 billion.

• Skilling sold 500,000 shares of Enron stock for $15.5 million before the collapse.

• For conspiracy, insider trading, lying to auditors and securities fraud, Skilling was sentenced to 24 years and 4 months in prison.

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Jeffrey K. Skilling

• “I am innocent of every one of these charges,” Mr. Skilling told the judge. In his five-minute speech, he reiterated that Enron collapsed because of a severe liquidity crisis and did not have enough dry powder to deal with the events that followed his abrupt resignation as chief in August 2001. But some outside lawyers saw little remorse in Mr. Skilling’s words. He was defiant to the end, said Philip Hilder, a Houston criminal defense lawyer.

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Aggressive Subtype

• Explosive

• Actively predatory

• Often violent

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Ted Bundy• He enrolled in the University of Washington and studied psychology, a subject in which he excelled. Bundy became an honors student and was well liked by his professors at the university.

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Ted Bundy

• Ted began sending out applications to various law schools, while at the same time he became active in politics. He worked on a campaign to re-elect a Washington governor, a position that allowed Ted to form bonds with politically powerful people in the Republican Party.

• He was even commended by the Seattle police for saving the life of a three-year-old boy who was drowning in a lake.

• He also committed least thirty-six brutal murders in four states

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Teen aged psychopaths in Allentown

• On February 26, 1995, in a quite suburb of Allentown, Bryan Freedman, 17 and his 15 brother David slit their father’s throat, stabbed their mother numerous times and smashed the head of their 12 year old brother Erik with a baseball bat. Cousin Ben Birdwell, 18 helped with the murders.

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“Dr. Robert Gordon, a clinical psychologist from the area and a renowned expert on the MMPI-2 personality assessment, said that Ben showed only normal signs of anxiety, nothing extreme, and, in fact, the test supported a diagnosis of a psychopathic personality. That meant Ben could probably deceive others with skill and would not be hindered by guilt or remorse. Rosen quotes Gordon as stating, "There are no signs he felt residual anxieties at the time of the crimes.”TruCrime Library By Katherine Ramsland and with Trista Dashner

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High Pd-O minus Pd-S = Pd in the normal range

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Causes- Psychodynamic - Childhood

• Bowlby (1944) saw a connection between antisocial personality disorder and maternal deprivation in the first five years of life.

• Glueck and Glueck (1968) saw indications that the mothers of children who developed this personality disorder tended to display a lack of consistent discipline and affection, and an abnormal tendency to alcoholism and impulsiveness.

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Causes: Psychodynamic - childhood

When parents are cold, uncaring, and dangerous this leads to poor attachment, empathy and trust. Introjects don’t lead to the development of a healthy super-ego (capacity for remorse or moral reasoning), mentalization of objects is remains primitive. There may be bizarre gaps in moral reasoning, "superego lacunae" or holes in their conscience. Think of Tony Soprano having affairs and killing for money, and then very moralistic towards his wife and children.

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Causes- PsychodynamicCharacterlogical

• Adoption studies support the role of both genetic and environmental contributions to the development of the disorder. Twin studies also indicate an element of hereditability of antisocial behavior (Lyons et al., 1995).

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Causes- Biological- Brains of Violent Criminals

• According to authors Nathaniel J. Pollone and James J. Hennessy, "[Various] studies over a period of nearly 40 years... suggest a relative incidence of neuropathology among violent offenders at ratios ranging from a high of 31:1 in the case of homicide offenders through 21:1 among `habitual aggressive' offenders to a low of 4:1 in the case of `one-time aggressives.' (35th Annual Meeting of the Academy of Criminal Justice Sciences, Albuquerque, NM, March 14, 1998)

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Frontal Lobe

• This area of the brain is responsible for self-control, planning, judgment, and the balance of individual versus social needs.

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• PET images of the brain of a normal person (left), a murderer with deprived background (middle) and a murderer with non-deprived background (right). Areas in red and yellow show a higher metabolic activity, and in black and blue of lower metabolic activity. The brain of a psychopath (right) has a very low activity in many areas, but which is strikingly absent in the frontal area (upper part of the images).

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Brain Injury Studies

A PET image of decrease in neural activity in the frontal area (upper part of the images) of the brain of a patient who sustained closed head injury (1A), and developed a psychopathic personality. Figure 1B shows a normal brain in the same area.

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Causes- Cognitive- Behavioral

Caused by mistaken beliefs that they learned, such as:

1) wanting is sufficient justification for acting out

2) if you think it is, then it is true3) undesirable consequences will not happen to you or won't matter

4) you're on your own5) focus on today

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Prevalence

• Estimates within clinical settings have varied from three to 30 percent. Not surprisingly the prevalence of the disorder is even higher in prisons (who include many violent offenders). Similarly, the prevalence of ASPD is higher among patients in alcohol or other drug abuse treatment programs than in the general population (Hare 1983).

• David Korten (2001) also reports research that shows a high proportion of these traits amongst CEOs of major corporations

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• Wherever they can control others

Psychopaths have little difficulty infiltrating the domains of business, politics, law enforcement, government, law and religion

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Mark Twain once said Congress may be America's only 'distinct criminal class'

• After researching public records, newspaper articles, civil court transcripts, and criminal records, Capitol Hill Blue discovered that:29 members of Congress have been accused of spousal abuse,7 have been arrested for fraud,19 have been accused of writing bad checks,117 have bankrupted at least two businesses,3 have been arrested for assault,71 have credit reports so bad they can't qualify for acredit card,14 have been arrested on drug-related charges,8 have been arrested for shoplifting,21 are current defendants in lawsuits.And in 1998 alone, 84 were stopped for drunk driving, but released after they claimed Congressional immunity.

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Child Psychopaths

Are there Bad Seeds?

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MacDonald triad: Children with a longer-than-usual period of

bedwetting, cruelty to animals, and

pyromania.These three traits are now included under conduct

disorder.A child who shows signs of antisocial personality

disorder may be diagnosed as having either conduct disorder or oppositional defiant disorder.

Markers in Childhood

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“Child Psychopaths” by Katherine Ramsland, Ph.D.

• “Jessica Holtmeyer, 16, hanged a learning-disabled girl in Pennsylvania and then bashed in her face with a rock. Afterward, a witness reported Holtmeyer to say that she wanted to cut the girl up and keep one of her fingers as a souvenir.

• it is increasingly clear that psychopathy is not exclusively an adult manifestation.”

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Treatment

• They tend to be very manipulative during treatment and tend to lie and cover up personal faults in themselves and have little insight into their behavior patterns.

• They tend to exhibit short-term enthusiasm for treatment, particularly after an incident which has brought them into contact with society or the law, however, once this anxiety is relieved and reduced,

• They frequently drop out of treatment and fall back into the same patterns that brought them into treatment initially.

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Treatment

• Therapy is usually counterproductive. Psychopaths learn how to use psychology to better manipulate people.

• Some limited issues may be the focus, such as anger management.

• Older patients with psychopathic traits who have some remorse and insight may improve. They may learn to better contain their acting out, IF they keep to the ground rules and stay long enough in treatment.

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Remember, it is difficult to spot a psychopath

• They will at first seem overly cooperative and friendly. They are sizing you up noting your physical, intellectual and moral capabilities, while trying to lull you into a false sense of security. They may invade your personal space just to see how you react.

• Once they have a sense of what kind of person you are, they will attempt to manipulate you; they are highly skilled in this regard.

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What to do?

• Keep strict boundaries

• Keep them from testing your personal space

• Set limits consistently (or they will sense your weakness and play on it)

• Keep goals focused

• Never do favors

• Get a consult

• If you are frightened or uncomfortable, do not treatment them!

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10.10 Terminating Therapy

– (a) Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service.

– (b) Psychologists may terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship.

– (c) Except where precluded by the actions of clients/patients or third-party payors, prior to termination psychologists provide pretermination counseling and suggest alternative service providers as appropriate.

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Fargo (1996) a car salesman has hired two men to kidnap his wife for a ransom of $1 million that he hopes to get from his rich father in-law. The husband hires two men, an aggressive psychopath and a passive/parasitic psychopath working together. What was meant to be a simple kidnapping for

money turns into multiples murders when the aggressive type explodes in violence.

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Fargo- The police officer questions the husband car salesman (also a passive/parasitic psychopath)

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House of Games (1987) - In House of Games, a handsome con man sucks in a female psychiatrist by making a deal with her. She asked him not to have her patient injured because of his gambling debts. He claims that he will write off her patient’s debts in exchange for informing him about the “tells” of another poker player. He charms her, invades her space,

touches her, and asks for a favor in the first few minutes of their meeting.

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The Sopranos (1999-2007) Tony Soprano’s mother is a cold hostile psychopath. She orders a hit on her own son. Tony is in denial about this, and physically attacks his therapist when she confronts him about his mother’s borderline personality and hostility towards him. Tony would rather displace his aggressive than get in touch with his feelings of sadness. He also turns his longing into an erotic

transference to his therapist.

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Sopranos- Tony testing boundaries, threats, projecting dishonesty, acting out transference instead of using insight

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Discussion

• Film is not a documentary about how to do therapy. Film must show drama such as in the boundary violations in therapy. But film can aid in discussions.

• When working with a psychopath, keep to strict ground rules and do a lot of listening. Set limits on their anger. Let their “bullets hit the wall.” If you feel too uncomfortable, do not continue and refer to another therapist if possible.

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Thank You

You may view this as often as you need. Please proceed to the C.E.

questionnaire.

Health & Medicine

Ethics and the Difficult Patient