Table Of ContentAntisocial Personality
Disorder
A Practitioner’s Guide to Comparative
Treatments
Edited by
FREDERICK ROTGERS, PSYD, ABPP and
MICHAEL MANIACCI, PSYD
New York
Copyright 2006 by Springer Publishing Company, Inc.
All rights reserved.
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Library of Congress Cataloging-in-Publication Data
Antisocial personality disorder: a practitioner’s guide to comparative treatments / [edited by]
Frederick Rotgers, Michael Maniacci.
p. ; cm. — (Springer series on comparative treatments for psychological disorders)
Includes bibliographical references and index.
ISBN 0-8261-5554-5 (hc)
1. Antisocial personality disorder—Treatment. I. Rotgers, Frederick. II. Maniacci,
Michael. III. Series.
[DNLM: 1. Antisocial Personality Disorder—therapy. 2. Psychotherapy—methods. WM
190 C7367 2005]
RC555.C66 2005
616.85'82—dc22
2005054056
ISBN 0-8261-5554-5
06 07 08 09 10 5 4 3 2 1
Printed in the United States of America by Bang Printing
Contents
Contributors v
1 Antisocial Personality Disorder: An Introduction 1
Frederick Rotgers and Michael Maniacci
Structure of the Book 2
Overview of APD 3
Questions for Authors 7
Treatment Approaches 9
2 The Case of Frank 11
Arthur Freeman
Background Information 11
Initial Assessment 19
3 A Psychodynamic Approach 21
Debra Benveniste
4 Adlerian Psychotherapy 47
Michael Maniacci
5 Millon’s Biosocial-Learning Perspective: 63
Personologic Psychotherapy
Darwin Dorr
Theory of Personologic Polarities 65
6 The Lifestyle Approach to Substance Abuse and Crime 91
Glenn D. Walters
The Lifestyle Model of Change 91
Essential Clinical Skills 95
Specific Questions 97
Conclusion 112
7 The Cognitive Behavioral Treatment Approach 115
Arthur Freeman & Brian Eig
iii
iv Contents
8 Dialectical Behavior Therapy 137
Robin A. McCann, Katherine Anne Comtois, and Elissa M. Ball
9 Motivational Interviewing 157
Joel I. Ginsburg, C.A. Farbring, and L. Forsberg
10 Integrating Psychotherapy and Medication 179
Sharon Morgillo Freeman and John M. Rathbun
Diagnostic Challenges 180
Pathophysiology of aggression and impulsivity 181
Impulsivity and Aggression 183
The Case of Frank 184
Treatment challenges 185
Medication Options 186
Options for Frank 188
Optimistic Prognostic Factors 190
Summary 190
11 Antisocial Personality Disorder: 195
Summary and Conclusions
Frederick Rotgers
Index 209
Contributors
Elissa M. Ball, MD, Institute for Forensic Psychiatry, Colorado Mental
Health Institute. Pueblo, Colorado
Debra Benveniste, MA, MSW, Private Practice, Putnam, Connecticut
Katherine Anne Comtois, PhD, Department of Psychiatry and Behavioral
Sciences, University of Washington, Seattle, Washington
Darwin Dorr, PhD, Wichita State University, Wichita, Kansas
Brian Eig, Department of Psychology, Philadelphia College of Osteopathic
Medicine, Philadelphia, Pennsylvania
Carl Ake Farbring, MA, Swedish National Prison & Probation Administra-
tion, Stockholm, Sweden
Lars Forsberg, PhD, Department of Clinical Neuroscience, Section of De-
pendency Research, Karolinska Institute, Stockholm, Sweden
Arthur Freeman, EdD, Department of Psychology, University of St. Francis,
Fort Wayne, Indiana
Joel I. D. Ginsburg, PhD, C. Psych, Psychologist, Correctional Service of
Canada, Fenbrook Institution, Gravenhurst, Ontario, Canada
Robin A. McCann, PhD, Institute for Forensic Psychiatry, Colorado Mental
Health Institute, Denver, Colorado
Sharon Morgillo Freeman, PhD, MSN, RN-CS, Indiana University Purdue
University, Aboite Behavioral Health Services, Fort Wayne, Indiana
John M. Rathbun, MD, Aboite Behavioral Health Services, Fort Wayne,
Indiana
Glenn D. Walters, PhD, Federal Correctional Institution, Schuylkill,
Pennsylvania
v
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C H A P T E R 1
Antisocial Personality Disorder
An Introduction
Frederick Rotgers and Michael Maniacci
The therapy of patients with disorders of character or personality has been
discussed in the clinical literature since the beginning of the recorded history
of psychotherapy. Literature on the psychotherapeutic treatment of specific
personality disorders has emerged more recently and is growing quickly.
The main theoretical orientation in the psychotherapeutic literature on treat-
ment of personality disorders has been psychoanalytic (e.g., Kernberg, 1975;
Masterson, 1978; Reid, 1978). Psychoanalytic writers have produced a rich
literature on treatment of these patients for more than 30 years.
More recently, cognitive behavioral therapists (e.g., Beck & Freeman,
1990; Young, 1994) have offered a cognitive behavioral treatment approach.
Despite the literature in this area, there have been few opportunities for a
comparison and integration of extant models. Very often, writers end up
“preaching to the converted” in that those therapists who are psychodynami-
cally oriented tend to read the psychodynamic literature just as cognitive and
behavioral therapists stick to their own literature. Cross fertilization of ap-
proaches is thereby stymied.
Probably no single diagnostic group engenders as much concern, con-
sternation, and fear among therapists as does Antisocial Personality Disorder
(APD). This concern and attention stems from the fact that these patients usu-
ally require more time in treatment (when they come), more energy on the
1
2 ANTISOCIAL PERSONALITY DISORDER
part of the therapist (where the patient may offer very little to the therapeutic
collaboration), and more time and attention from the care system (because
of the chronicity of personality disorders), all without the same progress and
gratification seen with many other patients. In fact, many therapists simply
throw up their hands and claim that these individuals cannot be treated in
psychotherapy. The patient diagnosed as having APD often ends up “clogging
up” the legal and mental health systems, continually relapsing and given to
extensive utilization of mental health treatment services with little positive
change.
Given all of the difficulties in treating these patients, they still must be
treated. The best model for treatment is debatable. Theorists often advocate
the application of their etiologic, conceptual, philosophical, and treatment
model, to the exclusion of other approaches. What has not, to this point,
been explicated are the similarities and differences between various etiologic,
conceptual, philosophical, and treatment models.
In this volume we attempt, in small measure, to provide a forum in
which experts in prominent models of treatment for patients with APD all
answer the same set of questions with respect to their treatment model, ad-
dressing both conceptual and technical aspects of the model. Authors were
provided with a prototypical case study of a patient with APD to serve as the
springboard for their answers.
Before we turn to the questions and a brief overview of APD, we need
to state that this book is not intended to be a comprehensive survey of the
treatment of APD. Rather, we have selected a number of prominent models of
treatment that we believe span the psychodynamic, eclectic, and behavioral
approaches to treating these patients. There are certainly other models avail-
able, and we do not intend to imply that these models are the only ones, nor
that they are the most efficacious. We leave the latter judgment to outcome
researchers, who are only recently beginning to examine outcomes specifi-
cally with APD.
STRUCTURE OF THE BOOK
In the remainder of this chapter we will present a brief overview of the con-
struct of APD, with a focus on diagnostic considerations and several ongoing
controversies regarding the construct of APD. We will not review the extant
treatment outcome literature, for the primary reason that there is virtually
no well-designed outcome research that focuses solely on APD outcomes. In
fact, virtually all of the experimental treatment outcome research with these
Antisocial Personality Disorder: An Introduction 3
patients has occurred in the context of treatment of substance use disorders,
a very common co-occurring set of disorders in patients with APD.
Following this overview, we will detail the questions our authors were
asked to address with respect to the treatment of Frank J., whose case is
presented in detail in chapter 2. The responses of our chapter authors fol-
low. We will conclude in our final chapter with a summary and synthesis of
the responses our authors provided. It is our hope that this discussion will
stimulate not only development and enhancement of treatment for patients
with APD, but that it will also provide impetus for outcome research on the
treatments outlined.
OVERVIEW OF APD
In this section we will briefly review the history and construction of the con-
cept of APD and the current criteria for its diagnosis, and we will describe
some of the clinical features of the disorder that are most relevant for treat-
ment. In addition, we will address two continuing controversies in the field
regarding APD: the relationship of morality and criminality to APD, and the
question of whether APD represents a qualitative or quantitative departure
from normal personality functioning. Finally, we will examine the somewhat
sparse outcome literature for the treatment of APD. Of necessity, this chapter
will be less than comprehensive. For a more detailed discussion of these issues
we would refer the reader to the excellent chapter on “Antisocial Personality
Disorders: The Aggrandizing Pattern” in Millon and Davis’s book Disorders of
Personality: DSM-IV and Beyond (1996, pp. 429–469). Although written from
a particular theoretical perspective, this chapter presents a detailed overview
of the concept of APD and reviews in more detail the controversies we will
only touch upon here.
The concept of APD is quite old, dating, in a surprisingly modern form,
to Aristotle (Millon & Davis, 1996), whose description of the “unscrupulous
man” is perhaps the earliest of this personality pattern. As the concept of APD
evolved into the 18th and 19th centuries, it became increasingly linked with
criminality and immoral behavior. This linkage persists today, and for some
theorists (e.g. Millon & Davis) it represents a major problem in the current
diagnostic system for APD. Specifically, the association of APD with criminal
and immoral behavior needlessly limits the concept to those with criminal
involvement or those whose behavior is considered immoral. Many theorists
believe that this limitation results in the omission of many people whose per-
sonality functioning is clearly the same as that in persons who end up in the
criminal justice system, but who never become so involved. It is believed
